So, we'll go on to the next to last speaker, Rezato Eden Nevzadi, who's going to speak to us about the development of a technical skills test to improve assessment and evaluation in neuroendoscopic education. Dear Chairman, dear audience, thank you very much for giving us the opportunity to present our data. So, in this presentation, we would like to introduce a model which we developed to assess for basic neuroendoscopic performance, and we would also like to talk about its implication in neurosurgical training. So, neuroendoscopy has gained increasing popularity in neurosurgery. Despite the purely neuroendoscopic procedures, such as the endoscopic third ventriculostomy, it is also used for many skull-based surgeries. Endoscopic-assisted surgeries allow the surgeon to see around the corner, where the microscope has a limited view. And finally, there's an increasing popularity also in spine surgery to use the endoscope. However, the recent success of neuroendoscopy has mostly relied on the successful breakthrough of endoscopic third ventriculostomy for the treatment of obstructive hydrocephalus. So, this procedure is not only important in the Western world, it plays also an important role overall in the world, because infantile hydrocephalus still represents a major health care problem. And endoscopic third ventriculostomy, with the additional catheterization of the choroid plexus, has proven effective to reduce shunt dependency and actually cure most of the affected children. So, we see that neuroendoscopic skills are not only important in the Western world, but also in underserved areas, the surgeons need to be equipped with this unique skill set and make it part of their surgical arsenal. So, what are the characteristics of neuroendoscopy? It is important to appreciate that we cannot simply transfer our general surgical skills to this specific surgical procedure. Neuroendoscopy requires a transposition from a 3D to 2D environment. It has an angled camera view. It is marked by deprivation of haptic feedback. The endoscope is needed for visualization and instrumentation. The endoscope needs to be maneuvered in narrow, high-risk anatomical locations, which doesn't allow for any mistakes. And finally, there is a limited number of cases selected for purely endoscopic procedures, which limits the exposure of the trainee to this surgical procedure. So, when U.S. resident graduates are asked how important the rate of neuroendoscopy in the daily surgical practice, over 75% will rate it as very important. However, 30% would rate their training as insufficient. That tells us that there is still some space for improvement regarding this issue. So, gastrointestinal surgeons faced similar problems many years ago, when a laparoscopic surgery was first introduced in their daily practice. In order to see how the trainees are doing with the laparoscopic instrumentation and how well they improve over time, they created simulators. Later on, they made simulators mandatory to the residents in order to go to the OR. Nowadays, a lot of surgical disciplines require their trainees to pass a simulator test in order to get ACGME accreditation. So, the idea of a simulator, which creates a safe and controlled environment for the trainee, is actually not really new. It allows the trainee to make mistakes and learn from them without any serious consequences. So the aircraft industry, for example, has been using flight simulators since over 100 years now. So the purpose of our model was actually also to create a simulator, which gives the trainee a safe and controlled environment, allows him to make mistakes, but meanwhile allows us to assess for their skill level and to see how well they improve over time. And the simulator needs to be standardized and objective. And finally, very important too, it needs to be affordable, so it can be used everywhere. So for this purpose, we designed three distinct tests. The first test we call the ring transfer test. The participants need to transfer six rings from the left side of a pegboard to the right side of a pegboard, using the endoscope bimanually for visualization and instrumentation. The second test we call the membrane cutting test. For this purpose, the endoscope was used again bimanually for visualization and instrumentation. The participants needed to cut a zigzag line along a polyethylene membrane. And the third test mimicked the surgical sequences of an endoscopic third ventriculostomy. So the participants perforated a hole in the polyethylene membrane, expanded the hole with a vitaphogatic balloon, and finally entered the opening with a third-degree camera. All three tests were scored by time. So we included a total of 16 participants in the study. And according to the surgical experience, we divided them into two groups. We set the cutoff at PGY5. We had a total of eight surgeons being PGY5 and younger. We called this cohort the junior surgeons. We had a total of eight surgeons being PGY5 and older, which we called the senior cohort. So after a one-hour theoretical introduction in basic neuroendoscopic techniques, we assessed all participants for baseline test performance. So they had to do all three tests. After they did the test, they had a four-hour hands-on neuroendoscopy course. And by the end of the day, they were reassessed for doing all the three tests. So when we take a look at the results, when we pool all the participants and all the tests together, which is demonstrated here in the left upper graph, we see that there is a significant improvement after repeating the test. And when we compare junior surgeons and senior surgeons at their baseline test performance, we see that there are significant differences between the two groups. And when we take the two groups and take a look how they do after repeating the test, we see actually that the significance gets lost. However, there's a clear trend visible in the senior cohort group, but lost significance. And finally, an interesting test too. So we compared the juniors after repeating the tests to the baseline test performance of the seniors, and we saw actually that there are hardly any differences. So when we subdivided the different tests and looked how well the participants improved after repeating the test, we saw that there is a significant improvement with each single test after repeating it. So what can we conclude from our data? A simulator has actually to address two different issues. One is validity in measurement, and the second one is accuracy in measurement. As the simulator was able to detect between more and less experienced surgeons, it proved thereby validity, and as the simulator was also able to assess improvement over time after repeating the test, it proved accuracy in measurement. So taking into account our data and the experience of the laparoscopic surgeons, we might postulate that such simulators might be an important adjunct in your surgical education training. And finally, this simulator represents an affordable skills test. Thank you very much.

Rezato Eden Nevzadi

technical skills test

neuroendoscopic education

simulators in surgical training

neuroendoscopic performance assessment