Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.
Department of Clinical Medicine, University of Bergen, Bergen, Norway.
BJS Open. 2022 May 2;6(3). doi: 10.1093/bjsopen/zrac071.
Surgical training is aimed towards entrusted professional activity to obtain operative independence. Laparoscopic appendicectomy is performed early in training but except for simulators, real-life evaluation towards proficiency is scarce. The aim of this study was to model how each consecutive step may impact on the overall proficiency score for surgical trainees performing laparoscopic appendicectomy.
This was an observational cohort study of laparoscopic appendicectomy performed by junior trainees (PGY1-4) under supervision and evaluated for each of eight steps. Each step was scored on a validated six-point performance scale and classified as 'fail', 'pass', or 'proficient'. Modelling was conducted with a multivariable regression model and artificial neural network model with a multilayer perceptron for the relationship between steps and overall performance.
Of 157 procedures, 97 (61.8 per cent) procedures were evaluated as 'proficient', 46 (29.3 per cent) were 'pass', and 14 (8.9 per cent) were 'fail'. In regression analyses, handling the mesoappendix was significantly associated with procedure proficiency, as were division of appendix, access to abdomen, and ability to handle the small bowel. The widest variation in operative flow was shown for steps involving mesoappendix and division of appendix, conceptualized in 'ebb-and-flow' and 'string-of-pearls' models. Sensitivity analyses for experience using 20 or fewer, 30 or fewer, or more than 30 procedures as cut-offs reproduced comparable results.
Consistent stumbling blocks for junior trainees performing laparoscopic appendectomies can be conceptualized through novel models that identify steps deemed to be the most difficult to trainees with variable experience.
外科培训旨在进行受托的专业活动，以获得手术独立性。腹腔镜阑尾切除术在培训早期进行，但除了模拟器之外，针对熟练程度的实际评估很少。本研究的目的是建立模型，以了解外科受训者进行腹腔镜阑尾切除术时，每个连续步骤如何影响整体熟练程度评分。
这是一项对初级受训者（PGY1-4）进行腹腔镜阑尾切除术的观察性队列研究，对每个手术的 8 个步骤进行评估。每个步骤均根据经过验证的 6 分绩效量表进行评分，并分为“失败”、“通过”或“熟练”。使用多变量回归模型和具有多层感知器的人工神经网络模型对步骤与整体绩效之间的关系进行建模。
在 157 例手术中，97 例（61.8%）被评估为“熟练”，46 例（29.3%）为“通过”，14 例（8.9%）为“失败”。在回归分析中，处理阑尾系膜与手术熟练程度显著相关，阑尾的分离、腹部进入和处理小肠的能力也是如此。涉及阑尾系膜和阑尾分离的步骤在手术流程中变化最大，被概念化为“潮起潮落”和“珍珠串”模型。使用 20 次或更少、30 次或更少或超过 30 次手术作为截止值进行的敏感性分析产生了类似的结果。
通过新颖的模型，可以将初级受训者进行腹腔镜阑尾切除术时遇到的一致障碍概念化，这些模型可以确定被认为是最具挑战性的步骤，并且根据受训者的经验不同，这些步骤也有所不同。
