欧米における手術指導の動向
北海道大学消化器外科II
渡邊祐介

Simulation-Based Training
FIGURE 3. Tie on a pass.

of the model, traversing the deep aspect of the incision, to
mimic a small blood vessel. Task 6 (Atraumatic tie; Figure 6)
used an empty 12 oz soda can filled with 30 pennies to achievea total weight of 90 g; the tab on the soda can was epoxied in the“up” position to ensure stability (while knot-tying) and a 4 mmtarget zone was marked at the center of the tab. A 2-7/8 in.
diameter circle was drawn on a sheet of white paper for use as atemplate to assess movement errors.
Through pilot novice and expert performance of the 6 tasks,
performance methods were standardized and definitions of errors were established. The tasks were arranged in order of increasing level of difficulty. For the various tasks (Table 1), errors
included: accuracy (the distance in mm outside of the targetzone), gap (distance in mm between the ligature and themodel), slippage (measured by cutting the tails to 1 cm andinserting pointed scissors within the loop of the knot and
FIGURE 1. Tie at depth.

Y. Kurashima et al.

Evaluation of laparoscopic inguinal hernia repair

Statistical analysis

57

scissors), and a stopwatch. Task 1 (Tie at depth; Figure 1), Task
Participant characteristics. The Mann-Whitney U test was
3 (Tie on a pass; Figure 3) and Task 4 (Suture ligation, stick tie;
FIGURE 3. Tie on a pass.
used to compare case numbers for novice and experienced
Figure 4) used a suture board (Ethicon Endo-Surgery, Inc.,
surgeons.
Cincinnati, OH). For Task 1 (Figure 1), the model was modiof the model, traversing the deep aspect of the incision, toReliability. Intraclass correlation coefficients (ICCs) were
fied by drawing a 1-mm black line on the hook inside of thecalculated to estimate interrater reliability for GOALS-GH,
mimic a small blood vessel. Task 6 (Atraumatic tie; Figure 6)
plastic cup, such that accuracy errors could be assessed. SimiGOALS, and VAS assessments. ICCs were calculated forused an empty 12 oz soda can filled with 30 pennies to achieve(1) attending surgeon and trained observer, (2) attending
larly, for Tasks 3 and 4 (Figure 3 and Figure 4, respectively), thesurgeon and self-assessment, and (3) trained observer anda total weight of 90 g; the tab on the soda can was epoxied in therubber tubing was marked with a 2-mm segment as a target
self-assessment in the OR, as well as for (1) trained observer“up” position to ensure stability (while knot-tying) and a 4 mmzone for ligature placement. Task 2 (Suture at depth; Figure 2)
1 and trained observer 2, (2) trained observer 1 and selftarget zone was marked at the center of the tab. A 2-7/8 in.
FIGURETie 2atpre-inked
depth.
assessment, and (3) trained observer 2 and self-assessment
used a slit Penrose
drain1.withtargets (FLS Suturingin the simulator. For each ICC, a 95% confidence interval
diameter circle was drawn on a sheet of white paper for use as a
Model, http://www.flsprogram.org), which was securely fixed(CI) was also 13
calculated. The internal consistency of the
SCOTT, GOOVA, AND TESFAY: KNOT-TYING AND SUTURING CURRICULUM
template to assess movement errors.
scissors),
anda stopwatch.
Task base
1 (Tieat depth;
FigureTask
using
Velcroto a wooden
insideof a 5.1
cm 1),
wide! 3 in.
GOALS-GH items was estimated using Cronbach’s !.
Through pilot
novice and expert performance of the 6 tasks,
3 (Tietall
onsectiona pass; Figure
and Task
stickFigure
tie; 5)of PVC3)pipe.
Task 45 (Suture(Ties inligation,
continuity;
FIGURE 3. Tie on a pass.
other institutions to reliably replicate their
Validity.efforts.
Construct validity of GOALS-GH, GOALS, andperformance methods were standardized and definitions of erFigureused4) auseda sutureboard(EthiconEndo-Surgery,Elora,Inc.,Canlaminatedfabricmodel(Dasie International,
Thus, there is a clear need to develop, validate,
VAS scoresand
was determined by comparing means forrors were established. The tasks were arranged in order of inFIGURE
Suture ligationtie).incision;
Cincinnati,
OH).
For
Task
(Figure1),the(stickmodel
was modi-a segnovice ofand experienced
surgeons using the Mann-Whitada) witha 10
cm
full14.
thicknesslongitudinalthrough May 2009. Residents had already completed 6 months
distribute such curricula, as was the goal
thismodel,
traversing
the Fordeeptheaspect
the (Table
incision,ney U test. Concurrent validity was assessed by correlatcreasing
levelof difficulty.
variousoftasks
1), toerrorsproject.
fied bydrawing
1-mmlatex
blacktubing
line onhookthroughinside ofmentof 12 aFrench
wastheplacedthethesurface of theof proficiency-based skills laboratory training, including ouring GOALS-GH and GOALS scores, GOALS-GH score/April 2013
195 mimica small accuracy
blood vessel.
6 (Atraumatictie; Figure
included:(the Task
distancein mm outsideof the 6)
targetplastic cup, such that accuracy errors could be assessed. Simiwere
and numberof previous LIHRs, and OR and simulator
basic open knot-tying and suturing, basic laparoscopic, and The models incorporated into the curriculum
used
an
empty
12
oz
soda
can
filledwith
30
penniestoachievezone), gap (distance in mm between11-13
the ligature and thecommercially available and relatively inexpensive;
performance using Spearman’s correlation coefficient.
arly, for Tasks 3 and 4 (Figure 3 and Figure 4, respectively), theFLS curricula, as previously described.
analyses were performed using SPSS Graduate Packa totalweightslippageof 90 g; thetab on the
can thewas tails
epoxiedtheandthese aspects cannot be overemphasized inAllthe
model),(measuredby sodacutting
to 1incm
rubber tubing was marked with a 2-mm segment as a target
context
During orientation, residents completed a questionnaire re11.0 (SPSS, Inc., Chicago, IL).
“up”
positiontoensurestability(whileknot-tying)
and
a
4
mm
inserting pointed scissors within the loop of the knot andof residency programs with limited educational budzone for ligature placement. Task 2 (Suture at depth; Figure 2)
garding baseline experience, viewed the 31-minute video-basedtarget zone was marked at the center of the tab. A 2-7/8 in. gets in need of practical training tools. Additionally, weused a slit Penrose drain with 2 pre-inked targets (FLS Suturing
tutorial, and completed a single (one-on-one) proctored repediameter circle was drawn on a sheet of white paper for use as a used currently accepted educational standards,
ResultsincludModel, http://www.flsprogram.org), which was securely fixedtition of each of the 6 tasks to assess their baseline performance
templatetoassessmovement
errors.
ing
adistributed,
structured,goal-oriented
approach,using Velcro to a wooden base inside of a 5.1 cm wide ! 3 in.
(pre-test). During the next 2 months, they self-practiced until
Participant characteristics
Throughpilot
noviceandexpertperformanceofthe6
tasks,
tooptimize
educational
benefitandmaximizetrainingtall section of PVC pipe. Task 5 (Ties in continuity; Figure 5)
the expert-derived proficiency levels were achieved for each task
efficiency; again, these issues are particularly
relevant
performance
methods
werestandardized
anddefinitions
of
erA
total
of 23 participants were assessed: 14 generalused a laminated fabric model (Dasie International, Elora, Canon at least 2 consecutive repetitions or until a maximum numsurgery residents(4 in PGY 3, 4 in PGY 4, and 6 in PGY 5)
toresidency
programs
in
light
of
the
80-hour
work
rors
were
established.
The
tasks
were
arranged
in
order
of
inada) with a 10 cm full thickness longitudinal incision; a segber of 80 repetitions had been performed. If proficiency for any
and 2 support
general surgeons (not experienced in laparoscopic
weekconstraints.
The
results
of
our
pilot
study
creasing
level
ofwas
difficulty.
For the various(Table further1), errors
hernia surgery) comprised the novice group, and 1 fellow inment of 12 French latex tubing was placed through the surface
given
task
demonstrated
during tasks
pre-testing,trainboth the educational benefit of the curriculum,
as noted
minimally
invasive surgery and 6 attending surgeons (exincluded:
accuracy(thedistanceinmmoutsideoftheing and post-testing were not required for that task.target
Trainees
perienced
infinal
LIHR) were in the experienced group (Tableinthesignificant
difference
betweenbaselineandzone),
gap(distanceinmm
betweentheligature
andthewere given unlimited 24-hour access to the skills laboratory and1).significant
Surgeons in the experienced group performed signifiperformance,andits
validity,
in
terms
of
model),
slippage (measured
by cutting
thelaboratory
tails
to 1 12cmuse
andcantly more LIHRs than those in the novice group (P !
instructional
videos.
Full-timeFIG.
7. The revised
Tasks
10 and 11skills
and thenew Taskcoordinatorsa Figure
2 The MLIHS.
(A) Outsidebetween
view. (B) Close-upof bilatdifferences
detected
novicesand experts(conFIGURE 5. Ties in continuity.
.01). Eighteen
participants (12 novices and 6 experienced
insertingpointedscissors
within
the
loop
of
the
knot
and
laminatedfabricmodel
tofacilitatecontinuousandinterrupted
suberalherniainsert.
were available for mentoring and additional assistance and feedstructvalidity).
surgeons) were assessed during TAPP (n " 5) or TEP (n "cuticular suturing. (Color version of figure is available online.)
13) in the OR, and 17 participants (11 novices and 6 expeback were provided as needed. Trainees were required to prac- While more eloquent virtual reality or higher-fidelity
rienced surgeons) were assessed during TAPP simulations
Evaluators
spreading; secure knots move ! 3 mm; 10 points is assessed fortice the tasks in order, achieving proficiency on a given task
models may either be currently available orunder
in theMLIHS.deTwelve participants (7 novices and 5 expeslippage, 20 points for disruption), breakage (20 points if a However,before thepracticing
subsequenttask.
wound theclosurepad usedforTrainees
Tasks 10were
andprovelopment,thelowfidelitymodelsweusedwere
effec- were assessed both in the OR and theriencedsurgeons)
Participants were evaluated by the attending surgeon, asimulator. that
suturepull-through and required re- trained
tive.observer,
This andis notsurprising,
given
other
research
ligature is broken), cuff error (10 points per ligature if cuff is !2 11 wasvidedprone
score tosheets(http://www8.utsouthwestern.edu/utsw/cda/
self-assessment.
Observers
includedaFLS Manual Skills Written Instructions
and Performance Guidelines

Simulation-Based Training

T SCORING INFORMATIONFLS Manual Skills Written Instructions
and Performance Guidelines

Skills testing component is intended to measure your technical skills during basic
urgical maneuvers. These five tasks, designed by Dr. Gerald Fried and customized foram, are based on the MISTELS program developed at McGill University and have beensted 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
d 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 foamormance Guidelines

appendage and secure the knot on the provided mark. Once you have inserted the endoloop into thee 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 thes difficulty, a maximum time limit has been set for eachfield
exercise.
all exercises,
scoredmark.
Once
you haved accuracy are considered important for performance and high scores result
from positionedtheendoloop
properly,
securerformed 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
pusher rod
down. A penalty will be assessed if the knot isthat they contribute equally to the total manual skills assessmentscore.

not secure and for any distance that the tie misses thecored 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 makeendoscopic scissors, large clip, 4x4 piece of gauze
rs, or any combination of inefficiency and imprecision. IfTiming
a task is
not completed
thebeginswhen an by
instrument(or endoloop) is
e 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 toeallowed,
it
will
not
resultinapassing
score
for
that
particulartask.
a square piece of gauze suspended between clips.
and Performance Guidelines

FLS Manual Skills Written Instructions
and Performance Guidelines

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.

thetopTransfer
of marked square on the floor of the trainer
Peg
ternMaryland
face up dissectors/graspers,
so that the open (unfolded)
edgeof the ring objects
wopegboard,
6 rubberalligator
to secure the bottom two corners ofe limit:
300clips
seconds
Task Four: Simple Suture withTask
Extracorporeal
Five: SimpleKnot
Suture with Intracorporeal Knot
ended off the bottom of the box.
Equipment:
needledriversof one needle
driverandone Maryland
one knotgboard on the lower Velcro™ strip in the center of the marked
square Twoon thefloor ofthe (or choiceEquipment:
Two needle drivers,
one suturedissector),of 15 cm length,
one endoscopic scissors, one suture
closed),- 120cm
length,one
endoscopic
scissors,one
penrosedoes not matter which peg pattern (parallel or circular) ispusher
on the(openleft or or
rightside ofone
the suture of 90block,one penrose drain with marked targets. Please note: self righting needle drivers are notmarkedone
block.
Pleaseself-righting
ke 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.
the side of the pegboard
corresponding
tothecandidate’s
non-dominant
hand.
appendage and secure the knot on the provided 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 seconds

er exercise requires you to lift the six objectsgPlace the drain firmly on the suture block,scored mark. Once you have positioned/dissector, first in your non-dominant hand, andPlacethethedrain
firmly on the suture block,and
andplace
placethe suture block on the lower
theendoloop
properly,
secure
the
knot
on
mark
object midair to your dominant hand.
the suture
blocktheon the lower Velcro™ strip.
Velcro™ strip.
near
the
base
of
the
foam
appendagebyslidingach object on a peg on the opposite side of thepusherdown.
A penalty will be assessed if the knot is
s no importance placedon therodcolorof theThisthesuturing
tasktherequires you to place aThis
longsuturing
suture task requires you to place a suturenotsecureand allforsixany distance thattie misses
order in which they areplaced.
Once
precisely
through two marks on a Penrose drain thatthrough
two
marks
in
a
longitudinallyslit
Penrosemark. is reversed.
een transferred, the process
has
beenslit along its long axis. You are thendrain.
Youarethenrequiredtotie
3singlethrowslifted in turn using the dominant handrequiredtotie the knot intracorporeally.
Timingwhen an instrumentextracorporeally,(or endoloop) isusing the knot-pusher to secure eachoard, transferred midair
to thebegins
other hand
The
first
throw
throwtheonligating
the drain.
to be a surgeon’s knot or double throw,the pegs on the originalsideonof thevisiblethe board.
monitor and ends whenloopYou must tie the knot tightly enoughmust
followedbytwosingleclose
the slit priorin thetodrain. Be careful not to avulse the drain
off throws. You must exchange
thread is cut. The endoloop cannot
be brokenrortask 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
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 the endoloop and requires bimanual skills. A video
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
theFLSwhendidactic. 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
tration 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: Two needle drivers (or choice 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 theof Ligating
Loop
mber
2012
applied.
This
task
tests
accuracyofplacementofthesutureand knot tying skills and requires
pusher(openorclosed),one
sutureof
90
120cm
length,one
endoscopic
scissors,one
penrosedrain
isavulsed
from
the
block
to which it is secured by Velcro™, a score of zero will be applied.
www.flsprogram.org
per/dissector or grasper with locked/ratcheted
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 tasksuture
is not are
permitted.
cut, regardless of tail length. Tails can be cut either individually or together. This is a more
Maximum time limit: 420 seconds
complex task incorporating several skills including depth perception, hand-eye coordination,
ambidexterity, and transferring skills. Please review the video demonstration of this task, included inPlace the drain firmly on the suture block, and place

手術指導
術前

術中

術後

BID model
術前

術中

術後

B

I

D

rieﬁngntraopteaching

ebrieﬁng

Roberts, N. K., Williams, R. G., Kim, M. J., & Dunnington, G. L. (2009). The Brieﬁng, Intraoperative
Teaching, Debrieﬁng Model for Teaching in the Operating Room. Journal of the American Collegeof Surgeons, 208(2), 299‒303.

BID modelB

rieﬁng

目標設定

I

ntraopteaching

Debrieﬁng

振り返り
強調
修正

Ahmed, et.al., 2013

BID modelB

rieﬁng

目標設定

I

ntraopteaching？

Roberts et.al., 2008Debrieﬁng

振り返り
強調
修正

国立がん研究センター東病院
大腸外科長 伊藤 雅昭先生