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.