Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif 94305, USA.
J Thorac Cardiovasc Surg. 2011 Jan;141(1):107-12. doi: 10.1016/j.jtcvs.2010.08.059. Epub 2010 Nov 11.
Limited exposure and visualization and technical complexity have affected resident training in mitral valve surgery. We propose simulation-based learning to improve skill acquisition in mitral valve surgery.
After reviewing instructional video recordings of mitral annuloplasty in porcine and plastic models, 11 residents (6 integrated and 5 traditional) performed porcine model mitral annuloplasty. Video-recorded performance was reviewed by attending surgeon providing audio formative feedback superimposed on video recordings; recordings were returned to residents for review. After 3-week practice with plastic model, residents repeated porcine model mitral annuloplasty. Performance assessments initially (prefeedback) and at 3 weeks (postfeedback) were based on review of video recordings on 5-point rating scale (5, good; 3, average; 1, poor) of 11 components. Ratings were averaged for composite score.
Time to completion improved from mean 31 ± 9 minutes to 25 ± 6 minutes after 3-week practice (P = .03). At 3 weeks, improvement in technical components was achieved by all residents, with prefeedback scores varying from 2.4 ± 0.6 for needle angles to 3.0 ± 0.5 for depth of bites and postfeedback scores of 3.1 ± 0.8 for tissue handling to 3.6 ± 0.8 for suture management and tension (P ≤ .001). Interrater reliability was greater than 0.8. In this sample, composite scores of first-year integrated and traditional residents were lower than those of senior level residents; comparatively, third-year integrated residents demonstrated good technical proficiency.
Simulation-based learning with formative feedback results in overall improved performance of simulated mitral annuloplasty. In complex surgical procedures, simulation may provide necessary early graduated training and practice. Importantly, a "passing" grade can be established for proficiency-based advancement.
接触机会有限、可视化效果不佳以及技术复杂等因素均会对住院医师在二尖瓣手术中的培训效果产生影响。我们拟采用基于模拟的学习方法来提高二尖瓣手术的技能获取。
在回顾二尖瓣环成形术的猪模型和塑料模型教学视频记录后，11 名住院医师（6 名综合培训住院医师和 5 名传统培训住院医师）完成了猪模型二尖瓣环成形术。手术视频由主刀医生进行评估，主刀医生会提供叠加在视频上的音频形成性反馈，之后将视频记录返还给住院医师以供复习。在使用塑料模型进行 3 周练习后，住院医师重复进行猪模型二尖瓣环成形术。在初次评估（预反馈）和 3 周后（反馈后），通过对 5 分制（5 分表示优秀，3 分表示一般，1 分表示较差）的 11 项评分标准（5 项评分分别为缝线角度、缝线深度、组织处理、缝合管理和张力）对视频记录进行评估，计算综合评分。
完成时间从平均 31 ± 9 分钟缩短至 3 周练习后的 25 ± 6 分钟（P =.03）。经过 3 周的练习，所有住院医师的技术操作评分均得到了提高，预反馈评分从缝线角度的 2.4 ± 0.6 分提高到组织处理的 3.1 ± 0.8 分，反馈后评分从缝线深度的 3.0 ± 0.5 分提高到缝合管理和张力的 3.6 ± 0.8 分（P ≤.001）。评分者间的可信度大于 0.8。在本样本中，一年级综合培训住院医师和传统培训住院医师的综合评分低于高级别住院医师；相比之下，三年级综合培训住院医师表现出了良好的技术熟练程度。
基于模拟的学习并结合形成性反馈可整体提高模拟二尖瓣环成形术的操作表现。在复杂的手术中，模拟可能为住院医师提供必要的早期分级培训和实践。重要的是，基于熟练程度可以建立“通过”标准。
