Surgical Endoscopy https://doi.org/10.1007/s00464-017-5992-0
and Other Interventional Techniques
Video review program enhances resident training in laparoscopic inguinal hernia: a randomized blinded controlled trial Ryota Tanaka1,2 · Francis DeAsis1 · Yalini Vigneswaran1 · John Linn1 · JoAnn Carbray1 · Woody Denham1 · Stephen Haggerty1 · Michael Ujiki1 Received: 17 April 2017 / Accepted: 2 December 2017 © Springer Science+Business Media, LLC, part of Springer Nature 2017
Abstract Background The purpose was to determine if a standardized video review program for residents improves operative performance. Methods Participation was offered to surgical residents rotating on a minimally invasive service. Residents were randomized to either the video review group or no video review group. Every participant in the video review group underwent video reviews with an attending surgeon for 30 min once weekly during their 1-month rotation. A blinded surgeon evaluated performance in the operating room using validated assessment tools. The amount of time the resident spent as primary surgeon was recorded. One-way analysis of variance was used to compare the video and no video review groups. Differences were considered statistically significant for p values < 0.05. Results Sixteen residents were randomized to the video review group (n = 8) or the no video review group (n = 8). Residents in the video review cohort significantly improved in creating a working space (p = 0.04), hernia sac reduction (p = 0.01), mesh placement (p = 0.01), knowledge of the procedure (p = 0.01), and overall competence (p = 0.02). Residents in the no video review group did not significantly improve in five of seven categories. The video review group significantly increased the time spent as primary surgeon (p = 0.02). Conclusion Video review with a coach proved to be beneficial for residents when learning laparoscopic inguinal hernia repairs. We conclude that systematic video review is a good supplemental tool in resident surgical training. Keywords Video review · Surgical education · Laparoscopic inguinal hernia Gaining surgical competence is a complex, multifactorial process that may take years of experience and on-the-job training. For educators, it is critical to provide suitable Poster presentation, Society of American Gastrointestinal and Endoscopic Surgeons, April 2015 meeting, Nashville, TN.
opportunities to learn the necessary knowledge, judgment, and skills, often in a short amount of time. Few would argue that finding ways to maximize training opportunities is a priority in this day and age. As time constraints in surgical education increase, a new emphasis will be placed on
* Michael Ujiki
[email protected]
Woody Denham
[email protected]
Ryota Tanaka t‑
[email protected]
Stephen Haggerty
[email protected]
Francis DeAsis
[email protected]
1
Department of Surgery, Section of Minimally Invasive Surgery, NorthShore University HealthSystem, 2650 Ridge Ave, Evanston, IL 60201, USA
2
Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
Yalini Vigneswaran
[email protected] John Linn
[email protected] JoAnn Carbray
[email protected]
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educational interventions that facilitate time efficient learning. We hypothesized that trainee review of their own videos of recent cases, with an experienced attending surgeon, would result in more rapid technical skill improvement. Using videotape review to enhance performance is not a new concept. Since the 1960s, video review has been used in several institutions to improve surgical technique, etc [1, 2]. Previous research suggests that video reviews are superior to the classic “see one, do one, teach one” system introduced by Halsted a century ago [3]. Some investigators have reported video review programs to be an effective educational intervention [4, 5]. Scherer et al. [6] reported that videotape review improved the performance of residents during algorithm-driven resuscitation of trauma patients. However, there is scant evidence on videotape reviews of one’s own operation in laparoscopic surgical resident training. Thus, the purpose of this study was to determine if a standardized video review program for surgical residents could improve clinical performance in the operating room (OR).
Methods Participation was offered to surgical residents at all postgraduate years (PGY1–PGY5) of training rotating on the minimally invasive surgery (MIS) service at our institution (NorthShore University HealthSystem, Evanston, IL, USA). There are six residents per PGY year within the program. This study was approved by the institutional review board (IRB) in our institution. After signing an informed consent, surgical residents were randomized into either the video review group or no video review group by a research coordinator using a computer generated randomization program. Residents were excluded from participation if they were unable to rotate for at least 4 weeks of the rotation with the participating attending surgeons. All participants filled out demographics forms and procedure-specific confidence surveys with 5-point Likert scales (total 25 points) before being evaluated during laparoscopic inguinal hernia repairs (LIHRs) in the OR. To assess performance, we used the Global Operative Assessment of Laparoscopic Skills-Groin Hernia (GOALS-GH) and visual analog scales (VAS) published by Kurashima et al. [7]. These assessments were completed at the end of each operation (LIHRs) by both the blinded attending surgeon evaluator (trained observer) and the resident (self evaluation). GOALS-GH is a fiveitem validated global rating scale used to evaluate the steps of LIHR (placement of trocars, creating peritoneal flap or creating and working in preperitoneal space, identification and resection of hernia sac, positioning and fixation of mesh, knowledge of anatomy and flow procedure). VAS were used to grade the difficulty of each
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case as well as the resident’s overall competency for each case. Confidence surveys were completed again at the end of each participant’s rotation. Residents were allowed to progress during a totally extraperitoneal LIHR and then subsequently evaluated by the attending blinded to the trainee’s group. Both groups received intra-operative education of the procedure from the attending surgeon that included description of the steps of the procedure, “watch and learn” after take over by the attending, and verbal coaching of the resident while they were the primary surgeon. The no video group received no more education from the attending outside of the OR. Videos for review (without audio) were recorded for every case and stored on a protected hard drive in a secure location without patient identifiers. Every participant in the video review group underwent video reviews of their own cases with a different attending surgeon for 30 min once a week during their 1-month rotation. Due to time constraints, fast-forwarding [8] was used when necessary to maximize efficiency. During each session, participants reviewed the steps of the case using the GOALS-GH form to facilitate the session. The attending coach and resident focused their review on trocar placement, creating and working in the preperitoneal space, instrumentation and handling, identification and dissection of the hernia sac, introduction and positioning of the mesh, and knowledge of the anatomy and procedure flow. The total GOALS-GH scores for each group were statistically analyzed using one-way ANOVA on scores gathered at three different time points: first 10 days of their rotation (“beginning”), the last 10 days of their rotation (“ending”), and middle (between the beginning and the ending). The GOALSGH scores, VAS sheets, and operation records (operative time, complication, and time of resident participation as primary surgeon, etc.) were also statistically compared between the beginning and the end within each group. The OR time was considered to be the time from skin incision to skin closure. Hernia size was measured with laparoscopic graspers. Cases with bilateral inguinal hernia repairs were excluded in our analysis. The primary measured outcome was the comparison between the first and last GOALS-GH scores. Secondary outcomes measured included VAS of competence, total OR time, and resident as primary surgeon time. Categorical variables in demographic data and confidence scores were analyzed using t test for comparison among the two groups. The differences were considered to be statistically significant if the p value was < 0.05. We hypothesized a 75% improvement in ending GOALS scores in the video group and a 50% improvement in the no video group. All statistical analyses were performed using SPSS 19.0 (IBM, Chicago, IL, USA).
Surgical Endoscopy
Results A total of 16 residents were randomized to either the video review group (n = 8) or the no video review group (n = 8). The participant demographics for each group are shown in Table 1 and there were no statistically significant differences among groups. Video game experience was measured due to previous studies showing improvement in laparoscopic skills in those with more experience [9]. The answer to the question of experience with LIHR was based on resident recall. Participants in the video review group showed statistically significant score improvement at the end of the month in four of the five items on GOALS-GH, as well as the total GOALS-GH score (p = 0.01, Fig. 1), and VAS competency score (p = 0.02) (Table 2). In contrast, only two of the five items (trocar and mesh) significantly improved in the no video review group (Table 2). The total GOALS-GH score at the end of the rotation was significantly better in the group that performed video review compared to the group that did
Table 1 Participant demographics on each group Variable
No video
Video
Participants (n) 8 8 PGY level, n (%) PGY1 1 (13) 0 PGY2 1 (13) 0 PGY3 0 1 (13) PGY4 1 (13) 5 (63) PGY5 5 (63) 2 (25) Sex, n (%) Male 3 (38) 4 (50) Female 5 (63) 4 (50) 30.4 ± 2.9 31.3 ± 1.6 Agea Handedness, n (%) Right 6 (75) 8 (100) Left 2 (25) 0 171.1 ± 10.1 169.8 ± 6.5 Height (cm)a Video game history, n (%) Never 1 (13) 4 (50) Past 6 (75) 3 (38) Present 1 (13) 1 (13) LIHR experience as primary before the study, n (%) None 2 (25) 3 (38) 1–5 3 (38) 1 (13) 6–25 3 (38) 3 (38) 26–50 0 1 (13) 9.3 ± 3.7 Number of LIHR experi- 8.5 ± 3.0 ence during the s tudya LIHR laparoscopic inguinal hernia repair a
Mean ± SD
p value
0.13
0.22 0.47 0.16 0.75 0.22
0.37
0.66
Fig. 1 Comparison of the no video and the video review groups in GOALS-GH total score on each period. Circles on lines are mean scores in the video review group. Triangles on broken lines are mean scores in the no video review group
not (21.0 ± 5.6 vs 14.8 ± 5.2, p = 0.018). There was no difference found in the difficulty of the cases between the two groups (Table 2). The video review group had a significant increase in the amount of time they spent as primary surgeon (less takeover) without significant change in the overall operative time (Table 3; p = 0.02). Residents in the video review group also reported higher confidence scores, though it did not reach significance (Fig. 2; pre vs post, p = 0.07).
Discussion Video can be thought of as an effective means of illustrating and teaching surgical technique. It is already used extensively for technical demonstrations at national conferences, as well as for surgical trainees’ skills assessment. Some investigators have reported positive results using video to improve the skills of residents and attendings for conventional surgery [4, 5]. On the other hand, skill acquisition may be more difficult for laparoscopic surgery than for conventional surgery, because laparoscopic surgery has altered depth perception, diminished tactile feedback, and limited range of motion. Nakada et al. [5] applied the “golf school” concept of video mentoring to teach urologists advanced laparoscopic techniques during a 2-day course. They reasoned that surgeons could use video to improve their technique in the same way a golfer might use video to improve their swing. In fact, they did show that urologists can improve select laparoscopic skills on a pelvic trainer
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Table 2 Performance of the laparoscopic inguinal hernia repair in video and no video groups Scale
GOALS-GH score on each item Trocar Creating and working in space Hernia sac Mesh Knowledge anatomy and procedure GOALS-GH total score VAS score Overall competence (cm) Degree of difficulty (cm)
No video
Video
Rotation start
Rotation end
p value
Rotation start
Rotation end
p value
3.1 2.4 1.6 1.9 2.2 11.1
4.0 2.5 2.3 3.1 2.9 14.8
0.04 0.86 0.18 0.01 0.07 0.09
3.6 2.9 2.0 2.6 2.7 13.7
4.6 4.2 3.8 4.3 4.1 21.0
0.08 0.04 0.01 0.01 0.01 0.01
2.2 2.1
4.5 2.0
0.06 0.84
3.7 2.5
7.5 2.7
0.02 0.82
Beginning the first 10 days of their rotations, Ending the last 10 days of their rotations. Data are presented as mean GOALS-GH global operative assessment of laparoscopic skills-groin hernia, VAS visual analog scales Table 3 Operative characteristics of the laparoscopic inguinal hernia repair in video and no video groups Item
TEP repairs without bilateral case (n) Operative time (min)a Time of resident participation as primary (min)a Bleeding (ml)a Hernia type, n Direct Indirect Pantaloon Femoral Hernia size (cm)a Peritoneal defect, n (%)
No video
Video
Beginning
Ending
p value
Beginning
Ending
p value
15 42.0 13.7 5.5
12 47.6 20.8 1.3
0.33 0.05 0.03
9 38.1 13.4 4.7
9 34.1 27.6 1.4
0.51 0.02 0.28
9 5 1 0 2.4 1 (7)
3 7 2 0 1.8 4 (33)
3 6 0 0 1.7 2 (22)
3 4 1 1 1.9 0
0.21
0.19 0.16
0.09
0.67 0.16
TEP totally extraperitoneal Beginning the first 10 days of their rotations, ending the last 10 days of their rotations
a
Data are presented as mean
using expert-mentored videotape analysis [5]. In the last decade, many different surgical procedures with the widespread and rapid application of minimally invasive techniques have created challenges for resident training in educational curricula. In the study, the video review group showed significant improvement in creating the preperitoneal space, identifying and adequately reducing the hernia sac, and positioning and fixating the mesh. In addition, this group had significantly improved flow and knowledge of the anatomy at the end of 1 month of training with only 2 h (per month) total of video review with an attending. Choi et al. [10] estimated the learning curve for laparoscopic total extraperitoneal (TEP) inguinal hernia repair by retrospectively analyzing the medical records of patients. For a beginner surgeon, 60 cases were estimated for preventing
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unnecessary complications and shortening operative time. In this study, the video review group demonstrated statistically significant improvement in overall competence after 18 cases. In contrast, the group without video review showed no significant improvement after 27 cases. Therefore, the learning curve with adding a video review program appears to be shortened with the only cost being that of dedicated time from the attending and resident of 2 h in a month. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was analyzed for assessing trainee impact on OR time in common general surgical procedures [11] and LIHR [12]. The results of these studies demonstrated that attending physicians have shorter case completion times when compared with cases in which residents participated. In our study, OR
Surgical Endoscopy
educational tool that is time efficient and should be integrated into the training curriculum for surgical residents.
Compliance with ethical standards Disclosure Ryota Tanaka, Francis DeAsis, Yalini Vigneswaran, John Linn, JoAnn Carbray, Woody Denham, Stephen Haggerty, Michael Ujiki have no conflicts of interest or financial ties to disclose.
References
Fig. 2 Box and Whisker plots of total pre- and post-confidence survey scores from each group. The bands inside the Box are the median. Circles denote outliers
times in the video review group were significantly shorter than the no video review group at the end of the rotation (47.6 vs 34.1 min, p = 0.02). In addition, OR time with resident as primary surgeon in the video review cohort was statistically longer (p = 0.02). Therefore, video-based review could be highly practical, decreasing the inconvenience and risks associated with live intra-operative mentoring for resident educations [13–15]. We acknowledge that this study has several limitations. First, the resident population was relatively small due to the limitations of our resident rotation schedule. The differences between groups, however, appear significantly different enough that more power is unlikely to change the conclusion. Second, due to limitations in the number of faculty that could teach and blindly assess the residents in the OR, only one assessor was utilized in this study. Ideally, multiple blinded assessors could be used and show strong inter-rater reliability. Third, we were unable to test retention in this study due to the fact that most residents did not rotate back on the service at a later date in residency during the study. Lastly, the time of the academic year was not recorded and this could influence the results based on resident experience though we feel that through randomization and the fact that experience with laparoscopic hernia repair was not statistically different (Table 1) may control for that. Video review is beneficial for residents when learning LIHR, and it is likely that similar results will be seen if used with other procedures as well or learners as well. We conclude that systematic video review is a good supplemental
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