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Background: The value of video-based self-assessment in enhancing surgical skills is uncertain. This study investigates the feasibility and estimates sample size for a full-scale randomized controlled trial to evaluate the effectiveness of video-based self-assessment to improve surgical performance of laparoscopic cholecystectomy in trainees., Methods: This parallel pilot randomized controlled trial included general surgery trainees performing supervised laparoscopic cholecystectomy randomized 1:1 to control (traditional intraoperative teaching) or intervention group (traditional teaching plus video-based self-assessment). Operative performance was measured by the attending surgeon blinded to group assignment at the time of surgery using standardized assessment tools (Global Operative Assessment of Laparoscopic Skills and Operative Performance Rating System). The intervention group had access to their video recordings on a web-based platform for review and self-assessment using the same instruments. The primary outcome for the estimation of sample size was the difference in faculty-assessed final operative performance (third submitted case). Feasibility criteria included >85% participation, >85% adherence to case submission and >85% completion of self-assessment., Results: Of 37 eligible trainees approached, 32 consented and were randomized (86%). There were 16 in the intervention group, 15 in the control group (55% male, 55% junior trainees), and 1 was excluded for protocol violation. Twenty-four (75%) of participants submitted 3 cases. Thirteen trainees (81%) accessed the platform and completed 26 (63.2%) case self-assessments. Fifty-five trainees per arm will be needed to power a full-scale laparoscopic cholecystectomy with Global Operative Assessment of Laparoscopic Skills and 130 trainees per arm with Operative Performance Rating System as the assessment tool., Conclusion: This pilot study contributes important data to inform the design of an adequately powered randomized controlled trial of video-based self-assessment to improve trainee performance of laparoscopic cholecystectomy. Although a priori trial feasibility criteria were not achieved, automated video capture and storage could significantly improve adherence in future trials., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: The Fundamentals of Laparoscopic Surgery (FLS) program tests basic knowledge and skills required to perform laparoscopic surgery. Educational experiences in laparoscopic training and development of associated competencies have evolved since FLS inception, making it important to review the definition of fundamental laparoscopic skills. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) assigned an FLS Technical Skills Working Group to characterize technical skills used in basic laparoscopic surgery in current practice contexts and their possible application to future FLS tests., Methods: A group of subject matter experts defined an inventory of 65 laparoscopic skills using a Nominal Group Technique. From these, a survey was developed rating these items for importance, frequency of use, and priority for testing for FLS certification. This survey was distributed to SAGES members, recent recipients of FLS certification, and members of the Association of Program Directors in Surgery (APDS). Results were collected using a secure web-based survey platform., Results: Complete data were available for 1742 surveys. Of these, 1143 comprised results for post-residency participants who performed advanced procedures. Seventeen competencies were identified for FLS testing prioritization by determining the proportion of respondents who identified them of highest priority, at median (50th percentile) of the maximum survey scale rating. These included basic peritoneal access, laparoscope and instrument use, tissue manipulation, and specific problem management skills. Sixteen could be used to show appropriateness of the domain construct by confirmatory factor analysis. Of these 8 could be characterized as manipulative tasks. Of these 5 mapped to current FLS tasks., Conclusions: This survey-identified competencies, some of which are currently assessed in FLS, with a high level of priority for testing. Further work is needed to determine if this should prompt consideration of changes or additions to the FLS technical skills test component., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The Fundamentals of Laparoscopy Surgery (FLS) program was launched over 15 years ago. Since then, there has been an exponential rise in advancements of laparoscopy and its uses. In response, we conducted an argument-based validation study of FLS. The purpose of this paper is to exemplify this approach to validation for surgical education researchers using FLS as an illustrative case., Methods: The argument-based approach to validation involves three key actions: (1) developing interpretation and use arguments; (2) research; and (3) building a validity argument. Drawing from the validation study of FLS each step is exemplified., Results: Qualitative and quantitative data sources from the FLS validity examination study provided evidence that both supported claims, but also generated backing for rebuttals. Some of the key findings were synthesized in a validity argument to illustrate its structure., Discussion: The argument-based validation approach described numerous advantages over other validation approaches: (1) it is endorsed by the foundational documents in assessment and evaluation research; (2) its specific language of claims, inferences, warrants, assumptions and rebuttals provides a systematic and unified way to communicate both the processes and outcomes of validation; and (3) the use of logic reasoning in building the validity document clearly delineates the relationship between evidence and the inferences made to support desired uses and interpretations from assessments., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: Laparoscopic suturing (LS) is a challenging laparoscopic skill to teach. Its complexity and nuances are not modeled or measured in current simulation and assessment platforms.The script concordance test (SCT) is used to assess clinical reasoning.The purpose of this study is to provide evidence for validity of this novel SCT based online assessment for LS skills., Design: We designed a video-based online SCT for LS using a cognitive task analysis and expert panelists.The CTA yielded 4 LS domains: needle handling (NH), tissue handling (TH), knot tying techniques (KT) and operative ergonomics (OE). Five-point scales with anchoring descriptors from -2 to +2 were used. Scoring was based on a modified SCT methodology., Setting and Participants: The test was administrated to 37 subjects (18 experts and 19 novices). There was no time limit given. A different expert group from the minimal invasive surgery (MIS) panelist were recruited. Experts were defined as surgeons and fellows with LS experience of >25 cases annually. Validity was assessed by comparing SCT scores of experienced and inexperienced surgeons. Cronbach's alpha was used to assess the internal consistency of the test., Results: The survey started off with 47 questions in each of the following domains: 13 NH, 4 TH, 20 KT and 10 OE. Thirty-seven surgeons (18 experts and 19 inexperienced surgeons). Questions that demonstrated a large discrepancy among experts and panelists with a weighted score difference more than 40 were discarded (n = 20). One question was discarded because it received a 100% score from all participants. This yielded 26 remaining questions in the following domains: 8 NH, 2 TH, 11 KT and 5 OE. The test reliability level (Cronbach a) was 0.80. The mean score was 72 ± 9% and 63 ± 15% (p = 0.02) for experts and inexperienced surgeons, respectively. The mean time to complete the test was 21 minutes., Conclusion: This study provides validity evidence for a novel intraoperative LS assessment. The variability of responses between experts and panelists suggests that SCT may capture the clinical differences/surgeon preferences in performing LS intraoperatively., Competing Interests: CONFLICT OF INTEREST The authors declared no conflicts of interest., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Self-review of recorded surgical procedures offers new opportunities for trainees to extend technical learning outside the operating-room. Valid tools for self-assessment are required prior to evaluating the effectiveness of video-review in enhancing technical learning. Therefore, we aimed to contribute evidence regarding the validity of intraoperative performance assessment tools for video-based self-assessment by general surgery trainees when performing laparoscopic cholecystectomies., Methods and Procedures: Using a web-based platform, general surgery trainees in a university-based residency program submitted recorded laparoscopic cholecystectomy procedures where they acted as the supervised primary surgeon. Attending surgeons measured operative performance at the time of surgery using general and procedure-specific assessment tools [Global Operative Assessment of Laparoscopic Skills (GOALS) and Operative Performance Rating System (OPRS), respectively] and entrustability level (O-SCORE). Trainees self-evaluated their performance from video-review using the same instruments. The validity of GOALS and OPRS for trainee self-assessment was investigated by testing the hypotheses that self-assessment scores correlate with (H1) expert assessment scores, (H2) O-SCORE, and (H3) procedure time and that (H4) self-assessment based on these instruments differentiates junior [postgraduate year (PGY) 1-3] and senior trainees (PGY 4-5), as well as (H5)simple [Visual Analogue Scale (VAS) ≤ 4] versus complex cases (VAS > 4). All hypotheses were based on previous literature, defined a priori, and were tested according to the COSMIN consensus on measurement properties., Results: A total of 35 videos were submitted (45% female and 45% senior trainees) and self-assessed. Our data supported 2 out of 5 hypotheses (H1 and H4) for GOALS and 3 out of 5 hypotheses (H1, H4 and H5) for OPRS, for trainee self-assessment., Conclusions: OPRS, a procedure-specific assessment tool, was better able to differentiate between groups expected to have different levels of intraoperative performance, compared to GOALS, a general assessment tool. Given the interest in video-based learning, there is a need to further develop valid procedure-specific tools to support video-based self-assessment by trainees in a range of procedures., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Fundoplication is performed routinely during laparoscopic repairs of a paraesophageal hernia, but the degree of fundoplication remains controversial. The purpose of this study is to assess postoperative dysphagia and reflux after a Dor versus a Nissen fundoplication in patients undergoing laparoscopic repair of giant paraesophageal hernias., Methods: We performed a retrospective cohort study of all patients undergoing laparoscopic repair of giant paraesophageal hernias with Nissen or Dor fundoplication between January 2012 and December 2017 at a high-volume center, excluding revisional and emergency cases. Primary outcomes were reflux and dysphagia at 1 and 6 months. Severe dysphagia was defined as intolerance to liquids. Balanced cohorts were created using coarsened exact matching., Results: A total of 106 patients were included, and 87 were matched (Dor = 48, Nissen = 58). Baseline characteristics were well balanced between matched groups. Mean follow-up duration was 17.7 months (standard deviation 16.4). The incidence of severe dysphagia at 1 month was less in the Dor group (0 of 48 vs 8 of 58, P = .02) with similar reflux symptoms. There was no difference in severe dysphagia and reflux symptoms at 6 months and at the latest visit., Conclusion: Dor fundoplication is associated with less severe, early postoperative dysphagia. Future studies assessing the relative importance of dysphagia and reflux on quality of life should be conducted to tailor the operative technique and optimize patient satisfaction., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Maintaining the existing FLS test centers requires considerable investment in human and financial resources. It can also be particularly challenging for those outside of North America to become certified due to the limited number of international test centers. Preliminary work suggests that it is possible to reliably score the FLS manual skills component remotely using low-cost videoconferencing technology. Significant work remains to ensure that testing procedures adhere to standards defined by SAGES for this approach to be considered equivalent to standard on-site testing., Objective: To validate the integrity and validity of the FLS manual skills examination administered remotely in a real-world environment according to FLS testing protocols and to evaluate participants' experience with the setting., Methods: Individuals with various levels of training from the University of Toronto completed a pre- and a post-test questionnaire. Participants presented to one of the two FLS testing rooms available for the study, each connected via Skype to a separate room with a FLS proctor who administered and scored the test remotely (RP). An on-site proctor (OP) was present in the room as a control. An invigilator was also present in the testing room to follow directions from the RP and ensure the integrity of test materials., Results: Twenty-one participants were recruited, and 20 completed the test. There was no significant difference between scores by RP and OP. Interrater reliability between the RP and OP was excellent. One critical error was missed by the RP, but this would not have affected the test outcome. Participants reported being highly satisfied., Conclusion: We demonstrate that proctors located remotely can administer the FLS skills test in a secure and reliable fashion, with excellent interrater reliability compared to an on-site proctor. Remote proctoring of the FLS examination could become a strategy to increase certification rates while containing costs.

Purpose: The selection of a laparoscopic approach for inguinal hernias varies among surgeons. It is unclear what is being done in actual practice. The purpose of this study was to report practice patterns for treatment of inguinal hernias among Quebec surgeons, and to identify factors that may be associated with the choice of operative approach., Methods: We studied a population-based cohort of patients who underwent an inguinal hernia repair between 2007 and 2011 in Quebec, Canada. A generalized linear model was used to identify predictors associated with the selection of a laparoscopic approach., Results: 49,657 inguinal hernias were repaired by 478 surgeons. Laparoscopic inguinal hernia repair (LIHR) was used in 8 % of all cases. LIHR was used to repair 28 % of bilateral hernias, 10 % of recurrent hernias, 6 % of unilateral hernias, and 4 % of incarcerated hernias. 268 (56 %) surgeons did not perform any laparoscopic repairs, and 11 (2 %) surgeons performed more than 100 repairs. These 11 surgeons performed 61 % of all laparoscopic cases. Patient factors significantly associated with having LIHR included younger age, fewer comorbidities, bilateral hernias, and recurrent hernias., Conclusion: An open approach is favored for all clinical scenarios, even for situations where published guidelines recommend a laparoscopic approach. Surgeons remain divided on the best technique for inguinal hernia repair: while more than half never perform LIHR, the small proportion who perform many use the technique for a large proportion of their cases. There appears to be a gap between the best practices put forth in guidelines and what surgeons are doing in actual practice. Identification of barriers to the broader uptake of LIHR may help inform the design of educational programs to train those who have the desire to offer this technique for certain cases, and have the volume to overcome the learning curve.

Purpose: Practice patterns for inguinal hernia repair vary significantly among surgeons. The purpose of this study was to identify perceived indications for laparoscopic inguinal hernia repair (LIHR), and to identify barriers to its adoption and educational needs for surgeons., Methods: A web-based survey was sent to general surgery members of several North American surgical societies, and to surgical residents through program directors. The 33-item survey was divided in 4 sections: demographics, utilization of techniques, management based on 11 clinical scenarios, reasons for not performing LIHR and educational needs for those who want to learn., Results: Six hundred and ninety-seven general surgeons and 206 general surgery residents responded to the survey. Surgeons with MIS fellowships, and surgeons at the beginning of their careers are more likely to perform LIHR. Out of the 11 clinical scenarios, surgeons preferred a laparoscopic approach (totally extraperitoneal or transabdominal preperitoneal) for bilateral (48 %) and recurrent (44 %) hernias. However, 46 % of respondents never perform LIHR. Of these, 70 % consider the benefits of laparoscopy to be minimal, 59 % said they lack the requisite training, and 26 % are interested in learning. Surgeons (70 %) and residents (73 %) agreed that the best educational method would be a course followed by expert proctoring., Conclusion: Surgeons remain divided on the utility of laparoscopic surgery for inguinal hernia repair. Nearly half of responding surgeons never perform LIHR, and the other half offer it selectively. One quarter of surgeons who do not perform LIHR are interested in learning. This reveals a knowledge gap that could be addressed with educational programs.

Background: Fundamentals of Laparoscopic Surgery (FLS) certification testing currently is offered at accredited test centers or at select surgical conferences. Maintaining these test centers requires considerable investment in human and financial resources. Additionally, it can be challenging for individuals outside North America to become FLS certified. The objective of this pilot study was to assess the feasibility of remotely administering and scoring the FLS examination using live videoconferencing compared with standard onsite testing., Methods: This parallel mixed-methods study used both FLS scoring data and participant feedback to determine the barriers to feasibility of remote proctoring for the FLS examination. Participants were tested at two accredited FLS testing centers. An official FLS proctor administered and scored the FLS exam remotely while another onsite proctor provided a live score of participants' performance. Participant feedback was collected during testing. Interrater reliabilities of onsite and remote FLS scoring data were compared using intraclass correlation coefficients (ICCs). Participant feedback was analyzed using modified grounded theory to identify themes for barriers to feasibility., Results: The scores of the remote and onsite proctors showed excellent interrater reliability in the total FLS (ICC 0.995, CI [0.985-0.998]). Several barriers led to critical errors in remote scoring, but most were accompanied by a solution incorporated into the study protocol. The most common barrier was the chain of custody for exam accessories., Conclusion: The results of this pilot study suggest that remote administration of the FLS has the potential to decrease costs without altering test-taker scores or exam validity. Further research is required to validate protocols for remote and onsite proctors and to direct execution of these protocols in a controlled environment identical to current FLS test administration.

Background: The incidence of incisional hernia has not decreased despite the use of laparoscopy for colon resections. The objective of this study is to evaluate the impact of the incision used for specimen extraction on the incidence of incisional hernia after laparoscopic colectomy., Methods: Patients who underwent laparoscopic colectomy without stoma at a single university tertiary-care centre from 2003 to 2009 were identified from an operating room database. Patients were contacted by telephone for participation, and underwent physical examination ± ultrasonography for incisional hernia at the specimen extraction site and completed the Body Image Questionnaire. Specimen extraction incisions were classified into midline, transverse and Pfannenstiel groups., Results: Out of a total of 251 patients, 99 patients agreed to participate (68 midline, 7 transverse, 24 Pfannenstiel), while 73 patients refused consent and 79 patients could not be contacted. Patients who refused consent were older (69.8 vs 62.4 years, p = 0.001) but otherwise were similar to participants with respect to gender, malignant disease, postoperative complications and extraction site. Mean length of follow-up was 37.0 months. The overall incidence of incisional hernia was 21% (21/99), being 29 % (20/68) after midline incision compared with 14 % (1/7) after transverse and 0 % (0/24) after Pfannenstiel incisions (p = 0.002). Of patients with incisional hernia, 47 % (10/21) were symptomatic. Patients with incisional hernia had lower cosmetic score (14.4 vs 17.7, p = 0.02) compared with those without, but there was no difference in body image score. There were no differences in body image or cosmesis between the three incisions., Conclusions: There is a high incidence of symptomatic incisional hernia after midline specimen extraction in laparoscopic colectomy, which negatively impacts cosmesis. The risk of hernia may be lower with the use of a transverse or Pfannenstiel incision for specimen extraction.

Background and Study Aim: The use of transluminal endoscopic access via the stomach or colon for flexible diagnostic peritoneoscopy has been proposed, although the diagnostic value of the technique has not yet been fully clarified. In this animal trial, the two main natural orifice transluminal endoscopic surgery (NOTES) approaches - transgastric (TG) and transcolonic (TC) - were compared with standard transabdominal access using both rigid (TAR) and flexible instruments (TAF) for diagnostic laparoscopy., Methods: A total of 48 peritoneoscopies were performed using two randomly assigned approaches in 24 anesthetized pigs. The ability of the examinations to detect 576 electrocautery markings simulating intraperitoneal metastases, to achieve complete organ visualization, and to simulate organ biopsies was analyzed., Results: Sensitivities for the detection of lesions were 78.5 %, 59.7 %, 48.6 %, and 38.9 % for TAR, TAF, TC, and TG, respectively; standard laparoscopy was superior to all other approaches (P < 0.01). Among the NOTES approaches, TC was superior for examining the upper abdomen (P = 0.03). Complete organ visualization was better with the transabdominal approach (visual analogue scale TAR 7.15, TAF 6.71) than with the NOTES access routes (TC 5.07, TG 4.35); standard rigid laparoscopy was superior to both NOTES approaches (P < 0.01). Organ biopsy simulation was possible in 87 %, 85 %, 72 %, and 65 % of cases with TAR, TAF, TC, and TG, respectively. Standard rigid laparoscopy was again superior to both NOTES approaches (TAR vs. TC, P = 0.03; TAR vs. TG, P < 0.01)., Conclusions: In this experimental trial, rigid standard laparoscopy provided better organ visualization, better lesion detection, and better biopsy capability than the transgastric and transcolonic NOTES approaches. In its current form, NOTES appears to be unsuitable for diagnostic laparoscopy.

Background and Study Aims: Open or laparoscopic gastrojejunostomy is an established treatment for malignant duodenal obstruction but may be associated with significant morbidity and mortality. The purpose of this study was to develop a model for an entirely endoscopic gastrojejunostomy to treat duodenal obstruction, and to compare this with the laparoscopic technique., Methods: During the first part of the study the endoscopic technique was developed and tested in porcine nonsurvival and survival experiments (n=12). During the second part of the study (n=10), endoscopic gastrojejunostomy for duodenal occlusion was compared with laparoscopic gastrojejunostomy in a survival randomized controlled trial (RCT). For both groups duodenal occlusion was achieved by the laparoscopic approach., Results: In the RCT, the median times for laparoscopic vs. endoscopic gastrojejunostomy were 70 minutes (interquartile range [IQR] 65-75) vs. 210 minutes (IQR 197-220; P=0.01). There was a trend toward increased anastomotic diameter at necropsy in the laparoscopic group (2 cm, IQR 2-3) compared to the endoscopic group (1.8 cm, IQR 1.6-1.8; P=0.06). One animal in the endoscopic group died secondarily to bowel ischemia from volvulus of the jejunal loop. One animal in the laparoscopic group was prematurely sacrificed due to extensive pulmonary congestion and edema. All anastomoses were intact and patent., Conclusions: Purely endoscopic gastrojejunostomy using the developed technique and devices is feasible and can result in adequate relief of duodenal obstruction. Endoscopic anastomoses tend to be smaller than laparoscopic anastomoses, with the procedures being more time-consuming and associated with higher complication rates., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Since the publication of the REMATCH trial results, it is estimated that almost 5 million Americans have been found to have heart failure. Limited availability of organs for transplantation, coupled with wider selection criteria for destination therapy, has resulted in a substantial increase in the number of patients with permanently assisted circulation. Given the high rate of complications related to circulatory assist devices, it is expected that these patients will be undergoing noncardiac surgical procedures more commonly., Materials and Methods: We describe a laparoscopic splenectomy in a patient supported with a Heartmate II left ventricular assist device. Using this case as a model, we discuss hemodynamic changes associated with pneumoperitoneum and anesthesia induction. Additionally, an extensive literature search was performed to asses the frequency of laparoscopic procedures performed on patients with circulatory support., Results: Laparoscopic splenectomy was performed without significant hemodynamic changes. To our knowledge, this is the first laparoscopic splenectomy performed in a patient with this mode of circulatory support., Conclusion: Laparoscopic procedures can safely be performed in patients with compensated heart failure, who are supported with ventricular assist devices.

Despite the advantages of laparoscopic inguinal hernia repair over the open approach in selected situations, laparoscopic inguinal hernia repair (LIHR) remains a challenge to teach and learn. The purpose of this study was to develop and validate a low-cost adaptable simulator for evaluation and training of LIHR. McGill Laparoscopic Inguinal Hernia Simulator (MLIHS) is a physical simulator that accurately represents inguinal anatomy. MLIHS permits to perform both transabdominal pre-peritoneal (TAPP) and totally extraperitoneal (TEP) repairs. Six experienced surgeons performed TAPP repairs using MLIHS. They were surveyed to establish face validity, and were scored using a previously validated global rating scale (maximum score = 25). Experienced surgeons considered MLIHS a useful tool for evaluating and training of LIHR. The mean (SD) global rating scores were 24.0 (± 0.6). The experienced surgeons considered MLIHS very useful for training and assessment. MLIHS is a valuable and affordable tool for training and evaluation of LIHR.

The Global Operative Assessment of Laparoscopic Skills (GOALS) is a valid and reliable measure of basic, non-procedure-specific laparoscopic skills. GOALS-incisional hernia (GOALS-IH) was developed to evaluate performance of laparoscopic incisional hernia repair (LIHR). The purpose of this study was to assess the validity and reliability of GOALS-IH during LIHR simulation. GOALS-IH assesses 7 domains with a maximum score of 35. A total of 12 experienced surgeons and 10 novices performed LIHR on the Surgical Abdominal Wall simulator. Performance was assessed by a trained observer and by self-assessment using GOALS-IH, basic GOALS and a visual analog scale (VAS) for overall competence. Both interrater reliability and internal consistency were high (.76 and .95 respectively). Experienced surgeons had higher mean GOALS-IH scores than novices (32.3 ± 2 versus 22.7 ± 5). There was excellent correlation between GOALS-IH and other measures of performance (GOALS r = .93 and VAS r = .93). GOALS-IH is easy to use, valid and reliable for assessment of simulated LIHR.

Introduction: Simulators are being used more and more for teaching and testing laparoscopic skills. However, it has yet to be firmly established that simulator performance reflects operative laparoscopic skill. The study reported here was designed to test the hypothesis that laparoscopic simulator performance predicts intraoperative laparoscopic skill., Methods: A review of our prospectively maintained database identified 40 subjects who underwent Fundamentals of Lapraoscopic Surgery (FLS) skills testing and objective intraoperative assessments within the same 6-month period. Subjects consisted of 22 novice (postgraduate year [PGY] 1-2), 10 intermediate (PGY 3-4), and 8 experienced (PGY 5, fellows, and attendings) laparoscopic surgeons. Laparoscopic performance was objectively assessed in the operating room using the previously validated Global Operative Assessment of Laparoscopic Skill (GOALS). Analysis of variance (ANOVA) was used to compare mean FLS scores and mean GOALS scores across experience levels. The relationship between individual FLS scores and GOALS scores was assessed with linear regression analysis. A multivariate analysis evaluated FLS score and surgeon experience as predictors of intraoperative GOALS score. A receiver-operator curve (ROC) was constructed in order to define an FLS cutoff score that predicts intraoperative performance at or above the level of experienced surgeons. Significance was defined as p < 0.05., Results: Mean FLS scores and mean GOALS scores increased with increasing experience. Individual FLS scores correlated significantly with intraoperative GOALS scores (0.77, p < 0.001). Multivariate analysis confirmed that FLS score is an independent predictor of intraoperative GOALS scores. The ROC identified an FLS cutoff score of 70 with optimal sensitivity (91%) and specificity (86%) for predicting a GOALS score at or above the level of experienced surgeons., Conclusions: In this study sample, FLS simulator scores were independently predictive of intraoperative laparoscopic performance as measured by GOALS. More precisely, an FLS cutoff score of 70 optimized sensitivity and specificity for expert intraoperative performance. A larger prospective study is justified to validate these findings.

Background: The McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) is a series of five tasks with an objective scoring system. The purpose of this study was to estimate the interrater and test-retest reliability of the MISTELS metrics and to assess their internal consistency., Methods: To determine interrater reliability, two trained observers scored 10 subjects, either live or on tape. Test-retest reliability was assessed by having 12 subjects perform two tests, the second immediately following the first. Interrater and test-retest reliability were assessed using intraclass correlation coefficients. Internal consistency between tasks was estimated using Cronbach's alpha., Results: The interrater and test-retest reliabilities for the total scores were both excellent at 0.998 [95% confidence interval (CI), 0.985-1.00] and 0.892 (95% CI, 0.665-0.968), respectively. Cronbach's alpha for the first assessment of the test-retest was 0.86., Conclusions: The MISTELS metrics have excellent reliability, which exceeds the threshold level of 0.8 required for high-stakes evaluations. These findings support the use of MISTELS for evaluation in many different settings, including residency training programs.

Background: Patients undergoing laparoscopic live donor nephrectomy (LLDN) commonly receive large amounts of fluid intraoperatively to counter the negative effects of pneumoperitoneum on renal function. Our aim is to demonstrate that a low-volume fluid management strategy does not adversely affect donor or recipient outcomes., Methods: Fifty-two patients underwent LLDN between December 2000 and January 2004. Data were collected in prospective databases, and augmented with retrospective medical record review. Donors were divided into two groups: the fluid-load group (n = 24) received > 10 ml/kg/h of intravenous crystalloids intraoperatively, while the fluid-restriction group (n = 28) received < 10 m/kg/h., Results: Donors in the fluid-restriction group had a lower intraoperative urine output. There were no differences in postoperative creatinine levels (117.5 micromol/L vs 121.5 micromol/L, p = 0.8) or complications (4.2% vs 7.1%, p = 0.9). In the recipients, there were no differences in postoperative creatinine levels up to 12 months, incidence of delayed graft function (18% vs 10%, p = 0.7) or acute rejection (9% vs 5%, p = 1.0) between groups., Conclusion: Lower volume fluid management strategies in LLDN do not appear to worsen recipient outcomes nor are they detrimental to the donors.

Background: Postoperative urinary retention (POUR) is a common complication of ambulatory inguinal herniorraphy, with an incidence reaching 38 %, and many surgeons require patients to void before discharge. This study aimed to assess whether the implementation of a bladder scan -based voiding protocol reduces the time until discharge after ambulatory inguinal herniorraphy without increasing the rate of POUR. Methods: As part of a perioperative care pathway, a protocol was implemented to standardize decision making after elective inguinal hernia repair (February 2012). Patients were assessed with a bladder scan, and those with <600 mL of urine were discharged home, whereas those with more than 600 mL of urine had an in-and-out catheterization before discharge. The patients received written information about urinary symptoms and instructions to present to the emergency department if they were unable to void at home. An audit of scheduled outpatient inguinal hernia repairs between October 2011 and July 2012 was performed. Comparisons were made using the t test, Fisher’s exact test, and Wilcoxon rank sum test where appropriate. Statistical significance was defined a priori as a p value lower than 0.05. Results: During the study period, 124 patients underwent hernia repair: 60 before and 64 after implementation of the protocol. The findings showed no significant differences in patient characteristics, laparoscopic approach (35 vs. 33 %; p = 0.80), proportion receiving general anesthesia (70 vs. 73 %; p = 0.67), or amount of intravenous fluids given (793 vs. 663 mL; p = 0.07). The proportion of patients voiding before discharge was higher after protocol implementation (73 vs. 89 %; p = 0.02). The protocol had no impact on median time to discharge (190 vs. 205 min; p = 0.60). Only one patient in each group presented to the emergency department with POUR (2 %). Conclusion: After ambulatory inguinal herniorraphy, implementation of a bladder scan-based voiding protocol did not result in earlier discharge. The incidence of POUR was lower than reported in the literature. [ABSTRACT FROM AUTHOR]