Surgical education interventions in liver surgery: a systematic review

The objective of the study was to identify and to evaluate the impact of educational interventions to learn and train liver surgery outside the operating room. A systematic literature search was conducted using PubMed, Web of Science, Embase, and ERIC databases from inception to September 2019 according to the PRISMA guidelines. Studies describing and assessing outcomes of educational interventions in liver surgery, outside the operating room, were included. Neither language nor date of publication restriction was applied. Methodological quality was appraised using NOS-E (Newcastle-Ottawa Scale for Education), and the level of evidence was evaluated based on GRADE (Grades of Recommendation Assessment, Development, and Evaluation) standards. Of the 10,403 screened abstracts, 53 articles were eligible for inclusion, comprising 27 descriptive studies (50.9%), 14 case series assessing any relevant outcome (26.4%), 8 non-randomized controlled trials (15.1%), and 4 randomized controlled studies (7.5%). Almost half (26/53) of the studies did not include any participants, while the remainder of the publications (27/53) involved 1306 learners. The majority of the studies focused on cognitive knowledge (31/53) and/or psychomotor skills training (24/53). Only one publication assessed affective skills. The GRADE score was very low or low in most articles (46/53). Five studies were scored high (5-6) according to NOS-E. Two studies reported data regarding the reliability and validity of employed assessment tools. High-quality studies, particularly well-designed randomized controlled trials that evaluate the effectiveness of simulation-based training on learner behavior and patient outcomes in liver surgery, are still lacking. Forthcoming studies should use robust assessment tools supported by validity evidence.