Development of an Evidence-Based Training Curriculum and Assessment Tool for Laparoscopic Appendicectomy Surgery

Abstract

The existing paradigm of many surgical training programs continue to follow a timebased apprenticeship model where learning occurs serendipitously in the clinical environment. Recently, there have been several drivers for a change in this pedagogical ideology to one that is competency-based. These include concerns regarding the effect of training on patient safety and health economics, the implementation of work-hour restrictions, the advent of minimally invasive surgery and increase in post-training fellow appointments, which have all served to reduce the learning opportunities for surgical trainees. Thus, additional methods of training and assessing operative skills are required to bridge this gap. Not only has simulation-based training been demonstrated to improve technical skills, but the skills acquired have also been shown to be transferable to the operating theatre. Virtual reality simulators can do this through a high-fidelity, standardised and reproducible environment with the ability to deliver immediate objective feedback on performance. Feedback within the operating theatre is possible through the use of objective assessment tools that allow quantitative evaluations of operative performance. These can be used to identify weaknesses for deliberate practice. The laparoscopic appendicectomy (LA) is one of the most common emergency procedures conducted. Although frequently performed by trainees, LA is associated with a significant learning curve of between 20 to 30 cases, and often provides trainees with their first experiences of laparoscopic surgery. Despite this, little research in training and assessing skills for LA has been previously conducted. This thesis had two main aims. The first was to develop a proficiency-based technical skills training curriculum for LA surgery using a high-fidelity VR simulator. The second aim was to develop an evidence-based objective procedure-specific evaluation tool designed to assess technical performance during LA surgery. Prior to this, the need for such training and assessment tools was determined and used to guide their development by investigating the practice patterns of LA surgery in Australia. A population-based study demonstrated that there was a rapid increase in the utilisation of LA surgery in New South Wales between 2000 and 2010. This provided the initial evidence for the need for a method of training and assessing skills in LA surgery. Further evidence for this need was shown in a retrospective study of the practice patterns of LA surgery within a single tertiary centre, which found that surgical trainees had limited and selective learning opportunities, as well as longer operating times than experts. A survey of all General surgery trainees in Australia suggested that a proportion of these trainees had performed unsupervised LA surgery whilst still being on the documented learning curve. This has important implications regarding patient safety and further suggested a need for tools to train and assess skills in LA surgery. The most frequently used techniques and instruments were elicited from the surveyed trainees to guide the development of these tools. The first internationally applicable proficiency-based VR simulation curriculum to train technical skills in LA surgery was developed after demonstrating the face, content and construct validity of the LA modules on the LAP MentorTM VR simulator and obtaining benchmarks of expert performance. A Delphi methodology was then used to attain expert consensus regarding the steps and descriptors of “poor”, “average” and “excellent” performance at each of these steps. These were used to develop the first multiinstitutionally derived procedure-specific evaluation tool for LA surgery. This tool was then demonstrated to have high inter-rater and test-retest reliability, as well as construct and concurrent validity when objectively assessing intra-operative performance during LA surgery. The educational tools developed in this thesis not only bridges the gap created by the increasingly limited learning opportunities, but also provides an avenue for competency-based surgical training. Through the training of skills to proficiency using the curriculum developed in this thesis, surgical trainees can enter the operating theatre as a ‘pre-trained novice’ with an attenuated learning curve. They would then be ready to undergo supervised training in actual LA surgery with continual objective assessment and feedback using the procedure-specific evaluation tool we developed. This would allow a cycle of training and assessment, where specific strengths and weaknesses can be identified, practiced deliberately and re-assessed for improvement, until a defined level of competence in LA surgery is attained. Such a paradigm would represent a shift in the ideology of surgical training to one that focuses on the demonstration of competence and proficiency and, above all else, the optimisation of patient safety.