Curriculum for Resident Education in Surgical Technique (CREST)

Recommended Instruments

• Maryland graspers (2)

Setup

1. Center the peg board on the Velcro strip in center of marked square
2. Place the 6 objects on the 6 pegs corresponding to your nondominant hand
3. Adjust the camera so the entire peg board is centered and visible

Time

• Proficiency time: 48 seconds
• Maximum allotted time: 300 seconds
• Timing starts when the first object is touched and stops when the last item is released

Task

Begin with the pegs arranged on the peg board side corresponding to your nondominant hand. Use your Maryland grasper to pick up each object with the nondominant hand, transfer the object mid-air to the dominant hand, and then place the object on the peg on the opposite side of the peg board. You will repeat this task until all the pegs have been transferred from the nondominant side to the dominant side.

Next, you will reverse the process and transfer the pegs back to the original side of the peg board with a mid-air transfer again from the dominant to nondominant hand.

Note that each transfer must be completed in mid-air without assistance from other items or the underlying peg board. There is no importance placed on the order of pegs transferred; however, it is recommended to establish a pattern to optimize efficiency and economy of movement.

Penalties

Penalties are given if the object is dropped outside of the field of view. If you drop an object outside of the field of view, continue the task with the remaining objects. If you drop an object within the field of view, simply retrieve the object with the hand it was dropped with and complete the task. Penalties are only given in this circumstance if you cannot retrieve the dropped item.

Recommended Instruments

• Maryland grasper (1)
• Endoscopic scissors (1)

Setup

1. Place the gauze with the marked circle in the jumbo clip (the open edge side in the clip) and place the clip on the upper Velcro strip
2. Use the alligator clips to attach to the bottom corners of the folded edge of the gauze to create a suspended and taut surface

Time

• Proficiency time: 98 seconds
• Maximum allotted time: 300 seconds
• Timing starts when the gauze is touched and stops when the circle is released

Task

While you may change hands with your instruments, this decreases efficiency of time. It is thus recommended that you use the Maryland graspers in your nondominant hand and the endoscopic scissors in your dominant hand.

Starting at the 5 o’clock position, begin cutting in a clockwise fashion until you reach the 11 or 12:00 o’clock position. During this time, you may readjust your Maryland graspers to maintain appropriate tension and cutting angles. Then, return to the 5 o’clock position. Grasp the circle with the Maryland graspers and continue cutting in a counterclockwise direction. Continue until you complete the task by releasing the circle. It may be useful to practice rotating the blades to optimize the precision along the line.

Note, if the gauze comes loose from the clip during the task, you may not reaffix the gauze, but complete the task with the gauze freed. Since the timing does not start until the gauze it touched with your instruments, you may take the time needed to be sure the gauze is secure.

Also, only the marked layer of the gauze is graded, so there is no need to worry or focus on the underlying layers of gauze.

Penalties

Penalties are given for cuts that deviate from the line.

Recommended Instruments

• Maryland or Locking grasper (1)
• Pair of endoscopic scissors (1)

Setup

1. Place the foam organ in the jumbo clip with the three appendages hanging out of the bottom of the clip
2. Place the jumbo clip on the lower Velcro strip within the black marked square within the FLS trainer
3. Adjust the camera to be sure the organ is in the field of view

Time

• Proficiency time: 53 seconds
• Maximum allotted time: 180 seconds
• Timing starts when an instrument or suture is visible on the monitor and ends when the suture is cut inside the trainer

Task

Using your dominant hand, advance the pre-tied ligating loop into the field of vision. With your nondominant hand, use the grasper as needed to assist with appropriate placement of the loop around the appendage. Break off the end of the endoloop where it is already scored. This can be accomplished with one hand or two. Next, gently advance the pusher to secure the knot down onto the marked line. Once the knot is secured, remove the graspers and use the endoscopic scissors to cut the end of yourloop material inside the trainer.

Penalties

Penalties are given for deviation of the knot from the marking on the foam appendage or if the knot is not secured.

Recommended Instruments

• Needle drivers (1–2)
• Maryland grasper (0–1)
• Knot pusher (open or closed)
• Pair of endoscopic scissors (1)

Suture

• 2–0 silk 90cm or 120cm in length

Setup

1. Place the foam block on the Velcro strip inside the black marked square
2. Center the Penrose drain securely on the suture block so that the slit in the Penrose drain is vertical
3. Adjust the camera

Time

• Proficiency time: 2 minutes 16 seconds (136 seconds)
• Maximum allotted time: 420 seconds
• Timing starts when an instrument is visible on the monitor and ends when both ends of the suture are cut inside the trainer

Task

For this task, it is recommended that you use a needle driver in your dominant hand and either a needle driver or Maryland grasper in your nondominant hand. You need a knot pusher—either open or closed, and one pair of endoscopic scissors. With your dominant hand, introduce the suture and needle into the box. Load the needle using the appropriate technique.

Grasp the Penrose drain with your nondominant hand to provide traction, place the needle on the black mark, and push through. Grab the needle with the dominant hand and complete the curve of the needle, being careful not to avulse the Penrose drain. Then, with the dominant hand, grasp the suture near the needle and bring the needle back through the same trocar it was introduced through. Now, you will tie a single knot and use the knot pusher to secure the throw onto the Penrose drain to close the slip. This will be repeated for a total of three knots. Once all three knots are secured, use the endoscopic scissors to cut the suture inside the trainer.

When using an open knot pusher, start with a two-handed throw. Hold the suture in your nondominant hand, and with your dominant hand rest the knot pusher on the nondominant hand. Place the end of the pusher onto the suture, and by gently pulling both strands and advancing the knot pusher, the knot is advanced onto the slit of the Penrose drain. Maintaining traction on the suture, remove the knot pusher, palm it, perform another two-handed throw, place the knot pusher on the suture, and advance the throw.

When using a closed knot pusher, you start with a two-handed throw, then thread the loose end of the suture through the knot pusher. Grasp both ends of the suture, gently pull both strands and advance the knot pusher until the knot is secure on the slit of the Penrose drain. Without releasing the knot pusher from the suture, throw a one-handed throw between the knot pusher and the trainer, then advance the knot pusher again. Do this until all three throws are secure. Then remove the knot pusher.

Note, since the timing of this task begins when instruments are visible inside the trainer, take the time you need to be sure your needle is best aligned for the task prior to beginning. This is easily accomplished by loading the suture directly from the packaging. Practice grasping the suture with the needle driver of your dominant hand at the initial curve of the suture. This will ensure the proper needle direction when introduced into the trainer. Remember, the suture must be introduced by the thread and not by the needle.

Penalties

Penalties are given for deviations from the black marks on the Penrose drain, incomplete closure of the Penrose slip, or for knots that slip or come apart when tension is applied. If the Penrose avulses, this is an automatic failure.

Recommended Instruments

• Needle drivers (2)
• Pair of endoscopic scissors (1)

Suture

• 2–0 silk 15cm in length

Setup

1. Place the foam block on the Velcro strip inside the black marked square
2. Center the Penrose drain securely on the suture block so that the slit in the Penrose drain is vertical
3. Adjust the camera

Time

• Proficiency time: 1 minute 52 seconds (112 seconds)
• Maximum allotted time: 600 seconds
• Timing starts when an instrument is visible on the monitor and ends when both ends of the suture are cut inside the trainer

Task

With your dominant hand, introduce the suture and needle into the box. Load the needle using the appropriate technique. Remember, take the time to load your needle correctly as you are graded on the precision of hitting the black marks. Once loaded appropriately, grasp the Penrose drain with your nondominant hand to provide traction, place the needle on the black mark and push through. You may now use your nondominant hand to adjust the Penrose to appropriately align the second mark with your needle. Push through, grab the needle with the nondominant hand, complete the curve of the needle being careful not to avulse the Penrose drain.

The first throw must be a surgeon’s knot or double throw. This can be accomplished by holding the needle with the nondominant hand, looping the suture twice with the dominant hand, and while moving both hands together, grasping the tail of the suture with the dominant hand. You will then cross your hands to tie the knot down. Drop the suture, then pick up the needle with your dominant hand. Loop and tie a single knot with your nondominant hand, cross hands to secure the knot, then repeat for your third and last knot being tied with your dominant hand. You must exchange hands with your needle between each throw, so that you are tying with the opposite hand for each throw to ensure the knot is square.

Once all three throws are complete and secured, introduce the endoscopic scissors to cut the suture inside the trainer.

Note that the time for this task does not start until instruments are visible on the screen. Therefore, it is worth taking the time to you need to be sure your needle is best aligned for the task prior to beginning. This is easily accomplished by loading the suture directly from the packaging. Practice grasping the suture with the needle driver of your dominant hand at the initial curve of the suture. This will ensure the proper needle direction when introduced into the trainer. Remember, the suture must be introduced by the thread and not by the needle.

Penalties

Penalties are given for deviations from the black marks on the Penrose drain, for incomplete closure of the Penrose slip, or for knots that slip or come apart when tension is applied. If the Penrose avulses, this is an automatic failure.