Surgical training: design of a virtual care pathway approach

Both intra- and perioperative care are essential for patients' safety. Training for intraoperative technical skills on simulators and for perioperative care in virtual patients have independently demonstrated educational value, but no training combining these 2 approaches has been designed yet. The aim of this study was to design a pathway approach for training in general surgery. A common disease requiring essential skills was chosen, namely, acute appendicitis.

Preoperative care training was created using virtual patients presenting with acute right iliac fossa (RIF) pain. A competency-based curriculum for laparoscopic appendectomy (LAPP) was designed on a virtual reality simulator: Novices (<10 LAPP) and experienced surgeons (>100 LAPP) were enrolled to perform 2 virtual LAPP for assessment of validity evidence; novices performed 8 further LAPP for analysis of a learning curve. Finally, postoperative virtual patients were reviewed after LAPP.

Four preoperative patient scenarios were designed with different presentations of RIF; not all required operative management. Comments were provided through case progression to allow autonomous practice. Ten novices and 10 experienced surgeons were enrolled for intraoperative training. Time taken (median values) of novices versus experienced surgeons (285 vs 259 seconds; P = .026) and performance score (67% vs 99%; P < .0001) demonstrated evidence for validity, whereas path length did not (916 vs 673 cm; P = .113). Proficiency benchmark criteria were defined for measures with validity evidence. Two postoperative virtual patients were created with an uneventful or complicated outcome.

A virtual care pathway approach has been designed for acute appendicitis, enabling trainees to follow simulated patients from admission to discharge.