Simulation-based training shown to build open vascular surgery skills

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Jonathan Lawaetz

A recent systematic review found that “carefully designed and structured” simulation-based training (SBT) in open vascular surgery is effective and can improve technical skills, especially in less experienced trainees. However, authors Jonathan Lawaetz (Rigshospitalet, Copenhagen, Denmark) and colleagues note that the supporting evidence “lacks homogeneity in the reporting standards and types of simulations”. Pass/fail standards that support proficiency-based learning and studies investigating skills transfer “should be the focus on future studies,” they write.

Lawaetz et al state that high procedural volume correlates with lower mortality for several open arterial procedures. However, they stress that a combination of fewer open surgical operations, reduced working hours, shorter residency training, and focus on patient safety has limited the exposure of vascular surgical trainees to open surgical procedures.

In this context, SBT programmes “provide the opportunity to practice skills and procedures without exposing patients to unnecessary risks,” they detail. The researchers hypothesise that—while surgeons cannot be fully trained in a simulated environment—SBT “may be an adjunct to the traditional apprenticeship approach in vascular surgery”.

Writing in the European Journal of Vascular and Endovascular Surgery (EJVES), the authors detail that their paper provides an overview of the literature on simulation-based training in open vascular surgery. Their investigation “reveals a lack of conformity and comparative research in this field,” they state, adding that it also “identifies features of simulation-based training that lead to the improvement of skill”.

In addition, the investigators note that their paper “evaluates assessment tools used in open vascular simulation” and “demonstrates inadequate validity evidence and a lack of procedure-specific tools”. It also “suggests what future educational research in open vascular surgery should focus on,” they state.

Lawaetz et al detail that the aim of this study was to systematically review the literature and give evidence-based recommendations for future initiatives for SBT and assessment in open vascular surgery.

The investigators performed a systematic review of PubMed, Embase, and the Cochrane Library, with the last search on 31 March 2020, to identify studies describing SBT and assessment in open vascular surgery. They evaluated Kirkpatrick’s levels for efficacy of training, and validity evidence for assessment tools according to the recommended contemporary framework by Messick.

Of 2,844 studies, Lawaetz and colleagues included 51 for data extraction. They found a high degree of heterogeneity in reporting standards and varying types of simulation. Vascular anastomosis was the most frequently simulated technical skill (43%), the authors write.

In addition, they report that assessment was mostly carried out using the Objective Structured Assessment of Technical Skills (55%), and that they found validity evidence for assessment told using outdated frameworks, and only one study used Messick’s framework.

“Self-directed training is valuable,” Lawaetz et al communicate in EJVES, adding that the low trainer to trainee ratio is important “to maximise efficiency,” and that experienced vascular surgeons are the most effective trainers.

The authors recognise some limitations to the present study. For example, they note that studies assessing endovascular components in SBT were excluded, however, they cite the reason for this being that the evidence for the benefits of SBT in the endovascular field is more established, and so the decision was made to focus on SBT in open vascular surgery.

Lawaetz and colleagues write that the search was narrowed to technical skills only “to provide a more focused and comprehensive overview of SBT and assessment” in this area. However, they acknowledge that non-technical skills go “hand in hand” with technical ones, and “have a significant impact on the technical performance”.

Finally, the researchers identify that the “lack of homogeneity” in the included studies prevented them from performing a quantitative meta-analysis.


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