Department of Surgery, University of California, San Francisco.
Department of Surgery, University of Illinois at Chicago.
JAMA Netw Open. 2022 Sep 1;5(9):e2229787. doi: 10.1001/jamanetworkopen.2022.29787.
The increase in minimally invasive surgical procedures has eroded exposure of general surgery residents to open operations. High-fidelity simulation, together with deliberate instruction, is needed for advanced open surgical skill (AOSS) development.
To collect validity evidence for AOSS tools to support a shared model for instruction.
DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study included postresidency surgeons (PRSs) and second-year general surgery residents (R2s) at a single academic medical center who completed simulated tasks taught within the AOSS curriculum between June 1 and October 31, 2021.
The AOSS curriculum includes 6 fine-suture and needle handling tasks, including deep suture tying (with and without needles) and continuous suturing using the pitch-and-catch and push-push-pull techniques (both superficial and deep). Teaching and assessment are based on specific microskills using a 3-dimensional printed iliac fossa model.
The PRS group was timed and scored (5-point Likert scale) on 10 repetitions of each task. Six months after receiving instruction on the AOSS tasks, the R2 group was similarly timed and scored.
The PRS group included 14 surgeons (11 male [79%]; 8 [57%] attending surgeons) who completed the simulation; the R2 group, 9 surgeons (5 female [55%]) who completed the simulation. Score and time variability were greater for the R2s compared with the PRSs for all tasks. The R2s scored lower and took longer on (1) deep pitch-and-catch suturing (69% of maximum points for a mean [SD] of 142.0 [31.7] seconds vs 77% for a mean [SD] of 95.9 [29.4] seconds) and deep push-push-pull suturing (63% of maximum points for a mean [SD] of 284.0 [72.9] seconds vs 85% for a mean [SD] of 141.4 [29.1] seconds) relative to the corresponding superficial tasks; (2) suture tying with a needle vs suture tying without a needle (74% of maximum points for a mean [SD] of 64.6 [19.8] seconds vs 90% for a mean [SD] of 54.4 [15.6] seconds); and (3) the deep push-push-pull vs pitch-and-catch techniques (63% of maximum points for a mean [SD] of 284.0 [72.9] seconds vs 69% of maximum points for a mean [SD] of 142.0 [31.7] seconds). For the PRS group, time was negatively associated with score for the 3 hardest tasks: superficial push-push-pull (ρ = 0.60; P = .02), deep pitch-and-catch (ρ = 0.73; P = .003), and deep push-push-pull (ρ = 0.81; P < .001). For the R2 group, time was negatively associated with score for the 2 easiest tasks: suture tying without a needle (ρ = 0.78; P = .01) and superficial pitch-and-catch (ρ = 0.79; P = .01).
The findings of this cohort study offer validity evidence for a novel AOSS curriculum; reveal differential difficulty of tasks that can be attributed to specific microskills; and suggest that position on the surgical learning curve may dictate the association between competency and speed. Together these findings suggest specific, actionable opportunities to guide instruction of AOSS, including which microskills to focus on, when individual rehearsal vs guided instruction is more appropriate, and when to focus on speed.
微创手术数量的增加侵蚀了普通外科住院医师接触开放手术的机会。高级开放手术技能（AOSS）的发展需要高保真模拟和精心指导。
收集 AOSS 工具的有效性证据，以支持共享的教学模式。
设计、设置和参与者：这是一项前瞻性队列研究，纳入了一家学术医疗中心的住院后外科医生（PRS）和第二年普通外科住院医师（R2），他们在 2021 年 6 月 1 日至 10 月 31 日期间完成了 AOSS 课程中的模拟任务。
AOSS 课程包括 6 项精细缝线和针处理任务，包括深部缝线结扎（带针和不带针）以及使用 Pitch-and-Catch 和 Push-Push-Pull 技术进行连续缝合（均为浅层和深层）。教学和评估基于特定的微观技能，使用 3 维打印的髂嵴模型。
PRS 组在 10 次重复任务中的每个任务中都进行了计时和评分（5 分李克特量表）。接受 AOSS 任务指导 6 个月后，R2 组也进行了类似的计时和评分。
PRS 组包括 14 名外科医生（11 名男性[79%]；8 名[57%]主治医生）完成了模拟；R2 组包括 9 名外科医生（5 名女性[55%]）完成了模拟。与 PRS 相比，R2 的评分和时间变异性更大所有任务。R2 在以下方面的得分较低且耗时较长：（1）深部 Pitch-and-Catch 缝合（最高得分为 77%，平均[SD]为 95.9 [29.4]秒，而深部 Push-Push-Pull 缝合的得分为 63%，平均[SD]为 284.0 [72.9]秒）和深部 Push-Push-Pull 缝合（最高得分为 63%，平均[SD]为 284.0 [72.9]秒，而深部 Push-Push-Pull 缝合的得分为 63%，平均[SD]为 284.0 [72.9]秒）；（2）带针的缝线结扎与不带针的缝线结扎（最高得分为 74%，平均[SD]为 64.6 [19.8]秒，而不带针的缝线结扎的得分为 90%，平均[SD]为 54.4 [15.6]秒）；（3）深部 Push-Push-Pull 与 Pitch-and-Catch 技术（最高得分为 63%，平均[SD]为 284.0 [72.9]秒，而深部 Pitch-and-Catch 技术的得分为 69%，平均[SD]为 142.0 [31.7]秒）。对于 PRS 组，时间与 3 项最难任务的得分呈负相关：浅层 Push-Push-Pull（ρ=0.60；P=0.02）、深部 Pitch-and-Catch（ρ=0.73；P=0.003）和深部 Push-Push-Pull（ρ=0.81；P<0.001）。对于 R2 组，时间与 2 项最简单任务的得分呈负相关：无针缝线结扎（ρ=0.78；P=0.01）和浅层 Pitch-and-Catch（ρ=0.79；P=0.01）。
这项队列研究的结果为一项新的 AOSS 课程提供了有效性证据；揭示了任务的差异性难度，可以归因于特定的微观技能；并表明在外科学习曲线上的位置可能决定了能力和速度之间的关联。这些发现共同为 AOSS 的教学提供了具体的、可操作的机会，包括重点关注哪些微观技能、何时单独练习和何时接受指导以及何时关注速度。
