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and works to establish standards for ASCs. ASCA requires all of its facility members to be accredited, licensed, or Medicare certi-fied. The ASCA was instrumental in forming the accrediting body that is now the largest accreditor of ambulatory surgery centers in the country.22CostsToday, more than 5300 Medicare-certified ASCs offer simi-lar services compared to those performed at HOPDs, and do so at a more efficient rate with lower costs. ASCs are able to accomplish this by decreasing administrative and overhead expenses.5 Expenses for an ASC include staff wages, insur-ance, utilities, rent, janitorial services, as well as resources necessary to handle patient records, including technology sys-tems. ASCs are able to schedule procedures without the risk of surgeries getting moved or cancelled due to emergencies. Additionally, ASCs enable patients to go home on the same day, therefore spending less time with staff in postoperative recovery rooms.Starting in 1982, Medicare has covered

Surgery_Schwartz. and works to establish standards for ASCs. ASCA requires all of its facility members to be accredited, licensed, or Medicare certi-fied. The ASCA was instrumental in forming the accrediting body that is now the largest accreditor of ambulatory surgery centers in the country.22CostsToday, more than 5300 Medicare-certified ASCs offer simi-lar services compared to those performed at HOPDs, and do so at a more efficient rate with lower costs. ASCs are able to accomplish this by decreasing administrative and overhead expenses.5 Expenses for an ASC include staff wages, insur-ance, utilities, rent, janitorial services, as well as resources necessary to handle patient records, including technology sys-tems. ASCs are able to schedule procedures without the risk of surgeries getting moved or cancelled due to emergencies. Additionally, ASCs enable patients to go home on the same day, therefore spending less time with staff in postoperative recovery rooms.Starting in 1982, Medicare has covered

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due to emergencies. Additionally, ASCs enable patients to go home on the same day, therefore spending less time with staff in postoperative recovery rooms.Starting in 1982, Medicare has covered surgical proce-dures provided in ASCs.21 There are two primary elements of total cost in a surgical procedure: the cost of physicians’ pro-fessional services and cost of the facility. Typically, providers bill for professional service separately, whereas facility costs are paid to the ASCs. Currently Medicare provides separate payments for 3500 surgical procedures under the ASC pay-ment system.5 The payment system is maintained by CMS, which adjusts fees annually to maintain budget neutrality. Through the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, payments to ASCs are based on the Outpatient Prospective Payment System (OPPS) and capped at no more than 59% of what is paid to hospitals for the same service.5During the period of 2008 to 2011, the growth in number of

Surgery_Schwartz. due to emergencies. Additionally, ASCs enable patients to go home on the same day, therefore spending less time with staff in postoperative recovery rooms.Starting in 1982, Medicare has covered surgical proce-dures provided in ASCs.21 There are two primary elements of total cost in a surgical procedure: the cost of physicians’ pro-fessional services and cost of the facility. Typically, providers bill for professional service separately, whereas facility costs are paid to the ASCs. Currently Medicare provides separate payments for 3500 surgical procedures under the ASC pay-ment system.5 The payment system is maintained by CMS, which adjusts fees annually to maintain budget neutrality. Through the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, payments to ASCs are based on the Outpatient Prospective Payment System (OPPS) and capped at no more than 59% of what is paid to hospitals for the same service.5During the period of 2008 to 2011, the growth in number of

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based on the Outpatient Prospective Payment System (OPPS) and capped at no more than 59% of what is paid to hospitals for the same service.5During the period of 2008 to 2011, the growth in number of ASCs plateaued. The system saved an estimated $7.5 bil-lion for the Medicare program and its beneficiaries.5 However, Brunicardi_Ch52_p2153-p2162.indd 215828/02/19 4:17 PM 2159AMBULATORY SURGERYCHAPTER 52growth in procedure volume during this time was greater in ASCs than in hospitals.3 This suggests that physicians and patients still preferred using ASCs, possibly due to advantages in cost, convenience, comfort, or the inability for hospitals to meet demand for outpatient surgeries.QualityThe majority of ambulatory surgery centers ensure safety through maintaining certification and licensing of the facili-ties and associated staff. There are strict regulations in place at both the state and federal level that ensure quality in ASCs, which have been detailed earlier. ASCs are held to

Surgery_Schwartz. based on the Outpatient Prospective Payment System (OPPS) and capped at no more than 59% of what is paid to hospitals for the same service.5During the period of 2008 to 2011, the growth in number of ASCs plateaued. The system saved an estimated $7.5 bil-lion for the Medicare program and its beneficiaries.5 However, Brunicardi_Ch52_p2153-p2162.indd 215828/02/19 4:17 PM 2159AMBULATORY SURGERYCHAPTER 52growth in procedure volume during this time was greater in ASCs than in hospitals.3 This suggests that physicians and patients still preferred using ASCs, possibly due to advantages in cost, convenience, comfort, or the inability for hospitals to meet demand for outpatient surgeries.QualityThe majority of ambulatory surgery centers ensure safety through maintaining certification and licensing of the facili-ties and associated staff. There are strict regulations in place at both the state and federal level that ensure quality in ASCs, which have been detailed earlier. ASCs are held to

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of the facili-ties and associated staff. There are strict regulations in place at both the state and federal level that ensure quality in ASCs, which have been detailed earlier. ASCs are held to the same high standard of care as all U.S. medical facilities. They have comparable rates of use of perioperative antibiotics, patient falls, wrong-site surgery, and use of safety checklists.23 Nation-wide and among all procedures, from 2014 to 2016 fewer than 2% of all visits to ASCs resulted in an unplanned hospital visit within 7 days.5 Of these hospital visits, 1.6% were emergency department or observation stays, and 0.6% were unplanned inpatient admissions.24 CMS is working to develop a new qual-ity measure that will track unplanned hospitalizations after care at an ASC. This would help create increasing data on the quality of ASCs. Due to the isolated nature of ASCs, provid-ers are often unaware when a patient goes to the emergency department or is admitted to an unaffiliated hospital

Surgery_Schwartz. of the facili-ties and associated staff. There are strict regulations in place at both the state and federal level that ensure quality in ASCs, which have been detailed earlier. ASCs are held to the same high standard of care as all U.S. medical facilities. They have comparable rates of use of perioperative antibiotics, patient falls, wrong-site surgery, and use of safety checklists.23 Nation-wide and among all procedures, from 2014 to 2016 fewer than 2% of all visits to ASCs resulted in an unplanned hospital visit within 7 days.5 Of these hospital visits, 1.6% were emergency department or observation stays, and 0.6% were unplanned inpatient admissions.24 CMS is working to develop a new qual-ity measure that will track unplanned hospitalizations after care at an ASC. This would help create increasing data on the quality of ASCs. Due to the isolated nature of ASCs, provid-ers are often unaware when a patient goes to the emergency department or is admitted to an unaffiliated hospital

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increasing data on the quality of ASCs. Due to the isolated nature of ASCs, provid-ers are often unaware when a patient goes to the emergency department or is admitted to an unaffiliated hospital following a procedure. Thus, such a measure from the CMS will help educate providers and allow for continued quality improve-ment among ASCs.Looking at the general surgical population, cholecys-tectomy represents a key procedure to track because it is frequently performed, requires technical skill, and can result in serious complications. Provided appropriate patient selec-tion, outpatient cholecystectomy has been demonstrated to be safely performed in ASCs. ASCs charge significantly less for performing this procedure after controlling for the variety of indications (median of $6028 for ASCs compared to $10,876 for HOPDs).25OwnershipIn 2017, 90% of ASCs have partial or complete physician own-ership, while 25% to 30% of ASCs are at least partially owned by hospitals, as compared to HOPDs,

Surgery_Schwartz. increasing data on the quality of ASCs. Due to the isolated nature of ASCs, provid-ers are often unaware when a patient goes to the emergency department or is admitted to an unaffiliated hospital following a procedure. Thus, such a measure from the CMS will help educate providers and allow for continued quality improve-ment among ASCs.Looking at the general surgical population, cholecys-tectomy represents a key procedure to track because it is frequently performed, requires technical skill, and can result in serious complications. Provided appropriate patient selec-tion, outpatient cholecystectomy has been demonstrated to be safely performed in ASCs. ASCs charge significantly less for performing this procedure after controlling for the variety of indications (median of $6028 for ASCs compared to $10,876 for HOPDs).25OwnershipIn 2017, 90% of ASCs have partial or complete physician own-ership, while 25% to 30% of ASCs are at least partially owned by hospitals, as compared to HOPDs,

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compared to $10,876 for HOPDs).25OwnershipIn 2017, 90% of ASCs have partial or complete physician own-ership, while 25% to 30% of ASCs are at least partially owned by hospitals, as compared to HOPDs, which are by definition owned and operated exclusively by the hospital. A trend is developing for hospitals to purchase ASC ownership stakes due to their cost efficiency and as a means of diversifying revenue streams.26 Physicians have been a driving force in the devel-opment of ASCs through their ownership and building of new facilities. Ownership of an ASC provides many clear advantages to the physician because of the increased control and autonomy over their practice. Some advantages include ease of scheduling, shorter waiting times to get patients in for elective surgery, and the ability to hire specially trained and highly skilled staff. Phy-sicians can also avoid the bureaucracies of a hospital, including having elective surgeries cancelled to make room for emergent surgeries and

Surgery_Schwartz. compared to $10,876 for HOPDs).25OwnershipIn 2017, 90% of ASCs have partial or complete physician own-ership, while 25% to 30% of ASCs are at least partially owned by hospitals, as compared to HOPDs, which are by definition owned and operated exclusively by the hospital. A trend is developing for hospitals to purchase ASC ownership stakes due to their cost efficiency and as a means of diversifying revenue streams.26 Physicians have been a driving force in the devel-opment of ASCs through their ownership and building of new facilities. Ownership of an ASC provides many clear advantages to the physician because of the increased control and autonomy over their practice. Some advantages include ease of scheduling, shorter waiting times to get patients in for elective surgery, and the ability to hire specially trained and highly skilled staff. Phy-sicians can also avoid the bureaucracies of a hospital, including having elective surgeries cancelled to make room for emergent surgeries and

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to hire specially trained and highly skilled staff. Phy-sicians can also avoid the bureaucracies of a hospital, including having elective surgeries cancelled to make room for emergent surgeries and delays due to more complicated surgeries. They can also ensure that the facility has specialized equipment for their particular specialty and can design the facility to meet their specific needs.26 Furthermore, physicians who perform surgeries in their own ASCs receive a share of the ASC’s facility payment in addition to payment for their professional services. This could present a conflict of interest in terms of referring patients and lowering the threshold for surgery, as discussed further in the next section.Potential for Conflict of InterestApproximately 90% of ASCs nationwide have at least some physician ownership stake. Many are joint ventures between hospitals and physicians.27 Increasing investment in these cen-ters may be explained in a number of ways, including an attempt by

Surgery_Schwartz. to hire specially trained and highly skilled staff. Phy-sicians can also avoid the bureaucracies of a hospital, including having elective surgeries cancelled to make room for emergent surgeries and delays due to more complicated surgeries. They can also ensure that the facility has specialized equipment for their particular specialty and can design the facility to meet their specific needs.26 Furthermore, physicians who perform surgeries in their own ASCs receive a share of the ASC’s facility payment in addition to payment for their professional services. This could present a conflict of interest in terms of referring patients and lowering the threshold for surgery, as discussed further in the next section.Potential for Conflict of InterestApproximately 90% of ASCs nationwide have at least some physician ownership stake. Many are joint ventures between hospitals and physicians.27 Increasing investment in these cen-ters may be explained in a number of ways, including an attempt by

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least some physician ownership stake. Many are joint ventures between hospitals and physicians.27 Increasing investment in these cen-ters may be explained in a number of ways, including an attempt by providers to assert greater control over their professional lives, such as by having greater authority in scheduling sur-geries and in purchasing equipment. Alternatively, this invest-ment trend may be explained by declining reimbursements for physician services and rising practice costs. These economic pressures have intensified providers’ interest in nontraditional revenue sources, such as ASC investment, as a means of gen-erating income.Ownership entitles physicians to collect a share of the facil-ity’s profits from referrals, in addition to their professional fees. One potential conflict of interest is that physician-owners might lower their thresholds for intervention, exposing the patient and healthcare system to the harm and cost associated with unneces-sary treatment. After

Surgery_Schwartz. least some physician ownership stake. Many are joint ventures between hospitals and physicians.27 Increasing investment in these cen-ters may be explained in a number of ways, including an attempt by providers to assert greater control over their professional lives, such as by having greater authority in scheduling sur-geries and in purchasing equipment. Alternatively, this invest-ment trend may be explained by declining reimbursements for physician services and rising practice costs. These economic pressures have intensified providers’ interest in nontraditional revenue sources, such as ASC investment, as a means of gen-erating income.Ownership entitles physicians to collect a share of the facil-ity’s profits from referrals, in addition to their professional fees. One potential conflict of interest is that physician-owners might lower their thresholds for intervention, exposing the patient and healthcare system to the harm and cost associated with unneces-sary treatment. After

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of interest is that physician-owners might lower their thresholds for intervention, exposing the patient and healthcare system to the harm and cost associated with unneces-sary treatment. After differences between patients and health-care markets are adjusted for, physicians with ownership in an ASC have been found to perform a higher number of procedures compared with nonowner physicians at the same facilities.27 It has been noted that the increase in outpatient surgery at ASCs was more than double the decline in similar procedures per-formed in the hospital setting.28-29The other potential conflict in physician ASC ownership is in regard to patient referral. There is some evidence that physi-cians with an ownership stake may refer well-insured patients to their own facilities while referring Medicare and Medicaid patients to hospital outpatient clinics.30-32Regardless of the reason for increasing investment in and utilization of ASCs, it is important to note that ASC owner-ship

Surgery_Schwartz. of interest is that physician-owners might lower their thresholds for intervention, exposing the patient and healthcare system to the harm and cost associated with unneces-sary treatment. After differences between patients and health-care markets are adjusted for, physicians with ownership in an ASC have been found to perform a higher number of procedures compared with nonowner physicians at the same facilities.27 It has been noted that the increase in outpatient surgery at ASCs was more than double the decline in similar procedures per-formed in the hospital setting.28-29The other potential conflict in physician ASC ownership is in regard to patient referral. There is some evidence that physi-cians with an ownership stake may refer well-insured patients to their own facilities while referring Medicare and Medicaid patients to hospital outpatient clinics.30-32Regardless of the reason for increasing investment in and utilization of ASCs, it is important to note that ASC owner-ship

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referring Medicare and Medicaid patients to hospital outpatient clinics.30-32Regardless of the reason for increasing investment in and utilization of ASCs, it is important to note that ASC owner-ship creates a potential conflict of interest for physicians. In the United States, physician financial interests are heavily regulated by the Stark Law. This can be either a financial investment, employment, or compensation agreement. To avoid conflicts of interest and potential legal violations, physicians should consult with attorneys and advisors knowledgeable in medical law and ethics prior to entering a financial relationship.33CHALLENGESReimbursementSavings from use of ASCs are primarily to the patient and health-care system. Reimbursement to ASCs for services provided is, as a direct result, lower than reimbursement paid to hospitals for the same procedures. It is up to ASCs, which operate as private corporations, to find profit and viability by keeping their costs low through

Surgery_Schwartz. referring Medicare and Medicaid patients to hospital outpatient clinics.30-32Regardless of the reason for increasing investment in and utilization of ASCs, it is important to note that ASC owner-ship creates a potential conflict of interest for physicians. In the United States, physician financial interests are heavily regulated by the Stark Law. This can be either a financial investment, employment, or compensation agreement. To avoid conflicts of interest and potential legal violations, physicians should consult with attorneys and advisors knowledgeable in medical law and ethics prior to entering a financial relationship.33CHALLENGESReimbursementSavings from use of ASCs are primarily to the patient and health-care system. Reimbursement to ASCs for services provided is, as a direct result, lower than reimbursement paid to hospitals for the same procedures. It is up to ASCs, which operate as private corporations, to find profit and viability by keeping their costs low through

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result, lower than reimbursement paid to hospitals for the same procedures. It is up to ASCs, which operate as private corporations, to find profit and viability by keeping their costs low through efficiency and staffing. Some steps suggested to improve the financial viability of maintaining an ASC include increasing the variety of procedures offered and grouping sur-geries in such a way as to maximize staffing usage.34Patient SelectionSafe use of ASCs is based on identification of patients who are unlikely to require admission to a hospital after their procedure. Thus far, ASCs do very well in this aspect. Unplanned admis-sions after ambulatory surgery occur in approximately 0.5% to 2.0% of cases.5,35-37 In the future, ASCs will be challenged to reduce this unplanned admission rate even further.Patients with Medicaid insurance, lower median household income, and a greater preoperative comorbidity burden have the Brunicardi_Ch52_p2153-p2162.indd 215928/02/19 4:17 PM 2160SPECIFIC

Surgery_Schwartz. result, lower than reimbursement paid to hospitals for the same procedures. It is up to ASCs, which operate as private corporations, to find profit and viability by keeping their costs low through efficiency and staffing. Some steps suggested to improve the financial viability of maintaining an ASC include increasing the variety of procedures offered and grouping sur-geries in such a way as to maximize staffing usage.34Patient SelectionSafe use of ASCs is based on identification of patients who are unlikely to require admission to a hospital after their procedure. Thus far, ASCs do very well in this aspect. Unplanned admis-sions after ambulatory surgery occur in approximately 0.5% to 2.0% of cases.5,35-37 In the future, ASCs will be challenged to reduce this unplanned admission rate even further.Patients with Medicaid insurance, lower median household income, and a greater preoperative comorbidity burden have the Brunicardi_Ch52_p2153-p2162.indd 215928/02/19 4:17 PM 2160SPECIFIC

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further.Patients with Medicaid insurance, lower median household income, and a greater preoperative comorbidity burden have the Brunicardi_Ch52_p2153-p2162.indd 215928/02/19 4:17 PM 2160SPECIFIC CONSIDERATIONSPART IIhighest odds of unplanned acute care use. These patients may benefit from interventions that enhance and streamline postop-erative follow-up.38 Additionally, the potential costs associated with postoperative acute care following procedures performed in ASCs are not insignificant. Patient specific predictors of unplanned hospital admission include age 65 years or older, anticipated operating time longer than 120 minutes, cardiac comorbidities, peripheral vascular disease, cerebrovascular dis-ease, malignancy, positive for human immunodeficiency virus (HIV), and regional or general anesthesia use.39The strongest predictor for unplanned inpatient hospital admission was the individual patient’s own history of previ-ous hospitalizations, particularly among older adults.

Surgery_Schwartz. further.Patients with Medicaid insurance, lower median household income, and a greater preoperative comorbidity burden have the Brunicardi_Ch52_p2153-p2162.indd 215928/02/19 4:17 PM 2160SPECIFIC CONSIDERATIONSPART IIhighest odds of unplanned acute care use. These patients may benefit from interventions that enhance and streamline postop-erative follow-up.38 Additionally, the potential costs associated with postoperative acute care following procedures performed in ASCs are not insignificant. Patient specific predictors of unplanned hospital admission include age 65 years or older, anticipated operating time longer than 120 minutes, cardiac comorbidities, peripheral vascular disease, cerebrovascular dis-ease, malignancy, positive for human immunodeficiency virus (HIV), and regional or general anesthesia use.39The strongest predictor for unplanned inpatient hospital admission was the individual patient’s own history of previ-ous hospitalizations, particularly among older adults.

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or general anesthesia use.39The strongest predictor for unplanned inpatient hospital admission was the individual patient’s own history of previ-ous hospitalizations, particularly among older adults. African American and Hispanic individuals also have had a markedly elevated risk of inpatient hospital admission, possibly related to cultural or socioeconomic issues of access to care.40 These mea-sures may provide a valuable target for quality improvement, cost improvement, and innovation.ASCs vs. Hospital Outpatient Departments vs. Office-Based Surgical SuitesCompetition is increasing among ASCs, HOPDs, and office-based surgical practices. The same improvements in anesthe-sia and surgical equipment that made outpatient surgery in a freestanding ASCs safe to perform have also led to a growing number of office based surgical suites and HOPDs. Procedures such as dental, ophthalmologic, endoscopy, cosmetic surgery, and liposuction are increasingly being performed in office-based

Surgery_Schwartz. or general anesthesia use.39The strongest predictor for unplanned inpatient hospital admission was the individual patient’s own history of previ-ous hospitalizations, particularly among older adults. African American and Hispanic individuals also have had a markedly elevated risk of inpatient hospital admission, possibly related to cultural or socioeconomic issues of access to care.40 These mea-sures may provide a valuable target for quality improvement, cost improvement, and innovation.ASCs vs. Hospital Outpatient Departments vs. Office-Based Surgical SuitesCompetition is increasing among ASCs, HOPDs, and office-based surgical practices. The same improvements in anesthe-sia and surgical equipment that made outpatient surgery in a freestanding ASCs safe to perform have also led to a growing number of office based surgical suites and HOPDs. Procedures such as dental, ophthalmologic, endoscopy, cosmetic surgery, and liposuction are increasingly being performed in office-based

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to a growing number of office based surgical suites and HOPDs. Procedures such as dental, ophthalmologic, endoscopy, cosmetic surgery, and liposuction are increasingly being performed in office-based facilities.41Physicians’ offices are under lower regulatory oversight in comparison to ASCs and HOPDs. This has resulted in the phenomenon of “practice drift,” whereby physicians perform procedures outside of their typical scope of practice. Despite several high-profile adverse events in lay media, prospective studies have demonstrated office-based surgical suites to be of similar safety.41,42 A recent, large study in the area of cosmetic surgery compared hospital-based procedures with office-based surgical suites and with ASCs and found accredited office-based surgical suites to be a safe alternative to ASCs and hospitals.43Aging PopulationWith increased risk of complications from surgery, the older adult population present a unique challenge to ASCs. ASCs must be prepared for

Surgery_Schwartz. to a growing number of office based surgical suites and HOPDs. Procedures such as dental, ophthalmologic, endoscopy, cosmetic surgery, and liposuction are increasingly being performed in office-based facilities.41Physicians’ offices are under lower regulatory oversight in comparison to ASCs and HOPDs. This has resulted in the phenomenon of “practice drift,” whereby physicians perform procedures outside of their typical scope of practice. Despite several high-profile adverse events in lay media, prospective studies have demonstrated office-based surgical suites to be of similar safety.41,42 A recent, large study in the area of cosmetic surgery compared hospital-based procedures with office-based surgical suites and with ASCs and found accredited office-based surgical suites to be a safe alternative to ASCs and hospitals.43Aging PopulationWith increased risk of complications from surgery, the older adult population present a unique challenge to ASCs. ASCs must be prepared for

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a safe alternative to ASCs and hospitals.43Aging PopulationWith increased risk of complications from surgery, the older adult population present a unique challenge to ASCs. ASCs must be prepared for complications that may arise from operating on older patients, and they must do so without the same resources as a hospital. The potential benefit of outpatient surgery for elderly patients is substantial, however, as older adults often suffer from postoperative cognitive dysfunction in an inpatient setting, which may be minimized with early discharge.44 Addi-tional benefits include lower cost to patients on fixed incomes and increased time and comfort at home.CONCLUSIONASCs represent a large benefit to society because of their poten-tial to reduce the financial burden of the healthcare system on the economy. At the same time, ASCs also provide high-quality care which is patient and family centered and convenient for providers. ASCs reduce the length of stay and minimize surgi-cal delays

Surgery_Schwartz. a safe alternative to ASCs and hospitals.43Aging PopulationWith increased risk of complications from surgery, the older adult population present a unique challenge to ASCs. ASCs must be prepared for complications that may arise from operating on older patients, and they must do so without the same resources as a hospital. The potential benefit of outpatient surgery for elderly patients is substantial, however, as older adults often suffer from postoperative cognitive dysfunction in an inpatient setting, which may be minimized with early discharge.44 Addi-tional benefits include lower cost to patients on fixed incomes and increased time and comfort at home.CONCLUSIONASCs represent a large benefit to society because of their poten-tial to reduce the financial burden of the healthcare system on the economy. At the same time, ASCs also provide high-quality care which is patient and family centered and convenient for providers. ASCs reduce the length of stay and minimize surgi-cal delays

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on the economy. At the same time, ASCs also provide high-quality care which is patient and family centered and convenient for providers. ASCs reduce the length of stay and minimize surgi-cal delays and cancellations. In the future, ASC quality will be rigorously tracked due to more regulatory oversight and data collection. The future of ambulatory surgical centers remains bright. Case numbers are increasing across many specialties, including general surgery, plastic surgery, vascular, urologic, and orthopedic practices. Surgeons should follow the matura-tion of ambulatory surgery closely.REFERENCESEntries highlighted in bright blue are key references. 1. Senagore EAJ. Ambulatory surgery centers. In: Encyclopedia of Surgery. 1st ed. Farmington Hills, MI: Gale Group; 2004:37-43. 2. Hall MJ, Schwartzman A, Zhang J, Liu X. Ambulatory surgery data from hospitals and ambulatory surgery centers: United States, 2010. Natl Health Stat Report. 2017;(102):1-15. 3. Cullen KA, Hall MJ, Golosinskiy

Surgery_Schwartz. on the economy. At the same time, ASCs also provide high-quality care which is patient and family centered and convenient for providers. ASCs reduce the length of stay and minimize surgi-cal delays and cancellations. In the future, ASC quality will be rigorously tracked due to more regulatory oversight and data collection. The future of ambulatory surgical centers remains bright. Case numbers are increasing across many specialties, including general surgery, plastic surgery, vascular, urologic, and orthopedic practices. Surgeons should follow the matura-tion of ambulatory surgery closely.REFERENCESEntries highlighted in bright blue are key references. 1. Senagore EAJ. Ambulatory surgery centers. In: Encyclopedia of Surgery. 1st ed. Farmington Hills, MI: Gale Group; 2004:37-43. 2. Hall MJ, Schwartzman A, Zhang J, Liu X. Ambulatory surgery data from hospitals and ambulatory surgery centers: United States, 2010. Natl Health Stat Report. 2017;(102):1-15. 3. Cullen KA, Hall MJ, Golosinskiy

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Schwartzman A, Zhang J, Liu X. Ambulatory surgery data from hospitals and ambulatory surgery centers: United States, 2010. Natl Health Stat Report. 2017;(102):1-15. 3. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Report. 2009;(11):1-25. 4. Munnich EL, Parente S. Procedures take less time at ambu-latory surgery centers, keeping costs down and ability to meet demand up. Health Affairs 2014;33(5):764-769. 5. Medicare Payment Advisory Commission. 2018. Report to the Congress: Medicare Payment Policy. Washington, DC: MedPAC. Available at: http://www.medpac.gov/-documents-/reports. Accessed August 27, 2016. 6. Advancing Surgical Care Association. Medicare cost savings tied to ASCs. 2013. Available at: http://www.advancingsurgicalcare.com/medicarecostsavings. Accessed August 27, 2018. 7. Definitive Healthcare. Top 10 outpatient procedures at ASCs and hospitals. 2014. Available at:

Surgery_Schwartz. Schwartzman A, Zhang J, Liu X. Ambulatory surgery data from hospitals and ambulatory surgery centers: United States, 2010. Natl Health Stat Report. 2017;(102):1-15. 3. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Report. 2009;(11):1-25. 4. Munnich EL, Parente S. Procedures take less time at ambu-latory surgery centers, keeping costs down and ability to meet demand up. Health Affairs 2014;33(5):764-769. 5. Medicare Payment Advisory Commission. 2018. Report to the Congress: Medicare Payment Policy. Washington, DC: MedPAC. Available at: http://www.medpac.gov/-documents-/reports. Accessed August 27, 2016. 6. Advancing Surgical Care Association. Medicare cost savings tied to ASCs. 2013. Available at: http://www.advancingsurgicalcare.com/medicarecostsavings. Accessed August 27, 2018. 7. Definitive Healthcare. Top 10 outpatient procedures at ASCs and hospitals. 2014. Available at:

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Available at: http://www.advancingsurgicalcare.com/medicarecostsavings. Accessed August 27, 2018. 7. Definitive Healthcare. Top 10 outpatient procedures at ASCs and hospitals. 2014. Available at: https://www.definitivehc.com/news/top-10-outpatient-procedures-at-ascs-and-hospitals. Accessed August 27, 2018. 8. Nicoll J. The surgery of infancy. Br Med J. 1909;18:753-754. 9. Eger EI, Saidman LJ, Westhorpe RN, eds. The Wondorous Story of Anesthesia. New York: Springer; 2014. 10. The report. Arizona Republic. Sept. 10, 1970. 11. Ambulatory Surgery Center Association. Looking back and looking forward where it all began. FASA Update. May/June 2004. 12. Orkand DS. Comparative Evaluation of Costs, Quality, and System Effects of Ambulatory Surgery Performed in Alterna-tive Settings: Final Report. Washington: U.S. Dept. of Health, Education, and Welfare, Health Care Financing Administra-tion, Office of Policy Planning and Research; 1977. 13. Ambulatory Surgery Center Association. Number of ASCs

Surgery_Schwartz. Available at: http://www.advancingsurgicalcare.com/medicarecostsavings. Accessed August 27, 2018. 7. Definitive Healthcare. Top 10 outpatient procedures at ASCs and hospitals. 2014. Available at: https://www.definitivehc.com/news/top-10-outpatient-procedures-at-ascs-and-hospitals. Accessed August 27, 2018. 8. Nicoll J. The surgery of infancy. Br Med J. 1909;18:753-754. 9. Eger EI, Saidman LJ, Westhorpe RN, eds. The Wondorous Story of Anesthesia. New York: Springer; 2014. 10. The report. Arizona Republic. Sept. 10, 1970. 11. Ambulatory Surgery Center Association. Looking back and looking forward where it all began. FASA Update. May/June 2004. 12. Orkand DS. Comparative Evaluation of Costs, Quality, and System Effects of Ambulatory Surgery Performed in Alterna-tive Settings: Final Report. Washington: U.S. Dept. of Health, Education, and Welfare, Health Care Financing Administra-tion, Office of Policy Planning and Research; 1977. 13. Ambulatory Surgery Center Association. Number of ASCs

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U.S. Dept. of Health, Education, and Welfare, Health Care Financing Administra-tion, Office of Policy Planning and Research; 1977. 13. Ambulatory Surgery Center Association. Number of ASCs per State. ASCs: a positive trend in healthcare. Advancing Surgi-cal Care. June 2017. Available at: https://www.ascassociation.org/advancingsurgicalcare/asc/numberofascsperstate. Accessed August 27, 2018. 14. Koenig L, Doherty J, Dreyfus J, Xanthapoulos J. An Analysis of Recent Growth of Ambulatory Surgical Centers. KNG Con-sulting. June 5, 2009. Available at: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.512.4498&rep=rep1&type= pdf 15. Colorado Ambulatory Surgery Center Association. Ambulatory surgery center history. Available at: https://www.coloradoasc.org/general-resources/asc-history/. Accessed August 27, 2018. 16. Centers for Medicare & Medicaid Services. Overview. www .cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/index.html. 17. Manchikanti L. Ambulatory surgery

Surgery_Schwartz. U.S. Dept. of Health, Education, and Welfare, Health Care Financing Administra-tion, Office of Policy Planning and Research; 1977. 13. Ambulatory Surgery Center Association. Number of ASCs per State. ASCs: a positive trend in healthcare. Advancing Surgi-cal Care. June 2017. Available at: https://www.ascassociation.org/advancingsurgicalcare/asc/numberofascsperstate. Accessed August 27, 2018. 14. Koenig L, Doherty J, Dreyfus J, Xanthapoulos J. An Analysis of Recent Growth of Ambulatory Surgical Centers. KNG Con-sulting. June 5, 2009. Available at: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.512.4498&rep=rep1&type= pdf 15. Colorado Ambulatory Surgery Center Association. Ambulatory surgery center history. Available at: https://www.coloradoasc.org/general-resources/asc-history/. Accessed August 27, 2018. 16. Centers for Medicare & Medicaid Services. Overview. www .cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/index.html. 17. Manchikanti L. Ambulatory surgery

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Accessed August 27, 2018. 16. Centers for Medicare & Medicaid Services. Overview. www .cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/index.html. 17. Manchikanti L. Ambulatory surgery centers and interven-tional techniques: a look at long-term survival. Pain Physician. 2011;14(2):177-215. 18. Ambulatory Surgery Center Association. What is an ASC? Available at: https://www.advancingsurgicalcare.com/ advancingsurgicalcare/asc/whatisanasc, Accessed August 27, 2018. 19. Hair B, Hussey P, Wynn B. A comparison of ambulatory periop-erative times in hospitals and freestanding owners. Am J Surg. 2012;204(1):23-27. 20. Trentman TL, Mueller JT, Gray RJ, Pockaj BA, Simula DV. Outpatient surgery performed in an ambulatory surgery center Brunicardi_Ch52_p2153-p2162.indd 216028/02/19 4:17 PM 2161AMBULATORY SURGERYCHAPTER 52versus a hospital: comparison of perioperative time intervals. Am J Surg. 2010;200(1):64-67. 21. Rechtoris M. 51 things to know about the ASC industry. Becker’s

Surgery_Schwartz. Accessed August 27, 2018. 16. Centers for Medicare & Medicaid Services. Overview. www .cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/index.html. 17. Manchikanti L. Ambulatory surgery centers and interven-tional techniques: a look at long-term survival. Pain Physician. 2011;14(2):177-215. 18. Ambulatory Surgery Center Association. What is an ASC? Available at: https://www.advancingsurgicalcare.com/ advancingsurgicalcare/asc/whatisanasc, Accessed August 27, 2018. 19. Hair B, Hussey P, Wynn B. A comparison of ambulatory periop-erative times in hospitals and freestanding owners. Am J Surg. 2012;204(1):23-27. 20. Trentman TL, Mueller JT, Gray RJ, Pockaj BA, Simula DV. Outpatient surgery performed in an ambulatory surgery center Brunicardi_Ch52_p2153-p2162.indd 216028/02/19 4:17 PM 2161AMBULATORY SURGERYCHAPTER 52versus a hospital: comparison of perioperative time intervals. Am J Surg. 2010;200(1):64-67. 21. Rechtoris M. 51 things to know about the ASC industry. Becker’s

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PM 2161AMBULATORY SURGERYCHAPTER 52versus a hospital: comparison of perioperative time intervals. Am J Surg. 2010;200(1):64-67. 21. Rechtoris M. 51 things to know about the ASC industry. Becker’s ASC Review. Available at: https://www.beckersasc.com/asc-turnarounds-ideas-to-improve-performance/50-things-to-know-about-the-asc-industry-2017.html. Accessed August 27, 2018. 22. Ambulatory Surgery Center Association. Medicare certifi-cation. Available at: www.ascassociation.org/federalregula-tions/medicarecertification. Accessed August 27, 2018. 23. Ambulatory Surgery Center Quality Collaboration. Quarterly Report, 2nd Quarter 2018. http://www.ascquality.org/qualityre-port.cfm. 24. Dickson V. CMS seeks closer look at quality of care at ambu-latory surgical centers. Modern Healthcare. 2017. Available at: http://www.modernhealthcare.com/article/20170711/NEWS/170719987. Accessed August 27, 2018. 25. Paquette IM, Smink D, Finlayson SR. Outpatient cholecys-tectomy at hospitals versus

Surgery_Schwartz. PM 2161AMBULATORY SURGERYCHAPTER 52versus a hospital: comparison of perioperative time intervals. Am J Surg. 2010;200(1):64-67. 21. Rechtoris M. 51 things to know about the ASC industry. Becker’s ASC Review. Available at: https://www.beckersasc.com/asc-turnarounds-ideas-to-improve-performance/50-things-to-know-about-the-asc-industry-2017.html. Accessed August 27, 2018. 22. Ambulatory Surgery Center Association. Medicare certifi-cation. Available at: www.ascassociation.org/federalregula-tions/medicarecertification. Accessed August 27, 2018. 23. Ambulatory Surgery Center Quality Collaboration. Quarterly Report, 2nd Quarter 2018. http://www.ascquality.org/qualityre-port.cfm. 24. Dickson V. CMS seeks closer look at quality of care at ambu-latory surgical centers. Modern Healthcare. 2017. Available at: http://www.modernhealthcare.com/article/20170711/NEWS/170719987. Accessed August 27, 2018. 25. Paquette IM, Smink D, Finlayson SR. Outpatient cholecys-tectomy at hospitals versus

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2017. Available at: http://www.modernhealthcare.com/article/20170711/NEWS/170719987. Accessed August 27, 2018. 25. Paquette IM, Smink D, Finlayson SR. Outpatient cholecys-tectomy at hospitals versus freestanding ambulatory surgical centers. J Am Coll Surg. 2008;206(2):301-305. 26. Ambulatory Surgery Center Association. Benefits of physician ownership. 2011. Available at: https://www.advancingsurgicalcare. com/asc/benefitsofphysicianownership. Accessed August 27, 2018. 27. Becker’s Hospital Review. ASC ownership trends in 2017: more complex joint venture deals. Available at: www.beckershospitalreview.com/hospital-transactions-and-valuation/asc-ownership-trends-in-2017-more-complex-joint-venture-deals.html. Accessed August 27, 2018. 28. Conrad DA, Sales A, Liang SY, et al. Impact of financial incen-tives on physician productivity in medical groups. Health Serv Res. 2002;37(4):885-906. 29. Hollenbeck BK, Dunn RL, Suskind AM, Strope SA, Zhang Y, Hollingsworth JM. Ambulatory surgery

Surgery_Schwartz. 2017. Available at: http://www.modernhealthcare.com/article/20170711/NEWS/170719987. Accessed August 27, 2018. 25. Paquette IM, Smink D, Finlayson SR. Outpatient cholecys-tectomy at hospitals versus freestanding ambulatory surgical centers. J Am Coll Surg. 2008;206(2):301-305. 26. Ambulatory Surgery Center Association. Benefits of physician ownership. 2011. Available at: https://www.advancingsurgicalcare. com/asc/benefitsofphysicianownership. Accessed August 27, 2018. 27. Becker’s Hospital Review. ASC ownership trends in 2017: more complex joint venture deals. Available at: www.beckershospitalreview.com/hospital-transactions-and-valuation/asc-ownership-trends-in-2017-more-complex-joint-venture-deals.html. Accessed August 27, 2018. 28. Conrad DA, Sales A, Liang SY, et al. Impact of financial incen-tives on physician productivity in medical groups. Health Serv Res. 2002;37(4):885-906. 29. Hollenbeck BK, Dunn RL, Suskind AM, Strope SA, Zhang Y, Hollingsworth JM. Ambulatory surgery

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incen-tives on physician productivity in medical groups. Health Serv Res. 2002;37(4):885-906. 29. Hollenbeck BK, Dunn RL, Suskind AM, Strope SA, Zhang Y, Hollingsworth JM. Ambulatory surgery centers and their intended effects on outpatient surgery. Health Serv Res. 2015;50(5):1491-1507. 30. Plotzke MR, Courtmanche C. Does procedure profitability impact whether an outpatient surgery is performed at an ambu-latory surgery center or a hospital? Health Econ. 20(7):817-830. 31. Mitchell JM. Effect of physician ownership of specialty hos-pitals and ambulatory surgery centers on frequency of use of outpatient orthopedic surgery. Arch Surg. 2010;145(8):732-738. 32. Gable JR, Fahlman C, Kang R, Wozniak G, Kletke P, Hay JW. Where do I send thee? Does physician-ownership affect referral patterns to ambulatory surgery centers? Health Affairs. 2008;27(3):165-174. 33. U.S. Department of Health and Human Services. Office of the Inspector General. A Roadmap for New Physicians: Fraud & Abuse Laws.

Surgery_Schwartz. incen-tives on physician productivity in medical groups. Health Serv Res. 2002;37(4):885-906. 29. Hollenbeck BK, Dunn RL, Suskind AM, Strope SA, Zhang Y, Hollingsworth JM. Ambulatory surgery centers and their intended effects on outpatient surgery. Health Serv Res. 2015;50(5):1491-1507. 30. Plotzke MR, Courtmanche C. Does procedure profitability impact whether an outpatient surgery is performed at an ambu-latory surgery center or a hospital? Health Econ. 20(7):817-830. 31. Mitchell JM. Effect of physician ownership of specialty hos-pitals and ambulatory surgery centers on frequency of use of outpatient orthopedic surgery. Arch Surg. 2010;145(8):732-738. 32. Gable JR, Fahlman C, Kang R, Wozniak G, Kletke P, Hay JW. Where do I send thee? Does physician-ownership affect referral patterns to ambulatory surgery centers? Health Affairs. 2008;27(3):165-174. 33. U.S. Department of Health and Human Services. Office of the Inspector General. A Roadmap for New Physicians: Fraud & Abuse Laws.

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to ambulatory surgery centers? Health Affairs. 2008;27(3):165-174. 33. U.S. Department of Health and Human Services. Office of the Inspector General. A Roadmap for New Physicians: Fraud & Abuse Laws. Available at: oig.hhs.gov/compliance/physician-education/01laws.asp. Accessed August 27, 2018. 34. American College of Surgeons. Should your health care system invest in an ambulatory surgery center? A decision-making framework [Internet]. Bulletin of the American College of Surgeons. 2017 [cited 2018 Nov 28]; Available from: http://bulletin.facs.org/2017/11/should-your-health-care-system-invest-in-an-ambulatory-surgery-center-a-decision-making-framework/. 35. Mezei G, Chung F. Return hospital visits and hospital readmis-sions after ambulatory surgery. Ann Surg. 1999;230(5):721-727. 36. Twersky R, Fishman D, Homel P. What happens after discharge? Return hospital visits after ambulatory surgery. Anesth Analg. 1997;84:319-324. 37. Fox JP, Vashi AA, Ross JS, Gross CP. Hospital based, acute

Surgery_Schwartz. to ambulatory surgery centers? Health Affairs. 2008;27(3):165-174. 33. U.S. Department of Health and Human Services. Office of the Inspector General. A Roadmap for New Physicians: Fraud & Abuse Laws. Available at: oig.hhs.gov/compliance/physician-education/01laws.asp. Accessed August 27, 2018. 34. American College of Surgeons. Should your health care system invest in an ambulatory surgery center? A decision-making framework [Internet]. Bulletin of the American College of Surgeons. 2017 [cited 2018 Nov 28]; Available from: http://bulletin.facs.org/2017/11/should-your-health-care-system-invest-in-an-ambulatory-surgery-center-a-decision-making-framework/. 35. Mezei G, Chung F. Return hospital visits and hospital readmis-sions after ambulatory surgery. Ann Surg. 1999;230(5):721-727. 36. Twersky R, Fishman D, Homel P. What happens after discharge? Return hospital visits after ambulatory surgery. Anesth Analg. 1997;84:319-324. 37. Fox JP, Vashi AA, Ross JS, Gross CP. Hospital based, acute

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R, Fishman D, Homel P. What happens after discharge? Return hospital visits after ambulatory surgery. Anesth Analg. 1997;84:319-324. 37. Fox JP, Vashi AA, Ross JS, Gross CP. Hospital based, acute care after ambulatory center discharge. Surgery. 2014;155(5): 743-753. 38. Molina G, Neville BA, Lipsitz SR, Gibbons L, Childers AK, et al. Postoperative acute care use after freestanding ambulatory surgery. J Surg Res. 2016;205(2):331-340. 39. Fleisher LA, Pasternak LR, Lyles A. A novel index of ele-vated risk of inpatient hospital admission immediately fol-lowing outpatient surgery. Arch Surg. 2007;142(3):263-268. 40. Fleisher LA, Pasternak LR, Herbert R, Anderson GF. Inpa-tient hospital admission and death after outpatient surgery in elderly patients: importance of patient and system charac-teristics and location of care. Arch Surg. 2004;139(1):67-72. 41. Urman RD, Punwani N, Shapiro FE. Office-based surgical and medical procedures: educational gaps. Ochsner J 2012;

Surgery_Schwartz. R, Fishman D, Homel P. What happens after discharge? Return hospital visits after ambulatory surgery. Anesth Analg. 1997;84:319-324. 37. Fox JP, Vashi AA, Ross JS, Gross CP. Hospital based, acute care after ambulatory center discharge. Surgery. 2014;155(5): 743-753. 38. Molina G, Neville BA, Lipsitz SR, Gibbons L, Childers AK, et al. Postoperative acute care use after freestanding ambulatory surgery. J Surg Res. 2016;205(2):331-340. 39. Fleisher LA, Pasternak LR, Lyles A. A novel index of ele-vated risk of inpatient hospital admission immediately fol-lowing outpatient surgery. Arch Surg. 2007;142(3):263-268. 40. Fleisher LA, Pasternak LR, Herbert R, Anderson GF. Inpa-tient hospital admission and death after outpatient surgery in elderly patients: importance of patient and system charac-teristics and location of care. Arch Surg. 2004;139(1):67-72. 41. Urman RD, Punwani N, Shapiro FE. Office-based surgical and medical procedures: educational gaps. Ochsner J 2012;

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and system charac-teristics and location of care. Arch Surg. 2004;139(1):67-72. 41. Urman RD, Punwani N, Shapiro FE. Office-based surgical and medical procedures: educational gaps. Ochsner J 2012; 12(4):383-388. 42. Coldiron B, Shreve E, Balkrishnan R. Patient injuries from surgical procedures performed in medical offices: three years of Florida data. Dermatol Surg. 2004;30(12 pt 1):1435-1443, discussion 1443. 43. Gupta V, Parikh R, Nguyen L, et al. Is office-based surgery safe? Comparing outcomes of 183,914 aesthetic surgical procedures across different types of accredited facilities. Aesthet Surg J. 2017;37(2):226-235. 44. Aurini L, White P. Anesthesia for the elderly outpatient. Curr Opin Anesthesiol. 2014;27:563-575.Brunicardi_Ch52_p2153-p2162.indd 216128/02/19 4:17 PM

Surgery_Schwartz. and system charac-teristics and location of care. Arch Surg. 2004;139(1):67-72. 41. Urman RD, Punwani N, Shapiro FE. Office-based surgical and medical procedures: educational gaps. Ochsner J 2012; 12(4):383-388. 42. Coldiron B, Shreve E, Balkrishnan R. Patient injuries from surgical procedures performed in medical offices: three years of Florida data. Dermatol Surg. 2004;30(12 pt 1):1435-1443, discussion 1443. 43. Gupta V, Parikh R, Nguyen L, et al. Is office-based surgery safe? Comparing outcomes of 183,914 aesthetic surgical procedures across different types of accredited facilities. Aesthet Surg J. 2017;37(2):226-235. 44. Aurini L, White P. Anesthesia for the elderly outpatient. Curr Opin Anesthesiol. 2014;27:563-575.Brunicardi_Ch52_p2153-p2162.indd 216128/02/19 4:17 PM

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BACKGROUNDIntroductionThe basic American surgical training model is patterned after that established by William Steward Halsted at the Johns Hopkins Hospital in the late 19th century. By tradition, it has consisted of a regulated apprenticeship system with incremental increases in clinical responsibility for resident surgeons over a specified period of time culminating with the expectation that independent surgical practice will be possible at its conclu-sion. While this approach has served well throughout the 20th century, the pace of changes in healthcare delivery and society itself has driven the need for new approaches to education and training. Among the important changes that the surgical training community has had to confront are an expanding array of medi-cal and surgical therapies, complex, new and sometimes disrup-tive technologies advancing at a dizzying pace, and increasing recognition of the opportunities for errors and adverse outcomes because of inadequate preparation

Surgery_Schwartz. BACKGROUNDIntroductionThe basic American surgical training model is patterned after that established by William Steward Halsted at the Johns Hopkins Hospital in the late 19th century. By tradition, it has consisted of a regulated apprenticeship system with incremental increases in clinical responsibility for resident surgeons over a specified period of time culminating with the expectation that independent surgical practice will be possible at its conclu-sion. While this approach has served well throughout the 20th century, the pace of changes in healthcare delivery and society itself has driven the need for new approaches to education and training. Among the important changes that the surgical training community has had to confront are an expanding array of medi-cal and surgical therapies, complex, new and sometimes disrup-tive technologies advancing at a dizzying pace, and increasing recognition of the opportunities for errors and adverse outcomes because of inadequate preparation

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complex, new and sometimes disrup-tive technologies advancing at a dizzying pace, and increasing recognition of the opportunities for errors and adverse outcomes because of inadequate preparation for this new world of surgical practice.1 Appreciation of the scale and insidious consequences of medical errors began to take hold in the 1990s when the groundbreaking Institute of Medicine report “To Err is Human” presented to the public a dire picture of the frequency and impli-cations of medical errors.2 Among the proposed new approaches to deal with this problem was the use of simulation training.Simulation is the imitation of an actual or possible real-world condition or event. The degree to which a simulation resembles its real-world counterpart describes its fidelity. There are innumerable specific applications of simulation to train or assess human performance on anticipated real-world tasks. As such, it is a valuable tool with great potential to increase safety in high-stakes

Surgery_Schwartz. complex, new and sometimes disrup-tive technologies advancing at a dizzying pace, and increasing recognition of the opportunities for errors and adverse outcomes because of inadequate preparation for this new world of surgical practice.1 Appreciation of the scale and insidious consequences of medical errors began to take hold in the 1990s when the groundbreaking Institute of Medicine report “To Err is Human” presented to the public a dire picture of the frequency and impli-cations of medical errors.2 Among the proposed new approaches to deal with this problem was the use of simulation training.Simulation is the imitation of an actual or possible real-world condition or event. The degree to which a simulation resembles its real-world counterpart describes its fidelity. There are innumerable specific applications of simulation to train or assess human performance on anticipated real-world tasks. As such, it is a valuable tool with great potential to increase safety in high-stakes

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specific applications of simulation to train or assess human performance on anticipated real-world tasks. As such, it is a valuable tool with great potential to increase safety in high-stakes undertakings such as commercial aviation, military training, and nuclear power generation. These are a few areas where such training has been implemented successfully. With the advent of widely available digital computing, the level of technology applied to simulation and simulators has made near-complete fidelity possible. Moreover, the enormous expense associated with full motion flight simulation, for example, has been made acceptable by safety gains that benefit entire popula-tions. In medicine, there has been gradual acceptance of the role of simulation to achieve these same goals, and this has led to an array of simulation methods and uses that specifically target surgical providers at all levels. The fundamental justification for commitment of resources to simulation is an ethical one: to

Surgery_Schwartz. specific applications of simulation to train or assess human performance on anticipated real-world tasks. As such, it is a valuable tool with great potential to increase safety in high-stakes undertakings such as commercial aviation, military training, and nuclear power generation. These are a few areas where such training has been implemented successfully. With the advent of widely available digital computing, the level of technology applied to simulation and simulators has made near-complete fidelity possible. Moreover, the enormous expense associated with full motion flight simulation, for example, has been made acceptable by safety gains that benefit entire popula-tions. In medicine, there has been gradual acceptance of the role of simulation to achieve these same goals, and this has led to an array of simulation methods and uses that specifically target surgical providers at all levels. The fundamental justification for commitment of resources to simulation is an ethical one: to

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led to an array of simulation methods and uses that specifically target surgical providers at all levels. The fundamental justification for commitment of resources to simulation is an ethical one: to reduce patient risk associated with invasive surgical procedures or management of complex clinical problems. Simulation meth-ods provide opportunities for surgical learners to practice their skills under safe conditions in preparation for clinical experi-ences and to be assessed and deemed ready for those encounters.Skills Labs and Skills TrainingThe history of surgical skills training outside the clinical oper-ating room (OR) is a long one, involving practice of surgical skills and procedures using various models, including animals and cadavers. Newer training practices, including simulation use in a laboratory setting, have emerged that focus on objec-tive assessment of skill and establishment of specific, defined levels of proficiency. These assessment-based approaches are relatively

Surgery_Schwartz. led to an array of simulation methods and uses that specifically target surgical providers at all levels. The fundamental justification for commitment of resources to simulation is an ethical one: to reduce patient risk associated with invasive surgical procedures or management of complex clinical problems. Simulation meth-ods provide opportunities for surgical learners to practice their skills under safe conditions in preparation for clinical experi-ences and to be assessed and deemed ready for those encounters.Skills Labs and Skills TrainingThe history of surgical skills training outside the clinical oper-ating room (OR) is a long one, involving practice of surgical skills and procedures using various models, including animals and cadavers. Newer training practices, including simulation use in a laboratory setting, have emerged that focus on objec-tive assessment of skill and establishment of specific, defined levels of proficiency. These assessment-based approaches are relatively

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use in a laboratory setting, have emerged that focus on objec-tive assessment of skill and establishment of specific, defined levels of proficiency. These assessment-based approaches are relatively recent educational developments and are being imple-mented as a means to improve surgeon skill in a safe setting for both learners and patients.3 The use of inanimate benchtop mod-els to test surgical skills required a leap into the world of vali-dation of measurement methodologies. The most important of these pioneering efforts was the implementation of the objective Skills and SimulationNeal E. Seymour and Carla M. Pugh 53chapterBackground2163Introduction / 2163Skills Labs and Skills Training / 2163Scientific Underpinnings of Simulator Use / 2165Simulation in Graduate Medical Education / 2165“Bootcamps” / 2166Specific Simulation Training and Assessment Applications2166Training Basic Surgical Skills / 2166Fundamentals of Laparoscopic Surgery / 2168Bench Models for Training Specific

Surgery_Schwartz. use in a laboratory setting, have emerged that focus on objec-tive assessment of skill and establishment of specific, defined levels of proficiency. These assessment-based approaches are relatively recent educational developments and are being imple-mented as a means to improve surgeon skill in a safe setting for both learners and patients.3 The use of inanimate benchtop mod-els to test surgical skills required a leap into the world of vali-dation of measurement methodologies. The most important of these pioneering efforts was the implementation of the objective Skills and SimulationNeal E. Seymour and Carla M. Pugh 53chapterBackground2163Introduction / 2163Skills Labs and Skills Training / 2163Scientific Underpinnings of Simulator Use / 2165Simulation in Graduate Medical Education / 2165“Bootcamps” / 2166Specific Simulation Training and Assessment Applications2166Training Basic Surgical Skills / 2166Fundamentals of Laparoscopic Surgery / 2168Bench Models for Training Specific

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2165“Bootcamps” / 2166Specific Simulation Training and Assessment Applications2166Training Basic Surgical Skills / 2166Fundamentals of Laparoscopic Surgery / 2168Bench Models for Training Specific Procedural Skills / 2168Transfer of Training / 2169Virtual Reality / 2169Virtual Reality for Flexible Endoscopy / 2172Virtual Reality for Endovascular Interventions / 2173Patient-Specific VR Surgery Simulation / 2174Robotic Surgery Simulators / 2174Fundamentals of Robotic Surgery / 2174Nontechnical Skills2175High-Fidelity Patient Simulation and Team Skills / 2175Error Prevention2177Simulation and Patient Outcomes2178Simulation Training for the Practicing Surgeon and Maintenance of Skill2179Future Considerations2179Brunicardi_Ch53_p2163-p2186.indd 216322/02/19 4:39 PM 2164Key Points1 Learning basic skills at the point of care imposes inef-ficiencies that might very well endanger support for the education mission.2 In 2006, the Accreditation Council for Graduate Medical Education

Surgery_Schwartz. 2165“Bootcamps” / 2166Specific Simulation Training and Assessment Applications2166Training Basic Surgical Skills / 2166Fundamentals of Laparoscopic Surgery / 2168Bench Models for Training Specific Procedural Skills / 2168Transfer of Training / 2169Virtual Reality / 2169Virtual Reality for Flexible Endoscopy / 2172Virtual Reality for Endovascular Interventions / 2173Patient-Specific VR Surgery Simulation / 2174Robotic Surgery Simulators / 2174Fundamentals of Robotic Surgery / 2174Nontechnical Skills2175High-Fidelity Patient Simulation and Team Skills / 2175Error Prevention2177Simulation and Patient Outcomes2178Simulation Training for the Practicing Surgeon and Maintenance of Skill2179Future Considerations2179Brunicardi_Ch53_p2163-p2186.indd 216322/02/19 4:39 PM 2164Key Points1 Learning basic skills at the point of care imposes inef-ficiencies that might very well endanger support for the education mission.2 In 2006, the Accreditation Council for Graduate Medical Education

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basic skills at the point of care imposes inef-ficiencies that might very well endanger support for the education mission.2 In 2006, the Accreditation Council for Graduate Medical Education Residency Review Committee for Surgery instituted a formal requirement for simulation training in surgical residency.3 Procedural skills training in a simulated environment has been shown to transfer to the real-life clinical setting.4 Early studies of virtual reality training using both proficiency-based and non–proficiency-based training methods showed it to be an effective means of improving laparoscopic skill both in the lab and in the operating room compared to non–virtual reality trained controls.5 Use of proficiency-based training in the context of a larger curriculum appears to be the best way to achieve good training results irrespective of the training platform used.6 When assessing simulator validity, researchers have noted that the use of robotic surgery simulators does translate to

Surgery_Schwartz. basic skills at the point of care imposes inef-ficiencies that might very well endanger support for the education mission.2 In 2006, the Accreditation Council for Graduate Medical Education Residency Review Committee for Surgery instituted a formal requirement for simulation training in surgical residency.3 Procedural skills training in a simulated environment has been shown to transfer to the real-life clinical setting.4 Early studies of virtual reality training using both proficiency-based and non–proficiency-based training methods showed it to be an effective means of improving laparoscopic skill both in the lab and in the operating room compared to non–virtual reality trained controls.5 Use of proficiency-based training in the context of a larger curriculum appears to be the best way to achieve good training results irrespective of the training platform used.6 When assessing simulator validity, researchers have noted that the use of robotic surgery simulators does translate to

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to achieve good training results irrespective of the training platform used.6 When assessing simulator validity, researchers have noted that the use of robotic surgery simulators does translate to the clinical environment and the learning curve for initial console training for surgeons is significantly decreased.7 Simulation training for communication and other teamwork-pertinent nontechnical skills requires learners to be embedded in realistic scenarios pertinent to a healthcare team’s actual clinical responsibilities.8 Simulation technology allows trainees the opportunity to execute a variety of tasks and procedures while also expe-riencing the cognitive demands of surgery, including error correction and surgical planning decisions.9 The immediate future of simulation in surgery will likely see expanded use of proficiency-based training given the consistent demonstrations of effectiveness in improving surgeon skills and improved educational outcomes as mea-sured in clinical

Surgery_Schwartz. to achieve good training results irrespective of the training platform used.6 When assessing simulator validity, researchers have noted that the use of robotic surgery simulators does translate to the clinical environment and the learning curve for initial console training for surgeons is significantly decreased.7 Simulation training for communication and other teamwork-pertinent nontechnical skills requires learners to be embedded in realistic scenarios pertinent to a healthcare team’s actual clinical responsibilities.8 Simulation technology allows trainees the opportunity to execute a variety of tasks and procedures while also expe-riencing the cognitive demands of surgery, including error correction and surgical planning decisions.9 The immediate future of simulation in surgery will likely see expanded use of proficiency-based training given the consistent demonstrations of effectiveness in improving surgeon skills and improved educational outcomes as mea-sured in clinical

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will likely see expanded use of proficiency-based training given the consistent demonstrations of effectiveness in improving surgeon skills and improved educational outcomes as mea-sured in clinical settings.10 Advances in wearables, motion tracking, and sensor tech-nologies allow for a wide variety of hybrid and augmented experiences in simulation as well as extensive opportuni-ties for the development of new performance metrics.structured assessment of technical skills (OSATS) program by educators at the University of Toronto.4,5 Using a series of repro-ducible physical models of surgical tasks (excision of a skin lesion, bowel anastomosis, insertion of a T tube, and abdominal wall closure) and carefully designed rating instruments, it was possible to show validity of these measurements when com-pared with skill manifested during surgery in animal models. This demonstration of practical measurement of skill in the lab, where observation for skills rating purposes can be more

Surgery_Schwartz. will likely see expanded use of proficiency-based training given the consistent demonstrations of effectiveness in improving surgeon skills and improved educational outcomes as mea-sured in clinical settings.10 Advances in wearables, motion tracking, and sensor tech-nologies allow for a wide variety of hybrid and augmented experiences in simulation as well as extensive opportuni-ties for the development of new performance metrics.structured assessment of technical skills (OSATS) program by educators at the University of Toronto.4,5 Using a series of repro-ducible physical models of surgical tasks (excision of a skin lesion, bowel anastomosis, insertion of a T tube, and abdominal wall closure) and carefully designed rating instruments, it was possible to show validity of these measurements when com-pared with skill manifested during surgery in animal models. This demonstration of practical measurement of skill in the lab, where observation for skills rating purposes can be more

Surgery_Schwartz_14138

Surgery_Schwartz

when com-pared with skill manifested during surgery in animal models. This demonstration of practical measurement of skill in the lab, where observation for skills rating purposes can be more read-ily achieved, was seminal in sparking both additional interest in lab-based training and in simulation as a mainstream educa-tional method for surgeons.The advent of laparoscopic general surgery in the late 1980s and early 1990s, a disruptive technology at that time, was a major driver for the use of surgical simulation to gain unfa-miliar and nonintuitive skills needed to safely perform limited-access videoscopic surgery. The recognition that bile duct injury risk is increased by surgeon inexperience stimulated interest in simulation in order to separate a component of the psychomotor learning curve for laparoscopy from the clinical OR and patient by transfering it to the training lab.6-8 At the same time, interest in the science of skills acquisition and measurement made efforts to gain

Surgery_Schwartz. when com-pared with skill manifested during surgery in animal models. This demonstration of practical measurement of skill in the lab, where observation for skills rating purposes can be more read-ily achieved, was seminal in sparking both additional interest in lab-based training and in simulation as a mainstream educa-tional method for surgeons.The advent of laparoscopic general surgery in the late 1980s and early 1990s, a disruptive technology at that time, was a major driver for the use of surgical simulation to gain unfa-miliar and nonintuitive skills needed to safely perform limited-access videoscopic surgery. The recognition that bile duct injury risk is increased by surgeon inexperience stimulated interest in simulation in order to separate a component of the psychomotor learning curve for laparoscopy from the clinical OR and patient by transfering it to the training lab.6-8 At the same time, interest in the science of skills acquisition and measurement made efforts to gain

Surgery_Schwartz_14139

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curve for laparoscopy from the clinical OR and patient by transfering it to the training lab.6-8 At the same time, interest in the science of skills acquisition and measurement made efforts to gain surgical proficiency with simulation more meaningful. The measured performance characteristics of experienced sur-geons came to be appreciated as useful learning targets for less experienced surgical learners, and the concept of proficiency-based training began to be implemented successfully not only for research purposes but also for formative education.9As simulation began to be used more extensively and skills labs either evolved or merged with multidisciplinary education centers using simulation as a primary instructional method, recognition of such centers as focal points for surgical education also grew. The American College of Surgeons (ACS) Education Division recognized early on that simulation training was an important educational method that surgeons could take advantage of and

Surgery_Schwartz. curve for laparoscopy from the clinical OR and patient by transfering it to the training lab.6-8 At the same time, interest in the science of skills acquisition and measurement made efforts to gain surgical proficiency with simulation more meaningful. The measured performance characteristics of experienced sur-geons came to be appreciated as useful learning targets for less experienced surgical learners, and the concept of proficiency-based training began to be implemented successfully not only for research purposes but also for formative education.9As simulation began to be used more extensively and skills labs either evolved or merged with multidisciplinary education centers using simulation as a primary instructional method, recognition of such centers as focal points for surgical education also grew. The American College of Surgeons (ACS) Education Division recognized early on that simulation training was an important educational method that surgeons could take advantage of and

Surgery_Schwartz_14140

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also grew. The American College of Surgeons (ACS) Education Division recognized early on that simulation training was an important educational method that surgeons could take advantage of and began to explore ways to facilitate growth and implement training centers. In 2006, the ACS began to accredit education centers engaged in simulation training as Level 1 (comprehensive) and Level 2 (focused) Education Institutes.10 The consortium of 95 institutes, as of early 2017, now spans the globe with centers across the United States and Canada as well as several institutions outside of North America.In 2007, the American College of Surgeons and the Asso-ciation of Program Directors in Surgery (APDS) initiated a project to provide a standardized skills curriculum for surgi-cal residents. These efforts produced the modular ACS-APDS skills curricula that represent the first comprehensive and widely available resource that prescribes simulation experi-ences as the principal means to achieve

Surgery_Schwartz. also grew. The American College of Surgeons (ACS) Education Division recognized early on that simulation training was an important educational method that surgeons could take advantage of and began to explore ways to facilitate growth and implement training centers. In 2006, the ACS began to accredit education centers engaged in simulation training as Level 1 (comprehensive) and Level 2 (focused) Education Institutes.10 The consortium of 95 institutes, as of early 2017, now spans the globe with centers across the United States and Canada as well as several institutions outside of North America.In 2007, the American College of Surgeons and the Asso-ciation of Program Directors in Surgery (APDS) initiated a project to provide a standardized skills curriculum for surgi-cal residents. These efforts produced the modular ACS-APDS skills curricula that represent the first comprehensive and widely available resource that prescribes simulation experi-ences as the principal means to achieve

Surgery_Schwartz_14141

Surgery_Schwartz

efforts produced the modular ACS-APDS skills curricula that represent the first comprehensive and widely available resource that prescribes simulation experi-ences as the principal means to achieve educational objectives.11 The resources and curricula are readily available to residency programs to address surgical resident learning needs and to facilitate simulation lab use as mandated by the Accreditation Council for Graduate Medical Education (ACGME). The three components of the curriculum are basic technical skills, proce-dural skills, and team skills. Although these have been acknowl-edged to be valuable and have been utilized to meet resident training needs, implementation has been limited according to a recent survey of residency programs.12 Elements of the basic skills curriculum were reported to be used by 36% of respon-dents while procedural and team training modules were reported to be in use by about half as many programs. Nonetheless, the article notes that simulation

Surgery_Schwartz. efforts produced the modular ACS-APDS skills curricula that represent the first comprehensive and widely available resource that prescribes simulation experi-ences as the principal means to achieve educational objectives.11 The resources and curricula are readily available to residency programs to address surgical resident learning needs and to facilitate simulation lab use as mandated by the Accreditation Council for Graduate Medical Education (ACGME). The three components of the curriculum are basic technical skills, proce-dural skills, and team skills. Although these have been acknowl-edged to be valuable and have been utilized to meet resident training needs, implementation has been limited according to a recent survey of residency programs.12 Elements of the basic skills curriculum were reported to be used by 36% of respon-dents while procedural and team training modules were reported to be in use by about half as many programs. Nonetheless, the article notes that simulation

Surgery_Schwartz_14142

Surgery_Schwartz

were reported to be used by 36% of respon-dents while procedural and team training modules were reported to be in use by about half as many programs. Nonetheless, the article notes that simulation methods had permeated surgical education and the various stakeholder organizations had taken steps to either endorse or implement programs for simulation use. The need to explore simulation-based education, as stated by the Surgical Council on Resident Education (SCORE), sug-gests a pathway by which simulation methods might become fully integrated into standardized cognitive elements of surgical residency curriculum.13 Based on current trends, a competency framework can be envisioned that combines advanced forms of Brunicardi_Ch53_p2163-p2186.indd 216422/02/19 4:39 PM 2165SKILLS AND SIMULATIONCHAPTER 53standards-based learning using simulation and measured per-formance in the OR for purposes of trainee advancement and certification.Scientific Underpinnings of Simulator UseThe assumption

Surgery_Schwartz. were reported to be used by 36% of respon-dents while procedural and team training modules were reported to be in use by about half as many programs. Nonetheless, the article notes that simulation methods had permeated surgical education and the various stakeholder organizations had taken steps to either endorse or implement programs for simulation use. The need to explore simulation-based education, as stated by the Surgical Council on Resident Education (SCORE), sug-gests a pathway by which simulation methods might become fully integrated into standardized cognitive elements of surgical residency curriculum.13 Based on current trends, a competency framework can be envisioned that combines advanced forms of Brunicardi_Ch53_p2163-p2186.indd 216422/02/19 4:39 PM 2165SKILLS AND SIMULATIONCHAPTER 53standards-based learning using simulation and measured per-formance in the OR for purposes of trainee advancement and certification.Scientific Underpinnings of Simulator UseThe assumption

Surgery_Schwartz_14143

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53standards-based learning using simulation and measured per-formance in the OR for purposes of trainee advancement and certification.Scientific Underpinnings of Simulator UseThe assumption that surgical technical skills can be effec-tively learned and tested outside the OR serves as the basis for simulation based assessment of skills before, during, and following training. This capability permits the explicit descrip-tion of understandable surgeon performance characteristics including those that can be characterized as desirable training goals (e.g., “expert”). The effectiveness of specific models of training can also be ascertained by comparative studies examin-ing educational endpoints, such as rate of learning, or testable performance either in simulations or in clinical settings. Sim-ulation-based learning has been described using various peda-gogical models to help educators understand and leverage the most effective strategies to achieve educational goals. The most fundamental

Surgery_Schwartz. 53standards-based learning using simulation and measured per-formance in the OR for purposes of trainee advancement and certification.Scientific Underpinnings of Simulator UseThe assumption that surgical technical skills can be effec-tively learned and tested outside the OR serves as the basis for simulation based assessment of skills before, during, and following training. This capability permits the explicit descrip-tion of understandable surgeon performance characteristics including those that can be characterized as desirable training goals (e.g., “expert”). The effectiveness of specific models of training can also be ascertained by comparative studies examin-ing educational endpoints, such as rate of learning, or testable performance either in simulations or in clinical settings. Sim-ulation-based learning has been described using various peda-gogical models to help educators understand and leverage the most effective strategies to achieve educational goals. The most fundamental

Surgery_Schwartz_14144

Surgery_Schwartz

learning has been described using various peda-gogical models to help educators understand and leverage the most effective strategies to achieve educational goals. The most fundamental concept used to justify time spent in skills training is the prospect of achieving progressively higher levels of skill pertinent to clinical care. For medical care providers, this pro-gression is commonly related to the learning model described by Dreyfus and Dreyfus.14 This model depicts changes in specific mental functions (recollection, recognition, decision, awareness) associated with incremental steps in the progres-sion from novice status to that of expert (Fig. 53-1). The rel-evance of Anders Ericsson’s description of deliberate practice to development of clinical skills is also widely accepted.15 This is predicated on the concept that “expert” performance is fun-damentally different than normal performance and results from behaviors that “reflect a life-long period of deliberate effort to

Surgery_Schwartz. learning has been described using various peda-gogical models to help educators understand and leverage the most effective strategies to achieve educational goals. The most fundamental concept used to justify time spent in skills training is the prospect of achieving progressively higher levels of skill pertinent to clinical care. For medical care providers, this pro-gression is commonly related to the learning model described by Dreyfus and Dreyfus.14 This model depicts changes in specific mental functions (recollection, recognition, decision, awareness) associated with incremental steps in the progres-sion from novice status to that of expert (Fig. 53-1). The rel-evance of Anders Ericsson’s description of deliberate practice to development of clinical skills is also widely accepted.15 This is predicated on the concept that “expert” performance is fun-damentally different than normal performance and results from behaviors that “reflect a life-long period of deliberate effort to

Surgery_Schwartz_14145

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This is predicated on the concept that “expert” performance is fun-damentally different than normal performance and results from behaviors that “reflect a life-long period of deliberate effort to improve performance in a specific domain.”16 The drive to achieve mastery in surgery, provides an aspirational model for the surgeon’s use of simulation because the opportunity for deliberate, repetitive practice of numerous skills in the clinical setting alone is insufficient and in many cases nearly impossi-ble. For this concept to be translated into effective educational results, simulation-based education must be of high quality, and the curricular framework created for its use must be directed toward carefully crafted, attainable, and clinically relevant edu-cational goals.Simulation in Graduate Medical EducationSurgery residency has been a particular area of focus for simula-tion use in assessment and training. The need for safe and rapid skills development is especially important in

Surgery_Schwartz. This is predicated on the concept that “expert” performance is fun-damentally different than normal performance and results from behaviors that “reflect a life-long period of deliberate effort to improve performance in a specific domain.”16 The drive to achieve mastery in surgery, provides an aspirational model for the surgeon’s use of simulation because the opportunity for deliberate, repetitive practice of numerous skills in the clinical setting alone is insufficient and in many cases nearly impossi-ble. For this concept to be translated into effective educational results, simulation-based education must be of high quality, and the curricular framework created for its use must be directed toward carefully crafted, attainable, and clinically relevant edu-cational goals.Simulation in Graduate Medical EducationSurgery residency has been a particular area of focus for simula-tion use in assessment and training. The need for safe and rapid skills development is especially important in

Surgery_Schwartz_14146

Surgery_Schwartz

Medical EducationSurgery residency has been a particular area of focus for simula-tion use in assessment and training. The need for safe and rapid skills development is especially important in this group of learn-ers whose time in training is limited and for whom every hour spent in education must be prioritized for highest impact. The added direct costs of operative care in training institutions has also provides a strong imperative to conduct training that mini-mizes negative implications of resident involvement in surgical cases.17 Learning basic skills at the point of care imposes inef-ficiencies that might very well endanger support for the education mission.11. Transcends reliance on rules, guidelines, and maxims2. Intuitive grasp of situations based on deep understanding3. Has a vision of what is possible4. Uses an analytical approach in new situationsExpertProÿcient1. Holistic view of situation2. Prioritizes importance of aspects3. Perceives deviations from the normal

Surgery_Schwartz. Medical EducationSurgery residency has been a particular area of focus for simula-tion use in assessment and training. The need for safe and rapid skills development is especially important in this group of learn-ers whose time in training is limited and for whom every hour spent in education must be prioritized for highest impact. The added direct costs of operative care in training institutions has also provides a strong imperative to conduct training that mini-mizes negative implications of resident involvement in surgical cases.17 Learning basic skills at the point of care imposes inef-ficiencies that might very well endanger support for the education mission.11. Transcends reliance on rules, guidelines, and maxims2. Intuitive grasp of situations based on deep understanding3. Has a vision of what is possible4. Uses an analytical approach in new situationsExpertProÿcient1. Holistic view of situation2. Prioritizes importance of aspects3. Perceives deviations from the normal

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Has a vision of what is possible4. Uses an analytical approach in new situationsExpertProÿcient1. Holistic view of situation2. Prioritizes importance of aspects3. Perceives deviations from the normal pattern4. Employs maxims for guidance, with meanings that adapt to the situation at handNovice1. Rigid adherence to taught rules or plans2. No exercise of discretionary judgementAdvancedbeginner1. Limited situational perception2. All aspects of work treated separately with equal importanceCompetent1. Coping with crowdedness (multiple activities, information)2. Some perception of actions in relation to goals3. Deliberate planning4. Formulates routinesFigure 53-1. Dreyfus model describing stepwise skills development. In surgery, specific stages of expertise are achieved through cognitive learning, technical practice, and experience and are defined by specific cognitive and behavioral characteristics affecting how we perceive, process, and act in the task environment. (Reproduced with

Surgery_Schwartz. Has a vision of what is possible4. Uses an analytical approach in new situationsExpertProÿcient1. Holistic view of situation2. Prioritizes importance of aspects3. Perceives deviations from the normal pattern4. Employs maxims for guidance, with meanings that adapt to the situation at handNovice1. Rigid adherence to taught rules or plans2. No exercise of discretionary judgementAdvancedbeginner1. Limited situational perception2. All aspects of work treated separately with equal importanceCompetent1. Coping with crowdedness (multiple activities, information)2. Some perception of actions in relation to goals3. Deliberate planning4. Formulates routinesFigure 53-1. Dreyfus model describing stepwise skills development. In surgery, specific stages of expertise are achieved through cognitive learning, technical practice, and experience and are defined by specific cognitive and behavioral characteristics affecting how we perceive, process, and act in the task environment. (Reproduced with

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learning, technical practice, and experience and are defined by specific cognitive and behavioral characteristics affecting how we perceive, process, and act in the task environment. (Reproduced with permission from University of South Australia; Teaching and Learning in Health Sciences: https://lo.unisa.edu.au/mod/book/view.php?id=611284&chapterid=104113.)Brunicardi_Ch53_p2163-p2186.indd 216522/02/19 4:39 PM 2166SPECIFIC CONSIDERATIONSPART IIDespite early examples of excellence in simulation lab use and fairly wide availability, a survey of residency programs in 2006 suggested the quality of usage for laparoscopic skills training was probably low and that more than half did not use a defined curriculum.18 Also in 2006, the ACGME Residency Review Committee (RRC) for Surgery instituted a formal requirement for simulation training in surgical residency.19 While the core program requirement did not define any specific educational objectives, performance outcomes, or specific methods

Surgery_Schwartz. learning, technical practice, and experience and are defined by specific cognitive and behavioral characteristics affecting how we perceive, process, and act in the task environment. (Reproduced with permission from University of South Australia; Teaching and Learning in Health Sciences: https://lo.unisa.edu.au/mod/book/view.php?id=611284&chapterid=104113.)Brunicardi_Ch53_p2163-p2186.indd 216522/02/19 4:39 PM 2166SPECIFIC CONSIDERATIONSPART IIDespite early examples of excellence in simulation lab use and fairly wide availability, a survey of residency programs in 2006 suggested the quality of usage for laparoscopic skills training was probably low and that more than half did not use a defined curriculum.18 Also in 2006, the ACGME Residency Review Committee (RRC) for Surgery instituted a formal requirement for simulation training in surgical residency.19 While the core program requirement did not define any specific educational objectives, performance outcomes, or specific methods

Surgery_Schwartz_14149

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a formal requirement for simulation training in surgical residency.19 While the core program requirement did not define any specific educational objectives, performance outcomes, or specific methods to be used, there was a mandate that simulation in surgical education be objectives-based and that it be incorpo-rated into residency curricula within 2 years. As of 2016, the relevant core program requirement indicates that “resources must include simulation and skills laboratories” and that “these facilities must address acquisition and maintenance of skills with a competency-based method of evaluation.”20 Since the original notification of the need to conduct this training, man-dated activities have expanded with the pairing of ACGME statements and new American Board of Surgery (ABS) require-ments for certifications in Fundamentals of Laparoscopic Surgery (FLS; instituted for 2010 residency graduates) and in Fundamentals of Endoscopic Surgery (FES; instituted for 2018 residency

Surgery_Schwartz. a formal requirement for simulation training in surgical residency.19 While the core program requirement did not define any specific educational objectives, performance outcomes, or specific methods to be used, there was a mandate that simulation in surgical education be objectives-based and that it be incorpo-rated into residency curricula within 2 years. As of 2016, the relevant core program requirement indicates that “resources must include simulation and skills laboratories” and that “these facilities must address acquisition and maintenance of skills with a competency-based method of evaluation.”20 Since the original notification of the need to conduct this training, man-dated activities have expanded with the pairing of ACGME statements and new American Board of Surgery (ABS) require-ments for certifications in Fundamentals of Laparoscopic Surgery (FLS; instituted for 2010 residency graduates) and in Fundamentals of Endoscopic Surgery (FES; instituted for 2018 residency

Surgery_Schwartz_14150

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require-ments for certifications in Fundamentals of Laparoscopic Surgery (FLS; instituted for 2010 residency graduates) and in Fundamentals of Endoscopic Surgery (FES; instituted for 2018 residency graduates). Both of these certifications demand lab-based practice in order to successfully pass respective technical skill test components.Both high and low technology and fidelity, off-the-shelf, simulation training solutions have become available for sur-gery residents’ lab-based training. Curricular content such as the ACS-APDS skills modules are readily available to facilitate a sufficient level of implementation to meet the RRC require-ments, although preparation methods have not been specifically prescribed by either the ACGME or the ABS. In 2015, the ABS issued a new requirement for a comprehensive multilevel Flexible Endoscopy Curriculum (FEC) paired with FES certification. This curriculum states explicitly that experiential requirements at the lower levels can be met with

Surgery_Schwartz. require-ments for certifications in Fundamentals of Laparoscopic Surgery (FLS; instituted for 2010 residency graduates) and in Fundamentals of Endoscopic Surgery (FES; instituted for 2018 residency graduates). Both of these certifications demand lab-based practice in order to successfully pass respective technical skill test components.Both high and low technology and fidelity, off-the-shelf, simulation training solutions have become available for sur-gery residents’ lab-based training. Curricular content such as the ACS-APDS skills modules are readily available to facilitate a sufficient level of implementation to meet the RRC require-ments, although preparation methods have not been specifically prescribed by either the ACGME or the ABS. In 2015, the ABS issued a new requirement for a comprehensive multilevel Flexible Endoscopy Curriculum (FEC) paired with FES certification. This curriculum states explicitly that experiential requirements at the lower levels can be met with

Surgery_Schwartz_14151

Surgery_Schwartz

for a comprehensive multilevel Flexible Endoscopy Curriculum (FEC) paired with FES certification. This curriculum states explicitly that experiential requirements at the lower levels can be met with simulation methods but it is left to individual programs to decide what preparatory practice in simulation might consist of for their own residents.21Options for simulation use in surgical training are cur-rently numerous and can be implemented with basic facilities and equipment, but the determination to use these methods suc-cessfully requires considerable effort that is greatly aided by fully motivated and engaged faculty members with protected time. There are now numerous guides and recommendations for successful surgical simulation lab start-ups.18,22-24“Bootcamps”Preparatory training for surgery residency both before and immediately after the start of residency is now a widely used educational practice. The rationale for these programs includes early development of basic skills that

Surgery_Schwartz. for a comprehensive multilevel Flexible Endoscopy Curriculum (FEC) paired with FES certification. This curriculum states explicitly that experiential requirements at the lower levels can be met with simulation methods but it is left to individual programs to decide what preparatory practice in simulation might consist of for their own residents.21Options for simulation use in surgical training are cur-rently numerous and can be implemented with basic facilities and equipment, but the determination to use these methods suc-cessfully requires considerable effort that is greatly aided by fully motivated and engaged faculty members with protected time. There are now numerous guides and recommendations for successful surgical simulation lab start-ups.18,22-24“Bootcamps”Preparatory training for surgery residency both before and immediately after the start of residency is now a widely used educational practice. The rationale for these programs includes early development of basic skills that

Surgery_Schwartz_14152

Surgery_Schwartz

surgery residency both before and immediately after the start of residency is now a widely used educational practice. The rationale for these programs includes early development of basic skills that would be of obvious use to the new trainee as well as determination of the status of basic skills that would serve as a needs assessment to model curricu-lar efforts expected to be most appropriate for the individual resident.25-27 The suggestion that new interns will render safer care has been garnered from results of intensive, short-duration preparatory training that shows higher level of skills measured in simulation are feasible compared to the “control” situation of not using such training.28 However, none of the current reports address whether intensive preparatory training addresses the “July Effect” by improving clinical effectiveness during the earliest months of training.28Much of the training and assessment during these pro-grams is accomplished using simulation methods. No

Surgery_Schwartz. surgery residency both before and immediately after the start of residency is now a widely used educational practice. The rationale for these programs includes early development of basic skills that would be of obvious use to the new trainee as well as determination of the status of basic skills that would serve as a needs assessment to model curricu-lar efforts expected to be most appropriate for the individual resident.25-27 The suggestion that new interns will render safer care has been garnered from results of intensive, short-duration preparatory training that shows higher level of skills measured in simulation are feasible compared to the “control” situation of not using such training.28 However, none of the current reports address whether intensive preparatory training addresses the “July Effect” by improving clinical effectiveness during the earliest months of training.28Much of the training and assessment during these pro-grams is accomplished using simulation methods. No

Surgery_Schwartz_14153

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the “July Effect” by improving clinical effectiveness during the earliest months of training.28Much of the training and assessment during these pro-grams is accomplished using simulation methods. No stan-dardized approach has yet been suggested, and at the present time the impact of specific simulation components is difficult to assess for senior students entering surgical training, or new interns. Sound recommendations on this await further study. A single meta-analysis of postgraduate “boot camp” programs both prior to or at the start of residency found that all programs utilized high and low technology simulation methods as “a key component.”29 Although the analysis included all medical spe-cialties, 93% of the studies were surgical in nature, underscor-ing the perceived value of this preparatory training for new surgeons. The examined studies were those where preand posttraining effects were measured in some way. The compiled data revealed that trainees who completed the programs

Surgery_Schwartz. the “July Effect” by improving clinical effectiveness during the earliest months of training.28Much of the training and assessment during these pro-grams is accomplished using simulation methods. No stan-dardized approach has yet been suggested, and at the present time the impact of specific simulation components is difficult to assess for senior students entering surgical training, or new interns. Sound recommendations on this await further study. A single meta-analysis of postgraduate “boot camp” programs both prior to or at the start of residency found that all programs utilized high and low technology simulation methods as “a key component.”29 Although the analysis included all medical spe-cialties, 93% of the studies were surgical in nature, underscor-ing the perceived value of this preparatory training for new surgeons. The examined studies were those where preand posttraining effects were measured in some way. The compiled data revealed that trainees who completed the programs

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preparatory training for new surgeons. The examined studies were those where preand posttraining effects were measured in some way. The compiled data revealed that trainees who completed the programs had uni-formly strong increases in skills development, knowledge, and confidence. In 2014 the ABS, ACS, APDS, and Association for Surgical Education, citing the evidence of effectiveness of these now numerous preparatory courses, officially endorsed them as a useful method to position fourth-year students and interns for early success in residency.30 Whether preresidency exposure to surgical simulation can influence a medical student’s decision to pursue a surgical career remains to be determined.SPECIFIC SIMULATION TRAINING AND ASSESSMENT APPLICATIONSTraining Basic Surgical SkillsThe use of the simulation lab to train open, laparoscopic, and flexible endoscopic basic skills in preparation for care and prac-tice clinical constitutes the most accessible and widely adopted set of simulation

Surgery_Schwartz. preparatory training for new surgeons. The examined studies were those where preand posttraining effects were measured in some way. The compiled data revealed that trainees who completed the programs had uni-formly strong increases in skills development, knowledge, and confidence. In 2014 the ABS, ACS, APDS, and Association for Surgical Education, citing the evidence of effectiveness of these now numerous preparatory courses, officially endorsed them as a useful method to position fourth-year students and interns for early success in residency.30 Whether preresidency exposure to surgical simulation can influence a medical student’s decision to pursue a surgical career remains to be determined.SPECIFIC SIMULATION TRAINING AND ASSESSMENT APPLICATIONSTraining Basic Surgical SkillsThe use of the simulation lab to train open, laparoscopic, and flexible endoscopic basic skills in preparation for care and prac-tice clinical constitutes the most accessible and widely adopted set of simulation

Surgery_Schwartz_14155

Surgery_Schwartz

simulation lab to train open, laparoscopic, and flexible endoscopic basic skills in preparation for care and prac-tice clinical constitutes the most accessible and widely adopted set of simulation training practices. In connection with these, the term “proficiency-based” training (sometimes used synony-mously with competency-based or objectives-based) is often used, and can be defined as the use of meaningful performance standards as educational goals for training. Implicit in the term is the expectation that if proficiency standards are achieved, a learner will be better positioned to perform to a desirable stan-dard in the clinical setting. Even these most basic skills have been shown to improve with proficiency-based training.31 Addi-tional benefits of proficiency-based approaches to basic surgical skills include knowledge of a surgical learner’s specific educa-tional needs and design of a larger skills curriculum roadmap that envisions progression to more advanced skills

Surgery_Schwartz. simulation lab to train open, laparoscopic, and flexible endoscopic basic skills in preparation for care and prac-tice clinical constitutes the most accessible and widely adopted set of simulation training practices. In connection with these, the term “proficiency-based” training (sometimes used synony-mously with competency-based or objectives-based) is often used, and can be defined as the use of meaningful performance standards as educational goals for training. Implicit in the term is the expectation that if proficiency standards are achieved, a learner will be better positioned to perform to a desirable stan-dard in the clinical setting. Even these most basic skills have been shown to improve with proficiency-based training.31 Addi-tional benefits of proficiency-based approaches to basic surgical skills include knowledge of a surgical learner’s specific educa-tional needs and design of a larger skills curriculum roadmap that envisions progression to more advanced skills

Surgery_Schwartz_14156

Surgery_Schwartz

to basic surgical skills include knowledge of a surgical learner’s specific educa-tional needs and design of a larger skills curriculum roadmap that envisions progression to more advanced skills training.Educators at Southern Illinois University implemented a program of intensive lab-based practice of basic skills as a pre-liminary requirement to participate in operative cases. Termed “Verification of Proficiency,” this program targets junior train-ees for assessment of skill using OSATS-like rating instruments, but its unique feature is the definition of a minimal level of skill that would permit a resident to assume the role of operator for specific case types.32,33More recently, the concept of “proficiency-based progression” has been used to describe a formalized process of use of sequenced proficiency standards and a continuum of progres-sively more advanced and challenging simulation experiences as a potential future model of training.34 Such a model would span whatever period

Surgery_Schwartz. to basic surgical skills include knowledge of a surgical learner’s specific educa-tional needs and design of a larger skills curriculum roadmap that envisions progression to more advanced skills training.Educators at Southern Illinois University implemented a program of intensive lab-based practice of basic skills as a pre-liminary requirement to participate in operative cases. Termed “Verification of Proficiency,” this program targets junior train-ees for assessment of skill using OSATS-like rating instruments, but its unique feature is the definition of a minimal level of skill that would permit a resident to assume the role of operator for specific case types.32,33More recently, the concept of “proficiency-based progression” has been used to describe a formalized process of use of sequenced proficiency standards and a continuum of progres-sively more advanced and challenging simulation experiences as a potential future model of training.34 Such a model would span whatever period

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proficiency standards and a continuum of progres-sively more advanced and challenging simulation experiences as a potential future model of training.34 Such a model would span whatever period of time was necessary for each learner to progress from basic surgical skills to more advanced ones.Open Surgical Skills. A variety of benchtop models for prac-tice and assessment of basic open skills are available, the most 2Brunicardi_Ch53_p2163-p2186.indd 216622/02/19 4:39 PM 2167SKILLS AND SIMULATIONCHAPTER 53Table 53-1ACS-APDS basic skills curriculum components• Asepsis and instrument identification• Knot tying• Suturing• Skin flaps• Skin grafts• Urethral catheterization• Airway management• Chest tube insertion• Central line insertion• Surgical biopsy• Laparotomy opening and closure• Basic laparoscopy skills• Advanced laparoscopy skills• Hand-sewn bowel anastomosis• Stapled bowel anastomosis• Arterial anastomosisFigure 53-2. Abdominal wall closure model made from commonly available

Surgery_Schwartz. proficiency standards and a continuum of progres-sively more advanced and challenging simulation experiences as a potential future model of training.34 Such a model would span whatever period of time was necessary for each learner to progress from basic surgical skills to more advanced ones.Open Surgical Skills. A variety of benchtop models for prac-tice and assessment of basic open skills are available, the most 2Brunicardi_Ch53_p2163-p2186.indd 216622/02/19 4:39 PM 2167SKILLS AND SIMULATIONCHAPTER 53Table 53-1ACS-APDS basic skills curriculum components• Asepsis and instrument identification• Knot tying• Suturing• Skin flaps• Skin grafts• Urethral catheterization• Airway management• Chest tube insertion• Central line insertion• Surgical biopsy• Laparotomy opening and closure• Basic laparoscopy skills• Advanced laparoscopy skills• Hand-sewn bowel anastomosis• Stapled bowel anastomosis• Arterial anastomosisFigure 53-2. Abdominal wall closure model made from commonly available

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laparoscopy skills• Advanced laparoscopy skills• Hand-sewn bowel anastomosis• Stapled bowel anastomosis• Arterial anastomosisFigure 53-2. Abdominal wall closure model made from commonly available materials using instructions in the ACS-APDS Basic Skills Curriculum module for this task.well-known of which are the OSATS tasks that remain in use more than 20 years after their inception. The ACS-APDS Basic Skills Curriculum (Table 53-1) is a useful resource for this.Generally, lower-fidelity models are more cost effec-tive for repetitive training because durability with reuse may be better than high-fidelity physical models and replacement costs can be minimized for many tasks. Examples can include simple models for abdominal wall closure (Fig. 53-2). The use of low-fidelity models in well-formulated curricular train-ing can be very effective in increasing resident skill, although high-quality measurement can be labor intensive. Bowel and vascular anastomosis training has been an

Surgery_Schwartz. laparoscopy skills• Advanced laparoscopy skills• Hand-sewn bowel anastomosis• Stapled bowel anastomosis• Arterial anastomosisFigure 53-2. Abdominal wall closure model made from commonly available materials using instructions in the ACS-APDS Basic Skills Curriculum module for this task.well-known of which are the OSATS tasks that remain in use more than 20 years after their inception. The ACS-APDS Basic Skills Curriculum (Table 53-1) is a useful resource for this.Generally, lower-fidelity models are more cost effec-tive for repetitive training because durability with reuse may be better than high-fidelity physical models and replacement costs can be minimized for many tasks. Examples can include simple models for abdominal wall closure (Fig. 53-2). The use of low-fidelity models in well-formulated curricular train-ing can be very effective in increasing resident skill, although high-quality measurement can be labor intensive. Bowel and vascular anastomosis training has been an

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well-formulated curricular train-ing can be very effective in increasing resident skill, although high-quality measurement can be labor intensive. Bowel and vascular anastomosis training has been an especially impor-tant point of focus given their prominence and highly technical nature in clinical practice. In a recent analysis of resident expe-rience with gastrointestinal anastomosis, Nemeth reported that although frequently performed (average 67 per resident), stapled anastomosis experience predominates during training (91% of laparoscopic procedures and 82% of open ones), suggesting a relatively small clinical experience with hand-sewn anastomotic methods, which remain critically relevant.35 Simulated bowel anastomosis models are widely available (Fig. 53-3), and there are numerous reports of successful curriculum-based devel-opment of this core technical skill generally utilizing OSATS rating instruments.36-38 Although further study is required to demonstrate a clinical effect of

Surgery_Schwartz. well-formulated curricular train-ing can be very effective in increasing resident skill, although high-quality measurement can be labor intensive. Bowel and vascular anastomosis training has been an especially impor-tant point of focus given their prominence and highly technical nature in clinical practice. In a recent analysis of resident expe-rience with gastrointestinal anastomosis, Nemeth reported that although frequently performed (average 67 per resident), stapled anastomosis experience predominates during training (91% of laparoscopic procedures and 82% of open ones), suggesting a relatively small clinical experience with hand-sewn anastomotic methods, which remain critically relevant.35 Simulated bowel anastomosis models are widely available (Fig. 53-3), and there are numerous reports of successful curriculum-based devel-opment of this core technical skill generally utilizing OSATS rating instruments.36-38 Although further study is required to demonstrate a clinical effect of

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of successful curriculum-based devel-opment of this core technical skill generally utilizing OSATS rating instruments.36-38 Although further study is required to demonstrate a clinical effect of this training, other experience strongly suggests that use of proficiency-based anastomosis training should be the next step. In an example of how this could be used for trainee benefit, Palter conducted a randomized trial of use of a proficiency-based technical skills and cognitive cur-riculum for abdominal wall closure.39 The technical skills com-ponent utilized a low-fidelity model for an OSATS assessments of both lab and OR performance. Residents in the intervention arm performed better on both clinical abdominal wall closure and a test of procedural knowledge than controls.Basic Laparoscopic Manipulative Skills. Current evidence supports the concept that basic laparoscopic skills should be developed in the training lab, avoiding safety concerns as well as the expenditure of time and

Surgery_Schwartz. of successful curriculum-based devel-opment of this core technical skill generally utilizing OSATS rating instruments.36-38 Although further study is required to demonstrate a clinical effect of this training, other experience strongly suggests that use of proficiency-based anastomosis training should be the next step. In an example of how this could be used for trainee benefit, Palter conducted a randomized trial of use of a proficiency-based technical skills and cognitive cur-riculum for abdominal wall closure.39 The technical skills com-ponent utilized a low-fidelity model for an OSATS assessments of both lab and OR performance. Residents in the intervention arm performed better on both clinical abdominal wall closure and a test of procedural knowledge than controls.Basic Laparoscopic Manipulative Skills. Current evidence supports the concept that basic laparoscopic skills should be developed in the training lab, avoiding safety concerns as well as the expenditure of time and

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Manipulative Skills. Current evidence supports the concept that basic laparoscopic skills should be developed in the training lab, avoiding safety concerns as well as the expenditure of time and effort that would result from learning in clinical settings. Specific programs for basic laparo-scopic skills development coupled with skills assessment were set forth 20 years ago at a time when this need was newly articu-lated for surgeons at all levels.7,40,41 These utilized videoscopic training “boxes” for two-handed practice using laparoscopic instruments to manipulate box contents. Programs such as the Rosser drills employed various dexterity tasks emphasizing time for task completion as a measure of performance. Later, McGill investigators began to apply greater scientific rigor to the design Brunicardi_Ch53_p2163-p2186.indd 216722/02/19 4:39 PM 2168SPECIFIC CONSIDERATIONSPART IIABFigure 53-3. A. Hand-sewn GI anastomosis from the ACS-APDS Basic Skills Curriculum module for this

Surgery_Schwartz. Manipulative Skills. Current evidence supports the concept that basic laparoscopic skills should be developed in the training lab, avoiding safety concerns as well as the expenditure of time and effort that would result from learning in clinical settings. Specific programs for basic laparo-scopic skills development coupled with skills assessment were set forth 20 years ago at a time when this need was newly articu-lated for surgeons at all levels.7,40,41 These utilized videoscopic training “boxes” for two-handed practice using laparoscopic instruments to manipulate box contents. Programs such as the Rosser drills employed various dexterity tasks emphasizing time for task completion as a measure of performance. Later, McGill investigators began to apply greater scientific rigor to the design Brunicardi_Ch53_p2163-p2186.indd 216722/02/19 4:39 PM 2168SPECIFIC CONSIDERATIONSPART IIABFigure 53-3. A. Hand-sewn GI anastomosis from the ACS-APDS Basic Skills Curriculum module for this

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design Brunicardi_Ch53_p2163-p2186.indd 216722/02/19 4:39 PM 2168SPECIFIC CONSIDERATIONSPART IIABFigure 53-3. A. Hand-sewn GI anastomosis from the ACS-APDS Basic Skills Curriculum module for this task. A full instructional presen-tation is available with the curriculum along with an assessment instrument for the educator to use. B. OSATS stapled bowel anastomosis model. (Reproduced with permission from de Montbrun SL, Macrae H Simulation in surgical education, Clin Colon Rectal Surg. 2012 Sep;25(3):156-165.)and testing of basic skills curricula, with a particular focus on the ability to characterize the skills acquisition process and dif-ferences between learner groups based on careful repetitive measurement.42 Further study showed that performance, mea-sured using these bench training tasks, correlated with perfor-mance measured in vivo animal models.43 In addition to helping learners prepare for basic tissue manipulation, training on basic tasks were found to shorten the

Surgery_Schwartz. design Brunicardi_Ch53_p2163-p2186.indd 216722/02/19 4:39 PM 2168SPECIFIC CONSIDERATIONSPART IIABFigure 53-3. A. Hand-sewn GI anastomosis from the ACS-APDS Basic Skills Curriculum module for this task. A full instructional presen-tation is available with the curriculum along with an assessment instrument for the educator to use. B. OSATS stapled bowel anastomosis model. (Reproduced with permission from de Montbrun SL, Macrae H Simulation in surgical education, Clin Colon Rectal Surg. 2012 Sep;25(3):156-165.)and testing of basic skills curricula, with a particular focus on the ability to characterize the skills acquisition process and dif-ferences between learner groups based on careful repetitive measurement.42 Further study showed that performance, mea-sured using these bench training tasks, correlated with perfor-mance measured in vivo animal models.43 In addition to helping learners prepare for basic tissue manipulation, training on basic tasks were found to shorten the

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training tasks, correlated with perfor-mance measured in vivo animal models.43 In addition to helping learners prepare for basic tissue manipulation, training on basic tasks were found to shorten the learning curves for more com-plex laparoscopic tasks such as suturing.44Fundamentals of Laparoscopic SurgeryFundamentals of Laparoscopic Surgery (FLS) was devised by minimally invasive surgical leaders in the Society of American Gastrointestinal and Endoscopic Surgeons as a means to assess laparoscopic surgical knowledge and skills for the purposes of certification of basic ability.45 This program represents the first broadly applied effort to demonstrate achievement of a specified level of basic surgical skill with such specific test-ing. Although most utilized by surgical residents, the resulting skills certification is applicable to a broad range of learners, including surgeons in practice as well as laparoscopic sur-geons in specialties other than general surgery. FLS consists of

Surgery_Schwartz. training tasks, correlated with perfor-mance measured in vivo animal models.43 In addition to helping learners prepare for basic tissue manipulation, training on basic tasks were found to shorten the learning curves for more com-plex laparoscopic tasks such as suturing.44Fundamentals of Laparoscopic SurgeryFundamentals of Laparoscopic Surgery (FLS) was devised by minimally invasive surgical leaders in the Society of American Gastrointestinal and Endoscopic Surgeons as a means to assess laparoscopic surgical knowledge and skills for the purposes of certification of basic ability.45 This program represents the first broadly applied effort to demonstrate achievement of a specified level of basic surgical skill with such specific test-ing. Although most utilized by surgical residents, the resulting skills certification is applicable to a broad range of learners, including surgeons in practice as well as laparoscopic sur-geons in specialties other than general surgery. FLS consists of

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resulting skills certification is applicable to a broad range of learners, including surgeons in practice as well as laparoscopic sur-geons in specialties other than general surgery. FLS consists of separate tests of knowledge and technical ability. The lat-ter component required integration of simulation tasks with a high degree of validation for both effectiveness in discerning skill and relevance to the respective clinical tasks. The McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) tasks were selected as the technical skills assessment component.46 These were developed independently from the FLS program and adapted to the FLS based on the predictive value of a subset of the tasks for clinical skills mani-fested in the OR. These tasks have remained core features of the certifying examination and have been extensively studied both as training curriculum components and as predictors of clinical performance.47,48 Recent work has suggested that

Surgery_Schwartz. resulting skills certification is applicable to a broad range of learners, including surgeons in practice as well as laparoscopic sur-geons in specialties other than general surgery. FLS consists of separate tests of knowledge and technical ability. The lat-ter component required integration of simulation tasks with a high degree of validation for both effectiveness in discerning skill and relevance to the respective clinical tasks. The McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) tasks were selected as the technical skills assessment component.46 These were developed independently from the FLS program and adapted to the FLS based on the predictive value of a subset of the tasks for clinical skills mani-fested in the OR. These tasks have remained core features of the certifying examination and have been extensively studied both as training curriculum components and as predictors of clinical performance.47,48 Recent work has suggested that

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core features of the certifying examination and have been extensively studied both as training curriculum components and as predictors of clinical performance.47,48 Recent work has suggested that spe-cific proficiency-based training can increase pass rates on FLS to 100%, supporting the general suppositions about the benefits of this model of training.49The more recently available FES serves a similar purpose to FLS for flexible endoscopy.50 This certification adds the important feature of use of a virtual reality flexible endoscopy simulator as one of the platforms for delivery of the technical skills test.Bench Models for Training Specific Procedural SkillsProcedure-specific simulation offers a unique opportunity to practice and evaluate wholesome surgical skill. This includes training and evaluating the relationship between basic and com-plex technical skills and surgical decision-making. While the majority of procedural simulation trainers focus on bedside procedures such as

Surgery_Schwartz. core features of the certifying examination and have been extensively studied both as training curriculum components and as predictors of clinical performance.47,48 Recent work has suggested that spe-cific proficiency-based training can increase pass rates on FLS to 100%, supporting the general suppositions about the benefits of this model of training.49The more recently available FES serves a similar purpose to FLS for flexible endoscopy.50 This certification adds the important feature of use of a virtual reality flexible endoscopy simulator as one of the platforms for delivery of the technical skills test.Bench Models for Training Specific Procedural SkillsProcedure-specific simulation offers a unique opportunity to practice and evaluate wholesome surgical skill. This includes training and evaluating the relationship between basic and com-plex technical skills and surgical decision-making. While the majority of procedural simulation trainers focus on bedside procedures such as

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and evaluating the relationship between basic and com-plex technical skills and surgical decision-making. While the majority of procedural simulation trainers focus on bedside procedures such as central venous catheter placement, blad-der catheterization, and intubation, a number of trainers also have been designed to simulate more complex procedures such as laparoscopic ventral hernia, laparoscopic colectomy, and robotic nephrectomy.51-53 Currently, both virtual reality and physical or hybrid models are used for procedure-specific simulations.54 While each technology has specific benefits, there is still a critical need for fabrication and design approaches that are efficient, cost effective, and produce anatomically accurate models with realistic tissue properties.55 A number of groups have explored the use of three-dimensional (3D) printing with varying degrees of success.56,57 As the printing substrate materi-als and 3D machines continue to decrease in price and increase in ease

Surgery_Schwartz. and evaluating the relationship between basic and com-plex technical skills and surgical decision-making. While the majority of procedural simulation trainers focus on bedside procedures such as central venous catheter placement, blad-der catheterization, and intubation, a number of trainers also have been designed to simulate more complex procedures such as laparoscopic ventral hernia, laparoscopic colectomy, and robotic nephrectomy.51-53 Currently, both virtual reality and physical or hybrid models are used for procedure-specific simulations.54 While each technology has specific benefits, there is still a critical need for fabrication and design approaches that are efficient, cost effective, and produce anatomically accurate models with realistic tissue properties.55 A number of groups have explored the use of three-dimensional (3D) printing with varying degrees of success.56,57 As the printing substrate materi-als and 3D machines continue to decrease in price and increase in ease

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have explored the use of three-dimensional (3D) printing with varying degrees of success.56,57 As the printing substrate materi-als and 3D machines continue to decrease in price and increase in ease of use, there will likely be a significant upsurge in the use of this approach to facilitate development of procedure spe-cific simulations. In addition to full immersion virtual reality, a number of groups are still exploring the benefits of computer-based learning for training procedure-specific surgical skills.58The training and assessment benefits of procedure-specific simulation are numerous. Not only does it allow an opportunity to assess technical skill in the context of a multistep procedure, forced errors and critical decisions can be combined with this technology, allowing for a more in-depth learning experience and skills assessment. By way of example, two multistep bed-side procedures were modified: bladder catheterization and central venous catheter insertion. Both simulations

Surgery_Schwartz. have explored the use of three-dimensional (3D) printing with varying degrees of success.56,57 As the printing substrate materi-als and 3D machines continue to decrease in price and increase in ease of use, there will likely be a significant upsurge in the use of this approach to facilitate development of procedure spe-cific simulations. In addition to full immersion virtual reality, a number of groups are still exploring the benefits of computer-based learning for training procedure-specific surgical skills.58The training and assessment benefits of procedure-specific simulation are numerous. Not only does it allow an opportunity to assess technical skill in the context of a multistep procedure, forced errors and critical decisions can be combined with this technology, allowing for a more in-depth learning experience and skills assessment. By way of example, two multistep bed-side procedures were modified: bladder catheterization and central venous catheter insertion. Both simulations

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in-depth learning experience and skills assessment. By way of example, two multistep bed-side procedures were modified: bladder catheterization and central venous catheter insertion. Both simulations had embed-ded clinical scenarios, which if executed incorrectly in real life might produce patient injury due to incorrect technique or equipment choices. During the implementation of these modi-fied, multistep procedures, it was possible to identify individual cognitive and technical errors that serve as opportunities for additional training.59,60 The ACS-APDS Procedural Skills Curriculum was developed to complement the Basic Skills Curriculum and offers detailed learning objectives for a vari-ety of surgical procedures. The goal of this curriculum was to address holistic surgical skills in a context where both technical Brunicardi_Ch53_p2163-p2186.indd 216822/02/19 4:39 PM 2169SKILLS AND SIMULATIONCHAPTER 53Table 53-2ACS-APDS procedural skills curriculum components• Laparoscopic

Surgery_Schwartz. in-depth learning experience and skills assessment. By way of example, two multistep bed-side procedures were modified: bladder catheterization and central venous catheter insertion. Both simulations had embed-ded clinical scenarios, which if executed incorrectly in real life might produce patient injury due to incorrect technique or equipment choices. During the implementation of these modi-fied, multistep procedures, it was possible to identify individual cognitive and technical errors that serve as opportunities for additional training.59,60 The ACS-APDS Procedural Skills Curriculum was developed to complement the Basic Skills Curriculum and offers detailed learning objectives for a vari-ety of surgical procedures. The goal of this curriculum was to address holistic surgical skills in a context where both technical Brunicardi_Ch53_p2163-p2186.indd 216822/02/19 4:39 PM 2169SKILLS AND SIMULATIONCHAPTER 53Table 53-2ACS-APDS procedural skills curriculum components• Laparoscopic

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in a context where both technical Brunicardi_Ch53_p2163-p2186.indd 216822/02/19 4:39 PM 2169SKILLS AND SIMULATIONCHAPTER 53Table 53-2ACS-APDS procedural skills curriculum components• Laparoscopic ventral hernia repair• Open colon resection, lap right colon resection• Laparoscopic sigmoid resection• Open right colon resection• Laparoscopic/open bile duct exploration• Laparoscopic ventral/incisional hernia repair (porcine model)• Laparoscopic appendectomy• Laparoscopic Nissen fundoplication• Sentinal node biopsy and axillary lymph node dissection• Open inguinal/femoral hernia repair• Laparoscopic inguinal hernia repair• Laparoscopic/open splenectomy• Laparoscopic/open cholecystectomy• Gastric resection and peptic ulcer disease• Parathyroidectomy/thyroidectomyand cognitive performance could be assessed at the same time.11 The simulation scenarios defined for this curriculum are listed in Table 53-2.Similar to the literature on basic skills training and assess-ment, procedural skills

Surgery_Schwartz. in a context where both technical Brunicardi_Ch53_p2163-p2186.indd 216822/02/19 4:39 PM 2169SKILLS AND SIMULATIONCHAPTER 53Table 53-2ACS-APDS procedural skills curriculum components• Laparoscopic ventral hernia repair• Open colon resection, lap right colon resection• Laparoscopic sigmoid resection• Open right colon resection• Laparoscopic/open bile duct exploration• Laparoscopic ventral/incisional hernia repair (porcine model)• Laparoscopic appendectomy• Laparoscopic Nissen fundoplication• Sentinal node biopsy and axillary lymph node dissection• Open inguinal/femoral hernia repair• Laparoscopic inguinal hernia repair• Laparoscopic/open splenectomy• Laparoscopic/open cholecystectomy• Gastric resection and peptic ulcer disease• Parathyroidectomy/thyroidectomyand cognitive performance could be assessed at the same time.11 The simulation scenarios defined for this curriculum are listed in Table 53-2.Similar to the literature on basic skills training and assess-ment, procedural skills

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be assessed at the same time.11 The simulation scenarios defined for this curriculum are listed in Table 53-2.Similar to the literature on basic skills training and assess-ment, procedural skills training and assessment has been shown to benefit learners when delivered via a structured curriculum. In addition, procedural skills training in a simulated environ-ment has been shown to transfer to the real-life clinical setting. In 2005, Issenberg et al published a review of the features and uses of simulation training that lead to effective learning.61 After reviewing 109 articles that specifically used simulation as an educational intervention and not for assessment alone, Issenberg and colleagues noted that feedback, repetitive practice, and curricular intervention were among the top three features that lead to effective learning. Of note, in this same article, it was noted that simulator validity was at the bottom of the list of features that lead to effective learning. In essence,

Surgery_Schwartz. be assessed at the same time.11 The simulation scenarios defined for this curriculum are listed in Table 53-2.Similar to the literature on basic skills training and assess-ment, procedural skills training and assessment has been shown to benefit learners when delivered via a structured curriculum. In addition, procedural skills training in a simulated environ-ment has been shown to transfer to the real-life clinical setting. In 2005, Issenberg et al published a review of the features and uses of simulation training that lead to effective learning.61 After reviewing 109 articles that specifically used simulation as an educational intervention and not for assessment alone, Issenberg and colleagues noted that feedback, repetitive practice, and curricular intervention were among the top three features that lead to effective learning. Of note, in this same article, it was noted that simulator validity was at the bottom of the list of features that lead to effective learning. In essence,

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features that lead to effective learning. Of note, in this same article, it was noted that simulator validity was at the bottom of the list of features that lead to effective learning. In essence, trainees need protected time to engage in simulation-based learning exercises that have a high-level focus on deliberate and repetitive practice based on personalized feedback. This model is very similar to that used to train professional athletes.62Transfer of TrainingThe determination that simulation-based education is effective requires assessment of training effect in either the clinical setting or one with a demonstrated relationship to a clinical setting. The latter might result from comparison to a validated “gold standard” training method. Establishing a relationship between lab-based training and performance in the OR requires validated measures of operative skills such as the widely used Global Assessment of Operative Laparoscopic Skills (GOALS) method described by Vassiliou.63 The

Surgery_Schwartz. features that lead to effective learning. Of note, in this same article, it was noted that simulator validity was at the bottom of the list of features that lead to effective learning. In essence, trainees need protected time to engage in simulation-based learning exercises that have a high-level focus on deliberate and repetitive practice based on personalized feedback. This model is very similar to that used to train professional athletes.62Transfer of TrainingThe determination that simulation-based education is effective requires assessment of training effect in either the clinical setting or one with a demonstrated relationship to a clinical setting. The latter might result from comparison to a validated “gold standard” training method. Establishing a relationship between lab-based training and performance in the OR requires validated measures of operative skills such as the widely used Global Assessment of Operative Laparoscopic Skills (GOALS) method described by Vassiliou.63 The

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and performance in the OR requires validated measures of operative skills such as the widely used Global Assessment of Operative Laparoscopic Skills (GOALS) method described by Vassiliou.63 The majority of studies of laparoscopic simulation training that examine transfer of skills to the clinical OR make comparisons to control groups without highly structured and non-simulation based training. The results of these studies should eliminate any doubts that surgical learners, especially students and residents, can achieve training benefits from both proficiency-based and timeor repetitionor session number-based simulation practice. When the results of proficiency-based training are dissected out from the other models of training, consistently higher levels of clinical or 3animal OR performance is observed with such training compared to without.64-67 In one such review of skills transfer studies conducted between 2007 and 2013, Dawe reported results for general surgery and gynecology

Surgery_Schwartz. and performance in the OR requires validated measures of operative skills such as the widely used Global Assessment of Operative Laparoscopic Skills (GOALS) method described by Vassiliou.63 The majority of studies of laparoscopic simulation training that examine transfer of skills to the clinical OR make comparisons to control groups without highly structured and non-simulation based training. The results of these studies should eliminate any doubts that surgical learners, especially students and residents, can achieve training benefits from both proficiency-based and timeor repetitionor session number-based simulation practice. When the results of proficiency-based training are dissected out from the other models of training, consistently higher levels of clinical or 3animal OR performance is observed with such training compared to without.64-67 In one such review of skills transfer studies conducted between 2007 and 2013, Dawe reported results for general surgery and gynecology

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is observed with such training compared to without.64-67 In one such review of skills transfer studies conducted between 2007 and 2013, Dawe reported results for general surgery and gynecology procedures using different virtual reality and non-VR laparoscopic simulation platforms (Table 53-3).48,67-77 For the 12 randomized controlled trials with surgical residents as study subjects, all but one showed significantly better clinical performance for intervention groups compared to non–simulation-trained controls.The comprehensive reviews of skills transfer data under-score the wide disparities in study design characteristics, metrics, simulator types, and the difficulties in comparing effectiveness of different simulation interventions. The “transfer effectiveness ratio” (TER) has been forwarded as a means of expressing the relative magnitude of the training effect and may provide a basis for comparison of cost or time efficiency of different training methods.78 To determine TER for a

Surgery_Schwartz. is observed with such training compared to without.64-67 In one such review of skills transfer studies conducted between 2007 and 2013, Dawe reported results for general surgery and gynecology procedures using different virtual reality and non-VR laparoscopic simulation platforms (Table 53-3).48,67-77 For the 12 randomized controlled trials with surgical residents as study subjects, all but one showed significantly better clinical performance for intervention groups compared to non–simulation-trained controls.The comprehensive reviews of skills transfer data under-score the wide disparities in study design characteristics, metrics, simulator types, and the difficulties in comparing effectiveness of different simulation interventions. The “transfer effectiveness ratio” (TER) has been forwarded as a means of expressing the relative magnitude of the training effect and may provide a basis for comparison of cost or time efficiency of different training methods.78 To determine TER for a

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as a means of expressing the relative magnitude of the training effect and may provide a basis for comparison of cost or time efficiency of different training methods.78 To determine TER for a simulation training effort, one would calculate the difference in clinical effort (time or some other measure such as number of cases) between simulator-trained and alternative-trained groups to achieve a desired level of clinical performance, divided by training time received by the simulator-trained group.Korndorffer raised concerns with studies of transfer of training when, irrespective of the improved results in lab performance with proficiency-based practice, residents studied by their group did not readily meet performance standards for more advanced skills set by expert surgeons in practice.79 Looking for opportunities to maximize the effectiveness of simulation training, Stefanidis proposed training to “automaticity” by adding a secondary visuospatial task to practice with laparoscopic

Surgery_Schwartz. as a means of expressing the relative magnitude of the training effect and may provide a basis for comparison of cost or time efficiency of different training methods.78 To determine TER for a simulation training effort, one would calculate the difference in clinical effort (time or some other measure such as number of cases) between simulator-trained and alternative-trained groups to achieve a desired level of clinical performance, divided by training time received by the simulator-trained group.Korndorffer raised concerns with studies of transfer of training when, irrespective of the improved results in lab performance with proficiency-based practice, residents studied by their group did not readily meet performance standards for more advanced skills set by expert surgeons in practice.79 Looking for opportunities to maximize the effectiveness of simulation training, Stefanidis proposed training to “automaticity” by adding a secondary visuospatial task to practice with laparoscopic

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Looking for opportunities to maximize the effectiveness of simulation training, Stefanidis proposed training to “automaticity” by adding a secondary visuospatial task to practice with laparoscopic suturing, but only after proficiency levels were achieved with more standard laparoscopic suturing practice.80 It was suggested that the added attentional challenge likely prompted the achievement of automaticity, the end result of which was much greater performance than was seen for proficiency-based practice alone. It is not clear, however, that simply adding to task difficulty improves training results if learner capabilities are not taken into account. In a separate study, Stefanidis also reported that increased task difficulty during proficiency-based training causes measurable increases in cognitive workload and that when confronted with these challenges, novice learners did not perform better than those in proficiency-based training at a lower level of difficulty, suggesting a

Surgery_Schwartz. Looking for opportunities to maximize the effectiveness of simulation training, Stefanidis proposed training to “automaticity” by adding a secondary visuospatial task to practice with laparoscopic suturing, but only after proficiency levels were achieved with more standard laparoscopic suturing practice.80 It was suggested that the added attentional challenge likely prompted the achievement of automaticity, the end result of which was much greater performance than was seen for proficiency-based practice alone. It is not clear, however, that simply adding to task difficulty improves training results if learner capabilities are not taken into account. In a separate study, Stefanidis also reported that increased task difficulty during proficiency-based training causes measurable increases in cognitive workload and that when confronted with these challenges, novice learners did not perform better than those in proficiency-based training at a lower level of difficulty, suggesting a

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in cognitive workload and that when confronted with these challenges, novice learners did not perform better than those in proficiency-based training at a lower level of difficulty, suggesting a possible mismatch between task challenges and capacity to learn.81 More work is required to characterize the proper balance of training difficulty and the capacity for learning in specific learners or learner groups.Virtual RealityThe use of virtual reality (VR) simulation as a way to deliver training experiences in surgery was proposed by Satava in 1993.82 Within a few years, practical applications of this technology led to the first commercially available laparoscopic simulators and studies to determine their value. The earliest and most functional VR platform was MIST-VR which permitted manipulation of abstract virtual objects using a realistic physical interface that transduced instrument motion into actions that could be observed in the virtual environment (Fig. 53-4).83 Even without a

Surgery_Schwartz. in cognitive workload and that when confronted with these challenges, novice learners did not perform better than those in proficiency-based training at a lower level of difficulty, suggesting a possible mismatch between task challenges and capacity to learn.81 More work is required to characterize the proper balance of training difficulty and the capacity for learning in specific learners or learner groups.Virtual RealityThe use of virtual reality (VR) simulation as a way to deliver training experiences in surgery was proposed by Satava in 1993.82 Within a few years, practical applications of this technology led to the first commercially available laparoscopic simulators and studies to determine their value. The earliest and most functional VR platform was MIST-VR which permitted manipulation of abstract virtual objects using a realistic physical interface that transduced instrument motion into actions that could be observed in the virtual environment (Fig. 53-4).83 Even without a

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of abstract virtual objects using a realistic physical interface that transduced instrument motion into actions that could be observed in the virtual environment (Fig. 53-4).83 Even without a force feedback apparatus and haptic, or “sense of touch,” cues expected with instrument–instrument or instrument–object interactions, learners could experience the psychomotor challenges of videolaparoscopy and iteratively train until Brunicardi_Ch53_p2163-p2186.indd 216922/02/19 4:39 PM 2170SPECIFIC CONSIDERATIONSPART IITable 53-3Randomized trials studying the effects of virtual reality training on surgical and OB-GYN resident operative performance vs. control trainees without virtual reality trainingAUTHOR (YEAR)PARTICIPANTS (N) AND SIMULATORPROCEDURE ASSESSEDCONCLUSIONAhlberg et al68 (2007)PGY 1–2 surgery residentsIG (7); Lap Sim VR simulatorCG (6) no simulationLaparoscopic cholecystectomyIG made fewer errors (P = 0.004), exposure (P = 0.040), clipping and tissue division (P <0.008), and

Surgery_Schwartz. of abstract virtual objects using a realistic physical interface that transduced instrument motion into actions that could be observed in the virtual environment (Fig. 53-4).83 Even without a force feedback apparatus and haptic, or “sense of touch,” cues expected with instrument–instrument or instrument–object interactions, learners could experience the psychomotor challenges of videolaparoscopy and iteratively train until Brunicardi_Ch53_p2163-p2186.indd 216922/02/19 4:39 PM 2170SPECIFIC CONSIDERATIONSPART IITable 53-3Randomized trials studying the effects of virtual reality training on surgical and OB-GYN resident operative performance vs. control trainees without virtual reality trainingAUTHOR (YEAR)PARTICIPANTS (N) AND SIMULATORPROCEDURE ASSESSEDCONCLUSIONAhlberg et al68 (2007)PGY 1–2 surgery residentsIG (7); Lap Sim VR simulatorCG (6) no simulationLaparoscopic cholecystectomyIG made fewer errors (P = 0.004), exposure (P = 0.040), clipping and tissue division (P <0.008), and

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1–2 surgery residentsIG (7); Lap Sim VR simulatorCG (6) no simulationLaparoscopic cholecystectomyIG made fewer errors (P = 0.004), exposure (P = 0.040), clipping and tissue division (P <0.008), and dissection (P <0.031) compared with CGBanks et al69 (2007)PGY 1 GYN residentsIG (10); Limbs & Things box trainerCG (10) no simulationBilateral tubal ligationIG scored higher than CG with all three evaluation tools: task-specific checklist (P = 0.002), OSATS (P = 0.003), pass-fail grade (P = 0.003)Cosman et al70 (2007)Junior surgical traineesIG (5); Lap Sim VR simulatorCG (5) no simulationLaparoscopic cholecystectomy (clip application and cystic artery division)IG had fewer errors (P = 0.05), better bimanual coordination (P = 0.05), higher global score (P = 0.04) than CGGala et al71 (2013)GYN residentsIG (48); FLS box trainerCG (54) no simulationPomeroy bilateral tubal ligationIG had higher OSATS progression score than CG (P = 0.03)Hogle et al72 (2009)PGY 1 surgery residentsIG (6);

Surgery_Schwartz. 1–2 surgery residentsIG (7); Lap Sim VR simulatorCG (6) no simulationLaparoscopic cholecystectomyIG made fewer errors (P = 0.004), exposure (P = 0.040), clipping and tissue division (P <0.008), and dissection (P <0.031) compared with CGBanks et al69 (2007)PGY 1 GYN residentsIG (10); Limbs & Things box trainerCG (10) no simulationBilateral tubal ligationIG scored higher than CG with all three evaluation tools: task-specific checklist (P = 0.002), OSATS (P = 0.003), pass-fail grade (P = 0.003)Cosman et al70 (2007)Junior surgical traineesIG (5); Lap Sim VR simulatorCG (5) no simulationLaparoscopic cholecystectomy (clip application and cystic artery division)IG had fewer errors (P = 0.05), better bimanual coordination (P = 0.05), higher global score (P = 0.04) than CGGala et al71 (2013)GYN residentsIG (48); FLS box trainerCG (54) no simulationPomeroy bilateral tubal ligationIG had higher OSATS progression score than CG (P = 0.03)Hogle et al72 (2009)PGY 1 surgery residentsIG (6);

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residentsIG (48); FLS box trainerCG (54) no simulationPomeroy bilateral tubal ligationIG had higher OSATS progression score than CG (P = 0.03)Hogle et al72 (2009)PGY 1 surgery residentsIG (6); Lap Sim VR simulatorCG (6) no simulationLaparoscopic cholecystectomyNo significant difference between IG and CG in GOALSDomain areas of depth perception, bimanual dexterity, efficiency, tissue handling, autonomyLarsen et al73 (2009)Firstand second-year OB-GYN registrarsIG (13); Lap Sim VR simulatorCG (11) no simulationSalpingectomyIG had higher score than CG in OSA-LS scale (P <0.001). IG completed procedure faster than CG (P <0.001)Sroka et al48 (2010)PGY 1–3 surgery residentsIG (8); FLS box trainerCG (8) no simulationLaparoscopic cholecystectomy (excision from liver bed)IG had higher total GOALS score than CG (P <0.001) and better GOALS domain scores for bimanual dexterity (P = 0.04), tissue handling (P = 0.04)Van Sickle et al74 (2008)PGY 3, 5–6 surgery residentsIG (11); MIST-VR

Surgery_Schwartz. residentsIG (48); FLS box trainerCG (54) no simulationPomeroy bilateral tubal ligationIG had higher OSATS progression score than CG (P = 0.03)Hogle et al72 (2009)PGY 1 surgery residentsIG (6); Lap Sim VR simulatorCG (6) no simulationLaparoscopic cholecystectomyNo significant difference between IG and CG in GOALSDomain areas of depth perception, bimanual dexterity, efficiency, tissue handling, autonomyLarsen et al73 (2009)Firstand second-year OB-GYN registrarsIG (13); Lap Sim VR simulatorCG (11) no simulationSalpingectomyIG had higher score than CG in OSA-LS scale (P <0.001). IG completed procedure faster than CG (P <0.001)Sroka et al48 (2010)PGY 1–3 surgery residentsIG (8); FLS box trainerCG (8) no simulationLaparoscopic cholecystectomy (excision from liver bed)IG had higher total GOALS score than CG (P <0.001) and better GOALS domain scores for bimanual dexterity (P = 0.04), tissue handling (P = 0.04)Van Sickle et al74 (2008)PGY 3, 5–6 surgery residentsIG (11); MIST-VR

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GOALS score than CG (P <0.001) and better GOALS domain scores for bimanual dexterity (P = 0.04), tissue handling (P = 0.04)Van Sickle et al74 (2008)PGY 3, 5–6 surgery residentsIG (11); MIST-VR simulatorCG no simulationNissen fundoplication (placement of intracorporeal sutures)IG completed task in less time (P <0.003), committed fewer errors (P <0.01), and had fewer needle manipulations (P <0.05) than CGZendejas et al75 (2011)Surgery residentsIG (26); Guildford MATTU TEP hernia task trainerCG (24) no simulationTEP inguinal hernia repairIG faster on first procedure (P <0.001) and had higher participation rates (P <0.001). For subsequent repairs IG remained faster than CG. GOALS score higher for IG (P = 0.001). Complications and overnight stay less likely for first TEP procedure in IG (P <0.05).Palter et al76 (2012)PGY 2–4 surgery residentsIG (9); curriculum including simulation training on LapSim VR simulatorCG (9) no simulationRight hemicolectomyIG had higher OSATS score (P = 0.030)

Surgery_Schwartz. GOALS score than CG (P <0.001) and better GOALS domain scores for bimanual dexterity (P = 0.04), tissue handling (P = 0.04)Van Sickle et al74 (2008)PGY 3, 5–6 surgery residentsIG (11); MIST-VR simulatorCG no simulationNissen fundoplication (placement of intracorporeal sutures)IG completed task in less time (P <0.003), committed fewer errors (P <0.01), and had fewer needle manipulations (P <0.05) than CGZendejas et al75 (2011)Surgery residentsIG (26); Guildford MATTU TEP hernia task trainerCG (24) no simulationTEP inguinal hernia repairIG faster on first procedure (P <0.001) and had higher participation rates (P <0.001). For subsequent repairs IG remained faster than CG. GOALS score higher for IG (P = 0.001). Complications and overnight stay less likely for first TEP procedure in IG (P <0.05).Palter et al76 (2012)PGY 2–4 surgery residentsIG (9); curriculum including simulation training on LapSim VR simulatorCG (9) no simulationRight hemicolectomyIG had higher OSATS score (P = 0.030)

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et al76 (2012)PGY 2–4 surgery residentsIG (9); curriculum including simulation training on LapSim VR simulatorCG (9) no simulationRight hemicolectomyIG had higher OSATS score (P = 0.030) than CG.IG able to perform more operative steps than CG (P = 0.021)Palter et al77 (2013)PGY 1–2 surgery residentsIG (9); curriculum including simulation training on LapSim VR simulator and on FLS box trainerCG (9) no simulationCholecystectomyIG had higher OSATS scores for first four procedures (P = 0.004, P = 0.036, P = 0.021, P = 0.023)PGY = postgraduate year; IG = intervention group; CG = control group; VR = virtual reality; OSATS = Objective Structured Assessment of Technical Skills; GOALS = Global Operative Assessment of Laparoscopic Skills; OSA-LS = Objective Structured Assessment of Laparoscopic Salpingectomy; TEP = totally extraperitoneal.Simulators: LapSim VR simulator (Surgical Science, Gothenburg, Sweden); laparoscopic stimulator and Minimal Access Therapy Unit (MATTU) (Limbs and Things,

Surgery_Schwartz. et al76 (2012)PGY 2–4 surgery residentsIG (9); curriculum including simulation training on LapSim VR simulatorCG (9) no simulationRight hemicolectomyIG had higher OSATS score (P = 0.030) than CG.IG able to perform more operative steps than CG (P = 0.021)Palter et al77 (2013)PGY 1–2 surgery residentsIG (9); curriculum including simulation training on LapSim VR simulator and on FLS box trainerCG (9) no simulationCholecystectomyIG had higher OSATS scores for first four procedures (P = 0.004, P = 0.036, P = 0.021, P = 0.023)PGY = postgraduate year; IG = intervention group; CG = control group; VR = virtual reality; OSATS = Objective Structured Assessment of Technical Skills; GOALS = Global Operative Assessment of Laparoscopic Skills; OSA-LS = Objective Structured Assessment of Laparoscopic Salpingectomy; TEP = totally extraperitoneal.Simulators: LapSim VR simulator (Surgical Science, Gothenburg, Sweden); laparoscopic stimulator and Minimal Access Therapy Unit (MATTU) (Limbs and Things,

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TEP = totally extraperitoneal.Simulators: LapSim VR simulator (Surgical Science, Gothenburg, Sweden); laparoscopic stimulator and Minimal Access Therapy Unit (MATTU) (Limbs and Things, Bristol, UK); Fundamentals of Laparoscopic Surgery (FLS) Training Box simulator (SAGES, Los Angeles, California, USA); Minimally Invasive Surgical Trainer—Virtual Reality (MIST-VR; Mentice, Gothenburg, Sweden).Modified with permission from Dawe SR, Pena GN, Windsor JA, et al. Systematic review of skills transfer after surgical simulation-based training, Br J Surg. 2014 Aug;101(9):1063-1076.Brunicardi_Ch53_p2163-p2186.indd 217022/02/19 4:39 PM 2171SKILLS AND SIMULATIONCHAPTER 53ABFigure 53-4. The surgical interface for MIST VR (A), consisting of rightand left-handed laparoscopic instruments on a gimbaled mount that transduces instrument motions into digital spatial data, which determine the location and actions of instruments in the virtual space (shown in B) in the course of manipulating

Surgery_Schwartz. TEP = totally extraperitoneal.Simulators: LapSim VR simulator (Surgical Science, Gothenburg, Sweden); laparoscopic stimulator and Minimal Access Therapy Unit (MATTU) (Limbs and Things, Bristol, UK); Fundamentals of Laparoscopic Surgery (FLS) Training Box simulator (SAGES, Los Angeles, California, USA); Minimally Invasive Surgical Trainer—Virtual Reality (MIST-VR; Mentice, Gothenburg, Sweden).Modified with permission from Dawe SR, Pena GN, Windsor JA, et al. Systematic review of skills transfer after surgical simulation-based training, Br J Surg. 2014 Aug;101(9):1063-1076.Brunicardi_Ch53_p2163-p2186.indd 217022/02/19 4:39 PM 2171SKILLS AND SIMULATIONCHAPTER 53ABFigure 53-4. The surgical interface for MIST VR (A), consisting of rightand left-handed laparoscopic instruments on a gimbaled mount that transduces instrument motions into digital spatial data, which determine the location and actions of instruments in the virtual space (shown in B) in the course of manipulating

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a gimbaled mount that transduces instrument motions into digital spatial data, which determine the location and actions of instruments in the virtual space (shown in B) in the course of manipulating two-handed virtual objects. Although basic renderings of geometric shapes, these virtual objects could be grasped, positioned, and treated with electrosurgery instruments, and they were shown to be an effective means to transfer skills to clinical surgery despite a relatively low level of fidelity to human tissues and absence of haptic feedback in the instrument interface.Table 53-4Studies comparing laparoscopic operative performance after training on virtual reality simulators vs. videoscopic box trainersAUTHOR (YEAR)STUDY ARMS (N)SUBJECTSPROFICIENCY-BASED TRAINING?CONCLUSIONSHamilton et al92 (2002)VR (24)Box trainer (25)Firstand second-year surgical residentsNoImproved rater-blinded global assessments of laparoscopic cholecystectomy for VR but not box-trainer trained subjectsYoungblood

Surgery_Schwartz. a gimbaled mount that transduces instrument motions into digital spatial data, which determine the location and actions of instruments in the virtual space (shown in B) in the course of manipulating two-handed virtual objects. Although basic renderings of geometric shapes, these virtual objects could be grasped, positioned, and treated with electrosurgery instruments, and they were shown to be an effective means to transfer skills to clinical surgery despite a relatively low level of fidelity to human tissues and absence of haptic feedback in the instrument interface.Table 53-4Studies comparing laparoscopic operative performance after training on virtual reality simulators vs. videoscopic box trainersAUTHOR (YEAR)STUDY ARMS (N)SUBJECTSPROFICIENCY-BASED TRAINING?CONCLUSIONSHamilton et al92 (2002)VR (24)Box trainer (25)Firstand second-year surgical residentsNoImproved rater-blinded global assessments of laparoscopic cholecystectomy for VR but not box-trainer trained subjectsYoungblood

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(2002)VR (24)Box trainer (25)Firstand second-year surgical residentsNoImproved rater-blinded global assessments of laparoscopic cholecystectomy for VR but not box-trainer trained subjectsYoungblood et al93 (2005)VR (16)Box trainer (17)No training (13)Medical studentsNoVR-trained students performed better than box trainer-trained on selected tasks in live porcine model. Both trained groups outperformed nontrained.Diesen et al94 (2011)VR (10)Box trainer (8)InternsMedical studentsNoNo difference in interval blinded video assessments of animal OR task performanceVR = virtual reality; OR = operating room.performance goals for precision, efficiency, and error avoidance were achieved. Performance measurement was automated and included time, instrument motion, and electrosurgery use metrics, as well as a tally of the occurrence of predefined errors. All metrics were free of human observer bias. Early studies of VR training using both proficiency-based and non–proficiency-based training

Surgery_Schwartz. (2002)VR (24)Box trainer (25)Firstand second-year surgical residentsNoImproved rater-blinded global assessments of laparoscopic cholecystectomy for VR but not box-trainer trained subjectsYoungblood et al93 (2005)VR (16)Box trainer (17)No training (13)Medical studentsNoVR-trained students performed better than box trainer-trained on selected tasks in live porcine model. Both trained groups outperformed nontrained.Diesen et al94 (2011)VR (10)Box trainer (8)InternsMedical studentsNoNo difference in interval blinded video assessments of animal OR task performanceVR = virtual reality; OR = operating room.performance goals for precision, efficiency, and error avoidance were achieved. Performance measurement was automated and included time, instrument motion, and electrosurgery use metrics, as well as a tally of the occurrence of predefined errors. All metrics were free of human observer bias. Early studies of VR training using both proficiency-based and non–proficiency-based training

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as well as a tally of the occurrence of predefined errors. All metrics were free of human observer bias. Early studies of VR training using both proficiency-based and non–proficiency-based training methods showed it to be an effective means of improving laparoscopic skill both in the lab and in the operating room compared to non-VR trained controls.68,84-87 Since the first studies of this type were performed almost 20 years ago, several comprehensive reviews of the growing body of literature on VR have continued to support the conclusion that skills acquired in VR transfer to the clinical setting (Table 53-3), not only for laparoscopy, but also for flexible endoscopy, sinuscopic surgery, and endovascular interventions.66,67,88-91 Largely due to small study sizes and some 4design limitations, the quality of evidence of these studies is consistently described as below level I.Based on available evidence, expanded use of VR for skills training could be justified, but few comparisons of

Surgery_Schwartz. as well as a tally of the occurrence of predefined errors. All metrics were free of human observer bias. Early studies of VR training using both proficiency-based and non–proficiency-based training methods showed it to be an effective means of improving laparoscopic skill both in the lab and in the operating room compared to non-VR trained controls.68,84-87 Since the first studies of this type were performed almost 20 years ago, several comprehensive reviews of the growing body of literature on VR have continued to support the conclusion that skills acquired in VR transfer to the clinical setting (Table 53-3), not only for laparoscopy, but also for flexible endoscopy, sinuscopic surgery, and endovascular interventions.66,67,88-91 Largely due to small study sizes and some 4design limitations, the quality of evidence of these studies is consistently described as below level I.Based on available evidence, expanded use of VR for skills training could be justified, but few comparisons of

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the quality of evidence of these studies is consistently described as below level I.Based on available evidence, expanded use of VR for skills training could be justified, but few comparisons of training effectiveness have been made between physical laparoscopic video trainer (“box” trainer) and laparoscopic VR simulator-based training. Crossover studies designed to determine if training in one environment improves performance in the other have not been especially helpful in defining the value of either. Only a few studies have compared the effects of the two training methods on OR performance (Table 53-4). Although some advantage has been suggested, the prevailing view is that both can be used for highly effective laparoscopic practice. Until better comparisons are made, use of proficiency-based training in the context of a larger curriculum appears to be the best way to achieve good training results irrespective of the training platform used.5Brunicardi_Ch53_p2163-p2186.indd

Surgery_Schwartz. the quality of evidence of these studies is consistently described as below level I.Based on available evidence, expanded use of VR for skills training could be justified, but few comparisons of training effectiveness have been made between physical laparoscopic video trainer (“box” trainer) and laparoscopic VR simulator-based training. Crossover studies designed to determine if training in one environment improves performance in the other have not been especially helpful in defining the value of either. Only a few studies have compared the effects of the two training methods on OR performance (Table 53-4). Although some advantage has been suggested, the prevailing view is that both can be used for highly effective laparoscopic practice. Until better comparisons are made, use of proficiency-based training in the context of a larger curriculum appears to be the best way to achieve good training results irrespective of the training platform used.5Brunicardi_Ch53_p2163-p2186.indd

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training in the context of a larger curriculum appears to be the best way to achieve good training results irrespective of the training platform used.5Brunicardi_Ch53_p2163-p2186.indd 217122/02/19 4:39 PM 2172SPECIFIC CONSIDERATIONSPART IIVR simulator systems are significant capital investments for simulation centers that have competing procurement priori-ties. In a prospective randomized trial, Orzech analyzed the cost impact of each type of training across Canadian residency pro-grams and found that the transfer of training effect was greater for VR as compared to the box trainer group. However, box trainer use was found to be more cost effective except in larger residencies.95 Although the reasons for the latter finding require further analysis, the high acquisition costs of VR systems can be offset by an economy of scale benefit not realized with physical models where staffing for purposes of task setup and assess-ment and consumable items related to many tasks represent

Surgery_Schwartz. training in the context of a larger curriculum appears to be the best way to achieve good training results irrespective of the training platform used.5Brunicardi_Ch53_p2163-p2186.indd 217122/02/19 4:39 PM 2172SPECIFIC CONSIDERATIONSPART IIVR simulator systems are significant capital investments for simulation centers that have competing procurement priori-ties. In a prospective randomized trial, Orzech analyzed the cost impact of each type of training across Canadian residency pro-grams and found that the transfer of training effect was greater for VR as compared to the box trainer group. However, box trainer use was found to be more cost effective except in larger residencies.95 Although the reasons for the latter finding require further analysis, the high acquisition costs of VR systems can be offset by an economy of scale benefit not realized with physical models where staffing for purposes of task setup and assess-ment and consumable items related to many tasks represent

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systems can be offset by an economy of scale benefit not realized with physical models where staffing for purposes of task setup and assess-ment and consumable items related to many tasks represent additive costs. Flexible endoscopy VR simulator device sharing was shown to work effectively for a skills acquisition program across a network of Texas institutions where procurement of numerous such simulators might not be practical.96The role of haptics has been debated for laparoscopic VR simulators since the inclusion of sophisticated force feedback hardware adds substantially to the cost of surgical VR as well as to system computing demands. In simulated endoscopic and laparoscopic procedures, effective haptic cues are important contributors to the fidelity of the experience. For basic skills acquisition these features have not been shown to offer significant advantages over nonhaptic VR systems, although for more advanced skills haptic cues may permit greater precision of instrument

Surgery_Schwartz. systems can be offset by an economy of scale benefit not realized with physical models where staffing for purposes of task setup and assess-ment and consumable items related to many tasks represent additive costs. Flexible endoscopy VR simulator device sharing was shown to work effectively for a skills acquisition program across a network of Texas institutions where procurement of numerous such simulators might not be practical.96The role of haptics has been debated for laparoscopic VR simulators since the inclusion of sophisticated force feedback hardware adds substantially to the cost of surgical VR as well as to system computing demands. In simulated endoscopic and laparoscopic procedures, effective haptic cues are important contributors to the fidelity of the experience. For basic skills acquisition these features have not been shown to offer significant advantages over nonhaptic VR systems, although for more advanced skills haptic cues may permit greater precision of instrument

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acquisition these features have not been shown to offer significant advantages over nonhaptic VR systems, although for more advanced skills haptic cues may permit greater precision of instrument use.97,98 However, surgical VR has advanced to the point where inventories of procedure types offered on specific commercially available systems are quite extensive and these will inevitably increase and encompass entire procedures. The realism of the user experience, including the haptic experience, may prove essential to effective learning of advanced surgical skills in a new generation of VR devices. The current generation of laparoscopic simulators are highly capable devices with a high degree of graphical realism, full haptic features, and numerous tasks available for training basic and procedural skills for general surgical, urologic, and gynecologic procedures (Fig. 53-5).Despite encouraging progress made in VR simulation, two separate publications in 2007 and 2015 identified ongoing

Surgery_Schwartz. acquisition these features have not been shown to offer significant advantages over nonhaptic VR systems, although for more advanced skills haptic cues may permit greater precision of instrument use.97,98 However, surgical VR has advanced to the point where inventories of procedure types offered on specific commercially available systems are quite extensive and these will inevitably increase and encompass entire procedures. The realism of the user experience, including the haptic experience, may prove essential to effective learning of advanced surgical skills in a new generation of VR devices. The current generation of laparoscopic simulators are highly capable devices with a high degree of graphical realism, full haptic features, and numerous tasks available for training basic and procedural skills for general surgical, urologic, and gynecologic procedures (Fig. 53-5).Despite encouraging progress made in VR simulation, two separate publications in 2007 and 2015 identified ongoing

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skills for general surgical, urologic, and gynecologic procedures (Fig. 53-5).Despite encouraging progress made in VR simulation, two separate publications in 2007 and 2015 identified ongoing com-putational challenges in development of very high-fidelity simu-lations for surgery.99,100 These include the unique VR problems of modeling human tissues and the added demands of rendering the appropriate deformations when tissues are manipulated. One of the practical examples of this is that of guidewire behavior during VR as compared to real-life endovascular procedures, where variable elasticity characteristics of blood vessel walls were observed to result in real tissue or wire deformations that the VR software could not depict accurately.101 Also identified were disparities between levels of resourcing for surgical VR versus mainstream computer gaming, raising important ques-tions on how the full power of this technology can be realized to more fully simulate complex operations with a

Surgery_Schwartz. skills for general surgical, urologic, and gynecologic procedures (Fig. 53-5).Despite encouraging progress made in VR simulation, two separate publications in 2007 and 2015 identified ongoing com-putational challenges in development of very high-fidelity simu-lations for surgery.99,100 These include the unique VR problems of modeling human tissues and the added demands of rendering the appropriate deformations when tissues are manipulated. One of the practical examples of this is that of guidewire behavior during VR as compared to real-life endovascular procedures, where variable elasticity characteristics of blood vessel walls were observed to result in real tissue or wire deformations that the VR software could not depict accurately.101 Also identified were disparities between levels of resourcing for surgical VR versus mainstream computer gaming, raising important ques-tions on how the full power of this technology can be realized to more fully simulate complex operations with a

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of resourcing for surgical VR versus mainstream computer gaming, raising important ques-tions on how the full power of this technology can be realized to more fully simulate complex operations with a high degree of fidelity and realism.Virtual Reality for Flexible EndoscopyThe use of virtual reality simulation to train for flexible endos-copy procedures is now well established and supported by consistent evidence of both skills transfer. Sedlack compared colonoscopy skills between small groups of inexperienced VR-trained and nontrained gastroenterology fellows and found that VR training resulted in farther progression into the colon, better inspection skills, and a higher percentage of completed studies (those that reached the cecum).102 This performance advantage extended out to 30 posttraining procedures. In the years since that report, four randomized controlled trials of VR training with blinding to training status during posttraining clinical colonos-copy have been

Surgery_Schwartz. of resourcing for surgical VR versus mainstream computer gaming, raising important ques-tions on how the full power of this technology can be realized to more fully simulate complex operations with a high degree of fidelity and realism.Virtual Reality for Flexible EndoscopyThe use of virtual reality simulation to train for flexible endos-copy procedures is now well established and supported by consistent evidence of both skills transfer. Sedlack compared colonoscopy skills between small groups of inexperienced VR-trained and nontrained gastroenterology fellows and found that VR training resulted in farther progression into the colon, better inspection skills, and a higher percentage of completed studies (those that reached the cecum).102 This performance advantage extended out to 30 posttraining procedures. In the years since that report, four randomized controlled trials of VR training with blinding to training status during posttraining clinical colonos-copy have been

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to 30 posttraining procedures. In the years since that report, four randomized controlled trials of VR training with blinding to training status during posttraining clinical colonos-copy have been conducted.103-106 Despite methodological issues with each of these trials (no proficiency-based training, unsuper-vised VR practice on one, vaguely defined training characteris-tics of control groups), all but one showed training benefits for Figure 53-5. Three different current generation laparoscopic virtual reality simulators. A. LapVR VR Simulator, CAE Healthcare, Sarasota, FL. B. Simbionix LAP Mentor VR simulator, Littleton, CO. C. LapSim VR simulator, Surgical Science AB, Gothenburg, Sweden.ABCBrunicardi_Ch53_p2163-p2186.indd 217222/02/19 4:39 PM 2173SKILLS AND SIMULATIONCHAPTER 53ABFigure 53-6. Representation of patient-specific aortic vascular anatomy during simulation of endovascular aortic replacement (EVAR) for abdominal aortic aneurysm, with distal graft limbs in the

Surgery_Schwartz. to 30 posttraining procedures. In the years since that report, four randomized controlled trials of VR training with blinding to training status during posttraining clinical colonos-copy have been conducted.103-106 Despite methodological issues with each of these trials (no proficiency-based training, unsuper-vised VR practice on one, vaguely defined training characteris-tics of control groups), all but one showed training benefits for Figure 53-5. Three different current generation laparoscopic virtual reality simulators. A. LapVR VR Simulator, CAE Healthcare, Sarasota, FL. B. Simbionix LAP Mentor VR simulator, Littleton, CO. C. LapSim VR simulator, Surgical Science AB, Gothenburg, Sweden.ABCBrunicardi_Ch53_p2163-p2186.indd 217222/02/19 4:39 PM 2173SKILLS AND SIMULATIONCHAPTER 53ABFigure 53-6. Representation of patient-specific aortic vascular anatomy during simulation of endovascular aortic replacement (EVAR) for abdominal aortic aneurysm, with distal graft limbs in the

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53ABFigure 53-6. Representation of patient-specific aortic vascular anatomy during simulation of endovascular aortic replacement (EVAR) for abdominal aortic aneurysm, with distal graft limbs in the ballerina (A. crossed) and standard (B. uncrossed) configurations. This example of patient-specific rehearsal requires preparation the virtual aorta from a DICOM (Digital Imaging and Communications in Medicine) format file of patient computed tomography (CT) or CT angiogram imaging data. Image is rendered on ANGIO Mentor VR simulator (3D Systems, Littleton, CO). (Reproduced with permission from Pakeliani D, Van Herzeele I, Lachat ML, et al: EVAR 2020: Training Future Aortic Spe-cialists. Emerging needs and the role of simulation. Endovascular Today 2017 March;16(3):95-100.)previously inexperienced VR-trained residents versus controls, especially in the earlier posttraining clinical cases based on either subjective determination of competency or measurement of procedure length. The study

Surgery_Schwartz. 53ABFigure 53-6. Representation of patient-specific aortic vascular anatomy during simulation of endovascular aortic replacement (EVAR) for abdominal aortic aneurysm, with distal graft limbs in the ballerina (A. crossed) and standard (B. uncrossed) configurations. This example of patient-specific rehearsal requires preparation the virtual aorta from a DICOM (Digital Imaging and Communications in Medicine) format file of patient computed tomography (CT) or CT angiogram imaging data. Image is rendered on ANGIO Mentor VR simulator (3D Systems, Littleton, CO). (Reproduced with permission from Pakeliani D, Van Herzeele I, Lachat ML, et al: EVAR 2020: Training Future Aortic Spe-cialists. Emerging needs and the role of simulation. Endovascular Today 2017 March;16(3):95-100.)previously inexperienced VR-trained residents versus controls, especially in the earlier posttraining clinical cases based on either subjective determination of competency or measurement of procedure length. The study

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VR-trained residents versus controls, especially in the earlier posttraining clinical cases based on either subjective determination of competency or measurement of procedure length. The study that did not show improved clini-cal performance compared to controls was a noninferiority com-parison to control subjects with undefined patient-based training where the two groups performed comparably well. Randomized trials of VR training for upper endoscopy have shown signifi-cant performance advantages in both procedure length and sub-jective assessment of competency compared to both nontrained and patient-based training control groups.107-109Based on the highly standardized test environment that can be experienced in VR and concurrent validity to clinical endos-copy, the SAGES FES program utilizes VR flexible endoscopy simulation for certification of skills. Systematic review of pub-lished literature on VR flexible endoscopy skills cite the need for better quality evidence in support of

Surgery_Schwartz. VR-trained residents versus controls, especially in the earlier posttraining clinical cases based on either subjective determination of competency or measurement of procedure length. The study that did not show improved clini-cal performance compared to controls was a noninferiority com-parison to control subjects with undefined patient-based training where the two groups performed comparably well. Randomized trials of VR training for upper endoscopy have shown signifi-cant performance advantages in both procedure length and sub-jective assessment of competency compared to both nontrained and patient-based training control groups.107-109Based on the highly standardized test environment that can be experienced in VR and concurrent validity to clinical endos-copy, the SAGES FES program utilizes VR flexible endoscopy simulation for certification of skills. Systematic review of pub-lished literature on VR flexible endoscopy skills cite the need for better quality evidence in support of

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VR flexible endoscopy simulation for certification of skills. Systematic review of pub-lished literature on VR flexible endoscopy skills cite the need for better quality evidence in support of best training practices and improved patient outcomes.110 Further study is required, especially in the area of proficiency-based VR flexible endos-copy training, which has been generally underutilized.Virtual Reality for Endovascular InterventionsVirtual reality simulation has been shown to be an effective alternative to training with animal or cadaver models for catheter-based vascular interventions. Current simulations allow development of basic guidewire and catheter handling skills, as well as practice in use of fluoroscopy, angioplasty, and stenting techniques. Procedural training for coronary, carotid, renal, neuro, peripheral vascular, and other interven-tions are feasible with measurement of learner performance in numerous areas such as procedure and fluoroscopy time, con-trast use, and

Surgery_Schwartz. VR flexible endoscopy simulation for certification of skills. Systematic review of pub-lished literature on VR flexible endoscopy skills cite the need for better quality evidence in support of best training practices and improved patient outcomes.110 Further study is required, especially in the area of proficiency-based VR flexible endos-copy training, which has been generally underutilized.Virtual Reality for Endovascular InterventionsVirtual reality simulation has been shown to be an effective alternative to training with animal or cadaver models for catheter-based vascular interventions. Current simulations allow development of basic guidewire and catheter handling skills, as well as practice in use of fluoroscopy, angioplasty, and stenting techniques. Procedural training for coronary, carotid, renal, neuro, peripheral vascular, and other interven-tions are feasible with measurement of learner performance in numerous areas such as procedure and fluoroscopy time, con-trast use, and

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carotid, renal, neuro, peripheral vascular, and other interven-tions are feasible with measurement of learner performance in numerous areas such as procedure and fluoroscopy time, con-trast use, and intervention effectiveness. Simulators display fluoroscopy images and allow for the selection and insertion of virtual catheter, balloon, and stent types, which are pertinent to the procedure being performed (Fig. 53-6). In small randomized trials, VR training has been shown to increase residents’ periph-eral angioplasty skills with transfer of lab-acquired skills to the clinical OR.111,112 After having previously shown that VR simu-lator assessment can effectively discriminate the level of clini-cal experience with carotid artery stenting among experienced interventionalists, Van Herzeele demonstrated that experienced interventionalists could also significantly increase carotid artery stenting skills following a 2-day intensive course of didactic and VR training for this procedure.113,114

Surgery_Schwartz. carotid, renal, neuro, peripheral vascular, and other interven-tions are feasible with measurement of learner performance in numerous areas such as procedure and fluoroscopy time, con-trast use, and intervention effectiveness. Simulators display fluoroscopy images and allow for the selection and insertion of virtual catheter, balloon, and stent types, which are pertinent to the procedure being performed (Fig. 53-6). In small randomized trials, VR training has been shown to increase residents’ periph-eral angioplasty skills with transfer of lab-acquired skills to the clinical OR.111,112 After having previously shown that VR simu-lator assessment can effectively discriminate the level of clini-cal experience with carotid artery stenting among experienced interventionalists, Van Herzeele demonstrated that experienced interventionalists could also significantly increase carotid artery stenting skills following a 2-day intensive course of didactic and VR training for this procedure.113,114

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that experienced interventionalists could also significantly increase carotid artery stenting skills following a 2-day intensive course of didactic and VR training for this procedure.113,114 Following training, decreased procedure and fluoroscopy time and decreased time for placement and retrieval of the embolic protection device were observed. Although differing clinical outcomes were not seen in this small study, it was noted that internal carotid artery spasm frequency decreased after training.The incorporation of actual patient vascular anatomic information taken from computerized tomography data into a vascular interventional simulation as an aid to procedural plan-ning or technical procedure performance has been referred to as “mission rehearsal” or more commonly now, procedure specific rehearsal or procedure specific simulation. It has been described most extensively for carotid artery stenting procedures and high-lights how VR simulation can be directed toward the immedi-ate

Surgery_Schwartz. that experienced interventionalists could also significantly increase carotid artery stenting skills following a 2-day intensive course of didactic and VR training for this procedure.113,114 Following training, decreased procedure and fluoroscopy time and decreased time for placement and retrieval of the embolic protection device were observed. Although differing clinical outcomes were not seen in this small study, it was noted that internal carotid artery spasm frequency decreased after training.The incorporation of actual patient vascular anatomic information taken from computerized tomography data into a vascular interventional simulation as an aid to procedural plan-ning or technical procedure performance has been referred to as “mission rehearsal” or more commonly now, procedure specific rehearsal or procedure specific simulation. It has been described most extensively for carotid artery stenting procedures and high-lights how VR simulation can be directed toward the immedi-ate

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rehearsal or procedure specific simulation. It has been described most extensively for carotid artery stenting procedures and high-lights how VR simulation can be directed toward the immedi-ate problems of clinical practice. Cates’ brief report of a single procedure was followed by small studies further demonstrat-ing the feasibility and general impressions of the value of this method.115-117 In a randomized comparison of trainees who per-formed either part-task rehearsal or rehearsal of the entire proce-dure, Willaert reported that a similar performance benefit could be achieved, suggesting a potentially more time-efficient way to train, although the embolic protection device was in place slightly longer in the part-task-trained group.118Brunicardi_Ch53_p2163-p2186.indd 217322/02/19 4:39 PM 2174SPECIFIC CONSIDERATIONSPART IIIn a recent multinational European study, Desender and colleagues randomized a series of 100 patients scheduled to undergo elective endovascular aneurysm

Surgery_Schwartz. rehearsal or procedure specific simulation. It has been described most extensively for carotid artery stenting procedures and high-lights how VR simulation can be directed toward the immedi-ate problems of clinical practice. Cates’ brief report of a single procedure was followed by small studies further demonstrat-ing the feasibility and general impressions of the value of this method.115-117 In a randomized comparison of trainees who per-formed either part-task rehearsal or rehearsal of the entire proce-dure, Willaert reported that a similar performance benefit could be achieved, suggesting a potentially more time-efficient way to train, although the embolic protection device was in place slightly longer in the part-task-trained group.118Brunicardi_Ch53_p2163-p2186.indd 217322/02/19 4:39 PM 2174SPECIFIC CONSIDERATIONSPART IIIn a recent multinational European study, Desender and colleagues randomized a series of 100 patients scheduled to undergo elective endovascular aneurysm

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4:39 PM 2174SPECIFIC CONSIDERATIONSPART IIIn a recent multinational European study, Desender and colleagues randomized a series of 100 patients scheduled to undergo elective endovascular aneurysm repair (EVAR) for infrarenal aortic aneurysm to either have their procedure rehearsed with VR simulation preoperatively or to have the pro-cedure performed without rehearsal.119 There were 26% fewer minor errors, 76% fewer major errors, and a 27% fewer errors causing procedural delay in the VR rehearsal group. In addition, this group had significantly fewer angiograms performed to visualize proximal and distal graft landing zones. In a follow-up of this study, Desender reported that patient-specific rehearsal before EVAR resulted in alteration of the operative plan for proximal landing zone (54%), distal landing zone (76%), stent graft main body size (16%), contralateral limb size (34%) or orientation (16%), and iliac extension size (28%). Ninety-two percent of these changes were

Surgery_Schwartz. 4:39 PM 2174SPECIFIC CONSIDERATIONSPART IIIn a recent multinational European study, Desender and colleagues randomized a series of 100 patients scheduled to undergo elective endovascular aneurysm repair (EVAR) for infrarenal aortic aneurysm to either have their procedure rehearsed with VR simulation preoperatively or to have the pro-cedure performed without rehearsal.119 There were 26% fewer minor errors, 76% fewer major errors, and a 27% fewer errors causing procedural delay in the VR rehearsal group. In addition, this group had significantly fewer angiograms performed to visualize proximal and distal graft landing zones. In a follow-up of this study, Desender reported that patient-specific rehearsal before EVAR resulted in alteration of the operative plan for proximal landing zone (54%), distal landing zone (76%), stent graft main body size (16%), contralateral limb size (34%) or orientation (16%), and iliac extension size (28%). Ninety-two percent of these changes were

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zone (54%), distal landing zone (76%), stent graft main body size (16%), contralateral limb size (34%) or orientation (16%), and iliac extension size (28%). Ninety-two percent of these changes were implemented during the actual EVAR case.119Patient-Specific VR Surgery SimulationIn addition to patient specific rehearsal for endovascular inter-ventions, VR simulations for OR surgical procedures have begun to use patient imaging data to rehearse procedures preop-eratively. While many surgeons consciously and subconsciously mentally rehearse procedures before entering the operating room, this process does not allow for fully explicit informa-tion sharing between team members. Moreover, even when the surgeon verbalizes a plan for other members of the OR team after the mental rehearsal, it is not uncommon to unintentionally exclude important details that team members may value. The use of anatomically accurate VR simulations, based on patient-specific anatomy, may allow for team-based

Surgery_Schwartz. zone (54%), distal landing zone (76%), stent graft main body size (16%), contralateral limb size (34%) or orientation (16%), and iliac extension size (28%). Ninety-two percent of these changes were implemented during the actual EVAR case.119Patient-Specific VR Surgery SimulationIn addition to patient specific rehearsal for endovascular inter-ventions, VR simulations for OR surgical procedures have begun to use patient imaging data to rehearse procedures preop-eratively. While many surgeons consciously and subconsciously mentally rehearse procedures before entering the operating room, this process does not allow for fully explicit informa-tion sharing between team members. Moreover, even when the surgeon verbalizes a plan for other members of the OR team after the mental rehearsal, it is not uncommon to unintentionally exclude important details that team members may value. The use of anatomically accurate VR simulations, based on patient-specific anatomy, may allow for team-based

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is not uncommon to unintentionally exclude important details that team members may value. The use of anatomically accurate VR simulations, based on patient-specific anatomy, may allow for team-based rehearsals and reduce the risk of human error. In addition, VR-based rehearsals may also facilitate doctor-patient communication.120Patient-specific VR simulations have recently emerged for a variety of complex operations including pancreatectomies, hepatectomies, renal surgery, and hand surgery.120-123 For one of the renal surgery simulations, patient-specific computed tomog-raphy (CT) data was captured and used to create 3D imaging for incorporation into the simulation.122 The anatomical accuracy of various structures such as arteries, veins, ureters, and even tumors was reported to be high. Another group compared the appearance of individual vascular structures while performing several patient-specific virtual hepatectomies simultaneously with real-life hepatectomies and also noted a

Surgery_Schwartz. is not uncommon to unintentionally exclude important details that team members may value. The use of anatomically accurate VR simulations, based on patient-specific anatomy, may allow for team-based rehearsals and reduce the risk of human error. In addition, VR-based rehearsals may also facilitate doctor-patient communication.120Patient-specific VR simulations have recently emerged for a variety of complex operations including pancreatectomies, hepatectomies, renal surgery, and hand surgery.120-123 For one of the renal surgery simulations, patient-specific computed tomog-raphy (CT) data was captured and used to create 3D imaging for incorporation into the simulation.122 The anatomical accuracy of various structures such as arteries, veins, ureters, and even tumors was reported to be high. Another group compared the appearance of individual vascular structures while performing several patient-specific virtual hepatectomies simultaneously with real-life hepatectomies and also noted a