© 2013 John Wiley & Sons A/S.

Clin Transplant 2013: 27 (Suppl. 25): 6–15 DOI: 10.1111/ctr.12155

Do we need animal hands-on courses for transplantation surgery? Golriz M, Hafezi M, Garoussi C, Fard N, Arvin J, Fonouni H, Nickkholgh A, Kulu Y, Frongia G, Schemmer P, Mehrabi A. Do we need animal hands-on courses for transplantation surgery? Abstract: Background: Transplantation surgery requires many years of training. This study evaluates and presents the results of our recent fouryr animal hands-on courses of transplantation surgery on participants’ training. Methods: Since 2008, five two-d hands-on courses of transplantation surgery were performed on swine models at our department. Sixty-one participants were asked to answer three questionnaires (pre-course, immediate post-course, subsequent post-course). The questions pertained to their past education, expectations, and evaluation of our courses, as well as our course’s effectiveness in advancing their surgical abilities. The results were analyzed, compared and are presented herein. Results: On average, 1.8 multiorgan procurements, 2.3 kidney, 1.5 liver, and 0.7 pancreas transplantations were performed by each participant. 41.7% of participants considered their previous practical training only satisfactory; 85% hoped for more opportunities to practice surgery; 73.3% evaluated our courses as very good; and 95.8% believed that our courses had fulfilled their expectations. 66% found the effectiveness of our course in advancing their surgical abilities very good; 30% good, and 4% satisfactory. Conclusion: Animal hands-on courses of transplantation surgery are one of the best options to learn and practice different operations and techniques in a near to clinical simulated model. Regular participation in such courses with a focus on practical issues can provide optimal opportunities for trainees with the advantage of direct mentoring and feedback.

Mohammad Golriza, Mohammadreza Hafezia, Camelia Garoussia, Nassim Farda, Jalal Arvina, Hamidreza Fonounia, Arash Nickkholgha, Yakob Kulua, Giovani Frongiab, Peter Schemmera and Arianeb Mehrabia a

Department of General, Visceral and Transplantation Surgery, University of Heidelberg and bDepartment of Pediatric Surgery, University of Heidelberg, Heidelberg, Germany Key words: animal – hands-on course – surgery – transplantation Corresponding author: Arianeb Mehrabi, MD, FICS, FEBS, Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany. Tel.: +49 6221 56 36223; Fax: +49 6221 56 7470; e-mail: [email protected]. de Conflict of interests: The authors declare that they have no conflict of interests. Accepted for publication 6 March 2013

Providing a promising surgical service is mostly dependent on the skills of the medical staff. The more skilled the staff, the higher the success rate of preventing and managing surgical complications (1, 2). However, the challenging question remains “how exactly can surgeon learn more effectively.” Different steps in the process of acquiring surgical skills include lectures, discussion workshops, multimedia, cadaver, ex vivo models, animal hands-on courses, and real operation rooms (3). While all of these are necessary and useful, one of the most appropriate methods, particularly for transplantation surgery, is hands-on courses. It is broadly believed that simulation offers an important route to safer care for patients and thus recommended that simulation-based training be fully integrated and funded within all stages of training programmes for clinicians (4). Usually, during their

6

tenure, fellows in transplantation surgery have acquired general surgery skills and had the opportunity to join different theoretical workshops, make use of multimedia methods, or assist in the operation room. However, the most challenging problem for them is the lack of practice opportunities at the beginning of their fellowship. Traditionally, residents acquire surgical skills in the operating room under the supervision of attending surgeons. However, in the current healthcare environment, this model is not always feasible. This is specially the case in the field of transplantation due to ethical concerns, rapid clinics turnover, slow learning curve times and high costs, and the lack of self-confidence of the residents due to their inexperience (5–9). Transplantation surgery is more difficult to learn than general surgery and it offers fewer opportunities to

Animal hands-on course for transplantation surgery practice. It demands more experience and mistakes result in more challenging morbidities and even mortalities. Consequently, the need to develop supplementary approaches to teaching surgical skills during the fellowships is increasing. To promote the art of surgery, such supplementary approaches have been practiced in various countries, including Canada (since 1962), the United States (since the mid-1960s), and the United Kingdom (since the mid-1970s) (10–12). More recently, surgical skills training has taken place in laboratories specifically designed for surgical skill development. In this setting, basic and advanced surgical skills are practiced and learnt on models, with the purpose of better preparing trainees for the operating room experience (13–17). Animal-based training allows trainees to learn in a low-stress environment, in which mistakes are permissible, procedures can be repeated multiple times to improve muscle memory, and informative feedback can lead more rapidly to skill competencies (18). Multiple studies have shown that animal-based training improves technical skills and competency when the procedures are subsequently performed on actual patients (3, 18–22). Hands-on courses have been shown to be superior to standard training and didactics (3, 6, 17, 23). The aim of this study is to present the evaluation of animal hands-on courses for transplantation surgery, which were performed at our department during the last four yr. Methods

Since 2003, our department has offered various animal hands-on courses in general surgery. These courses focus on the demonstration and practice of various standard surgical techniques and methods via open as well as laparoscopic approaches in porcine models. In 2008, we broadened the themes and have since offered animal hands-on courses in transplantation surgery. In this period (January 2008– January 2012), a total of five animal courses of transplantation surgery were offered at our department and 61 surgeons or fellows participated in them. Each course lasted two d. The focus of the first day was to practice multiorgan procurement (liver, pancreas, and kidney) and solid organ transplantation of liver, pancreas, and kidney. Mentors provided the participants with detailed feedback, and the participants had the chance to identify areas in which they could improve. On the second day, the participants repeated the performed surgeries and reflected on the key aims of the first day of practice. Fig. 1 outlines the flow of the operations. The operations were conducted using as few animals as possible. Because of their anatomical and physio-

Fig. 1. Flow of the performed operations.

logical similarities to humans, swine were used as the animal model (24–27). The weight of our model animals ranged from 35 to 40 kg. The operating rooms were equipped in the same manner as human operating rooms. The animals were anesthetized and prepared for the planned operations. The hands-on course lasted 10 h each day, beginning with a 15-min theoretical introduction about the anatomy of the swine. Following this, participants were divided into groups of four based on their speciality and experience. The courses focused on the hands-on aspects of transplantation, thereby limiting the time devoted to the theoretical explanation. Each group was directly paired with an experienced transplant surgeon who served as the group’s tutor. All of the working groups and their tutors were observed by a senior transplantation professor, who also liaised between various groups to share their experiences and prevent mistakes from reoccurring. The courses were ethically certified by the animal right officials of our state (Regierungspr€asidium Karlsruhe; AZ: A35-9185.82/A34/08). During the experiments, all animals received human care in compliance with the National Research Council’s criteria for human care, as outlined in the Guide for the Care and Use of Laboratory Animals prepared by the National Institutes of Health (NIH Publication 86-23, revised 1985). Following the experiment’s completion, all operated animals were euthanized while in deep anesthesia. All courses were evaluated prospectively and subjectively based on three questionnaires which were answered anonymously by the course participants. The pre-course questionnaire, which was administered prior to the beginning of the course, concerned three major categories: (i) demographic data of the participants (age, gender, level of experience, field of surgery [visceral, urology, vascular], center of education, and previous animal course experience), (ii) participants’ assessment of their previous education (theoretical, patient oriented, and practical as well as their perceived strengths and weaknesses), and (iii) participants’ unmet expectations of their previous education and hands-on courses. The immediate post-course questionnaire, which was answered at the end of each of our animal hands-on courses, was composed of three major categories: (i) training evaluation (general

7

Golriz et al.

score, met expectations, successful and unsuccessful aspects of the course, the appropriateness of its duration, participants’ interest to take the course again or recommend it to others), (ii) structures (organization, infrastructure facilities, mentoring, tutors, number of participants), and (iii) suggestion for future improvements. The subsequent postcourse questionnaire was answered at least six months after the course and concerned the impact of our course on the clinical surgical abilities of the attendees. We asked if the course had any positive effect on the participants’ surgical skills, and if so, to rank this effect in a range from poor to very good. Finally, we ask the attendees to discuss the two most important effects in detail. The quality control questions had six options: (i) very good, (ii) good, (iii) satisfactory, (iv) just adequate, (v) inadequate, and (vi) poor. Descriptive statistical analysis was performed using SPSS 18.0 for Windows (SPSS Corp., Chicago, IL, USA). Results

A total of five animal courses of transplantation were offered at our department and 61 trainees participated in them. Each participant performed as the first operator on average 1.8 multiorgan procurements (1.8 liver, 3.6 kidneys, and 1.8 pancreas), 2.3 kidney implantations, 1.5 liver implantations, and 0.7 pancreas implantations during each two-d course. In this process, each participant performed on average 4.8 arterial anastomosis, 8.6 venous anastomosis, 1.9 urethral anastomosis, and 1.2 bile duct anastomosis. Pre-course evaluations

Demographic data. The demographic data of the participants are summarized in Table 1. Eighty

Table 1. Demographic data of the participants Items Age 40 yr Gender Male Female Level Trained surgeon Attendings Junior Senior Head of the department

8

percent of the participants had previously performed kidney transplantations as first operator. This rate was 50% for liver transplantations and only 10% for pancreas transplantations. The remaining participants had assisted in these operations only as first assistant. When asked, they could not identify the exact number of operations they had performed. Most of the participants were from centers affiliated with the University (55% vs. 45% from the University) and had participated in such courses previously (81.7%). Previous education evaluation. Fig. 2 captures the participants’ assessment of their previous theoretical, patient-oriented and practical training. They considered their previous theoretical training (60% good, 30% satisfactory) better than their patientoriented training (55% good, 31.7% satisfactory) and these two better than their previous practical training (31.7% good, 41.7% satisfactory). When the participants were asked which aspect of their previous training program they considered most useful and which aspect least useful, only 31.5% indicated that the practical training courses were the most useful aspect of their overall training. Moreover, 52.7% considered their practical skills training and direct mentoring in the operation room insufficient. Expectations. Prior to taking the courses, 85% of the participants expressed that they would have welcomed more operation opportunities during their surgical educations than they had received. All of the participants expected more practice opportunities, including supplementary courses such as experimental hands-on ones. Fifty-one point seven percent indicated that such hands-on courses should last two d; 31.6% preferred daylong courses and 16.7% suggested that the courses be longer than two d. Immediate post-course evaluation

%

11.7 66.7 21.6 70 30 68.3 15 15 1.7

Training evaluation. Our courses achieved remarkably high scores (73.7% very good, 25% good, and 1.7% satisfactory). While 77.8% of the participants believed that our courses fulfilled their expectations, 18% of them indicated that our courses surpassed their expectations. Only 4.2% stated that the courses did not fulfill their expectations. The opportunity to practice was considered as the most significant aspect of our courses with 85%. Only 30% of the participants considered the duration of the course as an unsuccessful aspect and believed that the courses should have lasted longer than two d. On the other hand,

Animal hands-on course for transplantation surgery Participants' evaluation about their previous surgical education 100 Very Good 90

Good

80

Satisfactory

70

Just Adequate

60

Inadequate

50

Poor

40 30 20 10

Fig. 2. Participants’ evaluation about their previous surgical theoretical, patient-oriented and practical educations.

Theoritical education

60% of the participants considered the duration of our courses as optimal. All participants (100%) stated that they would like to participate again in similar hands-on courses, and all (100%) expressed that they would recommend our courses to colleagues. Structures. The organization and infrastructure facilities were considered, respectively, 63 and 61% very good, 32.9 and 37.3% good, and 4.1 and 1.7% satisfactory. The mentoring and quality of the tutors were likewise considered very good (58.3 and 71.2%), good (27.8 and 27.1%), and satisfactory (9.7 and 1.7%), respectively (Fig. 3). Almost all (96.6%) participants indicated that the number of members per group was optimal for practicing. Suggestions. Only 30.8% of the participants suggested that a part of our course be changed to

Patient-oriented education

Practical education

include a greater theoretical component, to be presented before each operation. At the end of the course, all of the participants believed that they could perform the practiced operations independently. No omissions were suggested. Participants were however not sure about how many such courses would suffice for a participant to become fully trained to perform in a clinical situation. In a follow-up survey conducted three months after the courses, all participants expressed their eagerness to once again take part in our courses. They believed that our practical courses had positively affected their clinical abilities. Subsequent post-course evaluation

In a follow-up evaluation six months or more after the courses’ completion, we inquired about the impacts of our courses on the participants’ abilities Participants' evaluation about our hands-on courses

100

Very good

90

Good Satisfactory

80

Just Adequate 70

Inadequate Poor

60 50 40 30 20

Fig. 3. Total evaluation of our handson courses through the participants and their valuation about organization, infrastructure facilities, mentoring, and quality of the tutors.

10

General Evaluation

Organisation

Infrastructure Facilities

Mentoring

Quality of the Tutors

9

Golriz et al.

to operate more effectively on humans. We reached 54 of 61 participants, all of whom confirmed that the course had advanced their surgical abilities. Sixty-six percent of them considered this effect as very good, 30% as good, and 4% as satisfactory. Finally, we ask them to indicate the two most important effects in detail. Most of the participants (77%) found that individually performing many vascular anastomoses in a situation similar to the clinic, without stress and time limitations, allowed them to learn the taught methods and evaluate their own strengths and weaknesses. Also, 45% of them believed that the opportunity to individually manage the entire transplantation process and to make decisions regarding next steps within the scope of the surgery helped them to internalize the flow of the transplantation surgery. Discussion

Advanced technical skills are one of the traits that a competent surgeon must possess, and society views technical ability as the most important quality in a surgeon (28). In recent years, acquiring extensive experience has proven to be challenging for surgeons and fellows. For example, to become a surgeon, the German Medical Association € (“Deutsche Arztekammer”) defines a minimal and expected duration of training with the key requirement of a certain amount of operative and nonoperative procedures. Problematically, however, the completion of the requirements takes significantly longer than the expected duration of training. Consequently, many trainees have to attend their programs longer than initially intended (29). A great part of this delay is caused by insufficient opportunities to perform surgery. This comes mostly from the lack of experience of the junior surgeons and fellows which also affects the opinions of deciding professors, who in turn do not select the juniors as the first operator. Moreover, even when juniors are chosen to operate, their own inexperience causes more complications and even leads to significantly higher costs (5). To solve these problems, it has been recommended that a large part of teaching and practice should occur outside the operating room (18). Considering the role of simulation as an important route to safer care for patients, it has also been recommended that simulation-based training be fully integrated and funded within training programmes for clinicians at all stages (30, 31). Therefore, other opportunities to gain more experience such as hands-on courses of surgery – which are rather adjunct than an alternative (31, 32) – are in high demand (19, 33–36).

10

Most participants in our hand-on courses were between the 30 and 40 yr old. This is exactly representative of the routine age of the surgeons and fellows of transplantation in Germany. Interestingly, 21.7% of our trainees were over 40 yr old, which indirectly reflects that even experienced surgeons feel that they need to practice and learn. There are only few University centers in each country and many clinical centers such as those affiliated with the University hospitals. However, we could see that 55% of the participants in our courses were from University centers. This can be suggestive of either the eagerness of University surgeons and fellows to learn and practice more and/ or of fewer opportunities for them to learn practical techniques in the early phases of their fellowships. In contrast, surgeons and fellows who work in University affiliated hospitals have most of the time more opportunities to perform multiorgan procurement or kidney transplantation. The majority of the participants considered their previous theoretical and patient-oriented training in the category “good” (55 and 60%, respectively). However, previous practical training was assessed as merely “satisfactory” by 41.7% of the participants, which represents the largest fraction. Moreover, only one-third (31.7%) considered their previous practical training “good.” This is representative of the practical training situation in German clinics, which do not provide enough opportunities for junior surgeons and fellows (mostly in the referral centers) to operate as the first operator. As a normal routine, they can generally only join the operation team as the first or second assistant. This is mostly the consequence of a large number of complicated cases which are referred to the University centers and necessitate more experience than the fellows have (6). However, the initial performance has shown to be only a predictor of the duration of training required to reach a certain level of proficiency, not the ultimate technical skill level (37, 38). Most surgical skills studies to date show that even those who are highly unskilled at the onset of training can reach a level of expert-based proficiency through the application of distributed and deliberate practice (19, 36). Based on the information participants provided about their previous training and their limited access to courses similar to ours directly before beginning of our hands-on courses, we can obviously see both their perceived deficiency of the practical training and participants’ eagerness for new opportunities to practice and learn surgical techniques. These can currently not be easily provided in the clinics. Although various modalities of surgical simulation exist, such as computer, video

Animal hands-on course for transplantation surgery simulation or models (3), these are all compromised by the absence of normal anatomical relationships and tissue handling. Animal hands-on courses are one of the best options for trainees. Live animal models are considered to be of high fidelity and are most desirable for advancing complex skills. These courses offer a similar atmosphere to the human operation rooms, excellent handling fidelity and live operative experience of dealing with bleeding or other challenging intraoperative situations via live animal tissue. Moreover, they allow participants to practice and learn under direct observation of tutors in a low-stress environment, where mistakes are permissible, procedures can be repeated multiple times to improve muscle memory, and where informative feedback can lead more rapidly to skill competency (18, 39). Drawbacks to these models are the high cost, their limited availability, and moral and ethical concerns (6, 40). In our hands-on courses, we focused on the practical issues and reduced theory lectures as much as possible. While, the pre-course evaluation indicated that the majority of the participants (85%) expected more practical experience during their education, surprisingly, the post-course evaluation revealed that nearly a third (30.8%) of the participants would have preferred more detailed theoretical explanation parallel to their practice in the hands-on courses. For such courses, to offer a variety of options and aid high-capacity learning in a short time, organization and management are key factors. Distribution of the participants in groups of four as we planned was evaluated as highly effective. In each operation, one of the trainees operated as the first operator, two of the trainees assisted as first and second assistant, and the fourth helped as the OR nurse. With several rotations in each group during a day, each participant took on all the roles, and thus had the opportunity to operate, assist, and observe. From the participants’ opinions about the course duration before the course (51.7% expected two d as optimal) as well as their evaluation after the course (60% considered two d as optimal), it can be concluded that two d would be an optimum duration for such courses. We planned a two-d course and repeated the first day plan on the second day. We think that for a handson course, one d would not be sufficient to practice and learn the planned schedule. On the other hand, a course lasting longer than two d would not likely be feasible, as participants could not easily take two d off work. We repeated the same plan on the second day to present the opportunity for the trainees to perform any left-over operations from the first day. Therefore, they could operate and

assist all planned operations, think through and discuss their problems and challenges from the first day, and practice them on the second day to achieve a high practical level of skill. Goff et al. (18) believe that multiple repetitions of the procedures in a low-stress environment with permissible mistakes can improve the muscle memory and lead to skill competency. Normally, after a one-d course, participants have practiced a technique only once and did not have enough time to repeat and practice it. Moreover, offering a variety of operations without giving the chance to repeat them would not be beneficial. Anastaskis et al. (41) could show that a single session course does not have an appreciable and sustained effect. Based on the results of our analysis and keeping in mind the infrequency of such courses in Germany (42), it can be concluded that a regular learning program through these kinds of courses can help the transplant surgeons and fellows gain more experience and develop their skills. However, the results of these trainings still need to be evaluated objectively via a prospective study. Achieving an evaluation of “very good” and “good” by 98.3% of the participants shows that we could offer a good transplantation hands-on course. This is the mirror picture of participants’ evaluation about organization, infrastructure facilities, mentoring, and the quality of tutors. We were well evaluated by the participants in each category, most likely because of our department clinical, experimental, and researchrelated backgrounds. Our tutors have been trained in a center with a high annual rate of multiorgan procurement, kidney and liver transplantations (43–49). Experimental transplantation surgery has been established in our department many years ago. It was developed and organized during the last years and provided an appropriate atmosphere for surgeons, fellows, and researcher to perform transplantation surgery parallel to their clinical practice (22, 50–55). With the last follow-up at least six months after the participation, we could see that the participants believed in the positive effects of this hands-on course, not only immediately after the course, but also after a six-month period—even if these assessments are subjective. One of the greatest challenges in transplantation surgery is anastomosis. The participants mentioned that this kind of intensive practice helped them learn the methods and assess their own strengths and weaknesses. Based on the participants’ assessment of their overall educational experience, learning process, time limits and clinical situations, we believe that a regular and well-organized program for animal hands-on courses can help the residents and fellows

11

Golriz et al.

of transplantation surgery boost their clinical abilities. In a literature review of hands-on courses with similar situation to our course, we found nine other studies, which are summarized in Table 2. The positive effect of hands-on courses, especially in the field of visceral surgery, can be seen in these studies from 1995 to 2012. Although the facilities and technology have evolved during the last 20 yr, animal hands-on courses have been constantly

evaluated remarkably positively. The reviewed studies show both subjectively and objectively that training sessions using porcine models improve resident perception of knowledge, and comfort with the techniques, reduce the operation time and optimize the learning curve. Although virtual reality simulators and web-based instructional videos are valuable supplemental training resources in surgical programs, they are no more effective than

Table 2. Overview of the animal hands-on studies which were performed during the last 20 yr

Authors

Year

Field

Place

Animal

Duration (day)

Number of attendees

Noar et al. (57)

1995

ERCP

USA

Porcine

1

NA

Mori et al. (58)

1997

Japan

Porcine

1.5

15

Olinger et al. (59)

1998

Laparoscopic cholecystectomy Laparoscopic spine fusion

Germany

Porcine

2

72

Mehrabi et al. (39)

2006

Da Vinci robotic visceral surgery

Germany

Rat Porcine

1

4

Cho et al. (60)

2008

Cricothyrotomy

South Korea

Porcine

1

49

Thomas et al. (61)

2010

Ex-vivo bowel surgery

USA

Porcine

1

31

Snyder et al. (62)

2010

Laparoscopic visceral surgery

USA

Porcine

1

36

Palter et al. (63)

2010

Laparoscopic visceral surgery

Canada

Porcine

1

14

Torre et al. (64)

2012

Laparoscopic visceral surgery

Italy

Porcine

n.a.

50

Golriz et al.

2012

Transplantation

Germany

Porcine

2

61

ERCP, endoscopic retrograde cholangiopancreatography; NA, not available; VR, virtual reality.

12

Results 95% of attendees believed that the porcine model is excellent and realistic 80% believed in improvement of their skills after participation Significant improvement of skills Decrease of the required operation time 42.2% applied the new technique successfully in man 98.3% agreed that for novel surgical techniques requiring advanced technical skills, there should first be training in a large animal model before the technique is applied in man Significant improvement of skills and reduction in the operating times and complications The porcine model scored higher on overall reality and preference compared to manikin model because of its reality and similarity to human anatomy Significant improvement in scores (10 point Likert scale) for lysis of adhesion (LOA), enterotomy repair, and understanding the principles of LOA VR training is no more effective than independent training with respect to surgical performance Porcine model better than synthetic model, the FLS black box, and the VR 81.8% of attendees rated the animal model as “extremely helpful,” while only 21.4% rated the VR model as “extremely helpful” Significant improvement regarding the duration of the procedures, rate of complications, and the need of a tutor after two participations. 96% of attendees found porcine model useful and 96% evaluated the course as “very useful” Evaluation: 73.3% very good, 95.8% fulfillment of expectations, 100% hope to reparticipation, 100% recommendation Effect on surgical abilities: 66% very good, 30% good, 4% satisfactory

Animal hands-on course for transplantation surgery independent training on animal models with respect to surgical performance. It should also be mentioned that the process of learning is dependent on the educational system, which varies from country to country. For example, in the US, fellows have more operative experience than fellows in Germany, so that such hands-on courses might be more suitable for US residents of surgery than fellows. However, in Germany, residents may normally assist only in transplantation and operate as the first operator only after finishing their residency. Therefore, in Germany, hands-on courses are appropriate for both residents and fellows. In the US, cutting-edge research has led to major advances in surgical education over the past decade. Innovative approaches have been developed to apply principles of adult learning and experiential learning to contemporary surgical education. Learner-centered education modules have been designed that include methods to assess knowledge and skills. Major emphasis is being placed on competency-based education and verification of competence. Advances in understanding concepts and methodology for teaching, learning, and assessment of clinical and technical skills are especially noteworthy. Faculty development has also been emphasized to enhance the skills of surgeon educators, to implement cuttingedge methods of education, and to facilitate training of the faculty to serve as effective preceptors and mentors. However, adoption of contemporary teaching, learning, and assessment methods by surgical residency programs has been slow. Most residency programs continue to use outmoded, century-old, apprentice-based educational methods and techniques (56). In summary, animal hands-on courses are useful considering the current problems of learning and training in the field of surgery, especially in psychomotor-oriented specialities such as transplantation surgery. With similar situations to the human operating room, the trainees can learn advanced operative techniques of transplantation surgery. The junior surgeons and fellows thereby practice the techniques that they seldom have the opportunity to perform on humans. Planning, organization, and tutoring are important aspects of such courses. Focusing on practical skills should not lead the trainers to omit theoretical content. Other studies are needed to objectively evaluate the role of such courses. Authors’ contributions

AM and MG participated in the design of the study. MG, MH, CG, and NF participated in the

review of the literature. MG and YK prepared the questionnaires. MG, YK, and AM revised the questionnaires and gave the final approval. MH, CG, NF, JA, and HF collected the data and categorized the results. AN and GF performed the statistical analysis. MG and AM were involved in drafting the manuscript. PS and AM revised the manuscript and gave final approval of the version to be published. All authors read and approved the final manuscript. References 1. BIRKMEYER JD, STUKEL TA, SIEWERS AE, GOODNEY PP, WENNBERG DE, LUCAS FL. Surgeon volume and operative mortality in the United States. N Engl J Med 2003: 349: 2117. 2. LIN HC, LIN CC. Surgeon volume is predictive of 5-year survival in patients with hepatocellular carcinoma after resection: a population-based study. J Gastrointest Surg 2009: 13: 2284. 3. SUTHERLAND LM, MIDDLETON PF, ANTHONY A et al. Surgical simulation: a systematic review. Ann Surg 2006: 243: 291. 4. Department of Health. 150 Years of the Annual Report of the Chief Medical Officer. London: DH, 2009. 5. BRIDGES M, DIAMOND DL. The financial impact of teaching surgical residents in the operating room. Am J Surg 1999: 177: 28. 6. ANASTAKIS DJ, REGEHR G, REZNICK RK et al. Assessment of technical skills transfer from the bench training model to the human model. Am J Surg 1999: 177: 167. 7. GATES EA. New surgical procedures: can our patients benefit while we learn? Am J Obstet Gynecol 1997: 176: 1293; discussion 1298. 8. CLARKE JR, JOHNSTON J, FINLEY ED. Getting surgery right. Ann Surg 2007: 246: 395; discussion 403. 9. STAHEL PF, CLAVIEN PA, HAHNLOSER D, SMITH WR. A new journal devoted to patient safety in surgery: the time is now! Patient Saf Surg 2007: 1: 1. 10. COUVES CM. A course in surgical technique for medical students. Can J Surg 1970: 13: 31. 11. LIPPERT FG 3rd, SPOLEK GA, KIRKPATRICK GS, BRIGGS KA, CLAWSON DK. A psychomotor skills course for orthopaedic residents. J Med Educ 1975: 50: 982. 12. BEVAN PG. Craft workshops in surgery. Br J Surg 1986: 73: 1. 13. SCALLON SE, FAIRHOLM DJ, COCHRANE DD, TAYLOR DC. Evaluation of the operating room as a surgical teaching venue. Can J Surg 1992: 35: 173. 14. HEPPELL J, BEAUCHAMP G, CHOLLET A. Ten-year experience with a basic technical skills and perioperative management workshop for first-year residents. Can J Surg 1995: 38: 27. 15. LOSSING AG, HATSWELL EM, GILAS T, REZNICK RK, SMITH LC. A technical-skills course for 1st-year residents in general surgery: a descriptive study. Can J Surg 1992: 35: 536. 16. QAYUMI AK, CHEIFETZ RE, FORWARD AD, BAIRD RM, LITHERLAND HK, KOETTING SE. Teaching and evaluation of basic surgical techniques: the University of British Columbia experience. J Invest Surg 1999: 12: 341. 17. MATSUMOTO ED, HAMSTRA SJ, RADOMSKI SB, CUSIMANO MD. A novel approach to endourological training: training at the surgical skills center. J Urol 2001: 166: 1261.

13

Golriz et al. 18. GOFF BA. Changing the paradigm in surgical education. Obstet Gynecol 2008: 112(): 328. 19. SCOTT DJ, BERGEN PC, REGE RV et al. Laparoscopic training on bench models: better and more cost effective than operating room experience? J Am Coll Surg 2000: 191: 272. 20. COLEMAN RL, MULLER CY. Effects of a laboratory-based skills curriculum on laparoscopic proficiency: a randomized trial. Am J Obstet Gynecol 2002: 186: 836. 21. BANKS EH, CHUDNOFF S, KARMIN I, WANG C, PARDANANI S. Does a surgical simulator improve resident operative performance of laparoscopic tubal ligation? Am J Obstet Gynecol 2007: 197: 541. e541–545. 22. MEHRABI A, GOLLING M, SCHWARZER H et al. Development of a computer based training program for liver transplantation. Transplant Proc 1999: 31: 3169. 23. GROBER ED, HAMSTRA SJ, WANZEL KR et al. The educational impact of bench model fidelity on the acquisition of technical skill: the use of clinically relevant outcome measures. Ann Surg 2004: 240: 374. 24. SAMPAIO FJ, PEREIRA-SAMPAIO MA, FAVORITO LA. The pig kidney as an endourologic model: anatomic contribution. J Endourol 1998: 12: 45. 25. SWINDLE MM, SMITH AC, HEPBURN BJ. Swine as models in experimental surgery. J Invest Surg 1988: 1: 65. 26. SWINDLE MM. Swine as replacements for dogs in the surgical teaching and research laboratory. Lab Anim Sci 1984: 34: 383. 27. GOLBY M, WHITE HJ. The operation of orthotopic renal allografting in the pig and its complications. Br J Surg 1971: 58: 287. 28. REZNICK R, REGEHR G, MACRAE H, MARTIN J, MCCULLOCH W. Testing technical skill via an innovative “bench station” examination. Am J Surg 1997: 173: 226. 29. FLIERL MA. German surgical residency training – quo vadis? Patient Saf Surg 2008: 2: 9. 30. 2009. DoHYotARotCMOLD. 31. CASEY PM, GOEPFERT AR, ESPEY EL et al. To the point: reviews in medical education–the Objective Structured Clinical Examination. Am J Obstet Gynecol 2009: 200: 25. 32. KNEEBONE R, AGGARWAL R. Surgical training using simulation. BMJ 2009: 338: b1001. 33. SROKA G, FELDMAN LS, VASSILIOU MC, KANEVA PA, FAYEZ R, FRIED GM. Fundamentals of laparoscopic surgery simulator training to proficiency improves laparoscopic performance in the operating room-a randomized controlled trial. Am J Surg 2010: 199: 115. 34. FRIED GM, FELDMAN LS, VASSILIOU MC et al. Proving the value of simulation in laparoscopic surgery. Ann Surg 2004: 240: 518. discussion 525-518. 35. TSUDA S, SCOTT D, DOYLE J, JONES DB. Surgical skills training and simulation. Curr Probl Surg 2009: 46: 271. 36. SEYMOUR NE, GALLAGHER AG, ROMAN SA et al. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg 2002: 236: 458. discussion 463-454. 37. MCCLUSKY DA 3rd, RITTER EM, LEDERMAN AB, GALLAGHER AG, SMITH CD. Correlation between perceptual, visuo-spatial, and psychomotor aptitude to duration of training required to reach performance goals on the MIST-VR surgical simulator. Am surg 2005: 71: 13. discussion 20-11. 38. RITTER EM, MCCLUSKY DA 3rd, GALLAGHER AG, ENOCHSSON L, SMITH CD. Perceptual, visuospatial, and psychomotor abilities correlate with duration of training required on a virtual-reality flexible endoscopy simulator. Am J Surg 2006: 192: 379.

14

39. MEHRABI A, YETIMOGLU CL, NICKKHOLGH A et al. Development and evaluation of a training module for the clinical introduction of the Da Vinci robotic system in visceral and vascular surgery. Surg Endosc 2006: 20: 1376. 40. HAMMOUD MM, NUTHALAPATY FS, GOEPFERT AR et al. To the point: medical education review of the role of simulators in surgical training. Am J Obstet Gynecol 2008: 199: 338. 41. ANASTAKIS DJ, WANZEL KR, BROWN MH et al. Evaluating the effectiveness of a 2-year curriculum in a surgical skills center. Am J Surg 2003: 185: 378. 42. http://www.aerztekammer-bw.de/10aerzte/20fortbildung/ 10fortbildungskalender/index.html. 43. MEHRABI A, KASHFI A, TONSHOFF B et al. Long-term results of paediatric kidney transplantation at the University of Heidelberg: a 35 year single-centre experience. Nephrol Dial Transplant 2004: 19(Suppl 4): iv69. 44. MEHRABI A, SCHEMMER P, SCHMIDT J et al. Heidelberg’s first experiences in establishing a living-donation liver transplantation programme. Nephrol Dial Transplant 2004: 19(Suppl 4): iv1. 45. MEHRABI A, WIESEL M, ZEIER M et al. Results of renal transplantation using kidneys harvested from living donors at the University of Heidelberg. Nephrol Dial Transplant 2004: 19(Suppl 4): iv48. 46. MEHRABI A, FONOUNI H, GOLRIZ M et al. [Living-donor kidney transplantation]. Chirurg 2010: 81: 794. 802-793. 47. FONOUNI H, GOLRIZ M, MEHRABI A et al. The role of an interdisciplinary transplant team on living donation kidney transplantation program. Transplant Proc 2010: 42: 137. 48. MEHRABI A, MOOD ZA, FONOUNI H et al. A single-center experience of 500 liver transplants using the modified piggyback technique by Belghiti. Liver Transpl 2009: 15: 466. 49. MEHRABI A, FONOUNI H, AYOUB E et al. A single center experience of combined liver kidney transplantation. Clin Transplant 2009: 23(Suppl 21): 102. 50. MEHRABI A, GOLLING M, JAHNKE C et al. Characterization of hepatic parenchymous perfusion heterogeneity and regional flow kinetics after porcine liver transplantation. Microvasc Res 2003: 65: 78. 51. MEHRABI A, KRAUS T, OTTO G et al. Quantification of hepatic microcirculation and intrahepatic shunt perfusion during experimental liver transplantation. Transplant Proc 1998: 30: 794. 52. MEHRABI A, KRAUS TW, KLAR E et al. Analysis of extravascular endothelin levels in UW solution and rinsing effluent of porcine liver grafts after cold storage. Transplant Proc 1995: 27: 2613. 53. FONOUNI H, TAHMASBI RAD M, GOLRIZ M et al. Using microdialysis for early detection of vascular thrombosis after kidney transplantation in an experimental porcine model. Nephrol Dial Transplant 2012: 27: 541. 54. FONOUNI H, ESMAEILZADEH M, JARAHIAN P et al. Early detection of metabolic changes using microdialysis during and after experimental kidney transplantation in a porcine model. Surg Innov 2011: 18: 321. 55. KLAR E, KRAUS T, OSSWALD BR et al. [Induction of impaired hepatic microcirculation by in situ hilus preparation in liver explantation]. Zentralbl Chir 1995: 120: 482. 56. PELLEGRINI CA, WARSHAW AL, DEBAS HT. Residency training in surgery in the 21st century: a new paradigm. Surgery 2004: 136: 953. 57. NOAR MD. An established porcine model for animate training in diagnostic and therapeutic ERCP. Endoscopy 1995: 27: 77.

Animal hands-on course for transplantation surgery 58. MORI T, HATANO N, MARUYAMA S, ATOMI Y. Significance of “hands-on training” in laparoscopic surgery. Surg Endosc 1998: 12: 256. 59. OLINGER A, PISTORIUS G, LINDEMANN W, VOLLMAR B, HILDEBRANDT U, MENGER MD. Effectiveness of a hands-on training course for laparoscopic spine surgery in a porcine model. Surg Endosc 1999: 13: 118. 60. CHO J, KANG GH, KIM EC et al. Comparison of manikin versus porcine models in cricothyrotomy procedure training. Emerg Med J 2008: 25: 732. 61. THOMAS MB, DANDOLU V, CAPUTO P, MILNER R, HERNANDEZ E. Resident education in principles and technique of

bowel surgery using an ex-vivo porcine model. Obstet Gynecol Int. 2010;2010:852647. 62. SNYDER CW, VANDROMME MJ, TYRA SL, PORTERFIELD JR Jr, CLEMENTS RH, HAWN MT. Effects of virtual reality simulator training method and observational learning on surgical performance. World J Surg 2011: 35: 245. 63. PALTER VN, ORZECH N, AGGARWAL R, OKRAINEC A, GRANTCHAROV TP. Resident perceptions of advanced laparoscopic skills training. Surg Endosc 2010: 24: 2830. 64. LA TORRE M, CARUSO C. Resident training in laparoscopic colorectal surgery: role of the porcine model. World J Surg 2012: 36: 2015. doi: 10.1007/s00268-012-1675-0.

15

Do we need animal hands-on courses for transplantation surgery?

Transplantation surgery requires many years of training. This study evaluates and presents the results of our recent four-yr animal hands-on courses o...
193KB Sizes 0 Downloads 0 Views