The case for surgical skills centres in Sub Saharan Africa: The benefits and the challenges.

The purpose of this paper is to describe the educational and practice utilities of establishing Surgical Skills Centres. The paper also defines significant obstacles to the establishment of such centres in Sub- Saharan Africa. In 1996, the Royal College of Physicians and Surgeons Canada responded to the evolving roles and obligations of medical specialists by implementing a framework of core competencies called the “CanMEDS Roles” which define surgeons as medical experts, communicators, collaborators, managers, health advocates, scholars and professionals. A key competency expected of the medical expert is the demonstration of proficiency in procedural skills2

Superior mesenteric artery clinical classification and morphometrical analysis

Background: The superior mesenteric artery is one of the most important arteries in the abdominal cavity, which is of great clinical importance, especially in surgical procedures and fatal ischemic complications. The aim of this study was to develop a clinical classification of the superior mesenteric artery. Materials and methods: Postmortem contrast-enhanced computed tomography of 104 (29.8% female, age 50.7±18.7) human bodies were analyzed. Based on anatomic predisposition to ischemic and iatrogenic complications, a three-tiered clinical classification of the superior mesenteric artery was developed. Type 0 was defined as standard risk for ischemic and iatrogenic complications. Type 1 was defined as increased thromboembolic risk with decreased risk of iatrogenic bleeding, and type 2 was defined as decreased ischemic risk with increased risk of iatrogenic bleeding. The supply area of the superior mesenteric artery was divided into 4 regions: pancreas, caecum, ascending colon, and transverse colon. Results: Type 0 (standard risk) was found in 62.5% of cases. Type 1 was most frequently observed in the ascending colon region (15.4%). Type 2 was most frequently observed in the pancreatic region (17.3%). Regarding type, most abnormalities were found in the region of the ascending colon (18.3%), pancreas region (17.3%), and transverse colon (16.3%). Conclusions: The proposed clinical classification of SMA links anatomic variations in morphology with their clinical significance. A simple, three-level classification can be easily applied in daily practice and serve as a great support for preoperative evaluation and recognition of patients at risk of iatrogenic or thromboembolic complications

56. Proficiency at the end of practice predicts retention of a technical clinical skills

A debate is emerging regarding the efficacy of proficiency based versus duration based training of technical skills. It is not clear whether the performance level attained at the end of practice (i.e., proficiency criteria), or the overall amount of practice performed during learning will best predict the retention of a technical clinical skill. The skill learned was the single-handed double square-knot. Forty two trainees learned the skill through video-based instruction and were divided into three groups (14 participants per group) each with a specific criterion time to tie the knot (10, 15, and 20 seconds). Practice continued until participants completed the knot within their criterion time. The total number of trials, and the overall practice time required to obtain each respective criterion were recorded during practice. Participants returned one-week later for a timed retention test consisting of one trial of the knot tying skill with no video instruction. A multiple regression analysis tested whether the amount of practice, the total practice time, or the criterion reached at the end of practice was the best predictor of the time taken to perform the skill during retention. This analysis showed that the number of practice trials was highly correlated with total practice time (r = .82, p = .01), therefore total practice time was withdrawn as a predictor variable from the subsequent analysis. The regression showed that the only significant predictor of retention performance was the criterion reached at the end of practice (p = .03). The number of practice trials was not found to significantly predict the retention performance (p = .87). The results support the notion that proficiency based training results in better retention of a technical clinical skill in comparison to duration based approaches. This provides evidence for the introduction of proficiency based educational approaches in technical skills curricula. Jowett N, LeBlanc V, Xeroulis G, MacRae H, Dubrowski A. Surgical skill acquisition with self-directed practice using computer-based video training. Am J Surg. 2007; 193(2):237-42. Gallagher AG, Ritter EM, Champion H, Higgins G, Fried MP, Moses G, Smith CD, Satava RM. Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training. Ann Surg. 2005; 241(2):364-72. Van Sickle KR, Ritter EM, McClusky DA, Lederman A, Baghai M, Gallagher AG, Smith CD. Attempted establishment of proficiency levels for laparoscopic performance on a national scale using simulation: the results from the 2004 SAGES Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) learning center study. Surg Endosc. 2007; 21(1):5-10

55. Simulation based training of technical surgical skills: A review of a five-year collaborative research program supported by the RCPSC Medical Education Funds

During the past five years, with support from the RCPSC, a collaborative group of researchers conducted projects investigating issues related to simulation based training of technical surgical skills. The aim of this presentation is to review the body of work generated, its significance, and outline future research plans. In all studies, participants were medical students and residents from 3 medical schools in Ontario. First, we successfully demonstrated that trainees benefit from simulation-based practice by improving their ability to multitask. This ability not only increases technical proficiency, but also results in an enhanced ability to learn other aspects of surgery. Second, we showed that the adaptation of learning theories helps in optimizing training curricula by matching the fidelity of a simulator to the trainees’ level of expertise. Third, we provided validation of both expert and computer based methods for assessment. We showed that computer based assessments are sufficient for the evaluation of trainees learning fundamental skills, while expert based measures are more effective in the evaluation of performance on complex technical skills. Finally we demonstrated that examination-induced stress has a facilitating effect on trainees’ skills performance. This body of research lends support for the inclusion of a simulation based approach to training technical skills. It also highlights the importance of the choice of assessment methods. Collectively this work highlights the need for further research in the optimization of training methods by the incorporation of learning theory into the existing training curricula. Related to this, further research in our laboratory will investigate the effects of practice schedule and expert feedback, as well as the role of self-regulated practice in the acquisition of technical surgical skills. Xeroulis GJ, Park J, Moulton CA, Reznick RK, Leblanc V, Dubrowski A. Teaching suturing and knot-tying skills to medical students: a randomized controlled study comparing computer-based video instruction and (concurrent and summary) expert feedback. Surgery 2007; 141(4):442-9. Brydges R, Sidhu R, Park J, Dubrowski A. Construct validity of computer-assisted assessment: quantification of movement processes during a vascular anastomosis on a live porcine model. Am J Surg. 2007; 193(4):523-9. Brydges R, Carnahan H, Backstein D, Dubrowski A. Application of motor learning principles to complex surgical tasks: searching for the optimal practice schedule. J Mot Behav. 2007; 39(1):40-8