TEACHING ADVANCED SURGICAL TECHNIQUE USING PEER-REVIEWED MULTIMEDIA: AN ASSESSMENT OF TECHNICAL COMPETENCE IN CADAVERIC-BASED SIMULATION

Abstract

Introduction

Retroperitoneal lymph node dissection (RPLND) is a highly effective surgery for the removal of testicular cancer metastases, with high cure rates and minimal risk when performed in expert centers. Despite this, some risk of postoperative functional infertility is still associated with RPLND when unintentional and preventable damage is caused to an intricate network of nerves. This is a particularly concerning complication given that testicular cancer primarily affects young males. Nerve-sparing RPLND is a rare and complex surgical procedure that can reduce the risk of this complication. However, it's also a procedure that most surgical trainees have limited exposure to. Therefore, we created expert-designed video learning material for the teaching of nerve-sparing RPLND. When used in combination with human cadaveric simulation, we believe that this video learning material can improve the surgical performance of trainees in this rare and complex procedure.

Methods

A group of 10 participants was recruited for a prospective study in which the performance of the nerve-sparing RPLND procedure by those participants was assessed both before and after watching expert-designed video learning material of the surgery. All of the participants were urology residents and fellows that were tasked with performing the procedure on either fresh or soft human cadavers before exposure to the video (unilateral portion) and again after exposure to it (contralateral portion). Their surgical performance was quantitatively assessed for operative time and percentage of lymph node (LN) mass resected and video-recorded for further qualitative assessment by a blinded expert surgeon using generic Objective Structured Assessment of Technical Skills (OSATS) and procedure-specific rating scales. Participants also completed a self-assessment of qualitative measures including for efficiency, technique, thoroughness (completeness of LN resection), quality (viability of nerve), and comfort level.

Results

The participants were randomized to perform either left-sided or right-sided RPLND first. The mean generic OSATS global rating scale (20.40 vs. 16.00, p<0.001), completeness of LN dissection score (3.63 vs. 2.38, p=0.007), preservation of nerve integrity score (3.63 vs. 2.08, p=0.010), and percentage of LN mass resected (81.57% vs. 52.07%, p<0.001) significantly increased in the second surgery. The mean self-assessment scores significantly improved in all aspects, including efficiency (51.40 vs. 24.20, p=0.003), technique (50.40 vs. 30.40, p=0.007), thoroughness (48.60 vs. 25.90, p<0.001), quality (45.20 vs. 20.10, p=0.003), and comfort level (61.00 vs. 24.90, p=0.002). The participants who performed the left-sided RPLND first had significantly higher mean improvement of the percentage of LN mass resected (43.12% vs. 15.88%, p=0.003) and completeness of LN dissection score (2.05 vs. 0.45, p=0.013).

Conclusions

The results of this study suggest that if expert-designed video learning material is combined with human cadaveric simulation to teach rare and complex surgical procedures, like nerve-sparing RPLND, there is significant potential for improvement in the surgical performance of trainees. Video alone can have both advantages and disadvantages to traditional paper-based learning material. However, when it is expert-designed and combined with simulation, it may have a substantial advantage in translating surgical research into technical prowess generally. Therefore, we expect that this combination can be successfully applied to the teaching of rare and complex surgical procedures in other fields as well.