key: cord-0691461-701r8sr5
authors: Torres, Inez Ohashi; Becari, Alice; Escudeiro, Gabriel de Paula Maroni; de Carvalho, João Pedro Lins Mendes; Simão da Silva, Erasmo; Puech-Leão, Pedro; De Luccia, Nelson
title: The use of a low-fidelity simulator to improve vascular anastomosis skills of residents during the COVID-19 pandemic
date: 2022-04-06
journal: Ann Vasc Surg
DOI: 10.1016/j.avsg.2022.03.032
sha: ce2c9571e0f822b0b40724c1cbd3a8d2f70dfba2
doc_id: 691461
cord_uid: 701r8sr5

Objectives To evaluate a workshop using a low-fidelity simulator for training vascular surgery residents in vascular anastomosis during the COVID-19 pandemic. Design Prospective, controlled, single-center Materials and Methods Vascular surgery residents at São Paulo University Medical School were enrolled in the COVID Group (five PGY-3 residents) or Control Group (five PGY-4 residents). The COVID Group was trained via a vascular anastomosis workshop. The residents were evaluated using Objective Structured Assessment of Technical Skills (OSATS), Final Product Analysis and time to perform the procedure. The number of anastomoses performed by the residents was calculated. Data were subjected to statistical analysis, and p<0.05 was considered significant. Results There was a significant reduction in the number of vascular anastomoses performed by the residents between the COVID group and the control group (mean 22.6±7.76 vs. 35.2 ±3.9, p=0.01, Student’s t test). Prior to the workshop, 80% of the residents from the COVID group failed to perform a vascular anastomosis on the simulator. During the workshop, there was improvement in the OSATS score (initial: 16.5, IQR 0, under supervision: 25, IQR 5, and at the end of the workshop: 26.5, IQR 2.5; p=0.049, Friedman’s test) and in the Final Product Analysis (initial: 14.5, IQR 6, under supervision: 26.5, IQR 4.625, end of the workshop: 27, IQR 4, p=0.049, Friedman’s test). Time was not significantly different (initial: 35.6, IQR 2.77; under supervision: 25.8 minutes, IQR 4.53; p=0.07, Friedman’s test). The residents’ technical scores were stable six months after the training, and there was no difference between their final scores and those of the control group. The residents from the COVID Group reported an improvement in their knowledge, technical skills and confidence after the workshop. Conclusions A workshop using a low-fidelity simulator improved vascular surgery residents’ skills and confidence in vascular anastomosis during the pandemic year, when they performed fewer surgical procedures.

Vascular anastomosis is a complex procedure in which a poorly placed stitch or inadequate knot 82 creates the potential for blood loss, vascular occlusion or even death. 1 Previous studies have 83

shown that trainee participation during infrainguinal bypass procedures is associated with 84 increased early postoperative graft failure, 1-3 greater operative time, greater odds of blood 85 transfusion, and a longer hospital stay than procedures performed by an attending surgeon 86 alone. 2 87

To prevent these kinds of complications, surgical laboratories, whose benefits have 88 already been demonstrated for vascular anastomosis, could be employed. 4,5,6, 7 The basic 89 technique can be learned on a simulator before the operative procedure, and the learned skills can 90 lead to improved performance in the operating room, with a higher level of competence after 91 skill training. 3, 8 However, access to vascular surgery simulations is limited. 9 92 Furthermore, there is concern among surgical educators that graduating trainees are 93 unprepared to independently practice the full spectrum of vascular surgery 3 ; this situation has 94 worsened during the COVID-19 pandemic, which has caused suspensions of elective surgery for 95 several months worldwide and reduced the number of surgeries performed by trainees. 10,11 96 For this reason, the present study aimed to evaluate a workshop using a simple, low-cost, 97 low-fidelity simulator to train vascular surgery residents in vascular anastomosis with the 98 intention of better preparing them for the operating room. It was developed during the first year 99 of the COVID-19 pandemic in Brazil in response to a request from residents. 100 101

This study was performed at Saõ Paulo University Medical School from March 2020 to March 105 2021. It was approved by the ethics committee at Plataforma Brasil (www.saude.gov. 106 br/plataformabrasil, CAAE 04557518.9.0000.0068). 107

The number of bypasses and arteriovenous fistula performed by the PGY-3 residents as 108 the main surgeon was assessed based on our medical records. We calculated the number of 109 anastomoses as the number of arteriovenous fistulas plus two times the number of bypasses. After the first COVID peak in Brazil in 2020, before elective surgeries restarted, PGY-3 128 residents were trained via a vascular anastomosis workshop using a low-fidelity simulator 129 produced in our laboratory (Laboratório de Investigação Médica -LIM02 FMUSP). The 130 simulator consists of a silicone tube connected to a pulsatile flow pump and placed inside a box 131 made in polymer simulating skin with a longitudinal incision (Figure 1 ). 132

On arrival at the laboratory, residents from both groups were given basic surgical 133 instruments, suture material and a segment of 8-mm polytetrafluoroethylene (PTFE; GORE, 134 Elkton, MD) and asked to perform an end-to-side anastomosis without training or formal 135 instruction. The assistant was a senior vascular surgeon instructed to behave passively, only 136 performing movements required by the residents. Two senior vascular surgeons evaluated and 137 scored the procedure. The PGY-4 residents were evaluated at this moment alone, and their score 138 was considered the control score we sought to achieve with the workshop. 139

Then, a lesson on standard anastomosis techniques was delivered. A 30-minute period 140 was dedicated to didactic teaching, which included detailed information on the step-by-step 141 construction of an end-to-side vascular anastomosis, with a live demonstration of an ideal 142 anastomosis using a PTFE graft to the silicone tube of the simulator, performed by the most 143 experienced surgeon in our department. 144

Residents in the COVID group performed the anastomosis again under the supervision of 145 the same senior vascular surgeons who assisted the first anastomoses, but now they were 146 instructed to guide the procedure, if necessary. 147

After that, residents practiced in two additional, individual training sessions (total 3 148 weeks, approximately 1 hour/week). During these sessions, the anastomoses were performed 149 under supervision and with feedback from a senior vascular surgeon. 150

At the end of one month, the residents from the COVID group performed one more 151 training session, where their evaluation was made (final workshop), and the same occurred at the 152 end of their PGY-3. Each group consisted of 5 residents, which is the total number of vascular surgery residents in 195 our institution. There was no difference comparing the age or sex of the residents of the two 196 groups; nevertheless, significantly fewer vascular anastomoses were performed by the residents 197 of the COVID group than by those of the control group, as shown in Table 1 . 198 This reduction occurred mainly during the first semester of 2020, when elective surgeries 199

were cancelled due to COVID-19, as shown in Figure 2 . This was a natural consequence of the 200 reduction in the total number of surgeries performed in our hospital during this period; the 201 number of bypasses was reduced by 25% and the number of arteriovenous fistulas was reduced 202 by 87.5% compared with the first semester of the previous year, as shown in Table 2 . Prior to the workshop, all the residents had already studied the theoretical part of the 223 procedure performed at least 1 anastomosis in the operating room. Nevertheless, when they were 224 left to perform the surgery independently, they were lost within the steps (therefore, they scored 225 low in time and motion and operation flow), the best position of the hand and needle holder to 226 perform a good stitch (low score in instrument handling), and they did not know how to use the 227 assistant, as shown by a detailed analysis of the OSATS scores (Table 3 ). 228 The final results of the COVID group were directly compared to the control group and no 237 significant difference in any of the outcomes was found at the end of PGY-3, as shown in Table  238 The residents answered a questionnaire, and the results are shown in Table 5 . providing clinically relevant and useful skills. 20 It is known that distributed practice (short 271 practice sessions with intervals between sessions) results in better acquisition and retention 272 compared with massed practice (practicing a task continuously in one long session). 11,23,24 The 273 training interval is also important: simple tasks are better acquired with shorter intertraining 274 intervals, whereas complex tasks appear to require a longer period of rest between task learning 275 segments. 20 Mitchell et al. 20 The progressive deterioration of knowledge and skills when not used over extended 288 periods is a well-studied phenomenon. 20, 24 This was avoided in our study since the residents 289 performed a good number of vascular anastomoses after the workshop (on average, 18.4 per 290 resident for one semester). Therefore, there was no difference between the postworkshop scores 291 and those obtained 6 months later. 292

This study has several limitations. Most importantly, this was a single-center study with a 293 small number of residents. However, this is the total number of residents in our institution, and 294 especially during the pandemic year, presential training involving different institutions was 295 difficult to organize. Additionally, this study does not illustrate the transferability of increased 296 surgical skill on this model to the operating room. However, this kind of benefit to the surgical 297 room has already been described with numerous types of simulator training for different skills. 298

Finally, the senior surgeons who evaluated the procedures were not blinded, which can imply 299 bias. Nevertheless, this was the most practical/feasible way of performing this evaluation. 300

Despite these limitations, this study shows that a 3-week workshop, with a mandatory 1-301 hour training session on low-fidelity simulators each week, improved vascular surgery residents' 302 skills and confidence in vascular anastomosis. This was important during the first year of the 303 COVID-19 pandemic, when the number of surgical procedures was reduced. Our results showed 304 that the residents reached proficiency on vascular anastomosis, although they performed fewer 305 surgeries compared to the previous year. Therefore, we intend to make this workshop a 306 mandatory activity for the PGY-3 and evaluate whether it improves surgical results. We also 307 intend to expand this training to other institutions and confirm the results with a larger number of 308 J o u r n a l P r e -p r o o f Student's t test was used to compare the mean number of anastomoses by group. The Kruskal-Wallis test was used to perform the statistical analyses.

Surgical trainee 324 participation during infrainguinal bypass grafting procedures is associated with increased 325 early postoperative graft failure

Operative autonomy among senior surgical 327 trainees during infrainguinal bypass operations is not associated with worse long-term 328 patient outcomes

A nationwide survey of vascular surgery trainees reveals 330 trends in operative experience, confidence, and attitudes about simulation

Vascular anastomosis model: relation 333 between competency in a laboratory-based model and surgical competency

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Simulation training improves resident 343 performance in hand-sewn vascular and bowel anastomoses

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Objective 363 structured assessment of technical skill (OSATS) for surgical residents

Testing technical skill via an 366 innovative "bench station" examination

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A guideline of selecting and reporting intraclass correlation coefficients 375 for reliability research

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69S-75S; discussion 75S

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Teaching 398 surgical skills: what kind of practice makes perfect?: a randomized, controlled trial

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Integrating simulation into a 403 surgical residency program: is voluntary participation effective?

 Table 5 . Subjective questionnaire answered by the residents after the workshop Median (IQR25-75%) Training was useful for Understanding the procedure 5 (5-5) Improving technical skills 5 (4-5) Improving the knowledge on the surgical material 4 (4-4) Training helped to understand and better manipulate Needle holder 5 (4-5) Potts's scissor 5 (4-5) Prolene threads 4 (4-4) Tweezers 4 (4-5) Graft 4 (4-5) Artery 3 (3-4) Realism of the simulation 4 (3-4) Training improves patient safety 5 (5-5) Self-confidence in performing the procedure Before the workshop 2 (2-3) After the workshop 4 (4-5) Score using a Likert scale: 1 (totally disagree) to 5 (totally agree)