Friday, June 19, 2015

Can surgical skills labs be effective for orthopedic residents? A positive example

Effectiveness of a Microvascular Surgery Training Curriculum for Orthopaedic Surgery Residents

The authors devised a microvascular training curriculum that began with learning the basics of microvascular surgery on nonliving models and progressed to performing end-to-end arterial anastomoses on a live rat femoral artery in the second session. Outcomes included a Global Rating Scale score (GRS), achievement of patency, and time to completion. The GRS assessed the resident’s respect for the surrounding tissue, time and motion, efficiency with and use of microsurgical instruments, performance of the anastomosis, and vessel patency. Patency was judged with use of the milking patency test, performed by using two jeweler’s forceps just distal to the anastomosis site. These were used to milk the blood out of the vessel, and immediate expansion of the empty vessel after the proximal forceps were released was indicative of a patent vessel. Timing of the anastomosis began at the initiation of the first stitch and ended with the completion of tying the last stitch. 

All residents significantly improved (p < 0.005) on Global Rating Scale scores. Of the twelve residents, patency was achieved by eleven at the final evaluation, compared with six before training. Time to completion of the anastomosis also improved significantly (p < 0.005).

Comment: There are many skills that surgeons need to acquire and, for many of these, the operating room is not the best place to acquire them.  On the other hand, many 'skills labs' such as the use of plastic bone models to teach prosthetic arthroplasty, do little to simulate the challenges encountered in real surgery.  

This study is a sound example of the evaluation of the use of a skills lab to help residents learn to perform an end to end arterial anastomosis of a transected live rat femoral artery - a vessel with  the size and feel of a human digital artery. As the authors point out, an arterial anastomosis is a surgical skill that is challenging to master because of the residents' variable clinical exposure to microsurgery, the premium of operating from time, and the steep learning curve requiring practice. 

What makes this study strong is it's use of a well-characterized, clinically analogous model with clear endpoints to test a robustly evaluatable hypothesis.  


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