Residency training for minimally invasive surgery

ABSTRACT Objective: to develop a training program in minimally invasive surgery, based on simulation and with an emphasis on the acquisition of laparoscopic competences. Methods: this was a prospective, observational study carried out at a university hospital in Belo Horizonte, Brazil, between April 2020 and January 2021. We recruited residents of surgical specialties for structured, progressive training according to instructional principles to promote learning, such as motivation, activation, demonstration, application, and integration. We filmed the skill tests at the program’s beginning, middle, and end, which were then anonymously evaluated by a surgical education expert. Individual performances were scored using the global assessment tools “GOALS” and “specific checklist for suture”. At the end, all participants received individual feedback and completed a questionnaire to assess the impact of training on the Kirkpatrick model. Results: 43 residents completed the program. The evolution of performances was evident and grew between tests. The average achievements were 29% in the initial test, 43% in the intermediate test, and 88% in the final test, with significant differences between all mean scores, with H=97.59, GL=2, p<0.0001. The program evaluation and learning perceptions were excellent, but only 10.7% of residents felt fully capable of performing unsupervised, low-complexity laparoscopic surgery at the end of training. Conclusions: the training program developed in this study proved to be feasible and promising as a strategy for teaching laparoscopic surgery.


INTRODUCTION
A t the end of 2019, a new infectious disease called coronavirus disease 19 (COVID-19) was responsible for the onset of a pandemic that affected and continues to affect health systems worldwide in different ways.
There was a sudden increase in the demand for care and hospital beds, which overloaded these systems 1 .Thus, the effective functioning of essential health services was threatened due to the lower availability of resources (material, economic, and human) that were directed towards fighting the pandemic 2 .In moments of greatest upsurge of the pandemic, world health authorities recommended that elective operations be avoided, to reduce the care burden caused by the new coronavirus by reducing the exposure of medical teams and patients to potential contamination 2,3 .Such recommendations also directly impacted the teaching and training of new medical professionals, especially those inserted in medical residency programs in surgical specialties [4][5][6] .
Since the volume of operations in hospitals was drastically reduced, surgical education based on the Halstedian model was also compromised 7 .
Therefore, in this pandemic scenario, together with the steep learning curve in the acquisition of operative skills in laparoscopy, training of residents outside the operating room was even more recommended 8 .Teaching through simulation models develops familiarity with the handling of laparoscopic instruments, as well as cognitive and technical competences in minimally invasive operations 9 .
Specific training programs in minimally invasive operations are developed and discussed in the literature 10 .However, most of these programs emphasize skill acquisition rather than competency development.To fill this gap, the objective of

RESULTS
In the online module, there were 67 registered participants.In the face-to-face modules, of the 50 residents invited, 43 (86%) completed the laparoscopic training.Of the seven residents who did not participate in this second stage, three (6%) were infected with the new coronavirus and four (80%) did not respond to the invitation.Those with COVID-19 were trained later, after disease resolution, but were not included in the study.
Table 1 shows the participants' demographic profile.In The evaluation of the basic module was excellent for Test 3 (final).The performance improvement was evident during training (Figure 2A), with significant differences between all the average scores, being H=97.59;GL=2; p<0.0001 (Figure 2B).

Residency training for minimally invasive surgery
In the first stage, virtual remote teaching was responsible for supporting and motivating information.
Motivation is an active part of building knowledge.The learner is an integral part of this process and there is constant interaction between the new knowledge and the prior one.In this interaction, prior knowledge incorporates other meanings and is strengthened, and if it does not exist, it will be presented, which will allow its own interpretation of the content and attribution of meaning.
Competence is directly influenced by the context 18 .Thus, a specialist considered competent in a given operation may be considered a novice in another context.In this study residents of different As important as teaching to the learner is feedback 19 .Therefore, we used two tools that have been validated in the literature: the Specific Checklist for Suture and the GOALS 13,14 .The checklists and global scales are used for evaluation in different contexts, including simulation, each with advantages and disadvantages.
Although checklists reduce the subjectivity of evaluators, evidence suggests that they can result in information loss when compared to global scales 13,14 .Thus, the joint use of these two assessment tools contributed to results interpretation and verification.
The most used model for evaluating the impact of training is the Kirkpatrick one 15 .According to this model, the outcomes of the training program for this work were excellent and can be classified into four levels.The first level would be the reaction of the apprentice who fully approved the proposed program.
The second would be the learning itself, displaying a significant improvement after training in the apprentices' perception.The transfer of learning, with a clear evolution in the skills and knowledge, would be the third level, while in the fourth would be the performance results in real operations.These levels are traditionally presented in a hierarchical order where results depend on good results at each of the initial levels 15 . The this study was to develop a training program in minimally invasive surgery, based on simulation and with emphasis on the acquisition of laparoscopic competences.2020, maintaining all the precautions recommended for the prevention of COVID-19, such as social distancing, use of masks, and frequent cleaning with alcohol.These modules consisted of review of theorical issues, demonstration of videos of operations and situations requiring certain laparoscopic skills, and application of new knowledge in training laparoscopic practice with dry Lab simulators.This stage of the program was based on simulation and proficiency, with individualized and progressive training (the resident only advanced to the next exercise after reaching the goal of the previous exercise), in addition to the presence of a tutor to assist the learner in time of need (Just In Time information) 12 .The face-to-face modules (Basic and Endosuture, sequentially) were composed of eight exercises for the development of laparoscopic skills and the practices were distributed over two days, allowing a large number of repetitions (Figure 1).
This study demonstrates the feasibility of implementing a teaching strategy based on simulation and competences, complementing and providing continuity to training of residents in the principles of minimally invasive surgery during the pandemic.The unique moment of the pandemic brought numerous care challenges that significantly impacted the residents' training process.Just before social isolation, the Center for Surgical Training and Education had just been inaugurated at the university hospital to provide health professionals with acquisition and development of new surgical competences, in addition to the feedback on the deficiencies identified during operative procedures in simulated environments.The training sessions for this study were carried out at this center, meeting the imposed challenges.Many authors suggest that the most effective scenarios for competence development are those that are centered on a problem 16 .Based on these authors, Merrill (2002) elaborated five instructional principles to promote learning, which are: (a) Learning is promoted when learners are engaged in solving real-world problems; (b) Learning is promoted when existing knowledge is activated as a foundation for new knowledge; (c) Learning is promoted when new knowledge is demonstrated to the learner; (d) Learning is promoted when new knowledge is applied by the learner; and (e) Learning is promoted when new knowledge is integrated into the learner's world 17 .Another instructional design model is the 4C/ID 12 .This model has four components which are: (1) learning task, which is the problem to be solved; (2) supportive information, which is the theory to solve the problem; (3) Just-In-Time (JIT) information, which are guidelines on how to solve the problem at the exact moment the learner needs it; and (4) part-task practice, which is the repeated training of parts of the task until the problem is solved as a whole.In a way, all these instructional principles were included in the training program of the present study.

Figure 2 .
Figure 2. Evolution of residents&#39; performance during training by the difference in scores between diagnostic tests in three moments.A. evolution of performances (average scores) during training; B. differences between the average performance scores, 1: being the test before the Basic module.2: the test after the Basic module and before the Endosuture module.3: the final test, after the end of the Endosuture module.
specialties participated, and training was divided in Basic and Endosuture modules, in which the developed laparoscopic skills were needed in different surgical contexts.The selection preferably of residents of the last year is justified, as these will be those who will soon be on the front line of patient care.The wide variability among residents' experiences in laparoscopy demonstrated the need for individualized training to keep them motivated.The second stage of the program allowed the activation of knowledge and, consequently, a cognitive framework that could be improved throughout the training program.Possible contexts were incorporated at the time of demonstration, with the discussion of videos in different situations of minimally invasive procedures.The data from this study showed that the different simulated scenarios used with progressive complexity, and mainly repetitions, allowed the increasing improvement in the performance of the participants in the laparoscopic suture tests performed at the beginning, middle, and end of practical training (29%, 43%, and 88% correct answers, respectively).

Table 1 .
Demographic profile of training participants, description of residents' specialties, previous experience with the skill worked, and behavioral data.
The percentage averages and standard deviations (DP) of the residents' performance scores were, respectively, 29% (SD 3.4) in Test 1 (initial), 43% (SD 4.3) in Test 2 (intermediate), and 88% (SD 2.9) in 80.4% of the participants and very good for 19.6%, while the Endosuture module one was excellent for 85.7% and very good for 14.3%.