外科医の評価
医学教育において最も深刻な問題の１つは，パフォーマンンスの観察に基づいた評価やフィードバックの欠如である
John Norcini and Vanessa Burch 2007
北海道大学消化器外科Ⅱ
渡邊祐介

目標
総括的評価と形成的評価の違いを説明できる
手術技能の評価を体験する
評価方法の手法や種類について理解するLearning Curve
熟達度

経験評価の違い
総括的評価

形成的評価

例

専門医試験

EPOC，フィードバック

目的合否判定，達成度判定

現状把握(ギャップ)，成長促進

タイミング

トレーニングの終わりに点数化（数値化）

直後．具体的フィードバック

学習者

関わらない

積極的に関わる

モチベーション

外因的

内因的学習への影響弱，短期的強，長く持続する

Learning Curve
熟達度

経験Learning Curve
熟達度

経験評価の重要性
到達度確認

学習促進

情報共有

Instructional Design

目標

評価

フィードバック

評価の種類知識

多肢選択問題，口頭試問

技術

パフォーマンスアセスメント

態度

OSCE

判断力 達成度

360 評価結紮

どう思いましたか？

どう思いましたか？

Instructional Design
タスク分析
目標

評価

フィードバック評価スケール作成

評価スケール作成
グループワーク
コンセンサスメソッド
結紮縫合評価ツール

FLS curricula, as previously described.
During orientation, residents completed a questionnaire regarding baseline experience, viewed the 31-minute video-basedtutorial, and completed a single (one-on-one) proctored repetition of each of the 6 tasks to assess their baseline performance(pre-test). During the next 2 months, they self-practiced until
the expert-derived proficiency levels were achieved for each task
on at least 2 consecutive repetitions or until a maximum number of 80 repetitions had been performed. If proficiency for any
given task was demonstrated during pre-testing, further training and post-testing were not required for that task. Trainees
FIGURE 1. Tie at depth.
were given unlimited 24-hour access to the skills laboratory andscissors),
and a stopwatch.
1 (Tie at depth;
Figure 1), Task
instructional videos.
Full-timeskillsTask
laboratory
coordinators
FIGURE 5. Ties in continuity.
3 (Tie on a pass; Figure 3) and Task 4 (Suture ligation, stick tie;were available for mentoring
and additional assistance and feedFigure 4) used a suture board (Ethicon Endo-Surgery, Inc.,OH). Trainees
For Task 1 (Figure
the model to
was pracmodiback were providedCincinnati,
as needed.
were1),required
fied by drawing a 1-mm black line on the hook inside of the
spreading; secure knots move ! 3 mm; 10 points is assessed fortice the tasks in order,
achieving proficiency on a given task
ORIGINAL REPORTS
plastic cup, such that accuracy errors could be assessed. SimiFIGURE 1. Tie at depth.
slippage, 20 points for disruption), breakage (20 points if abefore practicing larly,
theforsubsequenttask.3 andTrainees
were proTasks 3 and 4 (Figure
Figure 4, respectively),thetubing was marked with a 2-mm segment as a target
ligature is broken), cuff error (10 points per ligature if cuff is !2
vided score sheets rubber(http://www8.utsouthwestern.edu/utsw/cda/
zone for ligature placement. Task 2 (Suture at depth; Figure 2)sors), and a stopwatch. Task 1 (Tie at depth; Figure 1), Task
mm or 20 points per ligature if the ligature is cut while cutting
dept48035/files/517305.html),
includingdetailed
task
descripused a slit Penrose drainwith 2 pre-inked
targets(FLS
Suturing
Tie on a pass; Figure 3) and Task 4 (Suture ligation, stick tie;
FIGURE 3. Tie on a pass.
Model,and
http://www.flsprogram.org),
wassheets
securelywere
fixedtubing), palming (1 point each occurrence if fingers are inserted
tions, error definitions,proficiency levels;whichthese
ure 4) used a suture board (Ethicon Endo-Surgery, Inc.,
using Velcro to a wooden base inside of a 5.1 cm wide ! 3 in.
into
theneedledriverfingerrings),
loading
(1
point
each
ockeptinthesimulationlaboratory
andprogresswasmonitoredtall section of PVC pipe. Task 5 (Ties in continuity; Figure 5)
ncinnati, OH). For Task 1 (Figure 1), the model was modiused a laminatedfabric model(Dasiecompletion
International, Elora,
Cancurrence
iftheneedleisnotloadedwithinthewound),
avulsionweeklybyan
education
coordinator.
Uponof selfof
themodel,
traversing
thedeep
aspectoftheincision,tod by drawing a 1-mm black line on the hook inside of theada) with a 10 cm full thickness longitudinal incision; a segmimic
a
small
blood
vessel.
Task
6(Atraumatictie;
Figure
6)
(a
score
of
0
is
assessedifthePenrosedrain
isdetachedfromits
practice,
each
traineeunderwentanindividual
post-test
by
perstic cup, such that accuracy errors could be assessed. Simiment of 12 French latex tubing was placed through the surface
used
an
empty
12
oz
soda
can
filledwith
30
penniestoachieve
Velcro attachments), movement (20 points if the base of the canforming a single-proctored repetition of each task (withouty, for Tasks 3 and 4 (Figure 3 and Figure 4, respectively), thea total weight of 90 g; the tab on the soda can was is
epoxiedthe
movedin outsideof the circular template). A 31-minute video
warm-ups), and completed a questionnaire regarding his/herbber tubing was marked with a 2-mm segment as a target“up” position to ensure stability (while knot-tying)
and a 4wasmmcreated to demonstrate correct performance of eachne for ligature placement. Task 2 (Suture at depth; Figure 2)
tutorial
impressions about the curriculum. If post-test performance ontarget zone was marked at the center of the tab. A 2-7/8 in.
d a slit Penrose drain with 2 pre-inked targets (FLS Suturingtask as well as pitfalls and error avoidance strategies (http://
any task was below 80% of the proficiency level, remediation
diameter circle was drawn on a sheet of white paper for use as a FIGURE 1. Tie at depth.
odel, http://www.flsprogram.org), which was securely fixed
www8.utsouthwestern.edu/utsw/cda/dept48035/files/517305.
was required and consisted of additional self-practice and mantemplate to assess movement errors.
ng Velcro to a wooden base inside of a 5.1 cm wide ! 3 in.
html).
datory achievement of at least 90% of the proficiency level on
LaurenMashaud,
MD, Nabeel
MD,
Deborah
Hogg,
BS, andJ. Scott,MD
and a stopwatch.
Task 1 (Tie
at depth; Figure 1), Task
Throughpilot
novice and C.
expertperformanceofscissors),
the 6Danieltasks,
section of PVC
pipe. B.
Task
5 (Ties in continuity;
Figure 5) A. Arain,
3Similar(Tie onofa pass;
Figure3) andwork,
Task 4 (Suture
ligation, sticktie;
to ourprior
an objective
scoringsystem based FIGUREsubsequent
3. Tie on a pass.post-testing. Curriculum completion was enforced
performance methods were standardized and definitions
erd a laminated fabric model (Dasie International, Elora, CanFigure 4) used a suture board (Ethicon Endo-Surgery, Inc.,on
discrete
errorsandcutofftimes(themaximumallowablebythe surgery residency program director.
rors
were
established.
The
tasks
were
arranged
in
order
of
in) with a 10Department
cm full thickness
incision;a seg- of Texas Southwestern Medical School, Cincinnati,
For TaskSimulation
1 (Figure 1), the modelof longitudinal
Surgery, The
University
Dallas,OH).
Texas,
andwas modi- of the11,12
model,
traversing
thedeep
aspect of theto costs were calculated for both curtimefortask
completion)
for
each
task
was
created.
We
Man-hours
andincision,material
creasing level of difficulty. For the various tasks (Table
fied1),
by errors
drawing a 1-mm black line on the hook inside of thent of 12 Frenchlatextubing wasplaced throughUT
theSouthwestern
surfacemimic a small blood vessel. Task 6 (Atraumatic tie; Figure 6)
SkillsTraining
Laboratory,
Centerfor
Minimally
Invasive
Surgery,
Dallas,Texasplastic
cup,
such
that
accuracyerrorscouldbeassessed.
Simiincluded: accuracy (the distance in mm outsideusedof thethetarget
following scoring formula, which includeduseda multiplier
riculum development and implementation. Donated materials
an empty 12 oz soda can filled with 30 pennies to achieve
larly, for Tasks 3 and 4 (Figure 3 and Figure 4, respectively), thezone), gap (distance in mm between the ligature
thewas markedof rubber
10 andtotubing
increase
the penalty
forerrors:score"(cutofftime)#
includedboards,ligatures, sutures, wooden boards, andatotal
weight
of
90
g;
the
tab
on the sodasuture
can was epoxiedin thewith a 2-mm segment as a target“up”
positiontoensurestability(whileknot-tying)
and
a
4
mm
model), slippage (measured by cutting the tails(completion
tozone1 cm
and time)
for ligatureplacement.
Task
2(Sutureatdepth;
Figure2)#10 (sum of errors). Negativetarget
valueswere
soda cans; these items were excluded from this analysis. Costs
zone was marked at the center of the tab. A 2-7/8 in.
a slit Penrose
drain with 2 skills,
pre-inkedproficiencytargets (FLS Suturing
insertingpointed scissors
withinthe loopof knot-tying
theusedknot
and
BACKGROUND: The purpose of this study was
to develop
KEY
WORDS:
open
and suturingassigned
a
score
of
“0.”
Proficiency
levelswereestablishedbased
diametercirclewasdrawn
ona sheet of white paper for use as a
Model, http://www.flsprogram.org), which was securely fixedbased skills training, simulation-based
surgicaltraining,
an intermediate-level proficiency-based knot-tying and suturtemplate
to assess movement errors.
onusingscoresofto4aexperts
who
performed
5 consecutive
repetitions
Velcrowoodenbase
insideof a 5.1curricucm wide
! 3 in.
pilot novice and expert performance of the 6 tasks,
section
PVC6pipe.
TaskThe5 (Tiesexpert
in continuity;
Figure5) was Throughlum development and implementation
ing curriculum, evaluate construct validity, determine feasibilthroughMay 2009.
Residents
had already completed 6 monthsof talleach
of ofthetasks.
groupmean
calculated
2. Suturing at depth, interrupted, simple.
performance
methods were standardized
and definitionsof er-FIGURE
used a laminated fabric model (Dasie International, Elora, Canofproficiency-basedskillslaboratory
training, including ourrors were established.
of inity, document educational benefit, and quantify cost-effectiveand
2Knowledge,
SDlongitudinalfrom themean)
were trimmed;
in The tasks were arranged in orderada)outlierswitha 10(beyond
cmfull thickness
incision;a segCOMPETENCIES: Patient
Care,
Medical
PracJournal of Surgical Education • Volume 70/Number 2 • March/Aprcreasing
levelofdifficulty.
Forthevarioustasks(Table1),
errorsbasic open knot-tying and suturing, basic laparoscopic, andment4of of
12 Frenchlatex tubing
was placed
the surface
total,
120 data
pointswerethroughtrimmed.
A proficiency
level
ness of implementation within a surgery residency program.
included: accuracy (the distance in mm outside of the target
tice-Based Learning and
Improvement
FLSthecurricula,as previously described.11-13
equal to the trimmed mean $ 2 SD was selected, aszone),this levelof in mm between
gap (distanceligature and theresidents completed a questionnaire reMETHODS: Six tasks with standardized metrics were develmodel),duringslippage (measured by cutting During
the tails toorientation,
1 cm andperformance was achieved for each task by all 4 experts
inserting pointed scissors within theloop ofbaseline
the knot experience,andgardingviewed the 31-minute video-based
oped using commercially available bench models; 39 PGY-1
INTRODUCTIONtheir 5 repetitions. For each task, a normalized score was detutorial,
andcompletedasingle(one-on-one) proctored repesurgery residents were enrolled in a 2-month curriculum (orifined as the task score divided by the proficiency level multitition of each of the 6 tasks to assess their baseline performanceThe
traditional
apprenticeshipmodel(observe,
assist,andperentation/pre-test, self-practice, and a proctored post-test). Baseplied by 100. The composite score was defined as the sum of the(pre-test). During the next 2 months, they self-practiced until
form under supervision) has been the main modality by whichline trainee and expert performance were compared to assess
normalized scores for all 6 tasks.
the expert-derived proficiency levels were achieved for each task
surgery residents acquire the skills necessary for good operative
construct validity.
The study was conducted in the Simulation and Training
on at least 2 consecutive repetitions or until a maximum num1
techniques. This model also emphasizes further reinforcement
ber of 80 repetitions had been performed. If proficiency for any
Laboratory at the Southwestern Center for Minimally Invasive
RESULTS: Baseline trainee and expert performance were sigby requiring residentsSurgery
to progressively
increase
theiroperative
given task was demonstrated during pre-testing, further train(a level-1 ACS accredited education institute) at thenificantly different (451 ! 83 vs 644 ! 10, p " 0.001), supexposure with the goalUniversityof repeatedofpracticeleadingtoskill
masing and post-testing were not required for that task. Trainees
Texas Southwestern Medical School in Dallas,tery. However, given TX.
the current
milieuofwork-hour
limitaporting construct validity. All trainees achieved proficiency durwere given unlimited 24-hour access to the skills laboratory andAfter Institutional Review Board (IRB) approval, 39
instructional FIGURE
videos. Full-timeskills laboratory coordinators
tions,
financialconstraints,
as wellas ethicalconcerns,
residency
1.interrupted,
Tie at depth.
ing2.self-practice,completing30! 17 repetitions over 3.4 ! 3.8
FIGURE
SuturingFIGURE
at depth,
simple.
FIGURE 4.
Sutureligation (sticktie). PGY-1
FIGURE
5.inTies
continuity.
6. Atraumatic tie.
surgery
residents
participatedthisin study
from April
wereavailableformentoringandadditional assistance and feedprograms have looked towards other means to enhance trainhours. Significant differences were detected between baseline
urnalscissors),of Surgical
Education
Volume70/Number2
March/April
2013
195
•
•
2-3
back
were provided
as needed.
Traineesrequired topracandfinal
a stopwatch.
Task 1 (Tie at
depth;(451FigureJournal of Surgical
Education
70/Number
2 •wereMarch/April
2013• Volumeing, such as simulation.196In fact, in the past decade, the growthandtrainee composite
scores!1),
83Taskvs 607 ! 34, p "spreading;secure
knots
move
!
3
mm;
10
pointsisassessed
for
tice
the
tasks
in
order,
achievingproficiency
on
a
given
task
3 (Tie on a pass; Figure 3) and Task 4 (Suture ligation, stick tie;
3. Tie onskills
a pass.training has
inFIGURE
laparoscopic
resulted
numerous
FIGURE
2. Suturingin
at depth,
interrupted, robust
simple.
FIGURE 4. Suture ligation (stick tie).
0.001).
slippage,20
pointsfor disruption),breakage (20 points
if a
before practicing the subsequent task. Trainees were proFigure 4) used a suture board (Ethicon Endo-Surgery, Inc.,and validated skills curricula,and many
ofisthese
have 70/Number
now
been
Journal of Surgical
Education
2 • March/April
195• Volumecuff
ligature
broken),error (10points per2013
ligature if cuff is !2
vided score sheets(http://www8.utsouthwestern.edu/utsw/cda/
Cincinnati,
OH). For Task 1 (Figure1), the modelofwasthis
modi4-9
CONCLUSIONS:
Implementation
curriculum
waswidelyimplemented.
Moreover,best
methods,
includingdeof
themodel,
traversing
thedeep
aspectoftheincision,tomm or 20 points per ligature if the ligature is cut while cutting
dept48035/files/517305.html), including detailed task descripfied by drawing a 1-mm black line on the hook inside of thefeasible and cost-effective. Construct validity and educational
mimic a small bloodvessel.practice,
Task 6 (Atraumatictie; training,
Figure 6) and proficiency-based
liberate
distributed

結紮縫合練習法

Development, Validation, and Implementationof a Cost-Effective Intermediate-Level
Proficiency-Based Knot-Tying and Suturing
Curriculum for Surgery Residents

TABLE 1.
Task
Task 1:
Tie at depth

Task 2:
Suturing at depth

Task 3:
Tie on a pass

Task 4:
Suture ligation(stick tie)

Task 5:
Ties in Continuity

Task 6:
Atraumatic tie

Description
Place 2-0 silk ligature around a post (enclosed in a plastic cup) between the ball and the black line (1 mm)on the Ethicon knot-tying model and tie 3 square knots (either 1- or 2-handed). Time starts with 1 end of
the tie in each hand, outside the cup; time stops with completion of the final knot.
Errors: accuracy, gap, slippage, breakage
Cutoff time: 60 secondsExpert proficiency level: 41 (19 seconds with no errors)
The trainee must place a simple interrupted suture using 2-0 silk suture (30 cm) on a tapered needle andtie 3 square knots (either 1- or 2-handed) on the FLS suturing model. Time starts with the needle loadedin the needle driver in the dominant hand and the forceps held in the non-dominant hand; time stops
when both suture tails have been cut to 1cm in length.
Errors: accuracy, gap, slippage, breakage, palming, loading (not loading within the wound), Avulsion
Cutoff time: 180 secondsExpert proficiency level: 154 (26 seconds with no errors)
2-0 silk ligature attached to the tip of a curved hemostat. The trainee first wraps the tie around (and under
the right angle clamp held by the assistant) on the cut rubber tubing (with 1 mm of the 2 mm colored
segment exposed); 1 square knot is tied (either 1- or 2-handed) and the clamp is released after the
trainee says “off.” The trainee then ties 2 additional square knots. Time starts with the tie secured in the
curved hemostat; time stops with the completion of the third square knot.
Errors: accuracy, gap, slippage, breakage
Cutoff time: 120 secondsExpert proficiency level: 102 (18 seconds with no errors)
2-0 Silk suture (30 cm) on a tapered needle. Trainee must pass the needle through the rubber tubing(under the right angle clamp held by the assistant) with 1 mm of the 2 mm colored segment exposed.
The trainee then ties 1 square knot (either 1- or 2-handed). The trainee then passes the suture tail aroundthe right angle clamp and then ties 1 square knot. The clamp is released when the trainee says “off.”
The trainee then ties 2 additional knots. Time starts with the needle passage through the rubber tubing;time stops with the completion of the fourth square knot.
Errors: accuracy, gap slippage, breakage
Cutoff time: 120 secondsExpert proficiency level: 95 (25 seconds with no errors)
The trainee first passes the 4-0 silk ligature (preloaded on curved hemostats) to the proctor holding theright angle clamp exposing the tubing. The first ligature is held by the proctor in the left hand towards
the bench. The second ligature is passed to the proctor holding the right angle clamp and the trainee
then ties 3 square knots (either 1- or 2-handed). The trainee then ties the first ligature using 3 squareknots (either 1- or 2-handed). The rubber tubing between the 2 ligatures is cut, and both tails are cut to2 mm in length. Time starts with passage of the first curved hemostat to the assistant; time stops when
the last pair of suture tails has been cut.
Errors: gap, slippage, breakage, cuff error (cuff is !2 mm)
Cutoff time: 180 secondsExpert proficiency level: 141 (39 seconds with no errors)
4-0 Silk ligature is passed through the pop up tab ring (which is epoxied in the “up” position) on the 12
oz soda can. Using either a 1- or 2-handed technique, the trainee ties 3 square knots within the 4mm
marked target area on the tab. Time starts with each of the 2 strands of ligature in both hands; timestops when the last square knot has been tied.
Errors: accuracy, gap, slippage, breakage, movement
Cutoff time: 60 secondsExpert proficiency level: 40 (20 seconds with no errors)結紮縫合練習法

Journal of Surgical Research 141, 7–15 (2007)
doi:10.1016/j.jss.2007.02.043

A Cost-Effective Proficiency-Based Knot-Tying and Suturing Curriculumfor Residency Programs
Daniel J. Scott, M.D., F.A.C.S.,1 Mouza T. Goova, M.D., and Seifu T. Tesfay, R.N., M.S.
Southwestern Center for Minimally Invasive Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
10

JOURNAL OF SURGICAL RESEARCH: VOL. 141, NO. 1, SCOTT,JULY 2007
GOOVA, AND TESFAY: KNOT-TYING AND SUTURING CURRICU

Submitted for publication January 6, 2007

Therefore, the goal of this study was to develop a other institutions to reliably
structured open skills curriculum for knot-tying and Thus, there is a clear needsuturing using expert-derived performance goals, a distribute such curricula, aConclusions. This curriculum is cost-effective, feasivideo-based tutorial, and metrics based on time and project.
Background. The purpose of this study was to de- blewithinthe context
ofexamine
residency
training,
educaerrors.
Additionally,
we aimed to
the feasibilThe models incorporated ivelop a structured open skills curriculum for knot- tionally
ity of implementing
this andcurriculumas part of routine
beneficial,demonstrates
constructvalid-available andcommerciallyresident
training,
document cost-effectiveness,tying and suturing using expert-derived performance ity.
Morewidespread
adoption of andstandardized,
these aspects cannot be overe
evaluate
constructvalidity.
goals and to examine its feasibility, cost-effectiveness, validated skills curricula such as this byof residency
programs withresidency
gets in need of practical trainiand construct validity.
programs isMATERIALS
warranted.
© 2007 Elsevier Inc. All rights reserved.
AND METHODS
used currently accepted educa
Methods. Using commercially available bench modKey Words: surgical education; skill ing
acquisition;a distributed, structured
Modeland suturing
Curriculum Development
els, 11 standardized tasks (ranging from 2-handed knot-tying
andcurriculum; skills
training;
to optimize
educational benefi
knot-tying to running subcuticular closure) were de- skills
lab;technical
skills; bysuturing
simulation.
A needs
assessment
was performedinterviewingmodels;
numerous efficiency;
again, these issues
surgicalfacultyandresidents
toidentify
content
appropriate
forveloped and scored using previously validated metrics
to residency programs in lig
PGY1 level residents. Using established educational principles [21, 39],
week constraints. The results
based on time and errors. Expert performance wasclinically relevant knot-tying and suturing skills were deconstructed
INTRODUCTION
through tasks analysis. We aimed
to develop a set of tasks that both the educational benefit oused to establish training endpoints and to create awould comprehensively teach the identified content domains. Our in the significant difference bevideo tutorial. PGY 1 residents (n ! 4) were enrolled ingoal was to use low cost, commercially available materials so that the performance, and its validity
curriculum
be easily
institutions.
Various
FIG. 1. Task 1 (Palm
Needle Driver)is performed by grasping FIG.
7. Thecould
revisedTasks replicated
10 andhas
11 byandother
the new
Task
12 useaa prospective Institutional
Review
Board-approved
Surgical
education
evolvedimmensely
since themodelsandscoring
schemes
were
exploredthroughiterative
rep- differences detected between
the marked segments of a single thin rubber tube on the suture laminated fabric model to facilitate continuous and interrupted substruct validity).
pilot study that
includedorientationand cuticularapprenticeship
model
was
by
Haletitions,and 11 (Color
discretetasks ofweredeveloped(Table1, Figs.
1, 2,William
board.
(Color versionproctoredof figure is available
online.)suturing.
versionfigureis introduced
available
online.)3, and 4) using standard open surgical instruments (forceps, needle
While more eloquent virtua
baseline testing, self-training to proficiency, and proc- stedovera centuryago[1]. andWork-hour
limitations,drivers,
andscissors)
andequipment(stopwatch
ruler).
on time and errors can be readily assessed to objecmodels may either be current
tored post-testing(conducted over a 4-wk period). financial
The Palm Needle
Driver (Task 1)
and 1-ethicaland 2-handedknot-tying have forced
constraints,
andconcerns
tively measure performance. Bench models that use However,
the wound closure pad used for Tasks 10 andexercises (Tasks 2 to 6) use a suture board (donated) available from velopment, the low fidelity mBaseline trainee scores were compared with expert

8Task 1: Palm needle driver
Model
Description
ErrorsCutoff time (seconds)
Expert proficiency score
Task 2: Knot-tying, no tension,
2-handed
Model
Description
ErrorsCutoff time (seconds)
Expert proficiency score
Task 3: Knot-tying, no tension,
1-handed
Model
Description
ErrorsCutoff time (seconds)
Expert proficiency score
Task 4: Knot-tying, under
tension, 2-handed,
surgeon’s knot
Model
Description
ErrorsCutoff time (seconds)
Expert Proficiency Score
Task 5: Knot-tying, under
tension, 2-handed, slip
knot
Model
Description
ErrorsCutoff time (seconds)
Expert proficiency score
Task 6: Knot-tying, under
tension, 1-handed, slip
knot
Model
Description
ErrorsCutoff time (seconds)
Expert proficiency score
Task 7: Suturing, interrupted,
simpleModel
Description
ErrorsCutoff time (seconds)
Expert proficiency score
Task 8: Suturing, interrupted,
horizontal mattress
Model

JOURNAL OF SURGICAL RESEARCH: VOL. 141, NO. 1, JULY 2007

SCOTT, GOOVA, AND TESFAY: KNOT-TYING AND SUTURING CURRICULUMTABLE 1TABLE 1

Task Descriptions and Expert Proficiency Levels

continued
Description

Suture board
Grasp 5 mm colored segment on thin single rubber tubing by opening and closing (3 full clicks) the
needle driver held by palming only and perform the maneuver 5 times
Non-closure, accuracy, instrument drop, non-palming60
53 (7 seconds with no errors)

Suture board
Tie a 46 cm 2-0 silk ligature around 5 mm colored segment on thick single rubber tubing using only a2-handed technique, 3 square knots, time starts with tie in place, not crossed, 1 end in each hand
Accuracy, gap, slippage, breakage
60
50 (10 seconds with no errors)

Suture board
Tie a 46 cm 2-0 silk ligature around 5 mm colored segment on thick single rubber tubing using only a1-handed technique, 3 square knots
Accuracy, gap, slippage, breakage
60
50 (10 seconds with no errors)

Suture board
Tie a 46 cm 2-0 silk ligature around 5 mm colored segments to approximate thick double rubber tubing
set using only a 2-handed technique, surgeon’s knot then 2 squares (3 knots total)
Accuracy, Gap, Slippage, Breakage
60
47 (13 seconds with no errors)

Suture board
Tie a 46 cm 2-0 silk ligature around 5 mm colored segments to approximate thick double rubber tubing
set using only a 2-handed technique, slip knot on first 2 throws then 2 square throws (4 knots total)
Accuracy, gap, slippage, breakage
60
45 (15 seconds with no errors)

Suture board
Tie a 46 cm 2-0 silk ligature around 5 mm colored segments to approximate thick double rubber tubing
set using only a 1-handed technique, slip knot on first 2 throws then 2 square throws (4 knots total)
Accuracy, gap, slippage, breakage
60
45 (15 seconds with no errors)

FLS Penrose drain
30 cm, 3-0 undyed polysorb on tapered needle, pass needle through 2 inked targets for simple
interrupted suture, instrument tie surgeon’s knot then 2 squares (3 knots total)
Accuracy, gap, slippage, breakage, non-palming, needle loading120
102 (18 seconds with no errors)

FLS Penrose drain

ErrorsCutoff time (seconds)
Expert proficiency score
Task 9: Suturing, interrupted,
vertical mattress
Model
Description
ErrorsCutoff time (seconds)
Expert proficiency score
Task 10: Suturing, running,
simpleModel
Description
ErrorsCutoff time (seconds)
Expert proficiency score
Task 11: Suturing, running,subcuticular
Model
Description

ErrorsCutoff time (seconds)
Expert proficiency score
Revised task 10*: Suturing,running, simple
Model
Description
ErrorsCutoff time (seconds)
Expert proficiency score
Revised Task 11*: Suturing,running, subcuticular
Model
Description

ErrorsCutoff time (seconds)
Expert proficiency score
Task 12**: Suturing,interrupted, subcuticular
Model
Description

ErrorsCutoff time (seconds)
Expert proficiency score

9

30 cm, 3-0 undyed polysorb on tapered needle, pass needle through 4 inked targets for horizontal
mattress suture, instrument tie surgeon’s knot then 2 squares (3 knots total)
Accuracy, gap, slippage, breakage, non-palming, needle loading120
89 (31 seconds with no errors)

FLS Penrose drain
30 cm, 3-0 undyed polysorb on tapered needle, pass needle through 4 inked targets for verticalmattress suture, instrument tie surgeon’s knot then 2 squares (3 knots total)
Accuracy, gap, slippage, breakage, non-palming, needle loading120
89 (31 seconds with no errors)

Wound closure pad
46 cm 3-0 nylon on a cutting needle, model oriented perpendicular to bench edge, instrument tie
surgeon’s knot then 3 squares (4 knots total) at each corner, pass the needle through 22 inked
targets to perform simple running suture, tie to loop at end, cut tails !1 cm
Accuracy, gap, slippage, breakage, non-palming, needle loading, tails
600
435 [2’45" (165 seconds) with no errors]

Wound closure pad
46 cm 4-0 undyed monofilament on a cutting needle, model oriented horizontal to bench edge, no inked
targets, anchoring stitch in the first corner with instrument tie surgeon’s knot then 3 squares (4knots total), pass needle through subcuticular layer to perform running closure, and complete using
an Aberdeen (pull through the loop) knot (4 throws), cut tails flush
Gap, breakage, non-palming, needle loading, tails
600
396 [3’24" (204 seconds) with no errors]

Dasie model
46 cm 3-0 nylon on a cutting needle, model oriented perpendicular to bench edge, instrument tie
surgeon’s knot then 3 squares (4 knots total) at each corner, pass the needle through 22 inked
targets to perform simple running suture, tie to loop at end, cut tails !1 cm
Accuracy, gap, slippage, breakage, non-palming, needle loading, tails
600
435 [2’45" (165 seconds) with no errors]

Dasie model
46 cm 3-0 nylon on a cutting needle, model oriented horizontal to bench edge, no inked targets,anchoring stitch in the first corner with instrument tie (surgeon’s knot then 3 squares (4 knots total),pass needle through subcuticular layer to perform running closure, and complete using an Aberdeen(pull through the loop) knot (4 throws), cut tails flush
Gap, breakage, non-palming, needle loading, tails
600
396 [3’24" (204 seconds) with no errors]

Dasie Model
any length 3-0 nylon on a cutting needle, model oriented parallel to bench edge, 1.5 cm long fullthickness incision in the model (no inked targets), place a single buried subcuticular suture in a
vertical fashion (perpendicular to the incision) with an instrument tie [surgeon’s knot then 3 squares(4 knots total)], cut tails flush with the model surface
Gap, breakage, non-palming, needle loading, tails120
87 (33 seconds with no errors)* Tasks 10 and 11 were revised following the implementation study to enhance durability using the Dasie model.
** Task 12 was added in response to participant feedback.

Instructional Design
カークパトリックの４段階評価モデル

Instructional Design

Instructional Design
目標
重要性，難易度，関連性

方略
人，物，時間，教授法

Instructional
Time and Design
Accuracy

FLS Manual Skills Written Instructions
and Performance Guidelines

NT SCORING INFORMATIONFLS Manual Skills Written Instructions
and Performance Guidelines

Skills testing component is intended to measure your technical skills during basic
surgical maneuvers. These five tasks, designed by Dr. Gerald Fried and customized forgram, are based on the MISTELS program developed at McGill University and have beentested to ensure that they reflect the technical skills that are fundamental to theof laparoscopic surgery. All tasks are demonstrated in the FLS instructional curriculum
SkillsWritten Instructions
nd each task must be performed once during the test.
In this task, you are required to place a pre-tied ligating loop or endoloop around a tubular foamrformance Guidelines

appendage and secure the knot on the provided mark. Once you have inserted the endoloop into thehe five exercises are timed. While the actual time required for each exercise varies
of view,For
break
off the end of the plastic pusher at theits difficulty, a maximum time limit has been set for eachfield
exercise.
all exercises,
scoredmark.
Once
you havend accuracy are considered important for performance and high scores result
from positionedtheendoloop
properly,
secureerformed efficiently and without error. Each exercise has its own scoring formula the knot on the marktheforbase
the foam areappendage by sliding the
a combination of time and accuracy measures. The nearscorestheofexercises
pusherrod
down.
A
penalty
will be assessed if the knot is
o that they contribute equally to the total manual skills assessment score.

not secure and for any distance that the tie misses thescored for efficiency (time) and precision; penalties are applied
mark. for specific errors or lackA
person
will
fail
if
they
are
extremely
inefficient,extremely
imprecise, if they makee endoscopic scissors, large clip, 4x4 piece of gauze
rors, or any combination of inefficiency and imprecision. IfTiming
a task is
not completed
thebeginswhen an by
instrument(or endoloop) is
the test-taker will have failed that task. Reaching or exceedingthemaximum
time
visible on the monitor and ends when the ligating loop
) results in a score of zero; thus, if the time to complete
a taskis close
to
or at
the
FLS
ManualSkillsWrittenthreadis cut.
The
endoloopcannotInstructions
be broken prior tomeallowed,
it
will
not
resultinapassing
score
for
that
particulartask.
m a square piece of gauze suspended between clips.
and Performance Guidelines

at thetopTransfer
of marked square on the floor of the trainere:Peg

inserting it into the field of view. This task tests familiarity
with the endoloop and requires bimanual skills. A video
demonstration is included in Module 5 of the FLS didactic curriculum.

FLS Manual Skills Written Instructions
and Performance Guidelines

atternMaryland
face up dissectors/graspers,
so that the open (unfolded)
edgeof the ring objects
Twopegboard,
6 rubbered
alligator
clips
tosecurethebottomtwocornersofme limit: 300 seconds
Task Four: Simple Suture withTask
Extracorporeal
Five: SimpleKnot
Suture with Intracorporeal Knot
spended off the bottom of the box.
Equipment:Twoneedledrivers(orchoiceofoneneedleone Maryland
one knotegboard on the lower Velcro™ strip in the center of the marked square on the floor of theEquipment:
Twodriverneedleanddrivers,
one suturedissector),of 15 cm length,
one endoscopic scissors, one suture
pusher(openorclosed),one
sutureof
90
120cm
length,one
endoscopic
scissors,one
penroset does not matter which peg pattern (parallel or circular) is on the left or right side of theblock, one penrose drain with marked targets. Please note: self righting needle drivers are notmarkedone
block.
Pleaseself-righting
ake sure the pegboard In
is centered
the camera’s
field ofview.
Tothetargets,
six objects
this task,in you
are required
todrainplacewitha begin,pre-tiedligatingloopsuture
or endoloop
aroundnote:a tubular
foam needle drivers are notpermitted.
permitted.
n the side of the pegboard
corresponding
to the candidate’s
non-dominant
appendage
and secure
the knot on
the provided hand.
mark. Once you have inserted
the endoloop
intotheseconds
Maximum
Time Limit:
600
Maximum
limit:
field of view, break off the end of theplastic time
pusherat 420the secondsssfer exercise requires you to lift the six objects
ng
Place the drain firmly on the suture block,scored mark. Once you have positioned
er/dissector, first in your non-dominant hand, and
Place
the
drain
firmlyonthesutureblock,
andplace
placethe suture block on the lower
andthe endoloop properly, secure the knot on the marke object midair to your dominant hand.
thesuture
block
on
the
lower
Velcro™
strip.
Velcro™ strip.
the basesideof thefoam appendage by sliding theeach object on a peg onnear
the oppositeof thepusherrod
down.
A
penaltywillbeassessed
if
the
knot
is
e is no importance placed on the color of theThisthesuturing
tasktherequires you to place aThis
longsuturing
suture task requires you to place a suturenotsecureand allforsixany distance thattie misses
e order in which they areplaced.
Oncee.
precisely
through two marks on a Penrose drain thatthrough
two
marks
in
a
longitudinallyslit
Penrosemark.
been transferred, the process is reversed.
hasbeenslit along its long axis. You are thendrain.
Youarethenrequiredtotie
3singlethrowss lifted in turn using the dominant handrequiredtotie the knot intracorporeally.
extracorporeally,
using
the
knot-pusher
tosecureeach
Timingwhen an instrument (or endoloop) is
board, transferred midair
to thebegins
other hand
The
first
throw
must
throw
on
the
drain.
You
must
tie
the
knot
tightly
enoughto be a surgeon’s knot or double throw,on the pegs on the originalsideonof thevisiblethe board.
monitor and ends when the ligating loop
followedbytwosingle
close
the
slit
in
the
drain.
Be
carefulnottoavulsethedrain
off throws. You must exchange
thread is cut. The endoloop cannot be broken prior toerror
is task begins when you grasp the first object and ends upon
releaseofthelast
object.
hands
with
your
needlebetween each throw, so thatthe task
foamtests
block.
inserting it into the field of view. This
familiarity
r must be mid-air, without using the pegs or block for assistance. This exercise is timed
you are tying with the opposite hand for each throw
with theendoloop and requires bimanual skills. A video
ay is assessed for any object
dropped out of the field of view or any object dropped outside
to ensureknot isandsquare.
Timingan curriculum.
instrument is visibleon thethemonitorends when both ends of the suture
is included
in Module
5andof begins
theFLSwhendidactich. This exercise tests demonstration
hand-eye coordination,
ambidexterity
depth
perception.
A
are cut, regardless of length. Tails can be cut individually or together. A penalty is applied for any
stration of this task is included in Module 5 of the FLS didactic curriculum.
Skillsincludeproper slit
placementof thein the needle-driver, needle transferring,
deviationof the needle from themarks, foranyrequired
gap in thelongitudinalin the drain
andneedle
for a knot
Task Four: Simple Suturewith Extracorporeal
Knotsuturingskillsandknottying.
A
penaltyisappliedforanydeviationthat slips when tension is applied to it. If the drain is avulsed from the block, a score of zero will be of the suture from the marks, for
Equipment:Twoneedledrivers(orchoice of one needle driver and one Maryland
one knotany gapdissector),in the longitudinalslit in the drain and for a knot that slips when tension is applied to it. If theg of Ligating
Loop
ember
2012
applied.
This task
testsoneaccuracyof placementof thesuture and knot tying skills and requires
pusher(openorclosed),one
sutureof
90
120cm
length,endoscopic
scissors,one
penrosedrain
isavulsed
from
the
block
to which it is secured by Velcro™, a score of zero will be applied.
asper/dissector or grasper with locked/ratcheted www.flsprogram.org
ambidexterity, depth perception and tissue handling. Please review the video demonstration of this
drain
with
markedtargets,onesutureblock.
Pleasenote:
self-righting
needledriversarenot
one pre-tied ligating loop or endoloop, one foamtask included in Module 5 of the FLS didactic
curriculum for additional guidance. Please note: the use
Timing begins when an instrument is visible on the monitor and ends when both ends of thepermitted.

of a hemostat or other clamp for this task is not permitted.

Laparoscopic suturing60% of PDs felt that

Graduates are NOT proficientin laparoscopic suturing
Matter et al. Annals of Surgery 2014

Advanced models

New models for advanced laparoscopic suturing: taking itto the next level
Yusuke Watanabe1 • Katherine M. McKendy1 • Elif Bilgic1 • Ghada Enani1 •Amin Madani1 • Amani Munshi1 • Liane S. Feldman1 • Gerald M. Fried1 •Melina C. Vassiliou1

Needle Handling

Received: 14 February 2015 / Accepted: 8 May 2015
! Springer Science+Business Media New York 2015

Under Tension 

Abstract
Background Current simulations for laparoscopic suturing do not reflect the complexity of the skills required in
the operating room. The purpose of this study was to develop three novel advanced suturing tasks with assessment
metrics and to collect validity evidence for their measuresof suturing skill.
Methods We developed three tasks based on training gaps
identified through a previous needs assessment: needle
handling (NH), suturing under tension (UT), and continuous suturing (CS). Minimally invasive surgeons (MIS)and senior surgical residents (SR) completed these tasks
and a questionnaire regarding their educational value.
Performance was assessed by two raters based on time andaccuracy. Validity was assessed by comparing performanceaccording to the level of training and self-reported experience. The inter-rater reliability and internal consistencyof the tasks were calculated.

Continuous

Suturing
Results Thirty-one subjects (13 MIS, 18 SR) were enrolled in the study (median age 32; 77 % male). Comparedto the SR group, the MIS group had significantly greater
scores on all tasks. While all MIS surgeons completed thethree tasks within the allotted time, six (33 %) residents
could not complete at least one out of the three tasks.
Laparoscopic suturing experience correlated positively
with the scores of all tasks (NH 0.51, UT 0.70, CS 0.65.
p \ 0.01). Inter-rater reliability for all tasks was 0.99, andinternal consistency was 0.80. The majority of participants
agreed that the tasks were relevant to practice, helped
improve technical competence, and adequately measured
suturing ability.
Conclusions This study provides validity evidence forthree novel advanced laparoscopic suturing tasks. Performance on all tasks correlated significantly with training
level and self-reported experience. Integrating these tasks
into educational curricula may help improve residents’時間/エラー vs クオリティー
FFT

FFT
Time/accuracy

Time/accuracy妥当性と信頼性

Surg Endosc
DOI 10.1007/s00464-015-4285-8

and Other Interventional Techniques

REVIEW

A systematic review of performance assessment tools
for laparoscopic cholecystectomy
Yusuke Watanabe1,2 • Elif Bilgic1 • Ekaterina Lebedeva3 • Katherine M. McKendy1 •Liane S. Feldman1 • Gerald M. Fried1 • Melina C. Vassiliou1

信頼性(Reliability)
Received: 30 March 2015 / Accepted: 23 May 2015
! Springer Science+Business Media New York 2015

Abstract
Background Multiple tools are available to assess clinicalperformance of laparoscopic cholecystectomy (LC), butthere are no guidelines on how best to implement andinterpret them in educational settings. The purpose of thissystematic review was to identify and critically appraise
LC assessment tools and their measurement properties, inorder to make recommendations for their implementationin surgical training.
Methods A systematic search (1989–2013) was conducted in MEDLINE, Embase, Scopus, Cochrane, and grey
literature sources. Evidence for validity (content, response

direct observation (five tools, 30 %), or both (three tools,
18 %). Fourteen (82 %) tools reported inter-rater reliability
妥当性
and one reported a Generalizability
Theory coefficient.
Nine (53 %) had evidence forvalidity based on clinical(Validity)
experience and 11 (65 %) compared scores to otherassessments. Consequences of scores, educational impact,
applications to residency training, and how raters weretrained were not clearly reported. No studies mentioned
cost.
Conclusions The most commonly reported validity evidence was inter-rater reliability and relationships to otherknown variables. Consequences of assessments and rater