Current status of simulation training in plastic surgery residency programs: A review <s> INTRODUCTION <s> Our purposes were: 1) to establish the predictive validity of stereoscopic visual acuity and microsurgical performance, and 2) to establish the construct and concurrent validity of hand-motion analysis as an objective and sensitive measure of microsurgical performance. Using a surgical microscope, 50 surgical residents completed a standardized microsurgical suturing task at baseline and following microsurgical training. Microsurgical performance was evaluated by blinded, expert microsurgeons using global rating scales. Measures of stereoscopic visual acuity and hand-motion analysis were correlated with expert global rating scores. Global rating scores correlated significantly with number of hand movements (r = -0.47, P = 0.001) and hand-travel distance (r = -0.37, P = 0.008). Economy of hand-motion improved significantly following microsurgical training (number of hand movements, P = 0.046; hand-travel distance, P = 0.04). Measures of stereoscopic visual acuity did not correlate significantly with global rating scores. Hand-motion analysis appears to be an objective and sensitive instrument for assessing microsurgical performance, with evidence of both concurrent and construct validity. The predictive validity of stereoscopic visual acuity and microsurgical performance remains unclear. <s> BIB001 </s> Current status of simulation training in plastic surgery residency programs: A review <s> INTRODUCTION <s> ABSTRACT Purpose: We evaluated the durability of laboratory based technical skills training in urological microsurgery using bench model simulators. Methods and Materials: A total of 50 junior surgery residents (post-graduate years 1 to 3) were recruited to participate in a focused training program in urological microsurgery. Prior to training subjects were randomized to receive hands-on training with bench model simulators (silicone tubing or live rat vas deferens, 40) or didactic training alone (10). Four months following the original training program the technical performance of 18 returning subjects (13 from the bench model and 5 from the didactic training group) was reevaluated using a high fidelity, live animal model (vasovasostomy and rat vas deferens). Outcome measures included blinded, expert assessment of videotaped performance using checklists and global rating scores, and evaluation of anastomotic patency. Results: The retention test checklist (p Conclusions: Laboratory based technical skills training with bench models can lead to a significant retention of technical skill by novice surgeons. Measured performance improvements appear to be durable with time. However, the opportunity for repeat hands-on practice appears to maximize the retention of technical skill. <s> BIB002 </s> Current status of simulation training in plastic surgery residency programs: A review <s> INTRODUCTION <s> BACKGROUND ::: This study examined the impact of virtual reality (VR) surgical simulation on improvement of psychomotor skills relevant to the performance of laparoscopic cholecystectomy. ::: ::: ::: METHODS ::: Sixteen surgical trainees performed a laparoscopic cholecystectomy on patients in the operating room (OR). The participants were then randomized to receive VR training (ten repetitions of all six tasks on the Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR)) or no training. Subsequently, all subjects performed a further laparoscopic cholecystectomy in the OR. Both operative procedures were recorded on videotape, and assessed by two independent and blinded observers using predefined objective criteria. Time to complete the procedure, error score and economy of movement score were assessed during the laparoscopic procedure in the OR. ::: ::: ::: RESULTS ::: No differences in baseline variables were found between the two groups. Surgeons who received VR training performed laparoscopic cholecystectomy significantly faster than the control group (P=0.021). Furthermore, those who had VR training showed significantly greater improvement in error (P=0.003) and economy of movement (P=0.003) scores. ::: ::: ::: CONCLUSION ::: Surgeons who received VR simulator training showed significantly greater improvement in performance in the OR than those in the control group. VR surgical simulation is therefore a valid tool for training of laparoscopic psychomotor skills and could be incorporated into surgical training programmes. <s> BIB003 </s> Current status of simulation training in plastic surgery residency programs: A review <s> INTRODUCTION <s> SUMMARY Review date: 1969 to 2003, 34 years. Background and context: Simulations are now in widespread use in medical education and medical personnel evaluation. Outcomes research on the use and effectiveness of simulation technology in medical education is scattered, inconsistent and varies widely in methodological rigor and substantive focus. Objectives: Review and synthesize existing evidence in educational science that addresses the question, ‘What are the features and uses of high-fidelity medical simulations that lead to most effective learning?’. Search strategy: The search covered five literature databases (ERIC, MEDLINE, PsycINFO, Web of Science and Timelit) and employed 91 single search terms and concepts and their Boolean combinations. Hand searching, Internet searches and attention to the ‘grey literature’ were also used. The aim was to perform the most thorough literature search possible of peer-reviewed publications and reports in the unpublished literature that have been judged for academic quality. Inclusion and exclusion criteria: Four screening criteria were used to reduce the initial pool of 670 journal articles to a focused set of 109 studies: (a) elimination of review articles in favor of empirical studies; (b) use of a simulator as an educational assessment or intervention with learner outcomes measured quantitatively; (c) comparative research, either experimental or quasi-experimental; and (d) research that involves simulation as an educational intervention. Data extraction: Data were extracted systematically from the 109 eligible journal articles by independent coders. Each coder used a standardized data extraction protocol. Data synthesis: Qualitative data synthesis and tabular presentation of research methods and outcomes were used. Heterogeneity of research designs, educational interventions, outcome measures and timeframe precluded data synthesis using meta-analysis. Headline results: Coding accuracy for features of the journal articles is high. The extant quality of the published research is generally weak. The weight of the best available evidence suggests that high-fidelity medical simulations facilitate learning under the right conditions. These include the following: <s> BIB004 </s> Current status of simulation training in plastic surgery residency programs: A review <s> INTRODUCTION <s> BACKGROUND ::: Although there is growing evidence that practice on bench model simulators can improve the acquisition of technical skill in surgery, the degree to which these models have to approximate real-world conditions (model fidelity) to optimize learning is unclear. Previous research suggests that low-fidelity models may be adequate for novice learners. The purpose of this study was to assess the effect of model fidelity and surgical expertise on the acquisition of vascular anastomosis skill. ::: ::: ::: METHODS ::: Twenty-seven surgical residents participated in this institutional review board-approved study. Junior residents (postgraduate year 1 and 2) and senior residents (postgraduate year 4 or higher) were randomized into two groups: low-fidelity (n = 13) and high-fidelity (n = 14) model training. Both groups were given a 3-hour hands-on training session: the low-fidelity group used plastic models, and the high-fidelity group used human cadaver arms (brachial arteries) to practice graft-to-arterial anastomosis. One week later, all subjects participated in an animal laboratory in which they performed a single vascular anastomosis on a live, anesthetized pig (femoral artery). A blinded vascular surgeon scored candidate performance in the animal laboratory by using previously validated end points, including a checklist and final product analysis score. ::: ::: ::: RESULTS ::: Acquisition of skill was significantly affected by model fidelity and level of training as measured by both the checklist (P = .03) and final product analysis (P = .01; Kruskal-Wallis). Specifically, junior residents practicing on high-fidelity models scored better on the checklist (P = .05) and final product analysis (P = .04). Senior residents practicing on high-fidelity models scored better on final product analysis (P < .05). ::: ::: ::: CONCLUSIONS ::: Training in the laboratory does improve skill when assessed in a realistic setting. Both expertise groups showed better skill transfer from the bench model to live animals when practicing on high-fidelity models. For vascular anastomosis, it is important to provide appropriate model fidelity for trainees of different abilities to optimize the effectiveness of bench model training. <s> BIB005 </s> Current status of simulation training in plastic surgery residency programs: A review <s> INTRODUCTION <s> Microsurgery has expanded the scope of many surgical specialties and is evolving into an integral part of training programmes. The complexity of microsurgery requires considerable time and resources for adequate training and practice. This article reviews the validation of microsurgical models for microsurgery training and competence. © 2007 Wiley-Liss, Inc. Microsurgery, 2007. <s> BIB006 </s> Current status of simulation training in plastic surgery residency programs: A review <s> INTRODUCTION <s> Surgeons have to perform many complicated fine-motor movements, which are not part of the normal repertoire of body movements, and they must do this under very stressful conditions. These demands are similar to those facing professional sportsmen. Striving to perfect complicated movements is the ultimate goal in surgery, and it is a goal shared with professional sports. Because of these common aspirations, it seemed logical to us to combine surgery and sports science in an interdisciplinary fashion when designing training methods in surgery.1 ::: ::: Mental training, systematically and repeatedly imagining a movement without actually performing it, has been validated and applied successfully in professional sports for a long time.2,3 We thought that including mental training in surgical training might confer appreciable advantages. This study aimed to determine whether additional mental training is more effective in optimizing the performance of laparoscopic cholecystectomy than standard training or additional practical training. ::: ::: Mental Training ::: In addition to a detailed description of the procedure, which is readily available from an appropriate surgical atlas, mental training for surgery requires specific phrasing of instructions. Specific phrasing means that the procedure must first be broken down into its so-called nodal points, the necessary structural motor components that must be performed in sequence and are marked by a reduction in the degrees of freedom of action.4 Positive motor instructions and precise identification of potential hazards are then assigned to each nodal point, appropriate colored illustrations are included, and an “operation primer” is produced (Fig. 1).5,6 ::: ::: ::: ::: FIGURE 1. Page of operation primer for the laparoscopic cholecystectomy for nodal point 8. ::: ::: ::: ::: The primer forms the basis for both motor training sessions using operation simulators and mental training sessions. Four kinds of mental training sessions can be distinguished7: ::: ::: ::: External observative training: the trainee observes a model while it is performing the movement to be learned. ::: ::: ::: Subvocal training: the trainee calls up a clear visual image of the movement through external or internal self-talk. ::: ::: ::: Internal observative training: the trainee visualizes himself or another person from the outer perspective performing the movement he or she wants to practice. ::: ::: ::: Ideomotoric training: the trainee imagines the movement from the inner perspective. He visualizes himself executing the movement and tries to feel it, including as many sensory aspects of the process as possible. ::: ::: ::: ::: The combination of motor and mental training sessions forms the basis for building a functional mental representation of the surgical procedure. This can be seen as a determining quality marker in training; it integrates the half-conscious inner image of the movements that need to be performed and the conscious mental representation of the cognitive parts of the procedure.4 <s> BIB007 </s> Current status of simulation training in plastic surgery residency programs: A review <s> INTRODUCTION <s> Objective Cardiac surgery trainees might benefit from simulation training in coronary anastomosis and more advanced procedures. We evaluated distributed practice using a portable task station and experience on a beating-heart model in training coronary anastomosis. Methods Eight cardiothoracic surgery residents performed 2 end-to-side anastomoses with the task station, followed by 2 end-to-side anastomoses to the left anterior descending artery by using the beating-heart model at 70 beats/min. Residents took home the task station, recording practice times. At 1 week, residents performed 2 anastomoses on the task station and 2 anastomoses on the beating-heart model. Performances of the anastomosis were timed and reviewed. Results Times to completion for anastomosis on the task station decreased 20% after 1 week of practice (351 ± 111 to 281 ± 53 seconds, P = .07), with 2 residents showing no improvement. Times to completion for beating-heart anastomosis decreased 15% at 1 week (426 ± 115 to 362 ± 94 seconds, P = .03), with 2 residents demonstrating no improvement. Home practice time (90–540 minutes) did not correlate with the degree of improvement. Performance rating scores showed an improvement in all components. Eighty-eight percent of residents agreed that the task station is a good method of training, and 100% agreed that the beating-heart model is a good method of training. Conclusions In general, distributed practice with the task station resulted in improvement in the ability to perform an anastomosis, as assessed by times to completion and performance ratings, not only with the task station but also with the beating-heart model. Not all residents improved, which is consistent with a "ceiling effect" with the simulator and a "plateau effect" with the trainee. Simulation can be useful in preparing residents for coronary anastomosis and can provide an opportunity to identify the need and methods for remediation. <s> BIB008 </s> Current status of simulation training in plastic surgery residency programs: A review <s> INTRODUCTION <s> SUMMARY ::: Computer-based training simulators have been used extensively, most notably in flight simulation. Over the past 20 years, surgical simulators have been developed, initially for training of minimally invasive surgery and more recently for open surgical simulation. The key effort in today's surgical simulation field is to develop metrics to evaluate how well the skills learned in a simulator translate to improvement in real surgical skills, execution of procedures, and team cooperation in the operating room. The American College of Surgeons has begun implementing a phased approach to introduce simulation in training and education for general surgery. The authors believe that a similar training plan should be mandated for plastic surgery, to take advantage of the use of computers, virtual reality, and simulation in the training of plastic surgery residents and to explore the value of this technology for continuing medical education and maintenance of certification. This article gives a brief background and history of surgical simulation and its technology, followed by a detailed description of the three phases of the American College of Surgeons' plan and how the authors propose that each phase be implemented, with modifications as applicable for trainees in plastic surgery. <s> BIB009 </s> Current status of simulation training in plastic surgery residency programs: A review <s> INTRODUCTION <s> Objective To assess the effect of virtual reality training on an actual laparoscopic operation. Design Prospective randomised controlled and blinded trial. Setting Seven gynaecological departments in the Zeeland region of Denmark. Participants 24 first and second year registrars specialising in gynaecology and obstetrics. Interventions Proficiency based virtual reality simulator training in laparoscopic salpingectomy and standard clinical education (controls). Main outcome measure The main outcome measure was technical performance assessed by two independent observers blinded to trainee and training status using a previously validated general and task specific rating scale. The secondary outcome measure was operation time in minutes. Results The simulator trained group (n=11) reached a median total score of 33 points (interquartile range 32-36 points), equivalent to the experience gained after 20-50 laparoscopic procedures, whereas the control group (n=10) reached a median total score of 23 (22-27) points, equivalent to the experience gained from fewer than five procedures (P Conclusion Skills in laparoscopic surgery can be increased in a clinically relevant manner using proficiency based virtual reality simulator training. The performance level of novices was increased to that of intermediately experienced laparoscopists and operation time was halved. Simulator training should be considered before trainees carry out laparoscopic procedures. Trial registration ClinicalTrials.gov NCT00311792. <s> BIB010 </s> Current status of simulation training in plastic surgery residency programs: A review <s> INTRODUCTION <s> Background: ::: ::: Methods of surgical training that do not put patients at risk are desirable. A high-fidelity simulation of carotid endarterectomy under local anaesthesia was tested as a tool for assessment of vascular surgical competence, as an adjunct to training. ::: ::: ::: ::: Methods: ::: ::: Sixty procedures were performed by 30 vascular surgeons (ten junior trainees, ten senior trainees and ten consultants) in a simulated operating theatre. Each performed in a non-crisis scenario followed by a crisis scenario. Performance was assessed live by means of rating scales for technical and non-technical skills. ::: ::: ::: ::: Results: ::: ::: There was a significant difference in technical skills with ascending grade for both generic and procedure-specific technical skill scores in both scenarios (P < 0·001 for all comparisons). Similarly, there was also a significant difference in non-technical skill with ascending grade for both scenarios (P < 0·001). There was a highly significant correlation between technical and non-technical performance in both scenarios (non-crisis: rs = 0·80, P < 0·001; crisis: rs = 0·85, P < 0·001). Inter-rater reliability was high (α≥ 0·80 for all scales). ::: ::: ::: ::: Conclusion: ::: ::: High-fidelity simulation offers competency-based assessment for all grades and may provide a useful training environment for junior trainees and more experienced surgeons. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. <s> BIB011 </s> Current status of simulation training in plastic surgery residency programs: A review <s> INTRODUCTION <s> Over the past decade, driven by advances in educational theory and pressures for efficiency in the clinical environment, there has been a shift in surgical education and training towards enhanced simulation training. Microsurgery is a technical skill with a steep competency learning curve on which the clinical outcome greatly depends. This paper investigates the evidence for educational and training interventions of traditional microsurgical skills courses in order to establish the best evidence practice in education and training and curriculum design. A systematic review of MEDLINE, EMBASE, and PubMed databases was performed to identify randomized control trials looking at educational and training interventions that objectively improved microsurgical skill acquisition, and these were critically appraised using the BestBETs group methodology. The databases search yielded 1,148, 1,460, and 2,277 citations respectively. These were then further limited to randomized controlled trials from which abstract reviews reduced the number to 5 relevant randomised controlled clinical trials. The best evidence supported a laboratory based low fidelity model microsurgical skills curriculum. There was strong evidence that technical skills acquired on low fidelity models transfers to improved performance on higher fidelity human cadaver models and that self directed practice leads to improved technical performance. Although there is significant paucity in the literature to support current microsurgical education and training practices, simulated training on low fidelity models in microsurgery is an effective intervention that leads to acquisition of transferable skills and improved technical performance. Further research to identify educational interventions associated with accelerated skill acquisition is required. <s> BIB012 </s> Current status of simulation training in plastic surgery residency programs: A review <s> INTRODUCTION <s> Background With the increase in minimally invasive approaches to surgical disease and nonoperative management for solid organ injury, the open operative experience of current surgical residents has decreased significantly. This deficit poses a potentially adverse impact on both surgical training and surgical care. Simulation technology, with the potential to foster the development of technical skills in a safe, nonclinical environment, could be used to remedy this problem. In this study, we systematically review the current status of simulation technology in the training of open surgical skills with the aim of clarifying its role and promise in the education of surgical residents. Methods A systematic search of the PubMed database was performed with keywords: “surgical simulation,” “skill,” “simulat,” “surgery,” “surgery training,” “validity,” “surgical trainer,” “technical skill,” “surgery teach,” “skill assessment,” and “operative skill.” The retrieved studies were screened, and additional studies identified by a manual search of the reference lists of included studies. Results Thirty-one studies were identified. Most studies used low fidelity bench models designed to train junior residents in more basic surgical skills. Six studies used complex open models to train senior residents in more advanced surgical techniques. “Boot camp” and workshops have been used by some authors for short periods of intense training in a specialized area, with good results. Conclusions Despite the increasing use of simulation in the technical training of surgical residents, few studies have focused on the use of simulation in the training of open surgical skills. This is particularly true with regard to skills required to competently perform technically challenging open maneuvers under urgent, life-threatening circumstances. In an era marked by a decline in open operative experience, there is a need for simulation-based studies that not only promote and evaluate the acquisition of such less commonly performed techniques but also determine the efficacy with which they can be transferred from a simulated environment to a patient in an operating room. <s> BIB013 </s> Current status of simulation training in plastic surgery residency programs: A review <s> INTRODUCTION <s> To master the skills needed for microsurgery techniques, residents must enrol in a long and complex training program that includes manipulations on simulators, on ex vivo tissues and finally in vivo training. This final step consists of performing vascular anastomoses on murine models. We propose here a simulation program designed to decrease the number of rats used during the final in vivo training. Our study presents the materials used, the various exercises proposed and their evaluations. Two identical student groups were compared in the framework of the University Diploma of Microsurgery. Group A (seven students) followed a classic training program, all of whom achieved permeable vascular anastomoses. A total of 149 rats were needed for this group. Group B (seven students) first validated their manipulations on the task-trainer simulation program. A mean of 6 h was necessary to obtain this validation. All these students achieved the required permeable vascular anastomoses but only 77 rats were used fo... <s> BIB014 </s> Current status of simulation training in plastic surgery residency programs: A review <s> INTRODUCTION <s> In the last three decades, simulation has become a key tool in the training of doctors and the maintenance of patient safety. Simulation offers an immersive, realistic way of learning technical skills. Recent changes to the training schemes in many surgical specialities mean that the hours spent working between senior house officer and consultant have been reduced. This, combined with other pressures (such as reduced operating hours), means that surgery has moved away from its traditional apprenticeship model and toward a competency-based one. Simulation can be a standardized and safe method for training and assessing surgeons. Use of simulation for training has become significant alongside the development of laparoscopic techniques, and evidence suggests that skills obtained in simulation are applicable in real clinical scenarios. Simulation allows trainees to make mistakes, to ask the "what if?" questions, and to learn and reflect on such situations without risking patient safety. Virtual reality simulators have been used to allow experts to plan complicated operations and assess perioperative risks. Most recently, fully immersive simulations, such as those with whole theater teams involved, and patient-centered simulations allow development of other key skills aside from purely technical ones. Use of simulation in isolation from traditional teaching methods will furnish the surgeon in training with skills, but the best time and place to use such skills comes only with experience. In this article we examine the role of simulation in surgical training and its impact in the context of reduced training time. <s> BIB015 </s> Current status of simulation training in plastic surgery residency programs: A review <s> INTRODUCTION <s> Background While other surgical specialties have embraced virtual reality simulation for training and recertification, microsurgery has lagged. This study aims to assess the opinions of microsurgeons on the role of simulation in microsurgery assessment and training. Methods We surveyed faculty members of the American Society of Reconstructive Microsurgery to ascertain opinions on their use of simulation in training and opinions about the utility of simulation for skills acquisition, teaching, and skills assessment. The 21-question survey was disseminated online to 675 members. Results Eighty-nine members completed the survey for a 13.2% response rate. Few microsurgeons have experience with high-fidelity simulation, and opinions on its utility are internally inconsistent. Although 84% of respondents could not identify a reason why simulation would not be useful, only 24% believed simulation is a useful measure of clinical performance. Nearly three-fourths of respondents were skeptical that simulation would improve their skills. Ninety-four percent had no experience with simulator-based assessment. Conclusion Simulation has been shown to improve skills acquisition in microsurgery, but our survey suggests that unfamiliarity may foster bias against the technology. Failure to incorporate simulation may adversely affect training and may put surgeons at a disadvantage should these technologies be adopted for recertification by regulatory agencies. <s> BIB016 </s> Current status of simulation training in plastic surgery residency programs: A review <s> INTRODUCTION <s> Various simulation models for microsurgery have been developed to overcome the limitations of Halstedian training on real patients. We wanted to assess the status of microsurgery simulation in plastic surgery residency programs in the United States.Data were analyzed from responses to a survey sent to all plastic surgery program directors in the United States, asking for type of simulation, quality of facilities, utilization by trainees, evaluation of trainee sessions, and perception of the relevance of simulation.The survey response rate was 50%. Of all programs, 69% provide microsurgical simulation and 75% of these have a laboratory with microscope and 52% provide live animal models. Half share facilities with other departments. The quality of facilities is rated as good or great in 89%. Trainee utilization is once every 3 to 6 months in 82% of programs. Only in 11% is utilization monthly. Formal evaluation of simulation sessions is provided by 41% of programs. All program directors agree simulation is relevant to competence in microsurgery, 60% agree simulation should be mandatory, and 43% require trainees to complete a formal microsurgery course prior to live surgery.There seems to be consensus that microsurgical simulation improves competence, and the majority of program directors agree it should be mandatory. Developing and implementing standardized simulation modules and assessment tools for trainees across the nation as part of a comprehensive competency-based training program for microsurgery is an important patient safety initiative that should be considered. Organizing with other departments to share facilities may improve their quality and hence utilization. <s> BIB017
An increased emphasis on competency-based learning modules coupled with widespread departure from traditional models of Halstedian apprenticeship have fueled an educational transition away from the "see one, do one, teach one" ideology that is engrained in the culture of medical training. Across many medical specialties, a call for new training methods that facilitate the acquisition of surgical skills outside the operating room (OR) have led many residency programs to incorporate surgical simulation platforms BIB009 BIB002 BIB005 BIB012 . Prior to clinical application, medical trainees can acquire and refine surgical skills in synthetic, virtual, animal, and non-living models. Ideally, a surgical simulator would mimic the size, color, texture, recoil and environment of the OR BIB009 BIB015 , but to date, simulation technology is not yet capable of accurately replicating the physical attributes of human anatomy. Irrespective of these shortcomings, the value of simulation-based training is widely recognized with improvements in resident competency scores and surgical performance in the OR in both early and late stages of residency training BIB009 BIB015 BIB013  BIB001 BIB006 BIB014  BIB003 BIB010 BIB004 BIB008 . Despite vast potential for use in residency programs nationwide, current application of simulation-based training in plastic surgery appears extremely limited BIB016 . In a 2014 survey, utilization of surgical simulation by plastic surgery residents on a monthly basis was reported by only five of the 44 programs surveyed BIB007 . Although 80% of programs agreed that simulation based training should be mandatory, only 40% offered the opportunity for evaluation of trainee teaching sessions, or for formal course completion prior to clinical application BIB017 . Similarly, a 2016 survey of 89 microsurgery programs revealed that, clinical observation was disproportionately the most common method of training, implemented at a rate of 72%, compared with small animal models (67%), training courses or videos (33%), cadavers (28%), and high fidelity microsurgery simulators (2%). Given its success in other surgical specialties, the demand for simulation-based training in plastic surgery residency programs is certain to increase BIB014  BIB003 BIB008 BIB007 BIB011   . Further research is needed to determine how to best implement and improve the quality of simulation-based surgical training into the plastic surgery residency curriculum. In this review, current applications and potential benefits of incorporating simulation-based surgical training into a plastic surgery residency curriculum are explored in depth.