Advances in Pediatric Surgical Education: A Critical Appraisal of Two Consecutive Minimally Invasive Pediatric Surgery Training Courses

Abstract

Background:

Mandates for improved patient safety and increasing work hour restrictions have resulted in changes in surgical education. Educational courses increasingly must meet those needs. We sought to determine the experience, skill level, and the impact of simulation-based education (SBE) on two cohorts of pediatric surgery trainees.

Materials and Methods:

After Institutional Review Board (IRB) exempt determination, a retrospective review was performed of evaluations for an annual advanced minimally invasive surgery (MIS) course over 2 consecutive years. The courses included didactic content and hands-on skills training. Simulation included neonatal/infant models for rigid bronchoscopy-airway foreign body retrieval, laparoscopic common bile duct exploration, and real tissue diaphragmatic hernia (DH), duodenal atresia (DA), pulmonary lobectomy, and tracheoesophageal fistula models. Categorical data were analyzed with chi-squared analyses with t-tests for continuous data.

Results:

Participants had limited prior advanced neonatal MIS experience, with 1.95 ± 2.84 and 1.16 ± 1.54 prior cases in the 2014 and 2015 cohorts, respectively. The 2015 cohort had significantly less previous experience in lobectomy (P = .04) and overall advanced MIS (P = .007). Before both courses, a significant percentage of participants were not comfortable with DH repair (39%–42%), DA repair (50%–74%), lobectomy (34%–43%), and tracheoesophageal fistula repair (54%–81%). After course completion, > 60% of participants reported improvement in comfort with procedures and over 90% reported that the course significantly improved their perceived ability to perform each operation safely.

Conclusion:

Pediatric surgery trainees continue to have limited exposure to advanced MIS during clinical training. SBE results in significant improvement in both cognitive knowledge and trainee comfort with safe operative techniques for advanced MIS.

Introduction

Pediatric surgery trainees are at risk of insufficient exposure to advanced neonatal minimally invasive surgery (MIS) and endoscopy during training, particularly for rare index cases (e.g., esophageal atresia with tracheoesophageal fistula) specific to the field. The Accreditation Council for Graduate Medical Education (ACGME) defined category minimum numbers for Pediatric Surgery require a trainee to perform, among others, only six diaphragmatic hernia (DH) repairs, five esophageal atresia-tracheoesophageal fistula repairs, five lung resections, and five intestinal atresia repairs.¹ The ACGME National case log data of pediatric surgery trainees show that, for many procedures, these minimums are barely met. For example, the most recent graduating pediatric surgery trainees reported a median of 10 and minimum of four esophageal atresia–tracheoesophageal fistula repairs.² Depending on the trainee's access to faculty who are comfortable with and experienced in advanced thoracoscopy and laparoscopy, many will receive little to no exposure to minimally invasive treatment of these disorders. A recent study of self-reported annual case logs from board-certified practicing pediatric surgeons suggests that exposure after training remains limited, with reported annual medians of one esophageal atresia–tracheoesophageal fistula repair, one lung resection, one congenital DH repair, and two intestinal atresia repairs.³

Simulation-based education (SBE) seeks to recreate a specific clinical experience as accurately as possible, allowing deliberate practice (DP) while eschewing the inherent risk to the patient. SBE curricula provide the opportunity for trainees to improve cognitive performance and technical skills to gain or maintain proficiency in a procedure or operation. Importantly, SBE allows for DP in domain-specific tasks, which better translates to superior performance than merely experience, education, knowledge, and traditional clinical education.^4,5 Numerous studies have shown that participation in SBE results in improvement in skills assessments,^6–9 operative performance,^10–12 patient care outcomes,¹³ and cost.¹⁴ These findings have been confirmed in systematic reviews^15–18 and meta-analyses.^5,19

For more than 20 years, an annual advanced MIS course has been held for pediatric surgery trainees, hosted by a diverse group of pediatric surgery faculty passionate about minimally invasive surgical education. The course includes a combination of didactic sessions to improve cognitive knowledge followed by manual skills training using simulation models under the proctored guidance of faculty surgeons. Simulation models include synthetic neonatal rigid bronchoscopy with foreign body (FB) removal, synthetic laparoscopic common bile duct exploration (LCBDE) with choledocholith removal, and real tissue esophageal atresia with distal tracheoesophageal fistula (EA/TEF), pulmonary lobectomy for the left lower lobe, DH, and duodenal atresia (DA) models. Evaluations were distributed to participants after the 2014 and 2015 courses. We sought to determine participant self-reported experience and skill level while evaluating the impact of the course on participant comfort and perceived skill level. We hypothesized that participants would report minimal previous exposure to minimally invasive neonatal surgery and improvements in comfort after course completion.

Materials and Methods

Study settings and participants

After review and Institutional Review Board (IRB) exempt determination by Ann & Robert Lurie Children's Hospital of Chicago (IRB No.: 2014-15536), we conducted a retrospective review of evaluations collected during an advanced minimally invasive simulation course for senior pediatric surgery residents in September of 2014 and 2015. Participants were provided educational materials before the course. The 2-day course includes a combination of didactic content and hands-on simulation. The didactic portion of the course focused on minimally invasive approaches to index neonatal and infant anomalies, including esophageal atresia with distal tracheoesophageal atresia, infant lobectomy for congenital pulmonary malformations, DH, DA, and choledochal cyst. At the end of the 3-hour didactic portion of the course, participants presented to the simulation laboratory for a 4-hour proctored DP session for thoracoscopic EA/TEF, pulmonary lobectomy and DH, and laparoscopic DA, followed by a second 3-hour proctored DP session the following day, focusing on LCBDE and rigid bronchoscopy for airway FB.

Simulators

Thoracoscopic esophageal atresia with distal tracheoesophageal fistula

As previously described, a neonatal rib cage (right side) of acrylonitrile–butadiene–styrene was generated using a fused-deposition three-dimensional printer and secured to a silicone base.^20,21 A mediastinal block of second-trimester fetal bovine tissue was surgically modified to create a type C tracheoesophageal fistula (proximal atresia, distal fistula), with preservation of the vagus nerve and pleural integrity, and was positioned in the simulator. The model was then covered with a synthetic skin overlay. Participants were provided with 3-mm instruments and a 4-mm telescope to complete the EA/TEF repair. The only relevant anatomic difference in this model is the lack of azygous vein.

Thoracoscopic lobectomy

A neonatal rib cage (left side) was generated as above. A mediastinal block was surgically modified through injection of the left pulmonary artery and vein with blood substitute (dilute ketchup), as previously described,^22,23 positioned in the simulator, and covered with synthetic skin. Participants were provided with 3-mm instruments, a 4-mm telescope, and a 3-mm vascular sealing device to complete a left lower lobe lobectomy. The anatomic relationships of bovine vessels and bronchi are very similar to infant anatomy, with the exception of the lack of a complete major fissure.

Thoracoscopic DH

A neonatal rib cage (left side) was generated as above with a space for a slide insert at the anatomically most caudal position. Bovine diaphragm tissue was placed between two plastic semicircular inserts with interlocking teeth and positioned in the model with the esophageal hiatus in a posterolateral position, simulating a Bochdalek congenital DH. Bovine small and large bowels were herniated through the defect into the left hemithorax. The model was then covered with synthetic skin. Participants were provided with 3-mm instruments and a 4-mm telescope to complete reduction of herniated bowel through the defect and primary closure of a DH.

Laparoscopic DA repair simulator

The base of the simulator is generated as previously described, using the lower half of a neonatal rib cage, then adding a pelvis and stabilizing base.²⁴ An abdominal block of tissue (spleen, four-compartment stomach, duodenum, small and large intestine, liver, and pancreas) was surgically modified to fit the space of the simulator. The tissue was then secured in a configuration consistent with a type III DA, and covered with synthetic skin. Participants were provided with 3-mm instruments and a 4-mm telescope to complete a laparoscopic duodenoduodenostomy.

Laparoscopic common bile duct exploration

The laparoscopic common bile duct (CBD) simulator is a self-contained model of the liver, gallbladder, extrahepatic biliary tree, and duodenum. It is constructed with a combination of different synthetic materials, including a latex and polyvinyl chloride CBD, which are placed into a standard Fundamentals of Laparoscopic Surgery (FLS) box trainer utilizing the FLS camera to simulate a laparoscopic view. A second video camera system provides a simulated real-time fluoroscopic view of the biliary tree utilizing a mirror system that is displayed on a second monitor and is controlled by a foot pedal. A fiberoptic or video choledocoscope provides an endoscopic view that can be displayed in a “picture in picture” fashion in conjunction with the laparoscopic view on a single monitor. Participants are then provided with the necessary laparoscopic instruments and endoscopic equipment to perform a complete transcystic LCBDE with choledocoscopy to retrieve a simulated stone from the CBD. The laparoscopic CBD simulator was available for the 2015 course only.

Endoscopic FB removal

The rigid bronchoscopy-airway FB retrieval simulator consists of a SimNewB Neonatal Simulator for the oropharynx attached to a three-dimensional tracheobronchial airway composed of a rubber/plastic composite based on computed tomography images of an 18-month-old infant. Participants were provided with standard pediatric laryngoscopes and rigid bronchoscopy instruments and a disposable ureteral stone retrieval basket to retrieve a peanut particle and 5 mm plastic bead from within the airway. The laparoscopic CBD simulator was available for the 2015 course only.

Evaluations

Participants completed self-reported surveys before the course and after course completion. The 2014 precourse survey consisted of 21 items; 4 questions regarding the participant's advanced neonatal MIS experience (thoracoscopic EA/TEF repair, thoracoscopic lobectomy, thoracoscopic DH repair, and laparoscopic DA repair), and 17 questions about the participant's comfort level with a particular technique or procedure (not comfortable; somewhat comfortable, or very comfortable). The 2014 postcourse survey consisted of 27 items; 13 questions to determine if the participant improved in a particular area of interest (did not practice, practiced, comfort level not improved; or practiced, comfort level improved), 10 questions evaluating the importance of course aspects (most important, second most important, and third most important) and how well the course met expectations (did not meet my needs/expectations, met some of my needs/expectations, or met many of my needs/expectations), and 4 questions to determine how likely a participant is to perform a procedure (unlikely, somewhat likely, or very likely).

The 2015 precourse survey consisted of 30 items; six questions regarding the participant's prior advanced neonatal MIS experience (with the addition of LCBDE and rigid bronchoscopy for airway FB), and 24 questions about the participant's comfort level with a particular technique or procedure. The 2015 postcourse survey consisted of 27 items; 14 questions to determine if the participant improved in a particular area of interest, one question to determine if the course met expectations, four write-in spots for participants to answer prompts (Which of your education needs did we not meet in this course?, Which of your education needs did we meet in this course?, Would you recommend your fellowship continue to allow subsequent fellows to attend?, and What changes would you recommend for next year's course?) and eight questions to determine if the course materials and hands-on skills laboratories improved the participant's ability to perform a procedure more safely at his or her home institution.

Statistical analyses

Continuous data, including number of prior operations, were analyzed with the Student's t-test. Categorical data were analyzed with chi-squared test or Fisher's exact test, where appropriate. A P value less than .05 was considered statistically significant. Statistical analyses were performed using Stata version 13.0 (StataCorp LP, College Station, TX).

Results

Prior neonatal and infant MIS experience

Twenty-seven participants completed surveys in 2014, and 33 participants completed surveys in 2015. Prior advanced MIS experienced was limited, with mean case numbers ranging from 0.4 ± 0.6 (laparoscopic DA repair) to 3.8 ± 3.9 (thoracoscopic lobectomy). The 2015 cohort had significantly less experience with thoracoscopic lobectomy when compared with 2014 trainees, at 2.1 ± 1.9 versus 3.8 ± 3.9 cases, respectively (P = .04) and with overall advanced neonatal MIS (P = .007). The number of prior EA/TEF repairs, DH repairs, and DA repairs did not differ between groups (Table 1).

Table 1.

Participant Pediatric Minimally Invasive Surgery Experience

	2014	2015	P
Thoracoscopic EA/TEF repair	0.85 ± 1.06	0.59 ± 1.07	.36
Thoracoscopic lobectomy	3.78 ± 3.93	2.09 ± 1.89	.04
Thoracoscopic DH repair	2.3 ± 2.89	1.5 ± 1.67	.19
Laparoscopic DA repair	0.89 ± 1.48	0.44 ± 0.62	.12
Laparoscopic CBD exploration	—	0.47 ± 1.63	—
Rigid bronchoscopy for airway FB	—	4.09 ± 5.7	—

CBD, common bile duct; DA, duodenal atresia; DH, diaphragmatic hernia; EA/TEF, esophageal atresia/tracheoesophageal fistula; FB, foreign body.

Precourse comfort level with knowledge relating to and performing procedure

Before the course, participants self-reported a range of cognitive knowledge of anesthetic and/or anatomic factors related to each procedure and comfort in performing a particular procedure in 2014 and 2015. The majority of participants were comfortable with their MIS skills, with most reporting somewhat comfortable with “tying an intracorporeal knot under tension” (2014: 63.0%; 2015: 62.5%) and “energy selection for neonatal & infant MIS” (2014: 59.3%; 2015: 71.9%). Participants in 2014 were more likely to report being very comfortable versus somewhat comfortable or not comfortable with “instrument selection for neonatal and infant MIS” than 2015 participants [2014: 18/27 (66.7%) versus 2015: 12/32 (37.5%); P = .05] (Table 2).

Table 2.

Knowledge and Comfort with Minimally Invasive Surgery Procedure or Technique Before Course

	2014	2015	P
Tying intracorporeal knot under tension, n (%)			.48
Very comfortable	5 (18.5)	9 (28.1)
Somewhat comfortable	17 (63)	20 (62.5)
Not comfortable	5 (18.5)	3 (9.4)
Energy selection for neonatal and infant MIS, n (%)			.59
Very comfortable	9 (33.3)	8 (25)
Somewhat comfortable	16 (59.3)	23 (71.9)
Not comfortable	2 (7.4)	1 (3.1)
Instrument selection for neonatal and infant MIS, n (%)			.06
Very comfortable	18 (66.7)	12 (37.5)
Somewhat comfortable	8 (29.6)	18 (56.3)
Not comfortable	1 (3.7)	2 (6.3)
Thoracoscopic EA/TEF, n (%)
Knowledge of anesthetic concerns			N/A
Very comfortable	—	6 (18.8)
Somewhat comfortable	—	16 (50)
Not comfortable	—	10 (31.3)
Port locations for thoracoscopic TEF repair, n (%)			.24
Very comfortable	4 (14.8)	1 (3.2)
Somewhat comfortable	11 (40.7)	12 (38.7)
Not comfortable	12 (44.4)	18 (58.1)
EA/TEF repair			.07
Very comfortable	1 (3.8)	1 (3.2)
Somewhat comfortable	11 (42.4)	5 (16.1)
Not comfortable	14 (53.8)	25 (80.6)
Thoracoscopic lobectomy, n (%)
Knowledge of pulmonary anatomy			N/A
Very comfortable	—	1 (3.2)
Somewhat comfortable	—	19 (61.3)
Not comfortable	—	11 (35.5)
Port locations for thoracoscopic lobectomy			.29
Very comfortable	3 (11.1)	2 (6.5)
Somewhat comfortable	14 (51.9)	23 (74.2)
Not comfortable	9 (33.3)	6 (19.4)
Thoracoscopic lobectomy			.16
Very comfortable	4 (15.4)	1 (3.1)
Somewhat comfortable	11 (42.3)	20 (62.5)
Not comfortable	11 (42.3)	11 (34.4)
Thoracoscopic diaphragmatic hernia, n (%)
Techniques to reduce recurrence			N/A
Very comfortable	—	0 (0)
Somewhat comfortable	—	12 (38.7)
Not comfortable	—	19 (61.3)
Port locations for DH repair			.43
Very comfortable	7 (25.9)	4 (12.9)
Somewhat comfortable	12 (44.4)	14 (45.2)
Not comfortable	8 (3.7)	13 (41.9)
Thoracoscopic DH repair			.66
Very comfortable	7 (26.9)	5 (16.2)
Somewhat comfortable	9 (34.6)	13 (41.9)
Not comfortable	10 (38.5)	13 (41.9)
Laparoscopic DA repair, n (%)
Laparoscopic Ladd's procedure			N/A
Very comfortable	—	6 (18.8)
Somewhat comfortable	—	15 (46.8)
Not comfortable	—	11 (34.4)
Performing laparoscopic Ladd's if malrotation coexists			N/A
Very comfortable	—	3 (9.7)
Somewhat comfortable	—	12 (38.7)
Not comfortable	—	16 (51.6)
Port locations for laparoscopic DA repair			.14
Very comfortable	4 (14.8)	1 (3.2)
Somewhat comfortable	12 (44.4)	10 (32.3)
Not comfortable	11 (40.7)	20 (64.5)
Laparoscopic DA repair			.07
Very comfortable	3 (11.5)	1 (3.2)
Somewhat comfortable	10 (38.5)	7 (22.6)
Not comfortable	13 (50)	23 (74.2)
Laparoscopic CBD exploration, n (%)			N/A
Very comfortable	—	0 (0)
Somewhat comfortable	—	13 (40.6)
Not comfortable	—	19 (59.4)
Retrieval of airway FB with rigid bronchoscope			N/A
Very comfortable	—	10 (31.2)
Somewhat comfortable	—	11 (34.4)
Not comfortable	—	11 (34.4)

CBD, common bile duct; DA, duodenal atresia; DH, diaphragmatic hernia; EA/TEF, esophageal atresia/tracheoesophageal fistula; FB, foreign body; MIS, minimally invasive surgery; TEF, tracheoesophageal fistula.

Participant procedure-specific comfort was limited before the course, with > 80% of participants reporting being only somewhat comfortable or not comfortable with “knowledge of anesthetic concerns for EA/TEF” (2015 only), “port locations for thoracoscopic EA/TEF repair,” “EA/TEF repair,” “knowledge of pulmonary anatomy” (2015 only), “port locations for thoracoscopic lobectomy,” “thoracoscopic lobectomy,” “techniques to reduce recurrence for thoracoscopic DH,” “port locations for DH repair,” “thoracoscopic DH repair,” “laparoscopic Ladd's procedure,” “port locations for laparoscopic DA repair,” “laparoscopic DA repair,” “laparoscopic CBD exploration,” and “retrieval of airway FB with a rigid bronchoscope” (Table 2). Importantly, only 3.2% of participants reported being very comfortable with basic knowledge of pulmonary anatomy, and no participants reported being very comfortable with techniques to reduce recurrence after thoracoscopic DH repair.

Postcourse results

Over 60% of participants reported improvement (somewhat improved or markedly improved) in knowledge and comfort with a particular technique in each measured aspect of the course. The most notable improvements in comfort were seen in “techniques to reduce recurrence after thoracoscopic DH repair” (2015: 100%), “port locations for thoracoscopic DH repair” (2014: 89.7%; 2015: 96.6%), “knowledge of anesthetic concerns for thoracoscopic EA/TEF repair” (2015: 96.6%), “port locations for thoracoscopic EA/TEF” (2014: 89.7%; 2015: 96.6%), “techniques for CBD exploration” (2015: 96.6%), “port locations for laparoscopic DA repair” (2014: 86.2%, 2015: 96.4%) and “techniques for retrieval of airway FB” (2015: 93.1%). Where applicable, these differences were not statically significant between groups (Table 3).

Table 3.

Participant-Reported Cognitive and Skills Improvement After Course Completion

	2014	2015	P
Tying an intracorporeal knot under tension	21/24 (87.5)	24/29 (82.8)	.72
Energy selection for neonatal and infant MIS	14/22 (63.6)	20/29 (69)	.77
Instrument selection for neonatal and infant MIS	19/23 (82.6)	26/29 (89.7)	.69
EA/TEF repair
Knowledge of anesthetic concerns for thoracoscopic EA/TEF	—	28/29 (96.6)	N/A
Port locations for thoracoscopic EA/TEF	26/29 (89.7)	28/29 (96.6)	.61
Thoracoscopic lobectomy
Knowledge of pulmonary anatomy	—	24/29 (82.8)	N/A
Port locations	25/29 (86.2)	27/29 (93.1)	.67
Thoracoscopic DH repair
Techniques to reduce recurrence	—	29/29 (100)	N/A
Port locations	26/29 (89.7)	28/29 (96.6)	.61
Laparoscopic DA repair
Port locations	25/29 (86.2)	27/28 (96.4)	.35
Laparoscopic CBD exploration
Techniques for CBD exploration in adolescents	—	28/29 (96.6)	N/A
Retrieval of airway FB with rigid bronchoscope
Knowledge of instrumentation and assembly	—	26/29 (89.7)	N/A
Techniques for retrieval of airway FB	—	27/29 (93.1)	N/A

CBD, common bile duct; DA, duodenal atresia; DH, diaphragmatic hernia; EA/TEF, esophageal atresia/tracheoesophageal fistula; FB, foreign body; MIS, minimally invasive surgery.

Impact of course on the ability to perform operations safely

Participants in the 2015 cohort were asked to report what impact the course had on their ability to perform the associated operations safely at their home institution. The vast majority reported markedly improved or somewhat improved ability, with less than 10% reporting no improvement, and no participants reporting no improvement for thoracoscopic DH repair (Table 4).

Table 4.

Impact of Course on Perceived Ability to Perform Operations Safely (2015)

	Markedly improved	Somewhat improved	Not improved
Thoracoscopic EA/TEF repair	11/23 (47.8)	12/23 (52.2)	0/23 (0)
Thoracoscopic lobectomy	9/23 (39.1)	13/23 (56.5)	1/23 (4.4)
Thoracoscopic DH repair	14/23 (60.9)	9/23 (39.1)	0/23 (0)
Laparoscopic DA repair	15/23 (65.2)	7/23 (30.4)	1/23 (4.4)
Laparoscopic CBD exploration	17/23 (73.9)	4/23 (17.4)	2/23 (8.7)
Rigid bronchoscopy for airway FB	13/22 (56.5)	8/22 (34.8)	2/22 (8.7)

CBD, common bile duct; DA, duodenal atresia; DH, diaphragmatic hernia; EA/TEF, esophageal atresia/tracheoesophageal fistula; FB, foreign body.

Discussion

We present participant survey results from an annual advanced MIS course over 2 consecutive years. Participants included senior pediatric surgery trainees with more than 12 months of pediatric surgery training experience. Pediatric surgery residents undergoing 2 years of training after completion of general surgery before becoming board certified and entering practice. Despite years of surgical education, we found that participants had minimal advanced neonatal MIS experience. The average participant had previously completed < 1 thoracoscopic EA/TEF repair, < 1 laparoscopic DA repair, < 3 thoracoscopic DH repairs, and < 4 thoracoscopic lobectomies. Notably, the 2015 cohort had less experience with thoracoscopic lobectomy than the 2014 cohort. Whether this is due to disrupted historical referral patterns, changes in disease incidence, or trainee representation at each course, remain unclear.

Participants reported a notable lack of knowledge and comfort with the majority of advanced MIS procedures before the course. The highest comfort level was noted with basic techniques and instrument selection rather than in procedure-specific variables. Of notable concern is the fact that less than 5% of participants reported being very comfortable with “knowledge of pulmonary anatomy” (2015). This finding strongly suggests that curricula for even our advanced learners must continue to focus on anatomic relationships for normal anatomy, in addition to those of aberrant anatomy.

In each domain, the 2015 cohort reported less baseline knowledge and comfort than the 2014 cohort. This finding may be due to a selection bias of less experienced residents choosing to attend the course, compared with those trainees with extensive experience. It may also reflect normal variability among different participant groups. Only with continued longitudinal data collection can trends be accurately reported. Overall, 80% of participants reported cognitive and skills improvement across all procedures, with 100% reporting improved knowledge for “techniques to reduce recurrence” in thoracoscopic DH repair. These self-reported improvements correlated with participant's perceived ability to perform each operation safely at his or her home institution, with > 90% reporting either markedly improved or somewhat improved across all procedures practiced in the laboratory.

This annual pediatric surgery training course seeks to provide exposure to advanced minimally invasive neonatal surgery to trainees who have a baseline understanding of these disease processes, and experience with open surgical techniques. The participation of leading national experts in neonatal MIS allows trainees to discuss specific tips, tricks, and approaches to these diseases that they may not otherwise have access to in their home institution. Understanding that this is an exposure course, the principles of SBE dictate that isolated experience is not as effective as DP for gaining expertise in a particular procedure. Studies related to task mastery suggest that expert performance is related not to isolated exposure or practice alone, but to active engagement in DP focused on a specific task. DP involves feedback, time allocated for problem solving, and opportunities for repeat performance to improve. Importantly, expertise does not automatically develop from experience and education alone, further emphasizing the importance of DP in SBE.^4,25 In this course, trainees learn specific skills that can then be taken to their home institution and implemented in the care of their patients, as well as included in any available DP SBE curricula.

Few data exist to support an isolated training event and its ability to affect clinical performance and patient outcomes. However, systematic reviews and meta analyses have confirmed that skills learned during surgical simulation translate to the operating room. Sturm et al., analyzing 10 randomized controlled trials (RCTs) and one nonrandomized comparative study, found that simulation in laparoscopic cholecystectomy and colonoscopy/sigmoidoscopy resulted in improvement in some parameters in the operative setting,¹⁵ whereas Schmidt et al., analyzing 38 studies found that while simulation did not affect operative time, accuracy was improved.¹⁶ Buckley et al., analyzing 16 RCTs, found that operative time consistently improved after training, with better performance indicators in all trials, of which 88% were statistically significant.¹⁷ Dawe et al., reviewing 27 RCTs and 7 non-RCT comparative studies, noted strong evidence that participants who reached proficient status in simulation performed better in patient-based settings than those who did not.¹⁸ McGaghie et al., in review of 14 publications, found that the overall effect size when comparing SBE with traditional clinical education was 0.71 (P < .001), concluding that SBE with DP is superior to traditional clinical education in achieving specific acquisition goals,⁵ and Cook evaluated SBE for health professionals when compared with no intervention, and found that while data supporting SBE existed as early as 1973 that evidence supporting SBE was statistically significant by 2004.¹⁹ Although the data obtained during these annual courses are insufficient for analysis of the effect of simulation on participant skills and patient outcomes, these data are critical for the ongoing revision and revamping of courses designed to expose trainees to new neonatal minimally invasive techniques.

There are several limitations related to the interpretation of the data presented in this study. First, these data were collected during an annual pediatric surgery simulation course offered to senior pediatric surgery trainees in the United States and Canada. Although participants did not self-identify on the surveys, we, nonetheless, cannot know if there exists an acquiescent bias, that is, a tendency for participants to indicate a positive connotation, particularly considering that many participants have regular interactions with the faculty surgeons and may want to positively review content in which these surgeons are involved. Second, there exists the potential for an extreme response bias wherein participants may have selected ratings on the upper end of the scale with regard to cognitive and skills improvement after course completion. Third, only a portion of senior pediatric surgery trainees participate in the course each year, thus we are unable to determine if the baseline experience, knowledge, comfort levels, and improvements in perceived cognition and skills accurately represent those of the entire senior pediatric surgery trainee population. Third, our participation pool and thus sample size is relatively small, limiting our power to determine differences in each cohort and to draw more generalized conclusions. Finally, this study did not include postcourse questions regarding knowledge and comfort with a particular MIS procedure. These data could then be compared to precourse comfort data, which would permit statistical analyses to strengthen our ability to draw conclusions regarding the impact of the course.

Conclusion

Pediatric surgery trainees have limited exposure to advanced neonatal MIS during training. This limited exposure seems to continue into clinical practice. SBE results in improvement in both cognitive knowledge and comfort level with advanced MIS techniques and procedure-specific tasks, while improving participant's perceived ability to perform each operation safely. High-fidelity simulation models can be used to augment surgical education among trainees and potentially practicing surgeons.

Footnotes

Acknowledgments

The authors would like to acknowledge Northwestern Simulation at Northwestern University Feinberg School of Medicine for the continued support of their research. They would also like to thank the faculty surgeons who continually volunteer their time each year to teach their future pediatric surgeons during the simulation course.

Disclosure Statement

Authors C.D.G., G.H., B.S., and M.C. have no financial disclosures. K.A.B. discloses that the educational courses discussed in this article were supported by unrestricted educational grants from Boston Scientific, Just Right Surgical, Karl Storz Endoscopy–America, and Stryker Endoscopy.

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