Evaluation tool for a gastroenterostomy simulated training1 1 Research performed at Laboratory of Surgical Skills, Centro Universitário Christus (UNICHRISTUS), Fortaleza-CE, Brazil. Part of Master degree thesis, Postgraduate Program in Minimally Invasive Technology and Health Simulation. Tutor: Gleydson Cesar de Oliveira Borges.

Márcio Alencar Barreira Delano Gurgel Siveira Hermano Alexandre Lima Rocha Luiz Gonzaga de Moura Junior Charles Jean Gomes de Mesquita Gleydson Cesar de Oliveira Borges About the authors

Abstract

Purpose:

To create a checklist to evaluate the performance and systematize the gastroenterostomy simulated training.

Methods:

Experimental longitudinal study of a quantitative character. The sample consisted of twelve general surgery residents. The training was divided into 5 sessions and consisted of participation in 20 gastroenterostomys in synthetic organs. The training was accompanied by an experienced surgeon who was responsible for the feedback and the anastomoses evaluation. The anastomoses evaluated were the first, fourth, sixth, eighth and tenth. A 10 item checklist and the time to evaluate performance were used.

Results:

Residents showed a reduction in operative time and evolution in the surgical technique statistically significant (p<0.01). The correlation index of 0.545 and 0,295 showed a high linear correlation between time variables and Checklist. The average Checklist score went from 6.8 to 9 points.

Conclusion:

The proposed checklist can be used to evaluate the performance and systematization of a simulated training aimed at configuring a gastroenterostomy.

Key words:
Education, Medical; Simulation Training; Anastomosis, Surgical; Laparoscopy; hecklist

Introduction

It is compulsory to define a training program for the teaching of laparoscopic surgery11 Nácul MP, Cavazzola LT, Melo MC. Current status of residency training in laparoscopic surgery in Brazil: a critical review. Arq Bras Cir Dig. 2015 Dec;28(1):81-5. doi: 10.1590/S0102-67202015000100020.
https://doi.org/10.1590/S0102-6720201500...
through the simulators use and a structured curriculum22 Kockerling F, Pass M, Brunner P, Hafermalz M, Grund S, Sauer J, Lange V, Schroder W. Simulation-based training - evaluation of the course concept "laparoscopic surgery curriculum" by the participants. Front Surg. 2016 Aug;3:47. doi: 10.3389/fsurg.2016.00047.
https://doi.org/10.3389/fsurg.2016.00047...
. The simulated training of a manual gastrointestinal anastomosis can be used to teach the skills needed to perform complex procedures via the laparoscopic method33 Beyer-Berjot, L, Palter V, Grantcharov T, Aggarwal R. Advanced training in laparoscopic abdominal surgery: a systematic review. Surgery. 2014 Sep;156(3):676-88. doi: 10.1016/j.surg.2014.04.044.
https://doi.org/10.1016/j.surg.2014.04.0...
.

The surgical simulation needs to identify a goal, systematize a training, use performance evaluation tools and perform evaluations with the purpose of validating the effectiveness of the proposed educational program44 Cristancho SM, Moussa F, Dubrowski A. A framework-based approach to designing simulation-augmented surgical education and training programs. Am J Surg. 2011 Sep;202(3):344-51. doi: 10.1016/j.amjsurg.2011.02.011.
https://doi.org/10.1016/j.amjsurg.2011.0...
. Twenty-four specialists in surgical education in several countries suggest that a curriculum based on the simulated training of any surgical procedure should create, evaluate and implement a specific assessment tool for the exercise performed55 Zevin B, Levy JS, Satava RM, Grantcharov TP. A consensus-based framework for design, validation, and implementation of simulation-basedtraining curricula in surgery. J Am Coll Surg. 2012 Oct;215(4):580-6.e3. doi: 10.1016/j.jamcollsurg.2012.05.035.
https://doi.org/10.1016/j.jamcollsurg.20...
. An interview with surgeons and residents of General Surgery of three different services came to the conclusion that technical evaluation is essential for quality training in laparoscopic surgery66 Singh P, Aggarwal R, Pucher PH, Duisberg AL, Arora, Darzi A. Defining quality in surgical training: perceptions of the profession. Am J Surg. 2014 Apr;207(4):628-36. doi: 10.1016/j.amjsurg.2013.07.044.
https://doi.org/10.1016/j.amjsurg.2013.0...
.

An evaluation tool creation contributes to the technical performance monitoring in an objective and trustworthy manner77 Louridas M, Szasz P, de Mintbrun S, Harris KA, Grantcharov TP. International assessment practices along the continuum of surgical training. Am J Surg. 2016 Aug;212(2):354-60. doi: 10.1016/j.amjsurg.2015.12.017.
https://doi.org/10.1016/j.amjsurg.2015.1...
. A well-structured checklist showed to be able to analyze progress in the ability to make a vascular anastomosis88 Duran CA, Shames M, Bismuth J, Lee JT. Validated assessment tool paves the way for standardized evaluation of trainees on anastomotic models. Ann Vasc Surg. 2014 Jan;28(1):115-21. doi: 10.1016/j.avsg.2013.07.005.
https://doi.org/10.1016/j.avsg.2013.07.0...
. There is a need to develop an assessment tool to be inserted into a training curriculum for a gastroenterostomy. Therefore, the purpose of this study is to create a Checklist to evaluate performance and systematize the simulated training of a gastroenterostomy.

Methods

This longitudinal experimental study was approved by the Research Ethics Committee of Centro Universitário Christus (number 1,317,965) and Brazil platform system (Approval with CAAE number 49573215.7.0000.5049).

This study respects the ethical precepts of human research and presents no possibility of damage to the physical, biological, psychic, moral, intellectual, social, cultural or spiritual dimension of the human being, at any stage of research or as a result of it. The research was carried out in the Laboratory of Surgical Skills of Centro Universitário Christus, located in the city of Fortaleza, Ceará-Brazil. Twelve residents of General Surgery at the end of the second year of training participated in the study.

Surgical procedure

After a first theoretical session consisting of a basic course of endosutures, videos and orientations, the residents began the training which aimed at the participation in the making of twenty anastomoses, being ten as main surgeon and ten as assistant surgeon. Dual training was used to strengthen teamwork and contribute to learning through error analysis. The complexity of the procedure, too, requires a helper. The organs used during training with the residents were a stomach and a segment of synthetic jejunum. The gastroenterostomy was carried out through a continuous suture in single plane with two Seda 3.0 wires99 Barreira MA, Siveira DG, Rocha HA, Moura-Junior LG, Mesquita CJ, Borges GC. Model for simulated training of laparoscopic gastroenterostomy. Acta Cir Bras. 2017 Jan;32(1):81-9. doi: 10.1590/s0102-865020170110.
https://doi.org/10.1590/s0102-8650201701...
.

The procedures were distributed in five sessions, with approximate interval of one week and total duration of six weeks. The training was accompanied by an experienced surgeon who was responsible for the feedback and evaluation of anastomoses. The anastomoses evaluated were the first, fourth, sixth, eighth and tenth. The first one chosen to serve as the initial evaluation. In the other sessions the last anastomosis was evaluated. The simulation was performed in the Endosuture Trainning Box.

Evaluation of anastomoses

The evaluation of the anastomoses was done by the same surgeon and occurred during the training. The evaluator was previously trained to evaluate the participants uniformly. A 10-item Checklist (Chart 1) was used which was elaborated by three surgeons with experience in simulation of surgical procedures and anastomoses by laparoscopy in real patients. The time to perform the procedure, too, was noted. The timing began with the wire entry into the simulator cavity and ended with the removal of the wire.

Chart 1
Checklist for laparoscopic gastroenterostomy training.

Statistical analysis

Quantitative numerical results were presented as measures of central tendency. Normality tests were performed for numerical variables. Depending on the normality of the variables, ANOVA or Mann-Whitney tests were performed, as appropriate. Simple linear regression and multiple analyzes were performed to verify the statistical significance of the correlations. Comparisons with p value up to 0.05 were considered significant. The data were tabulated and analyzed by the SPSS software (Statistical Package for the Social Sciences), v23, SPSS, Inc. for the analysis and evaluation of the collected data.

Results

Figure 1 shows a significant reduction in operative time to make a gastroenterostomy. The correlation index (r) of 0.545 represents a high linear correlation between the variables, and the p <0.01 a statistically significant result.

Figure 1
Relationship between the number of anastomoses made and time.

Figure 2 shows an improvement in the Checklist score during the training of gastrojejunal anastomoses. The average score went from 6.8 to 9 points. The correlation index (r) of 0.295 shows a high linear correlation between the variables, and p <0.01 a statistically significant result. Thus, there was an improvement in the quality of the anastomoses and the operative technique at the training end.

Figure 2
Relationship between the number of anastomoses made and the score in the Checklist.

Discussion

The technical ability evaluation through different evaluation instruments is useful in teaching the surgery, since it can define a goal to be obtained. Currently, there are several ways to analyze proficiency in performing surgical procedures. However, new evaluation tools need to be developed to analyze the capacity to perform increasingly specific tasks1010 Szasz P, Louridas M, Harris KA, Aggarwal R, Grantcharov P. Assessing technical competence in surgical trainees: a systematic review. Ann Surg. 2015 Jun;261(6):1046-55. doi: 10.1097/SLA.0000000000000866.
https://doi.org/10.1097/SLA.000000000000...
. Some skills assessment methods are: observation by specialists using global assessment scales and specific checklist for a given task, computer video analysis and mechanical outcome metrics (eg, anastomoses mechanical integrity)1111 Shackelford S, Bowyer M. Modern metrics for evaluating surgical technical skills. Curr Surg Rep. 2017 Aug;5(24):1-10. doi: 10.1007/s40137-017-0187-0.
https://doi.org/10.1007/s40137-017-0187-...
.

The global assessment scale Objective Structured Assessment Technical Skills (OSATS) is applied to any assessment of surgical skills and assesses knowledge, manipulation skill, and action record. It consists of seven assessment items on a 5-point Likert scale. The minimum score of each participant may be 7 points and the maximum of 35 points, having to reach 21 points or more to be considered competent in an individual task1212 Martin JA, Regehr G, Reznick R, MacRae H, Murnaghan J, Hutchison C, Brown M. Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg. 1997 Feb;84(2):273-8. doi: 10.1046/j.1365-2168.1997.02502.x.
https://doi.org/10.1046/j.1365-2168.1997...
,1313 Denadai R, Saad-Hossne R, Todelo AP, Kirylko L, Souto LR. Low-fidelity bench models for basic surgical skills training during undergraduate medical education. Rev Col Bras Cir. 2014 Mar-Apr;41(2):137-45. doi: 10.1590/S0100-69912014000200012.
https://doi.org/10.1590/S0100-6991201400...
. The OSATS scale with some modifications was used to evaluate the evolution of twenty-four general surgery residents during a training in five different practice stations. At the training end, it was observed that this scale can establish a learning curve and thus allow adequate surgical skills progression monitoring1414 Hopmans CJ, den Hoed PT, van der Laan L, van der Harst E, van der Elst M, Mannaerts GH, Dawson I, Timman R, Wijnhoven BP, Ijzermans JN. Assessment of surgery residents› operative skills in the operating theater using a modified Objective Structured Assessment of Technical Skills (OSATS): a prospective multicenter study. Surgery. 2014 Nov;156(5):1078-88. doi: 10.1016/j.surg.2014.04.052.
https://doi.org/10.1016/j.surg.2014.04.0...
.

The OSATS scale has a specific checklist for suture and can be a useful tool for evaluation and teaching different techniques of laparoscopic sutures and intracorporeal skills1515 Chang OH, Kinq LP, Modest AM, Hur HC. Developing an objective structured assessment of technical skills for laparoscopic suturing and intracorporeal knot tying. J Surg Educ. 2016 Mar-Apr;73(2):258-63. doi: 10.1016/j.jsurg.2015.10.006.
https://doi.org/10.1016/j.jsurg.2015.10....
. A simulated training of ten gastroenterostomy shows a statistically significant improvement (p<0.01) in the OSATS scale score. The evolution of the surgical technique and the final quality of the anastomosis was important, resulting in the last operation an average score of 33.4 points on the OSATS scale. There is a high linear correlation between the improvement in the OSATS scale score and the number of anastomoses made99 Barreira MA, Siveira DG, Rocha HA, Moura-Junior LG, Mesquita CJ, Borges GC. Model for simulated training of laparoscopic gastroenterostomy. Acta Cir Bras. 2017 Jan;32(1):81-9. doi: 10.1590/s0102-865020170110.
https://doi.org/10.1590/s0102-8650201701...
.

A short training for forty-eight general surgery residents used the OSATS scale and a structured Checklist to evaluate the making of an intestinal anastomosis. There was a significant improvement in the score of both assessment tools after training. Some Checklist items were: the thread and needle proper selection, needle and tissues manipulation, spacing between points (3 to 5 mm), similar tissue amount on both sides of the suture, three adjusted nodes and operation flow1616 Reznick R, Regehr G, MacRae H, Martin J, McCulloch W. Testing technical skill via an innovative "bench station" examination. Am J Surg. 1997 Mar;173(3):226-30. doi: 10.1016/S0002-9610(97)89597-9.
https://doi.org/10.1016/S0002-9610(97)89...
. At the end of the general surgery residency, six residents were evaluated concerning the ability to perform an intestinal anastomosis and a high number of errors were observed despite a high score on the OSATS scale. Therefore, it is important to use more than one evaluation tool to improve awareness of the need for additional learning1717 D´Angelo AL, Cohen ER, Kwan C, Laufer S, Greenberg C, Greenberg J, Wiegmann D, Pugh CM. Use of decision based simulations to assess resident readiness for operative independence. Am J Surg. 2015 Jan;209(1):132-9. doi: 10.1016/j.amjsurg.2014.10.002.
https://doi.org/10.1016/j.amjsurg.2014.1...
.

Global Operative Assessment of Laparoscopic Skills (GOALS) is easy to use, reliable, valid and can be an effective means of providing surgeons in training feedback on the skills development in laparoscopic surgery. There are 5 items that score from 1 (lowest level of performance) to 5 (best performance level) and can vary the final score between 5 and 25. The evaluated items are related to depth perception, bimanual dexterity, efficiency, tissue manipulation and autonomy. The items are specific to evaluate laparoscopic skills, but do not evaluate a specific procedure1818 Vassiliou MC, Feldman LS, Andrew CG, Bergman S, Leffondré K, Stanbridge D, Fried GM. A global assessment tool for evaluation of intraoperative laparoscopic skills. Am J Surg. 2005 Jul;190(1):107-13. doi: 10.1016/j.amjsurg.2005.04.004.
https://doi.org/10.1016/j.amjsurg.2005.0...
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A training conducted by 32 volunteers (surgeons, residents and medical students) showed that the GOALS is suitable for performance evaluation in laparoscopic surgery after using the MacGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS)1919 Wolf R, Medici M, Fiard G, Long JA, Moreau-Gaudry A, Cinquin P, Voros S. Comparison of the goals and MISTELS scores for the evaluation of surgeons on training benches. Int J Comput Assist Radiol Surg. 2018 Jan;13(1):95-103. doi: 10.1007/s11548-017-1645-y.
https://doi.org/10.1007/s11548-017-1645-...
. The MISTELS exercises Comprise five tasks inspired by typical tasks performed during laparoscopic cholecystectomies, appendicectomies, inguinal hernia repair or Nissen fundoplication. The tasks are pegboard transfers, pattern cutting, a ligating loop placement, extracorporeal and intracorporeal knot2020 Vassiliou MC, Ghitulescu GA, Feldman LS, Stanbridge D, Leffondré K, Sigman HH, Fried GM. The MISTELS program to measure technical skill in laparoscopic surgery : evidence for reliability. Surg Endosc. 2006 May;20(5):744-7. doi: 10.1007/s00464-005-3008-y.
https://doi.org/10.1007/s00464-005-3008-...
. The MISTELS system has been further validated since the original study and has been shown to be highly reliable and valid system2020 Vassiliou MC, Ghitulescu GA, Feldman LS, Stanbridge D, Leffondré K, Sigman HH, Fried GM. The MISTELS program to measure technical skill in laparoscopic surgery : evidence for reliability. Surg Endosc. 2006 May;20(5):744-7. doi: 10.1007/s00464-005-3008-y.
https://doi.org/10.1007/s00464-005-3008-...
,2121 Beyer L, Troyer JD, Mancini J, Bladou F, Berdah SV, Karsenty G: Impact of laparoscopy simulator training on the technical skills of future surgeons in the operating room: a prospective study. Am J Surg. 2011 Sep;202(3):265-72. doi: 10.1016/j.amjsurg.2010.11.008.
https://doi.org/10.1016/j.amjsurg.2010.1...
.

A specific checklist for anastomoses training may contribute to performance evaluation1616 Reznick R, Regehr G, MacRae H, Martin J, McCulloch W. Testing technical skill via an innovative "bench station" examination. Am J Surg. 1997 Mar;173(3):226-30. doi: 10.1016/S0002-9610(97)89597-9.
https://doi.org/10.1016/S0002-9610(97)89...
. Some important items that should be included in the Checklist of a particular surgery can be obtained while viewing common technical errors of expert surgeons and beginners. These are important items that should be included in a Checklist to evaluate a suture: needle positioning and conduction, tissue handling and damage, similar distance between stitches, continuous suture flow, wire manipulation, surgical nodes quality, and the use of both hands2222 Guni S, Raison N, Challacombe B, Khan S, Dasgupta P, Ahmed K. Development of a technical checklist for the assessment of suturing in robotic surgery. Surg Endoscop. 2018 Sep;32:4402-7. doi: 10.1007/s00464-018-6407-6.
https://doi.org/10.1007/s00464-018-6407-...
.

A laparoscopic stitch training and surgical nodes used a Checklist to evaluate the proficiency acquisition. The checklist was composed by the following items: distance between knots (5 to 7 mm), Tissue margins (4 to 5 mm), Symmetry of the edges of knots and Adequate Knot tension. Another variable analyzed was the knots amount in 18 minutes. This teaching model was able to show the evolution in the learning curve2323 Ferreira Filho F, Moura Júnior LG, Rocha HA, Rocha SG, Ferreira LF, Ferreira AF. Abdominal cavity simulator for skill progression in videolaparoscopic sutures in Brazil. Acta Cir Bras. 2018 Jan;33(1):75-85. doi: 10.1590/s0102-865020180010000008.
https://doi.org/10.1590/s0102-8650201800...
.

Technical competence can be assessed by creating specialist scales that are based on the degree of support that residents need during a particular stage of the surgical procedure. For example, a score of 1 can be established for the need for total support of the expert surgeon, score 5 when there is safety in performing the procedure without any kind of help, and score 6 for the cases where the procedure was performed perfectly2424 Miskovic D, Wyles SM, Carter F, Coleman MG, Hanna GB. Development, validation and implementation of a monitoring tool for training in laparoscopic colorectal surgery in the English National Training Program. Surg Endosc. 2011 Apr;25(4):1136-42. doi: 10.1007/s00464-010-1329-y.
https://doi.org/10.1007/s00464-010-1329-...
.

Brazilian surgeons have created a questionnaire to evaluate the learning of general surgery residents during their training. Four questions were asked for eleven different types of operations. The questions were related to knowledge of the anatomy, operative technique and surgical ability2525 Santos EG, Salles GF. Construction and validation of a surgical skills assessment tool for general surgery residency program. Rev Col Bras Cir. 2015 Jul;42(6):407-12. doi: 10.1590/0100-69912015006010.
https://doi.org/10.1590/0100-69912015006...
. A questionnaire with several items related to a training curriculum can be used to evaluate satisfaction with a specific training program2626 Pinheiro EFM, Barreira MA, Moura Junior LG, Mesquita CJG, Silveira RAD. Simulated training of a laparoscopic vesicourethral anastomosis. Acta Cir Bras. 2018 Aug;33(8):713-22. doi: 10.1590/s0102-865020180080000007.
https://doi.org/10.1590/s0102-8650201800...
.

A study analyzed a suture training in ex vivo pig’s stomach and registered through Motion analysis metrics the evolution in the development of the proposed task. The time of execution and the length of the path traveled by laparoscopic instruments should be used in the evaluation of movements in a laparoscopic suture exercise. Therefore, the analysis of movements is effective as a method for objective evaluation of psychomotor skills in laparoscopic suture. However, this method does not take into account the quality of the suture2727 Sánchez-Margallo JA, Sánchez-Margallo FM, Oropesa I, Enciso S, Gómez EJ. Objective assessment based on motion-related metrics and technical performance in laparoscopic suturing. Int J Comput Assist Radiol Surg. 2017 Feb;12(2):307-14. doi: 10.1007/s11548-016-1459-3.
https://doi.org/10.1007/s11548-016-1459-...
. An effective method for assessing the progression of psychomotor skills during the manufacture of an intestinal anastomosis employed internal measurements of air pressure and image processing during the training of 53 surgeons. In the analysis of the prepared anastomosis, the following criteria were used: volumes of air pressure leak, numbers of full-thickness sutures, suture tensions, areas of wound-opening and performance times. The system used seems to be useful in assessing the progression of skills in laparoscopic suture2828 Uemura M, Yamashita M, Tomikawa M, Obata S, Souzaki R, Leiri S, Ohuchida K, Matsuoka N, Katayama T, Hashizume M. Objective assessment of the suture ligature method for the laparoscopic intestinal anastomosis model using a new computerized system. Surg Endosc. 2015 Feb;29(2):444-52. doi: 10.1007/s00464-014-3681-9.
https://doi.org/10.1007/s00464-014-3681-...
.

A simulated training program in laparoscopic anastomosis selected twelve residents of surgical specialties who attended 4 weeks during one year (20 hours per week) to perform the proposed task. There was an average of 15.8 enteroanastomoses per resident and 16.4 gastroenteroanastomoses per resident. The time to perform the anastomoses reduced as time passed by and reached the plateau after 70 hours of training. Some of the criteria used to evaluate the quality of anastomoses were: anastomosis leak test after hydrostatic test with saline solution and adequate suture tension. There was a lack of an evaluation tool to systematize the exercise and to evaluate in more detail the evolution of the technique and quality of the anastomosis2929 Rodríguez-Sanjuán JC, Manuel-Palazuelos C, Fernández-Díez MJ, Gutiérrez-Cabezas JM, Alonso-Martín J, Redondo-Figuero C, Herrera-Norenã LA, Gómez-Fleitas M. Assessment of resident training in laparoscopic surgery based on a digestive system anastomosis model in the laboratory. Cir Esp. 2010 Jan;87(1):20-5. doi: 10.1016/j.ciresp.2009.08.003.
https://doi.org/10.1016/j.ciresp.2009.08...
.

Some tips to assist the evaluation of surgical performance are: choosing the right evaluation tools, using generic and specific evaluation scales, observation during training should be prioritized, avoiding evaluator bias, evaluator training, using the most evaluations and possible advisers, prioritize formative evaluation in relation to summative, and finally, monitor and report the experiences and results3030 Strandbygaard J, Scheele F, Sorensen JL. Twelve tips for assessing surgical performance and use of technical assessment scales. Med Teach. 2017 Jan;39(1):32-7. doi: 10.1080/0142159X.2016.1231911.
https://doi.org/10.1080/0142159X.2016.12...
.

In controlled environments the variance across predictive measurements is likely to be low, and therefore R2 values can be expected to lie in the 0.8 range. In clinical studies, however, R2 values vary widely depending on the nature of the analysis. For example, when comparing associating surgical technical factors, values of R2 are reported in the 0.2 to 0.4 range3131 Hamilton DF, Ghert M, Simpson AH. Interpreting regression models in clinical outcome studies. Bone Joint Res. 2015 Sep;4(9):152-3. doi: 10.1302/2046-3758.49.2000571.
https://doi.org/10.1302/2046-3758.49.200...
. It was evident that during the training the time for making anastomoses and the increase in Checklist scores had a high correlation index and a statistically significant result. It is important to introduce this assessment tool into a structured training curriculum. Simulated training of a gastroenterostomy can be performed with good results when using a black box, silk threads, good quality tweezers and synthetic organs3232 Barreira MA, Rocha HA, Mesquita CJ, Borges GC. Desenvolvimento de um currículo para treinamento simulado de uma anastomose laparoscópica. Rev Bras Educ Med. 2017 July;41(3):424-31. doi: 10.1590/1981-52712015v41n3rb20160106.
https://doi.org/10.1590/1981-52712015v41...
.

Conclusion

The proposed Checklist can be used to evaluate the performance and systematization of simulated training aimed at making a gastrostomy.

References

  • 1
    Nácul MP, Cavazzola LT, Melo MC. Current status of residency training in laparoscopic surgery in Brazil: a critical review. Arq Bras Cir Dig. 2015 Dec;28(1):81-5. doi: 10.1590/S0102-67202015000100020.
    » https://doi.org/10.1590/S0102-67202015000100020
  • 2
    Kockerling F, Pass M, Brunner P, Hafermalz M, Grund S, Sauer J, Lange V, Schroder W. Simulation-based training - evaluation of the course concept "laparoscopic surgery curriculum" by the participants. Front Surg. 2016 Aug;3:47. doi: 10.3389/fsurg.2016.00047.
    » https://doi.org/10.3389/fsurg.2016.00047
  • 3
    Beyer-Berjot, L, Palter V, Grantcharov T, Aggarwal R. Advanced training in laparoscopic abdominal surgery: a systematic review. Surgery. 2014 Sep;156(3):676-88. doi: 10.1016/j.surg.2014.04.044.
    » https://doi.org/10.1016/j.surg.2014.04.044
  • 4
    Cristancho SM, Moussa F, Dubrowski A. A framework-based approach to designing simulation-augmented surgical education and training programs. Am J Surg. 2011 Sep;202(3):344-51. doi: 10.1016/j.amjsurg.2011.02.011.
    » https://doi.org/10.1016/j.amjsurg.2011.02.011
  • 5
    Zevin B, Levy JS, Satava RM, Grantcharov TP. A consensus-based framework for design, validation, and implementation of simulation-basedtraining curricula in surgery. J Am Coll Surg. 2012 Oct;215(4):580-6.e3. doi: 10.1016/j.jamcollsurg.2012.05.035.
    » https://doi.org/10.1016/j.jamcollsurg.2012.05.035
  • 6
    Singh P, Aggarwal R, Pucher PH, Duisberg AL, Arora, Darzi A. Defining quality in surgical training: perceptions of the profession. Am J Surg. 2014 Apr;207(4):628-36. doi: 10.1016/j.amjsurg.2013.07.044.
    » https://doi.org/10.1016/j.amjsurg.2013.07.044
  • 7
    Louridas M, Szasz P, de Mintbrun S, Harris KA, Grantcharov TP. International assessment practices along the continuum of surgical training. Am J Surg. 2016 Aug;212(2):354-60. doi: 10.1016/j.amjsurg.2015.12.017.
    » https://doi.org/10.1016/j.amjsurg.2015.12.017
  • 8
    Duran CA, Shames M, Bismuth J, Lee JT. Validated assessment tool paves the way for standardized evaluation of trainees on anastomotic models. Ann Vasc Surg. 2014 Jan;28(1):115-21. doi: 10.1016/j.avsg.2013.07.005.
    » https://doi.org/10.1016/j.avsg.2013.07.005
  • 9
    Barreira MA, Siveira DG, Rocha HA, Moura-Junior LG, Mesquita CJ, Borges GC. Model for simulated training of laparoscopic gastroenterostomy. Acta Cir Bras. 2017 Jan;32(1):81-9. doi: 10.1590/s0102-865020170110.
    » https://doi.org/10.1590/s0102-865020170110
  • 10
    Szasz P, Louridas M, Harris KA, Aggarwal R, Grantcharov P. Assessing technical competence in surgical trainees: a systematic review. Ann Surg. 2015 Jun;261(6):1046-55. doi: 10.1097/SLA.0000000000000866.
    » https://doi.org/10.1097/SLA.0000000000000866
  • 11
    Shackelford S, Bowyer M. Modern metrics for evaluating surgical technical skills. Curr Surg Rep. 2017 Aug;5(24):1-10. doi: 10.1007/s40137-017-0187-0.
    » https://doi.org/10.1007/s40137-017-0187-0
  • 12
    Martin JA, Regehr G, Reznick R, MacRae H, Murnaghan J, Hutchison C, Brown M. Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg. 1997 Feb;84(2):273-8. doi: 10.1046/j.1365-2168.1997.02502.x.
    » https://doi.org/10.1046/j.1365-2168.1997.02502.x
  • 13
    Denadai R, Saad-Hossne R, Todelo AP, Kirylko L, Souto LR. Low-fidelity bench models for basic surgical skills training during undergraduate medical education. Rev Col Bras Cir. 2014 Mar-Apr;41(2):137-45. doi: 10.1590/S0100-69912014000200012.
    » https://doi.org/10.1590/S0100-69912014000200012
  • 14
    Hopmans CJ, den Hoed PT, van der Laan L, van der Harst E, van der Elst M, Mannaerts GH, Dawson I, Timman R, Wijnhoven BP, Ijzermans JN. Assessment of surgery residents› operative skills in the operating theater using a modified Objective Structured Assessment of Technical Skills (OSATS): a prospective multicenter study. Surgery. 2014 Nov;156(5):1078-88. doi: 10.1016/j.surg.2014.04.052.
    » https://doi.org/10.1016/j.surg.2014.04.052
  • 15
    Chang OH, Kinq LP, Modest AM, Hur HC. Developing an objective structured assessment of technical skills for laparoscopic suturing and intracorporeal knot tying. J Surg Educ. 2016 Mar-Apr;73(2):258-63. doi: 10.1016/j.jsurg.2015.10.006.
    » https://doi.org/10.1016/j.jsurg.2015.10.006
  • 16
    Reznick R, Regehr G, MacRae H, Martin J, McCulloch W. Testing technical skill via an innovative "bench station" examination. Am J Surg. 1997 Mar;173(3):226-30. doi: 10.1016/S0002-9610(97)89597-9.
    » https://doi.org/10.1016/S0002-9610(97)89597-9
  • 17
    D´Angelo AL, Cohen ER, Kwan C, Laufer S, Greenberg C, Greenberg J, Wiegmann D, Pugh CM. Use of decision based simulations to assess resident readiness for operative independence. Am J Surg. 2015 Jan;209(1):132-9. doi: 10.1016/j.amjsurg.2014.10.002.
    » https://doi.org/10.1016/j.amjsurg.2014.10.002
  • 18
    Vassiliou MC, Feldman LS, Andrew CG, Bergman S, Leffondré K, Stanbridge D, Fried GM. A global assessment tool for evaluation of intraoperative laparoscopic skills. Am J Surg. 2005 Jul;190(1):107-13. doi: 10.1016/j.amjsurg.2005.04.004.
    » https://doi.org/10.1016/j.amjsurg.2005.04.004
  • 19
    Wolf R, Medici M, Fiard G, Long JA, Moreau-Gaudry A, Cinquin P, Voros S. Comparison of the goals and MISTELS scores for the evaluation of surgeons on training benches. Int J Comput Assist Radiol Surg. 2018 Jan;13(1):95-103. doi: 10.1007/s11548-017-1645-y.
    » https://doi.org/10.1007/s11548-017-1645-y
  • 20
    Vassiliou MC, Ghitulescu GA, Feldman LS, Stanbridge D, Leffondré K, Sigman HH, Fried GM. The MISTELS program to measure technical skill in laparoscopic surgery : evidence for reliability. Surg Endosc. 2006 May;20(5):744-7. doi: 10.1007/s00464-005-3008-y.
    » https://doi.org/10.1007/s00464-005-3008-y
  • 21
    Beyer L, Troyer JD, Mancini J, Bladou F, Berdah SV, Karsenty G: Impact of laparoscopy simulator training on the technical skills of future surgeons in the operating room: a prospective study. Am J Surg. 2011 Sep;202(3):265-72. doi: 10.1016/j.amjsurg.2010.11.008.
    » https://doi.org/10.1016/j.amjsurg.2010.11.008
  • 22
    Guni S, Raison N, Challacombe B, Khan S, Dasgupta P, Ahmed K. Development of a technical checklist for the assessment of suturing in robotic surgery. Surg Endoscop. 2018 Sep;32:4402-7. doi: 10.1007/s00464-018-6407-6.
    » https://doi.org/10.1007/s00464-018-6407-6
  • 23
    Ferreira Filho F, Moura Júnior LG, Rocha HA, Rocha SG, Ferreira LF, Ferreira AF. Abdominal cavity simulator for skill progression in videolaparoscopic sutures in Brazil. Acta Cir Bras. 2018 Jan;33(1):75-85. doi: 10.1590/s0102-865020180010000008.
    » https://doi.org/10.1590/s0102-865020180010000008
  • 24
    Miskovic D, Wyles SM, Carter F, Coleman MG, Hanna GB. Development, validation and implementation of a monitoring tool for training in laparoscopic colorectal surgery in the English National Training Program. Surg Endosc. 2011 Apr;25(4):1136-42. doi: 10.1007/s00464-010-1329-y.
    » https://doi.org/10.1007/s00464-010-1329-y
  • 25
    Santos EG, Salles GF. Construction and validation of a surgical skills assessment tool for general surgery residency program. Rev Col Bras Cir. 2015 Jul;42(6):407-12. doi: 10.1590/0100-69912015006010.
    » https://doi.org/10.1590/0100-69912015006010
  • 26
    Pinheiro EFM, Barreira MA, Moura Junior LG, Mesquita CJG, Silveira RAD. Simulated training of a laparoscopic vesicourethral anastomosis. Acta Cir Bras. 2018 Aug;33(8):713-22. doi: 10.1590/s0102-865020180080000007.
    » https://doi.org/10.1590/s0102-865020180080000007
  • 27
    Sánchez-Margallo JA, Sánchez-Margallo FM, Oropesa I, Enciso S, Gómez EJ. Objective assessment based on motion-related metrics and technical performance in laparoscopic suturing. Int J Comput Assist Radiol Surg. 2017 Feb;12(2):307-14. doi: 10.1007/s11548-016-1459-3.
    » https://doi.org/10.1007/s11548-016-1459-3
  • 28
    Uemura M, Yamashita M, Tomikawa M, Obata S, Souzaki R, Leiri S, Ohuchida K, Matsuoka N, Katayama T, Hashizume M. Objective assessment of the suture ligature method for the laparoscopic intestinal anastomosis model using a new computerized system. Surg Endosc. 2015 Feb;29(2):444-52. doi: 10.1007/s00464-014-3681-9.
    » https://doi.org/10.1007/s00464-014-3681-9
  • 29
    Rodríguez-Sanjuán JC, Manuel-Palazuelos C, Fernández-Díez MJ, Gutiérrez-Cabezas JM, Alonso-Martín J, Redondo-Figuero C, Herrera-Norenã LA, Gómez-Fleitas M. Assessment of resident training in laparoscopic surgery based on a digestive system anastomosis model in the laboratory. Cir Esp. 2010 Jan;87(1):20-5. doi: 10.1016/j.ciresp.2009.08.003.
    » https://doi.org/10.1016/j.ciresp.2009.08.003
  • 30
    Strandbygaard J, Scheele F, Sorensen JL. Twelve tips for assessing surgical performance and use of technical assessment scales. Med Teach. 2017 Jan;39(1):32-7. doi: 10.1080/0142159X.2016.1231911.
    » https://doi.org/10.1080/0142159X.2016.1231911
  • 31
    Hamilton DF, Ghert M, Simpson AH. Interpreting regression models in clinical outcome studies. Bone Joint Res. 2015 Sep;4(9):152-3. doi: 10.1302/2046-3758.49.2000571.
    » https://doi.org/10.1302/2046-3758.49.2000571
  • 32
    Barreira MA, Rocha HA, Mesquita CJ, Borges GC. Desenvolvimento de um currículo para treinamento simulado de uma anastomose laparoscópica. Rev Bras Educ Med. 2017 July;41(3):424-31. doi: 10.1590/1981-52712015v41n3rb20160106.
    » https://doi.org/10.1590/1981-52712015v41n3rb20160106

  • Financial source:

    none

  • 1
    Research performed at Laboratory of Surgical Skills, Centro Universitário Christus (UNICHRISTUS), Fortaleza-CE, Brazil. Part of Master degree thesis, Postgraduate Program in Minimally Invasive Technology and Health Simulation. Tutor: Gleydson Cesar de Oliveira Borges.

Publication Dates

  • Publication in this collection
    2019

History

  • Received
    28 Nov 2018
  • Reviewed
    26 Jan 2019
  • Accepted
    23 Feb 2019
Sociedade Brasileira para o Desenvolvimento da Pesquisa em Cirurgia Al. Rio Claro, 179/141, 01332-010 São Paulo SP Brazil, Tel./Fax: +55 11 3287-8814 - São Paulo - SP - Brazil
E-mail: sgolden@terra.com.br