It’s a widely accepted adage that practice makes perfect. In today's surgical environment, the ability given to residents and attending alike to improve their proficiency outside of the OR is a critical addition to their practice. Technical proficiency is not something to be achieved later in a surgeon’s tenure - rather, it is an integral factor in helping to improve patient safety and surgical outcomes today.

Although real-world experience is still gained in the operating room (OR), today’s surgeons can also take advantage of new technologies to enhance their proficiency beyond the OR. This article will first look at the relationship between technical skill and post-operative outcomes through several scientific publications and then present digital tools aimed at helping surgeons improve their surgical proficiency.

Study 1

Surgical Skill and Complication Rates After Bariatric Surgery[1]

This milestone study, with over 1,000 citations, published in the New England Journal of Medicine, investigated whether variation in clinical outcomes for patients was due to the technical skill of the surgeon or other external factors. 20 surgeons submitted videos of laparoscopic gastric bypass operations, which were anonymously assessed by a minimum of 10 peer surgeons. The technical skills of each surgeon were analyzed against complication rates and patient outcomes.

Results

Surgeons with high technical skills (top-quartile assessment score) were associated with shorter operating times, lower complication rates, lower rates of readmission to the hospital, less need for re-operation, lower mortality, and fewer visits to the emergency department compared to surgeons with lower technical skills (bottom-quartile assessment score). The study also suggests that peer assessment by video can provide a reliable indicator of a surgeon’s technical proficiency.

Study 2

Avoiding Surgical Skill Decay: A Systematic Review on the Spacing of Training Sessions[2]

This well-cited systematic review was conducted to confirm if spaced repetition of training improves long-term retention of surgical skills among medical students and surgical trainees compared to intensive training in a single prolonged session. From an initial search of 1,955 articles, 11 were selected and analyzed. The group sizes in each study varied from 16 to 145 participants and the time intervals between spaced training sessions varied from five minutes to 2.5 months. 

Results

Students who practiced under spaced repetition conditions gained better practical skills and had better long-term retention scores than students who learned intensively in just one session. There was no set definition of long or short intervals, and the times were different in each of the 11 studies. This suggests that the advantage of spaced repetition can be realized using different time intervals, giving trainers the freedom and flexibility to choose how long trainees wait between sessions. The results of this systematic review also suggest that students benefit from longer spacing between skill training sessions irrespective of the level of complexity.

Study 3

Dimensional Virtual Reality Models for Surgical Planning of Robotic-Assisted Partial Nephrectomy on Surgical Outcomes[3]

After a first publication by Van Cleynenbreugel, et al.[4] this is the second comparative study by Shirk, et al. demonstrating an impact of 3D reconstruction on clinical outcomes. The purpose of this trial was to assess the effect of pre-operative review of reconstructed 3D images on surgical patient outcomes. A single-blind randomized clinical trial was performed in which 92 patients had robotic-assisted partial-nephrectomies performed at 1 of 6 hospitals by 1 of 11 surgeons. 48 patients were randomly assigned to a conventional pre-operative CT/MRI scans group, while 44 patients were assigned to a 3D virtual reality (VR) group. For the patients in the 3D VR group, the surgeons were provided both pre-operative CT/MRI scans and 3D VR imaging.

Results

The patients in the 3D VR group had shorter operative times, a reduction in blood loss, a shorter clamp tissue ischaemia time, and a shorter hospital stay compared to the conventional group. These results suggest that the use of 3D VR imaging can be a useful tool in improving patient outcomes.

New tools to increase surgical proficiency among trainees

These studies show clear links between improved patient outcomes and factors such as technical skill, spaced training sessions, and the use of 3D imaging. How can surgeons and surgical trainers capitalize on emerging tools to achieve these benefits?

Today’s residency programs recognize that teaching or showing a trainee a procedure or skill is only the first step in surgical advancement; trainees must be given opportunities to build on the technical skills developed in the OR. And although trainees can attend courses, read books and journals, and gain postgraduate qualifications, new medical technologies designed to support the trainee in developing their surgical proficiency are emerging.

Online Peer-Reviewed Video Platforms

Video review platforms are giving surgeons and trainees options for peer feedback and video-based assessment, like the C-SATS™ product. Surgeons can upload their surgical videos and receive constructive, qualitative feedback as well as crowd-sourced quantitative review of their surgical technique. Additional AI-driven features can provide information about surgical proficiency and trends over time.

The creators of C-SATS product are not the only group of doctors who recognize the value of video review. Video-based review is the preferred method of surgical learning for many healthcare professionals.

Robotic Simulation

The use of robotic surgery is becoming more widespread, and many machines come with a simulation mode that allows the surgeon and their assistant to practice the surgery in advance of the actual patient procedure.[5]

Roger Kneebone’s research into simulators has suggested that more clinical time should be reserved for simulation training for medical students and surgical trainees. Simulation has multiple benefits: the option for repeated practice, feedback using objective measures of performance, and the assurance of a clinical environment where novices and trainees of all grades can practice a skill or participate in a simulated clinical scenario in a realistic setting.[6]

Robotic surgery in general offers technical advantages such as greater range of movement, haptic feedback, better visualization of the operating field, precision movements for complex surgeries—and opportunities for enhanced surgical training.[7] Some surgical robots can now be programmed to study human gestures, assess technical skills, and give feedback as part of a surgical training program.[8] While incorporating feedback from robots into surgical training is not yet a widely established practice, its use may well increase in the future.

3D and Virtual Reality Modeling for Better Pre-operative Planning

3D modeling and virtual reality tools bring a host of benefits for surgeons performing laparoscopic and robotic procedures. One such tool, ETHICON™ 3D Pre-operative Planning powered by Visible Patient, S.a.S., uses a patient’s CT or MRI images to create interactive 3D models for organs such as lung, liver, colon, and kidney to more holistically formulate their surgical plan and approach. The VP PLANNING™ product also gives surgeons the ability to use a resection simulation tool to pre-operatively visualize different segment resection scenarios of the kidney, liver, or lung and compute approximations of resection volumes and remaining tissue.

With 3D and VR modeling associated with improved patient outcomes[3], these tools can prove invaluable to surgeons looking to advance their proficiency.

The relationship between technical skill and post-operative outcomes is substantiated through the results of several scientific articles. Spaced repetition teaching methods tailored to trainees has been shown to be more beneficial than older methods. Digital tools, such as 3D and VR modeling and secure video-sharing and assessment platforms, are gaining the attention of tenured surgeons and trainees alike. While they could be considered disruptive to some, these technologies have been shown to potentially improve patient outcomes. Their use is likely to continue to expand, and ideally someday in the not-too-distant future become increasingly mainstream. More research is required so these emerging technologies can be better understood and better used to allow surgeons and their patients to benefit.