British JoumalofPlasttc
Suwerv (1991). 44.6548
Video assessment of surgical technique M. F. Stranc, J. G. M. McDiarmid and L. C. Stranc Section of Plastic Surgery, Health Sciences Centre, and Department of Human Genetics, University of Manitoba, Winnipeg, Canada SUMMARY. The surgical technique of nine trainee surgeons, as recorded on videotape, was evaluated under five headings using a scoring system and the results were discussed with them. Six of the trainees were assessed on more than one occasion during their training. All trainees felt that they had benefited from the assessment.
cal applications of the skill being evaluated (see Fig. 1). The mark assigned to each of the individual items in the assessment was weighted primarily with respect to the relative importance of the task to the procedure as a whole, but also taking into account the degree of accuracy with which it could be reliably measured. To facilitate marking, the sections were organised, as far as possible, according to the chronological order in which they were encountered during the operative procedure. Later the resident together with a senior surgeon (MFS) reviewed the videotape and completed the score card (Fig. 1). A detailed description of the apportioning of marks is discussed below.
This study was undertaken in an attempt to provide an objective means of assessing surgical performance from a videotape whilst doing a simple operation. Later a senior surgeon, together with the resident, went over the videotape and evaluated his performance on the basis of five skill categories: planning, manual dexterity, efficiency/economy of movement, communication and concentration. Summing up the marks in each section produced a score out of 100 points. We believe that this provides a useful tool for assessing overall surgical performance and identifying problem areas.
Method
1. Planning Videotapes of nine surgeons working in the Section of Plastic Surgery, University of Manitoba, from 1984 to the present were evaluated. Since the primary aim of this exercise was to hone surgical skills, only minor procedures which the surgeon was felt to be competent to perform were videotaped. All operations were performed under local anaesthesia. In total 20 procedures were assessed, with six individuals evaluated longitudinally. Consent of both the patient and the surgeon was obtained prior to taping. Performance in five categories was evaluated :
If the procedure could have been accomplished more easily had a scrubbed assistant been present, then a surgeon lost marks if he did not elect to have assistance. Similarly, if the appropriate instruments were not on the tray, marks were deducted. If either the patient or the surgeon was positioned in such a way that access to the operative field was cumbersome, a mark was lost. Marks were also deducted if the incision was poorly orientated, demonstrating a lack of knowledge of the anatomy of the area and the procedure to be performed, or if the incision was positioned in such a way that a poor scar would be produced. Performance of the procedure in a logical fashion was allotted 12 points. Marks were lost if the local anaesthetic was not given prior to organising the tray, or if the sutures or dressing were not ready when required, since each of these would result in time being wasted. Marks would also be deducted for any deviation from the logical sequence of events, i.e. if the patient was draped prior to prepping.
(1) Planning-the
degree to which a surgeon had familiarised himself with the procedure he/she was to perform both in terms of the approach he would be using and also his anticipation of future needs both in terms of equipment and personnel (22 marks). (2) Manual dexterity-the degree to which hand-eye co-ordination was demonstrated (47 marks). ability of the surgeon to operate (3) Efficiency-the without wasting moves or materials, thus saving both time and resources (14 marks). (4) Communication (12 marks). (5) Concentration (5 marks).
2. Manual dexterity
Overall performance in each of these areas was determined by gauging the performance of a number of routinely encountered tasks which reflected practi-
(i) Preoperative. Performance in five areas was evaluated: prepping, draping, marking of incision, local anaesthetic infiltration and testing of anaesthesia. 65
66
British Journal of Plastic Surgery VIDEO
EVALUATION
NOTE: If a particular
category was not covered in the procedure performed, i.e. utilisation of nurse/ assistant (section 1), do not score that section and adjust the denominator to calculate the final mark. This does not apply for tasks that were delegated by the surgeon to another team member and were inadequately performed. 1. Planning Pre-op-scrubbed assistant, if necessary -appropriate instruments on tray -patient positioned appropriately -surgeon positioned appropriately -position/orientation of incision
(2 marks) (2 marks) (2 marks) (2 marks) (4 marks)
Procedure carried out in logical order (10 marks) Deduct marks if: -local not injected prior to organising tray and preparing -sutures not prepared for closure (- 2 marks) dressing not ordered/prepared in advance (- 2 marks) -prep before draping (- 2 marks)
sutures (- 2 marks)
~
Subtotal
: -/22
Subtotal:
--/8
Subtotal:
-/lo
Subtotal
: -/6
marks
2. Manual dexterity Pre-op-prepping (1 mark) Araping (2 marks) -precise outlining of incision (1 mark) -local anaesthetic infiltration (3 marks) -testing anaesthesia (1 mark) Incision
-keeping to marked outline (4 marks) depth protection (3 marks) decisive movements (3 marks)
Haemostasis
Wound closure
-whilst cutting (2 marks) -maintenance of pressure -use of cautery (2 marks)
to area during procedure
marks
(2 marks)
-wound edge eversion (2 marks) -wound edge approximation (3 marks) -atraumatic handling of tissues (5 marks) -placement of stitches (2 marks) -suture tension (3 marks) -knot off line of wound (1 mark) -inappropriate no. of stitches (- 1 mark) -inappropriate choice of suture material (- 1 mark) -inappropriate no. of throws and knots for suture material
Maintenance Dressing
marks
used (- I mark) Subtotal:
~ -/16 -/3
of sterile field (3 marks) --covers wound and is securely applied (2 marks) -provides adequate support without restricting blood supply (2 marks) Subtotal
3. Eficiency deftness with which procedure performed (8 marks) -utilisation of nurse/assistant (6 marks) +excessive consumption of disposable materials i.e. gowns/drapes/gloves
marks
marks marks
-
: -/4
marks
(- 1 mark) Subtotal
: -/14
~ marks
Subtotal
: -/12
marks
4. Communication *asy to hear and understand (2 marks) -communication with the team: -adequate verbalisation of needs (4 marks) -communication with patient: *xplanation of procedure (2 marks) -advice about behaviour restrictions following -advice re care for dressing (2 marks)
surgery
(2 marks)
5. Ability to concentrate (5 marks)
-/S TOTAL :
Fig. 1 Figure I-Score
card.
-/lo0
marks marks
Video Assessment of Surgical Technique Marks were deducted if these steps were performed in an over-repetitive or inadequate manner, if an excessive number of towels was used to drape the patient or if the patient was inadequately covered. Marking of the incision was scored highly if a surgeon clearly defined the area to be incised. Anaesthetic infiltration was ideally performed without undue haste and with carefully placed sites of injection to ensure adequate anaesthesia of the entire area. A mark was deducted if the wrong anaesthetic was used or if there was no attempt made to test for adequate anaesthesia before beginning the incision. (ii) Incision. The incision that was performed with a slow, deft stroke while maintaining a constant depth of penetration or plane of dissection was considered to be ideal. Marks were lost if a surgeon did not keep to the marked outline or whose incision consisted of multiple feathery strokes, or if no attempt was made to gauge the depth of the incision. (iii) Haemostasis. Full marks were given to a surgeon who followed behind the blade with gauze, applying pressure to the incision, and who maintained pressure to the area during the procedure. Recognition of the need for cautery and its judicious use was also given marks. Failure to maintain pressure to the wound or the under- or over-enthusiastic use of cautery was also penalised. (iv) Wound closure. High marks were obtained in this category when a satisfactory degree of wound edge eversion and approximation was achieved. Atraumatic handling of the tissues was also considered to be important both in terms of the instrument(s) used and the manner in which the tissues were handled. The number, placement and order of insertion of sutures were evaluated when sutures were used for wound closure. Marks were deducted when too many or too few sutures were used, when the sutures were not appropriately placed or were inserted in an order which did not allow optimal wound edge approximation, i.e. marks would be lost for failing to insert key sutures to produce satisfactory tissue orientation prior to placing less crucial stitches. If sutures were either too lax (gaping wound) or too tight (blanching of the wound edges) then the surgeon was marked down. Marks were lost when the suture knots were not positioned away from the line of the wound, thus making suture removal more difficult. Use of inappropriate suture material or an inappropriate number of throws for that material were also penalised. (v) Maintenance of a sterilefield. Marks were lost for any lapse of sterile technique during the procedure, e.g. unremedied contamination of gloves or drapes. (vi) Dressing. Marks were lost if the dressing used did not cover the wound, provide adequate support without restricting blood supply or was not securely applied. 3. Eficiency This category reflected the ability of the surgeon to operate without wasting moves or materials, thus saving both time and resources.
67 Full marks were scored by the surgeon who demonstrated economy of movement and who delegated tasks to the assistant (when applicable), thus minimising the length of the procedure. Efficiency in the use of time was marked according to the complexity of the procedure, with a relatively more timeconsuming operation being marked more leniently. The surgeon who kept changing his tool for no obvious reason or who showed undue hesitancy in performing any surgical manoeuvre lost marks, and wasted moves also reduced the overall efficiency score. Excessive consumption of disposable materials, i.e. multiple changes of gloves or use of an excessive number of drapes, was marked down since this was not only an unnecessary waste of supplies but also of time (in changing the garment). 4. Communication As the surgeon seldom works alone, communication with the team was determined to be vital. A high score was given where the surgeon’s comments, requests and observations were clear and easily heard. Marks were lost when a surgeon was non-communicative or when his/her speech was indistinct. Communication with the patient was also necessary to obtain a high score: informing him/her what to expect in each successive step of the procedure and giving adequate advice as to postoperative behaviour restrictions and dressing care. 5. Concentration The attention of the surgeon was estimated by observation of the surgeon’s direction of gaze, his/her ability to ignore distractions and his/her ability to complete the task in hand without unnecessary pause or hesitation.
Discussion Observation is the traditional method by which we are trained in surgical technique. Video assessment is a logical extension of this since it permits a surgeon to “take a step back” and both observe and criticise his/ her own performance. It allows more detailed scrutiny than is possible in the operating theatre where constant interruptions or the presence of an individual evaluating the surgeon may have a detrimental effect on performance. Other disciplines and professions have used observation of self as an adjunct to observation of others for many years. Pilots for many of the commercial airlines are videotaped as a matter of routine during their training to evaluate and attempt to improve their response to simulated emergency situations (Bender, 1970; Horner, 1970). Videotape analysis has also been widely applied to improve performance and accelerate the learning process in training for tennis (Miller and Gabbard, 1988), gymnastics (Holt, 1987) and diving (McCormick et al., 1982), to name but a few sports. The potential of this technique to train surgeons
68 had already been recognised by the late 1960s. Goldman et al. wrote several excellent papers describing the advantages of video to teach surgical techniques (Goldman et al., 1969, 1970, 1972). In order to analyse surgical technique successfully, each task performed must be broken down into a series of discrete steps. This approach was demonstrated by Barnes er al. (1989) who dissected fundamental surgical skills into their basic elements of movement. Individuals’ progress can thus be determined by evaluating their performance over time or by comparing their performance of an element against an expected or optimal level of performance. The structured evaluation used in the present study was produced by observations of plastic surgery residents, thus it emphasises those aspects of surgery important to this specialty. For example, the desirability of a good scar is reflected by the number of marks allocated to the placement and production of the incision and its subsequent suturing. It is unlikely that this seemingly straightforward procedure will be analysed in such depth except in this context. All trainees who participated in this study felt that they had benefited from it. We feel that this is, in part, due to the manner in which the videotapes were reviewed : a conscious effort must be made to comment upon tasks that are performed well in addition to pointing out areas for improvement. In most other fields of education there are examinations which allow objective assessment and draw attention to any technical ilaws so that they may be remedied. In surgery there is, as yet, no method of objective assessment of performance in the operating theatre. It is not enough for a surgeon simply to perform written and oral examinations, especially now when we have the technology available to help us perform a more thorough evaluation of the trainee. Conclusion
We believe that videotape analysis of surgical performance provides a very useful adjunct to traditional training methods as it offers the surgeon a unique perspective of his own technique. Poor technique can
British Journal of Plastic Surgery thus be more easily identified and corrected, producing both a shorter learning curve and a more proficient surgeon.
References Barnes, R. W., Lang, N. P. and WhIteside, M. F. (1989). Halsteadian technique revisited : innovations in teaching surgical skills. Ann& ofSurgery, 210,118. Bender, G. (1970). Video training in the airline industry. Educotionul Television, 2, 30. Goldman, L. I., Maier, W. P., Rosemood, G. P., Saltzman, S. W. and
Cramer, L. M. (1969). Teaching surgical technique by the critical review of videotaped performance-the surgical instant replay. Surgery, 66,237. Goldman, L. I., Maier, W. P., SaItznmn, S. W. and Rosentoad, G. P. (1970). Patterns of inefficient operative technique identified by analysis of videotape performance. Current Topics in Surgical Research, 2,545. Goldman, L. I., Saltzman, S. W. and Rosemoral, G. P. (1972).
Television equipment and its application in the learning of surgical skills. Journalof Medical Education, 47, 786. Holt, J. (1987). Video: a tremendous learning aid for any gymnastics program. International Gymnast, January 1987, p. 36. Homer. W. (1970). FinalPilot PerformanceRatinnScales. Pittsbureh: American Institutes for Research in the Behavioral Sciences. _ McCormick, J., Subbaiah, P. and Arnold, H. (1982). A method for identification of some components ofjudging springboard diving. Research Quarterly for Exercise and Sport, 53, 313. Miller, G. and Gabbard, C. (1988). Eff%ts of visual aids on acquisition of selected tennis skills. Perceptual and Motor Skills. 67,603.
The Authors M. F. Straac, FRCS(Jhg), FRCSC, FACS, Head, Section of Plastic
Surgery, Health Sciences Centre, Winnipeg; Professor, University of Manitoba, Winnipeg. J. G. M. McDiannld, Clinical Clerk, University of Aberdeen, Foresterhill, Aberdeen, Scotland. L. C. Strane, BSA, MSe, Research Associate, Department of Human Genetics, University of Manitoba, Winnipeg. Requests for reprints to: Dr M. F. Stranc, GF307 Section of Plastic Surgery, Health Sciences Centre, 820 Sherbrook Street, Winnipeg, Manitoba, Canada R3A lR9. Paper received 6 March 1990. Accepted 26 June 1990.
Suwerv (1991). 44.6548
Video assessment of surgical technique M. F. Stranc, J. G. M. McDiarmid and L. C. Stranc Section of Plastic Surgery, Health Sciences Centre, and Department of Human Genetics, University of Manitoba, Winnipeg, Canada SUMMARY. The surgical technique of nine trainee surgeons, as recorded on videotape, was evaluated under five headings using a scoring system and the results were discussed with them. Six of the trainees were assessed on more than one occasion during their training. All trainees felt that they had benefited from the assessment.
cal applications of the skill being evaluated (see Fig. 1). The mark assigned to each of the individual items in the assessment was weighted primarily with respect to the relative importance of the task to the procedure as a whole, but also taking into account the degree of accuracy with which it could be reliably measured. To facilitate marking, the sections were organised, as far as possible, according to the chronological order in which they were encountered during the operative procedure. Later the resident together with a senior surgeon (MFS) reviewed the videotape and completed the score card (Fig. 1). A detailed description of the apportioning of marks is discussed below.
This study was undertaken in an attempt to provide an objective means of assessing surgical performance from a videotape whilst doing a simple operation. Later a senior surgeon, together with the resident, went over the videotape and evaluated his performance on the basis of five skill categories: planning, manual dexterity, efficiency/economy of movement, communication and concentration. Summing up the marks in each section produced a score out of 100 points. We believe that this provides a useful tool for assessing overall surgical performance and identifying problem areas.
Method
1. Planning Videotapes of nine surgeons working in the Section of Plastic Surgery, University of Manitoba, from 1984 to the present were evaluated. Since the primary aim of this exercise was to hone surgical skills, only minor procedures which the surgeon was felt to be competent to perform were videotaped. All operations were performed under local anaesthesia. In total 20 procedures were assessed, with six individuals evaluated longitudinally. Consent of both the patient and the surgeon was obtained prior to taping. Performance in five categories was evaluated :
If the procedure could have been accomplished more easily had a scrubbed assistant been present, then a surgeon lost marks if he did not elect to have assistance. Similarly, if the appropriate instruments were not on the tray, marks were deducted. If either the patient or the surgeon was positioned in such a way that access to the operative field was cumbersome, a mark was lost. Marks were also deducted if the incision was poorly orientated, demonstrating a lack of knowledge of the anatomy of the area and the procedure to be performed, or if the incision was positioned in such a way that a poor scar would be produced. Performance of the procedure in a logical fashion was allotted 12 points. Marks were lost if the local anaesthetic was not given prior to organising the tray, or if the sutures or dressing were not ready when required, since each of these would result in time being wasted. Marks would also be deducted for any deviation from the logical sequence of events, i.e. if the patient was draped prior to prepping.
(1) Planning-the
degree to which a surgeon had familiarised himself with the procedure he/she was to perform both in terms of the approach he would be using and also his anticipation of future needs both in terms of equipment and personnel (22 marks). (2) Manual dexterity-the degree to which hand-eye co-ordination was demonstrated (47 marks). ability of the surgeon to operate (3) Efficiency-the without wasting moves or materials, thus saving both time and resources (14 marks). (4) Communication (12 marks). (5) Concentration (5 marks).
2. Manual dexterity
Overall performance in each of these areas was determined by gauging the performance of a number of routinely encountered tasks which reflected practi-
(i) Preoperative. Performance in five areas was evaluated: prepping, draping, marking of incision, local anaesthetic infiltration and testing of anaesthesia. 65
66
British Journal of Plastic Surgery VIDEO
EVALUATION
NOTE: If a particular
category was not covered in the procedure performed, i.e. utilisation of nurse/ assistant (section 1), do not score that section and adjust the denominator to calculate the final mark. This does not apply for tasks that were delegated by the surgeon to another team member and were inadequately performed. 1. Planning Pre-op-scrubbed assistant, if necessary -appropriate instruments on tray -patient positioned appropriately -surgeon positioned appropriately -position/orientation of incision
(2 marks) (2 marks) (2 marks) (2 marks) (4 marks)
Procedure carried out in logical order (10 marks) Deduct marks if: -local not injected prior to organising tray and preparing -sutures not prepared for closure (- 2 marks) dressing not ordered/prepared in advance (- 2 marks) -prep before draping (- 2 marks)
sutures (- 2 marks)
~
Subtotal
: -/22
Subtotal:
--/8
Subtotal:
-/lo
Subtotal
: -/6
marks
2. Manual dexterity Pre-op-prepping (1 mark) Araping (2 marks) -precise outlining of incision (1 mark) -local anaesthetic infiltration (3 marks) -testing anaesthesia (1 mark) Incision
-keeping to marked outline (4 marks) depth protection (3 marks) decisive movements (3 marks)
Haemostasis
Wound closure
-whilst cutting (2 marks) -maintenance of pressure -use of cautery (2 marks)
to area during procedure
marks
(2 marks)
-wound edge eversion (2 marks) -wound edge approximation (3 marks) -atraumatic handling of tissues (5 marks) -placement of stitches (2 marks) -suture tension (3 marks) -knot off line of wound (1 mark) -inappropriate no. of stitches (- 1 mark) -inappropriate choice of suture material (- 1 mark) -inappropriate no. of throws and knots for suture material
Maintenance Dressing
marks
used (- I mark) Subtotal:
~ -/16 -/3
of sterile field (3 marks) --covers wound and is securely applied (2 marks) -provides adequate support without restricting blood supply (2 marks) Subtotal
3. Eficiency deftness with which procedure performed (8 marks) -utilisation of nurse/assistant (6 marks) +excessive consumption of disposable materials i.e. gowns/drapes/gloves
marks
marks marks
-
: -/4
marks
(- 1 mark) Subtotal
: -/14
~ marks
Subtotal
: -/12
marks
4. Communication *asy to hear and understand (2 marks) -communication with the team: -adequate verbalisation of needs (4 marks) -communication with patient: *xplanation of procedure (2 marks) -advice about behaviour restrictions following -advice re care for dressing (2 marks)
surgery
(2 marks)
5. Ability to concentrate (5 marks)
-/S TOTAL :
Fig. 1 Figure I-Score
card.
-/lo0
marks marks
Video Assessment of Surgical Technique Marks were deducted if these steps were performed in an over-repetitive or inadequate manner, if an excessive number of towels was used to drape the patient or if the patient was inadequately covered. Marking of the incision was scored highly if a surgeon clearly defined the area to be incised. Anaesthetic infiltration was ideally performed without undue haste and with carefully placed sites of injection to ensure adequate anaesthesia of the entire area. A mark was deducted if the wrong anaesthetic was used or if there was no attempt made to test for adequate anaesthesia before beginning the incision. (ii) Incision. The incision that was performed with a slow, deft stroke while maintaining a constant depth of penetration or plane of dissection was considered to be ideal. Marks were lost if a surgeon did not keep to the marked outline or whose incision consisted of multiple feathery strokes, or if no attempt was made to gauge the depth of the incision. (iii) Haemostasis. Full marks were given to a surgeon who followed behind the blade with gauze, applying pressure to the incision, and who maintained pressure to the area during the procedure. Recognition of the need for cautery and its judicious use was also given marks. Failure to maintain pressure to the wound or the under- or over-enthusiastic use of cautery was also penalised. (iv) Wound closure. High marks were obtained in this category when a satisfactory degree of wound edge eversion and approximation was achieved. Atraumatic handling of the tissues was also considered to be important both in terms of the instrument(s) used and the manner in which the tissues were handled. The number, placement and order of insertion of sutures were evaluated when sutures were used for wound closure. Marks were deducted when too many or too few sutures were used, when the sutures were not appropriately placed or were inserted in an order which did not allow optimal wound edge approximation, i.e. marks would be lost for failing to insert key sutures to produce satisfactory tissue orientation prior to placing less crucial stitches. If sutures were either too lax (gaping wound) or too tight (blanching of the wound edges) then the surgeon was marked down. Marks were lost when the suture knots were not positioned away from the line of the wound, thus making suture removal more difficult. Use of inappropriate suture material or an inappropriate number of throws for that material were also penalised. (v) Maintenance of a sterilefield. Marks were lost for any lapse of sterile technique during the procedure, e.g. unremedied contamination of gloves or drapes. (vi) Dressing. Marks were lost if the dressing used did not cover the wound, provide adequate support without restricting blood supply or was not securely applied. 3. Eficiency This category reflected the ability of the surgeon to operate without wasting moves or materials, thus saving both time and resources.
67 Full marks were scored by the surgeon who demonstrated economy of movement and who delegated tasks to the assistant (when applicable), thus minimising the length of the procedure. Efficiency in the use of time was marked according to the complexity of the procedure, with a relatively more timeconsuming operation being marked more leniently. The surgeon who kept changing his tool for no obvious reason or who showed undue hesitancy in performing any surgical manoeuvre lost marks, and wasted moves also reduced the overall efficiency score. Excessive consumption of disposable materials, i.e. multiple changes of gloves or use of an excessive number of drapes, was marked down since this was not only an unnecessary waste of supplies but also of time (in changing the garment). 4. Communication As the surgeon seldom works alone, communication with the team was determined to be vital. A high score was given where the surgeon’s comments, requests and observations were clear and easily heard. Marks were lost when a surgeon was non-communicative or when his/her speech was indistinct. Communication with the patient was also necessary to obtain a high score: informing him/her what to expect in each successive step of the procedure and giving adequate advice as to postoperative behaviour restrictions and dressing care. 5. Concentration The attention of the surgeon was estimated by observation of the surgeon’s direction of gaze, his/her ability to ignore distractions and his/her ability to complete the task in hand without unnecessary pause or hesitation.
Discussion Observation is the traditional method by which we are trained in surgical technique. Video assessment is a logical extension of this since it permits a surgeon to “take a step back” and both observe and criticise his/ her own performance. It allows more detailed scrutiny than is possible in the operating theatre where constant interruptions or the presence of an individual evaluating the surgeon may have a detrimental effect on performance. Other disciplines and professions have used observation of self as an adjunct to observation of others for many years. Pilots for many of the commercial airlines are videotaped as a matter of routine during their training to evaluate and attempt to improve their response to simulated emergency situations (Bender, 1970; Horner, 1970). Videotape analysis has also been widely applied to improve performance and accelerate the learning process in training for tennis (Miller and Gabbard, 1988), gymnastics (Holt, 1987) and diving (McCormick et al., 1982), to name but a few sports. The potential of this technique to train surgeons
68 had already been recognised by the late 1960s. Goldman et al. wrote several excellent papers describing the advantages of video to teach surgical techniques (Goldman et al., 1969, 1970, 1972). In order to analyse surgical technique successfully, each task performed must be broken down into a series of discrete steps. This approach was demonstrated by Barnes er al. (1989) who dissected fundamental surgical skills into their basic elements of movement. Individuals’ progress can thus be determined by evaluating their performance over time or by comparing their performance of an element against an expected or optimal level of performance. The structured evaluation used in the present study was produced by observations of plastic surgery residents, thus it emphasises those aspects of surgery important to this specialty. For example, the desirability of a good scar is reflected by the number of marks allocated to the placement and production of the incision and its subsequent suturing. It is unlikely that this seemingly straightforward procedure will be analysed in such depth except in this context. All trainees who participated in this study felt that they had benefited from it. We feel that this is, in part, due to the manner in which the videotapes were reviewed : a conscious effort must be made to comment upon tasks that are performed well in addition to pointing out areas for improvement. In most other fields of education there are examinations which allow objective assessment and draw attention to any technical ilaws so that they may be remedied. In surgery there is, as yet, no method of objective assessment of performance in the operating theatre. It is not enough for a surgeon simply to perform written and oral examinations, especially now when we have the technology available to help us perform a more thorough evaluation of the trainee. Conclusion
We believe that videotape analysis of surgical performance provides a very useful adjunct to traditional training methods as it offers the surgeon a unique perspective of his own technique. Poor technique can
British Journal of Plastic Surgery thus be more easily identified and corrected, producing both a shorter learning curve and a more proficient surgeon.
References Barnes, R. W., Lang, N. P. and WhIteside, M. F. (1989). Halsteadian technique revisited : innovations in teaching surgical skills. Ann& ofSurgery, 210,118. Bender, G. (1970). Video training in the airline industry. Educotionul Television, 2, 30. Goldman, L. I., Maier, W. P., Rosemood, G. P., Saltzman, S. W. and
Cramer, L. M. (1969). Teaching surgical technique by the critical review of videotaped performance-the surgical instant replay. Surgery, 66,237. Goldman, L. I., Maier, W. P., SaItznmn, S. W. and Rosentoad, G. P. (1970). Patterns of inefficient operative technique identified by analysis of videotape performance. Current Topics in Surgical Research, 2,545. Goldman, L. I., Saltzman, S. W. and Rosemoral, G. P. (1972).
Television equipment and its application in the learning of surgical skills. Journalof Medical Education, 47, 786. Holt, J. (1987). Video: a tremendous learning aid for any gymnastics program. International Gymnast, January 1987, p. 36. Homer. W. (1970). FinalPilot PerformanceRatinnScales. Pittsbureh: American Institutes for Research in the Behavioral Sciences. _ McCormick, J., Subbaiah, P. and Arnold, H. (1982). A method for identification of some components ofjudging springboard diving. Research Quarterly for Exercise and Sport, 53, 313. Miller, G. and Gabbard, C. (1988). Eff%ts of visual aids on acquisition of selected tennis skills. Perceptual and Motor Skills. 67,603.
The Authors M. F. Straac, FRCS(Jhg), FRCSC, FACS, Head, Section of Plastic
Surgery, Health Sciences Centre, Winnipeg; Professor, University of Manitoba, Winnipeg. J. G. M. McDiannld, Clinical Clerk, University of Aberdeen, Foresterhill, Aberdeen, Scotland. L. C. Strane, BSA, MSe, Research Associate, Department of Human Genetics, University of Manitoba, Winnipeg. Requests for reprints to: Dr M. F. Stranc, GF307 Section of Plastic Surgery, Health Sciences Centre, 820 Sherbrook Street, Winnipeg, Manitoba, Canada R3A lR9. Paper received 6 March 1990. Accepted 26 June 1990.
