Training to proficiency in surgery using simulation: is there a moral obligation?

A deontological approach to surgical ethics advocates that patients have the right to receive the best care that can be provided. The ‘learning curve’ in surgical skill is an observable and measurable phenomenon. Surgical training may therefore carry risk to patients. This can occur directly, through inadvertent harm, or indirectly through theatre inefficiency and associated costs. Trainee surgeon operating, however, is necessary from a utilitarian perspective, with potential risk balanced by the greater societal need to train future independent surgeons.New technology means that the surgical learning curve could take place, at least in part, outside of the operating theatre. Simulation-based deliberate practice could be used to obtain a predetermined level of proficiency in a safe environment, followed by simulation-based assessment of operative competence. Such an approach would require an overhaul of the current training paradigm and significant investment in simulator technology. This may increasingly be viewed as necessary in light of well-discussed pressures on surgical trainees and trainers.This article discusses the obligations to trainees, trainers and training bodies raised by simulation technology, and outlines the current arguments both against and in favour of a simulation-based training-to-proficiency model in surgery. The significant changes to the current training paradigm that would be required to implement such a model are also discussed.

Learning curve of trainees performing laparoscopic appendectomy- a register-based study

Background Appendectomy is one of the first procedures that surgical trainees are expected to manage alone. The purpose of this study was to analyse the learning curve of a cohort of surgical trainees and to explore the association between trainee surgeon volume and complication rate. Method The study was based on a cohort extracted from the local appendectomy register at Södersjukhuset (transl. South Hospital), Stockholm. The register includes patient characteristics, surgical method, operation time, and 30-day complications. First-year surgical trainees attending the hospital’s trainee programme were included and followed over five years of training. Trainees who had performed less than ten procedures during the period of the study were excluded. The learning curve was described using moving average of order ten for each trainee, studying the trend in operation time with increasing volume. The cumulative sum technique was used to chart changes in complication rates of the trainees. Results 586 procedures performed by 9 surgical trainees were included, of which 97.6% were performed laparoscopically. A plateau in operation time on the learning curve was reached at 60 procedures. For three of the trainees, the 30-day complication rate decreased after completing the learning curve, whereas for two others it increased. In a multivariate analysis, operation times differed more between the trainees than it did between procedures performed early or late in the programme. Shortest versus longest mean operation time (41 min versus 89 min). Conclusion At least 60 procedures are required to reach sufficient proficiency in appendectomy. This highlights the importance of meticulous selection of surgical trainees, structure of training programmes, feedback, and assessment.

537 Implications of Covid-19 on Vitreoretinal and Cataract Surgery

Introduction The coronavirus pandemic (COVID-19) has greatly impacted ophthalmic surgery, including changes to surgical protocols and training. We explored the effects on vitreoretinal and cataract surgeries, which constitute the commonest areas of ophthalmic surgery. Method Literature searches were performed for the terms “vitreoretinal”, and “cataract”, each in combination with “surgery” and “Covid-19”. Relevant results were assessed to determine perceived impact on ophthalmic theatres. Results 36 search results were analysed; 25 and 11 for cataract and vitreoretinal surgery respectively. Efforts to reduce infection rates have significantly reduced non-urgent operations, with reports of just 5.7% of ophthalmologists in certain areas performing cataract surgeries. Furthermore, surgeons have been advised to perform bilateral cataract surgery, and to combine phacoemulsification with vitreoretinal surgery, thereby avoiding deferred operations and further exposure. Other recommended changes in surgical strategies to enhance safety include three-dimensional heads-up displays for vitreoretinal surgeries, novel microscope drapes, and virtual consultations for surgery follow-up. Various reports indicate a negative impact on junior surgeon training and mental well-being; indeed, The Royal College of Ophthalmology has recommended assigning operations to experienced surgeons. Conclusions Ophthalmic surgery rates and protocols have been impacted in the effort to reduce Covid-19 spread. Trainee surgeon education and well-being warrant further attention.

408 Hand Trauma Consent

Background Consenting patients for procedures is a regular process for a trainee surgeon. The process of consent has come under scrutiny in recent years due to inadequacies highlighted by legal cases. With over 1.36 million patients attending A&E per year with hand trauma, this is the most common acute referral to Plastic surgeons. Aim To review current local practice by auditing risks and complications from hand trauma consent forms. To develop and implement a standardised pre-printed label including relevant risks and complications for hand trauma. Method Sample of hand trauma related consent forms audited assessing and comparing the risks and complications sections to a standardised set agreed locally by Consultant Plastic surgeons, cross referenced with literature. Standardised label including relevant risks and complications put into practice then re-audit their use. Results Use of the new standardised label demonstrated an elimination of omissions and increased adherence to 100% for all the relevant risks and complications. Conclusions Significant improvements in the process of consent were achieved through the development and implementation of a standardised risk and complications label. This ensures standards from the GMC and RCS guidelines are satisfied; positively impacting on service provision by improving the quality of the consent process.

The learning curve for endoscopic tympanoplasties: a single-institution experience, in Birmingham, UK

ObjectiveThis study aimed to assess whether increasing operative experience results in better surgical outcomes in endoscopic middle-ear surgery.MethodsA retrospective single-institution cohort study was performed. Patients underwent endoscopic tympanoplasty between May 2013 and April 2019 performed by the senior surgeon or a trainee surgeon under direct supervision from the senior surgeon. Following data collection, statistical analysis compared success rates between early (learning curve) surgical procedures and later (experienced) tympanoplasties.ResultsIn total, 157 patients (86 male, 71 female), with a mean age of 41.6 years, were included. The patients were followed up for an average of 43.2 weeks. The overall primary closure rate was 90.0 per cent.ConclusionThis study demonstrates an early learning curve for endoscopic ear surgery that improves with surgical experience. Adoption of the endoscopic technique did not impair the success rates of tympanoplasty.

Training surgeons and the informed consent discussion in paediatric patients: a qualitative study examining trainee participation disclosure

BackgroundThe process of obtaining informed consent is an important and complex pursuit, especially within a paediatric setting. Medical governing bodies have stated that the role of the trainee surgeon must be explained to patients and their families during the consent process. Despite this, attitudes and practices of surgeons and their trainees regarding disclosure of the trainee’s participation during the consent process has not been reported in the paediatric setting.MethodsNineteen face-to-face interviews were conducted with surgical trainees and staff surgeons at a tertiary-level paediatric hospital in Toronto, Canada. These were transcribed and subsequently thematically coded by three reviewers.ResultsFive main themes were identified from the interviews. (1) Surgeons do not consistently disclose the role of surgical trainees to parents. (2) Surgical trainees are purposefully vague in disclosing their role during the consent discussion without being misleading. (3) Surgeons and surgical trainees believe parents do not fully understand the specific role of surgical trainees. (4) Graduated responsibility is an important aspect of training surgeons. (5) Surgeons feel a responsibility towards both their patients and their trainees. Surgeons do not explicitly inform patients about trainees, believing there is a lack of understanding of the training process. Trainees believe families likely underestimate their role and keep information purposely vague to reduce anxiety.ConclusionThe majority of surgeons and surgical trainees do not voluntarily disclose the degree of trainee participation in surgery during the informed consent discussion with parents. An open and honest discussion should occur, allowing for parents to make an informed decision regarding their child’s care. Further patient education regarding trainees’ roles would help develop a more thorough and patient-centred informed consent process.

Tom Chapman and the Glasgow Punch

Thomas Lightbody Chapman (1903 – 1966) founded the urological department at the Victoria Infirmary, Glasgow. After travelling to the Mayo Clinic in America to learn the new technique of punch prostatectomy he brought that procedure back to Glasgow. The prostatic punch required skill to master but could be successful in the right hands. Chapman was a great teacher who used innovative techniques to educate his students in the skills of punch prostatectomy. These included a training model where the trainee surgeon could be observed punching out a phantom prostate and a cine-film using both live action and animation to demonstrate the technique. Keen to share his enthusiasm for the punch prostatectomy he organized a meeting of like-minded urologists, a group which became the Punch Club, a travelling urology club still active today. Tom Chapman was a colourful and dynamic individual, devoted to his work and his patients. His name will be remembered as being almost synonymous with the punch prostatectomy in Great Britain.