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Laura Beyer-Berjot, MD, Vanessa Palter, MD, PhD,

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1 ADVANCED TRAINING IN LAPAROSCOPIC ABDOMINAL SURGERY (ATLAS): A SYSTEMATIC REVIEW
Laura Beyer-Berjot, MD, Vanessa Palter, MD, PhD, Teodor Grantcharov, MD, PhD,and Rajesh Aggarwal, PhD, MA, FRCS. ACS AEI Meeting 16/03/2013

2 There are no conflict of interest in this study.

3 Training out of the or: simulation
Introduction Training out of the or: simulation Widely spread this last decade Proved its positive impact in the OR for basic laparoscopic skills Simulation tools: VT VR simulators AR simulators Live animals Cadavers Reznick RK, et al. N Engl J Med 2006; 355: Aggarwal R, et al. Br J Surg 2004; 91: Scott DJ, et al. J Am Coll Surg 2000; 191: Seymour NE, et al. Ann Surg 2002; 236: Grantcharov TP, et al. Br J Surg 2004; 91: Beyer L, et al. Am J Surg 2011; 202:

4 Training out of the or: atlas
Introduction Training out of the or: atlas Simulation and advanced laparoscopic surgery? Junior surgeons have limited access as a primary operator PGY 3-5: > 50% no experience in lap foregut / bariatric surgery 36% in lap colorectal surgery ATLAS:  residents participation in the OR without altering patients outcomes. Palter VN, et al. Surg Endosc 2010; 24: Lin E, et al. Am J Surg 2003; 186: 45-8.

5 Training out of the or: atlas
Introduction Training out of the or: atlas “Adequacy of Dr. Halsted’s one-century-old apprenticeship model is questionable in lap colorectal surgery” Potential benefits: Reduce learning curves Provide safe implementation in the OR Essani R, et al. Dis Colon Rectum 2009; 52:

6 Training out of the or: atlas
Introduction Training out of the or: atlas Aggarwal R, et al. Obes Surg 2007; 17:

7 Training out of the or: atlas
Introduction Training out of the or: atlas However, few articles dealing with ATLAS “Notable lack of available data on (its) educational value”. Aims of this review: To identify and evaluate the place of ATLAS in surgical education To define ways to improve this training. Miskovic D, et al. Ann Surg 2010; 252: Retablissement jeuno-colique le + fréquent

8 Methods 2 reviewers (LB, VP) Systematic review: Inclusion: Exclusion:
MEDLINE, EMBASE, and The Cochrane Library search No beginning date cutoff / until July 18, 2012 PRISMA standards Inclusion: All original studies dealing with ATLAS Exclusion: Non-English-language publications Editorial letters, reviews, guidelines, technical notes

9 Data extraction Assessment of methodological quality
Methods Data extraction Type of training model Type of advanced procedure evaluated Type of study i.e. RCT, non-randomized controlled trial, single-group pre-/ post-test, case series, descriptive study Purpose(s) of the study i.e. training or assessment, model description, satisfaction of trainees, construct validity, transfer of skills and learning curve. Assessment of methodological quality Cochrane Handbook for Systematic Reviews of Intervention

10 Results Flow chart

11 Results Flow chart

12 Methodological quality
Results Methodological quality 54 articles involving 1030 surgical trainees and 33 nurses: 8 RCTs 12 non-randomized controlled trials 1 single-group pre-/ post-test 33 cases series No RCT had a low risk of bias: Allocation sequence = 8 Blinding = 5 Type of allocation concealment = 2 Follow-up = 1

13 Types of advanced procedures
Results Types of advanced procedures

14 Types of advanced procedures
Results Types of advanced procedures 1/ Nissen fundoplication 2/ Sigmoid colectomy

15 Types of training models
Results Types of training models

16 Types of training models
Results Types of training models

17 Types of training models
Results Types of training models

18 Types of training models
Results Types of training models RCT

19 Conclusion Conclusion Wealth of data for basic skills simulation but only few studies for ATLAS. Genuine need for ATLAS 54 studies, very heterogeneous: Gastric and colorectal Porcine and VT Mainly intraoperative / technical skills training only Level of evidence: low But only RCT to assess TS in the OR: results are encouraging

20 Ways to improve? Higher level of evidence
Conclusion Ways to improve? Higher level of evidence Construct validity and training curricula Competency-based curricular approach using simulation to train on technical & non-technical skills Cognitive training Decision making Teamwork Design a pathway care approach that a complex procedure needs.


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