Metric-Based Simulation Training

Abstract

Computer-based simulation has several advantages when compared with conventional methods for surgical training. One major advantage is that the same experience or sequence of events can be replicated repeatedly. This repetition allows the trainee to learn from mistakes in a safe environment. Another benefit which is probably of equal if not more omportance is the objective feedback a trainee can receive. Since everything a trainee “does” on a computer-based simulator is essentially data, all actions can be tracked.

Appendix: Emory VR to OR Lap. Chole. Procedure-Related Definitions for Master Study

Exposure

Exposure Starts: Once fundus is stable

Exposure Ends: When clip appears

Exposure Errors

Lack of Progress – Absolutely no progress is made for an entire minute. Each minute spent dealing with the consequences of a predefined error represents lack of progress and should be evaluated as such.

Burn Non-target tissue – Any application of electrocautery to nontarget tissue.

Non-target structure injury – There is a perforation or tear of a non-target structure (i.e. liver, bowel, common duct) with or without associated bleeding or bile leakage. Injury in this instance does not include electrocautery along the surface, as this would be classified as burning non-target tissue.

Instrument out of view – A dissecting instrument with cautery capability is placed outside the field of view of the telescope such that the tip is unviewable. An instrument will be considered to have cautery capabilities at the moment that cautery is applied to tissue and at all times thereafter until the instrument is changed. Hook instruments are an exception in that they are considered to always have cautery capabilities. No error will be attributed to an incident of an instrument out of view as the result of a sudden telescope movement.

Attending takeover – The supervising attending surgeon takes the dissecting instrument or retracting instrument from the resident and performs a component of the procedure. The error occurs throughout the entire period the attending has control and each interval during this period will evaluated as such. The error ends once the resident resumes control of the instrument(s).

Gallbladder injury – There is gallbladder wall perforation with or without leakage of bile.

Cystic duct injury – There is a perforation or tear of the cystic duct indicated by leakage of bile.

Cystic artery injury – There is a perforation or tear of the cystic artery indicated by hemorrhage. Scoring continues until the hemorrhage is arrested. If a clip is applied, it is applied safely and appropriately, otherwise it is considered an error for the interval it was placed.

Inappropriate dissection – Dissection is conducted such that either (1) tearing of tissue occurs during dissection within the triangle of Calot, or (2) the plane of dissection within the triangle extends to include areas along the common bile duct.

Incorrect angle of gallbladder retraction – Retraction of gallbladder is provided such that dissection proceeds within an inadequately distracted, or “closed” Triangle of Calot prior to fenestration of triangle window.

Dropped retraction – Retracted tissue is suddenly dropped. Errors are counted only if re-grasping and retraction along a similar angle are subsequently required.

Clipping/Tissue Division

Note:

• 1. Given that total clipping time may take less that 1 min, scoring intervals for this segment will be event driven. Each clip placement will be considered a separate event. Additionally the transection of the cystic artery and the cystic duct will be considered separate events.

• 2. If the cystic artery, or cystic duct are not exposed together prior to clipping and tissue division of each respective structure, the clip/tissue division evaluation will proceed for the exposed structure, followed by a continuation of the exposure evaluation until the unexposed structure is prepared (i.e. if the cystic artery is clipped prior to cystic duct exposure, the cystic artery clipping and division will be evaluated until transection of tissue occurs, then the exposure evaluation will continue until a clip designated for the cystic duct appears).

Clipping Start: The appearance of the clip

Clipping End: Once clip is placed

Tissue Division Start: The appearance of shears

Tissue Division End: Transection of tissue

General Errors (applies to both clipping and transection)

Attending takeover – The supervising attending surgeon takes the dissecting instrument or retracting instrument from the resident and performs a component of the procedure. The error occurs throughout the entire period the attending has control and each interval during this period will evaluated as such. The error ends once the resident resumes control of the instrument(s).

Clipping Application Errors

Clip overlap – Clip placed on previously placed clip.

Clip spacing error – Less than 1 mm spacing between distal porta and proximal gallbladder clips.

Poor clip orientation – Clip placed >10° from perpendicular as oriented to cystic duct or cystic artery after clip applier is removed.

Partial closure – Partial closure of cystic artery or duct (clip does not completely cross structure).

Poor Application – Clip is applied such that it is (1) incompletely closed, (2) scissored or (3) requires re-grasp manipulation.

Poor visualization – Clip applied without visualization of the tip of the clip applier.

Non-target tissue clipped – Clip applied to non-target tissue caught in closed tip outside cystic duct or cystic artery.

Clip drop – Clip comes out of clip applier prior to application. Application occurs once any part of the structure being clipped is within the jaws of the clip applier.

Tissue Division Errors

Inappropriate division – Cut less than 1 mm to nearest porta side clip.

Clip cutting – Scissors closure on clip.

Nontarget injury – Cut nontarget tissue.

Dissection

Dissection Start: Appearance of hook cautery instrument

Dissection End: Gallbladder is free from liver bed

Dissection Errors

Lack of Progress – No progress is made for an entire minute of the dissection. Each minute spent dealing with the consequences of a predefined error represents lack of progress and should be evaluated as such.

Burn Nontarget tissue – Any application of electrocautery to nontarget tissue with the exception of the final part of the fundic dissection where some current transmission may occur.

Instrument out of view – The dissecting instrument is placed outside the field of view of the telescope such that the tip is unviewable. No error will be attributed to an incident of an instrument out of view as the result of a sudden telescope movement.

Attending takeover – The supervising attending surgeon takes the dissecting instrument or retracting instrument from the resident and performs a component of the procedure. The error occurs throughout the entire period the attending has control and each interval during this period will evaluated as such. The error ends once the resident resumes control of the instrument(s).

Gallbladder injury – There is gallbladder wall perforation with or without leakage of bile.

Liver injury – There is liver capsule and parenchyma penetration, or capsule stripping with or without associated bleeding.

Incorrect plane of dissection – The dissection is conducted outside the recognized plane between the gallbladder and the liver (i.e. in the submucosal plane on the gallbladder, or subcapsular plane on the liver).

Tearing tissue – Uncontrolled tearing of tissue with the dissecting or retracting instrument.