Cole Simon J, Mackenzie Hugh, Ha Joon, Hanna George B, Miskovic Danilo
Department of Surgery and Cancer, Imperial College London, London, UK.
Surg Endosc. 2014 Mar;28(3):979-86. doi: 10.1007/s00464-013-3265-0. Epub 2013 Nov 7.
The effect of coaching on surgical quality and understanding in simulated training remains unknown. The aim of this study was compare the effects of structured coaching and autodidactic training in simulated laparoscopic surgery.
Seventeen surgically naive medical students were randomized into two groups: eight were placed into an intervention group and received structured coaching, and nine were placed into a control group and received no training. They each performed 10 laparoscopic cholecystectomies on a virtual reality simulator. The surgical quality of the first, fifth, and 10th operations was evaluated by 2 independent blinded assessors using the Competency Assessment Tool (CAT) for cholecystectomy. Understanding of operative strategy was tested before the first, fifth, and 10th operation. Performance metrics, path length, total number of movements, operating time, and error frequency were evaluated. The groups were compared by the Mann-Whitney U test. Proficiency gain curves were plotted using curve fit and CUSUM models; change point analysis was performed by multiple Wilcoxon signed rank analyses.
The intervention group scored significantly higher on the CAT assessment of procedures 1, 5, and 10, with increasing disparity. They also performed better in the knowledge test at procedures 5 and 10, again with an increasing difference. The learning curve for error frequency of the intervention group reached competency after operation 7, whereas the control group did not plateau by procedure 10. The learning curves of both groups for path length and number movements were almost identical; the mean operation time was shorter for the control group.
Clinically relevant markers of proficiency including error reduction, understanding of surgical strategy, and surgical quality are significantly improved with structured coaching. Path length and number of movements representing merely manual skills are developed with task repetition rather than influenced by coaching. Structured coaching may represent a key component in the acquisition of procedural skills.
在模拟训练中，指导对手术质量和理解的影响尚不清楚。本研究的目的是比较结构化指导和自主学习训练在模拟腹腔镜手术中的效果。
17名无手术经验的医学生被随机分为两组：8名被分到干预组，接受结构化指导；9名被分到对照组，不接受任何训练。他们每人在虚拟现实模拟器上进行10次腹腔镜胆囊切除术。由2名独立的盲法评估者使用胆囊切除术能力评估工具（CAT）对第1、5和10次手术的手术质量进行评估。在第1、5和10次手术前测试对手术策略的理解。评估性能指标、路径长度、总动作数、手术时间和错误频率。采用曼-惠特尼U检验对两组进行比较。使用曲线拟合和累积和模型绘制熟练度增益曲线；通过多次威尔科克森符号秩分析进行变点分析。
干预组在第1、5和10次手术的CAT评估中得分显著更高，且差距越来越大。他们在第5和10次手术的知识测试中也表现得更好，差异同样越来越大。干预组错误频率的学习曲线在第7次手术后达到胜任水平，而对照组在第10次手术时仍未达到平稳状态。两组路径长度和动作数的学习曲线几乎相同；对照组的平均手术时间更短。
结构化指导能显著提高包括减少错误、理解手术策略和手术质量等临床相关的熟练度指标。仅代表手工技能的路径长度和动作数通过任务重复得到提高，而非受指导影响。结构化指导可能是获得操作技能的关键组成部分。
