Models for Training and Evaluation of Flexible Endoscopic Skills Using the Step Program

D. Berger-richardson, Y. Kurashima, MD, P. Kaneva, MSc, L. S Feldman, MD, G. M Fried, MD, M. C Vassiliou, MD. Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, and The Arnold and Blema Steinberg Medical Simulation Centre, McGill University


Objective: Flexible endoscopy is an increasingly important skill for gastrointestinal surgeons, but training opportunities are limited. Simulation may have a role to play, however, existing virtual reality models are criticized for their high cost and metrics that are difficult to interpret. The SAGES STEP (Surgeons Training Endoscopic Proficiency) program provides a complete flexible endoscopy setup to qualifying institutions for resident education. The purpose of this study was to create and validate tasks using the STEP program for training and evaluation of the basic skills required for flexible endoscopy.

Learning objectives were retroflexion, instrument targeting, navigation, loop reduction and mucosal inspection. Models were created using low cost, readily available materials such as fabric, paper and wood. Metrics were developed to value both efficiency and precision.

(1) Retroflexion
Model: A box containing various symbols scattered throughout 6 inner walls and 3 lumens. The trainee enters the endoscope into the box through a lumen and must identify the symbols using retroflexion.

(2) Targeting
Model: A hollow tube in which two metal targets are placed in close proximity. The trainee must position open biopsy forceps to touch both metal targets simultaneously to complete an open electrical circuit, sounding a buzzer.

(3) Navigation and loop reduction
Model: A “Slinky” (Poof-Slinky Inc., Plymouth, MI) covered with fabric is secured to the bottom of a cardboard box. Trainees must navigate the curves of the slinky, which is prone to formation of loops, thus creating opportunities for loop reduction.

(4) Mucosal evaluation
The same “Slinky” model is used to develop the skills of mucosal evaluation. Within folds of the lumen, there are stud earrings that the trainee must identify.

Four novices (NE) and 4 experienced endoscopists (EE) were evaluated during performance of these tasks using the STEP gastroscope setup. Scores were compared using independent T-tests (Statistical Software SAS 9.2).

(1) Retroflexion: In the time allotted, NE identified a mean of 10.8 (±5.1) symbols, while EE identified 21.3 (±2.5; p=0.01).

(2) Targeting: In the NE group, 0/4 participants successfully completed 4 biopsies. In the EE group, 3/4 participants completed the task in the allotted time.

(3) Navigation and loop reduction: In the NE group, 1/4 completed the task. In the EE group, all 4 participants reached the end of the lumen within the allotted time.

(4) Mucosal evaluation: In the NE group, a mean of 5.3 (± 1.0) targets were identified compared to 7.8 (±1.7) in the EE group (p=0.04).

Conclusion: This pilot study describes the creation of a new set of tasks to model the basic skills of flexible endoscopy that can be used in conjunction with the STEP program. The metrics discriminate between NE and EE. This low cost simulator may be a useful tool for training and evaluation of the skills fundamental to flexible endoscopy.

Session Number: Poster – Poster Presentations
Program Number: P162
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