RESUMO RACIONAL: A pandemia de COVID-19 teve um efeito negativo na educação cirúrgica na América Latina, diminuindo o treinamento cirúrgico dos residentes e a prática clínica supervisionada. OBJETIVOS: Identificar estratégias que foram propostas ou implementadas para adaptar o treinamento cirúrgico e a prática clínica supervisionada às limitações relacionadas ao COVID-19 na América Latina. MÉTODOS: Foi realizada revisão de literatura entre abril-maio de 2021, dividida em duas buscas. O primeiro procurou identificar estratégias de adaptação em América Latina para treinamento cirúrgico e prática clínica supervisionada. A segunda foi realizada como complemento para identificar metodologias propostas no resto do mundo. RESULTADOS: Na primeira busca, foram selecionados 16 dos 715 artigos. Na segunda, foram selecionados 41 dos 1.637 artigos. Estratégias adaptativas propostas na América Latina com foco em videoconferência e simulação. No resto do mundo, foram sugeridas análises críticas remotas de cirurgias gravadas/ao vivo, tele-mentoria intra-cirúrgica e gravação de cirurgia com feedback pós-operatório. CONCLUSÕES: Múltiplas estratégias de adaptação para educação cirúrgica durante a pandemia de COVID-19 foram propostas na América Latina e no resto do mundo. Há uma oportunidade de implementar novas estratégias a longo prazo para treinamento cirúrgico e prática clínica supervisionada, embora mais estudos prospectivos sejam necessários para gerar recomendações baseadas em evidências.

ABSTRACT BACKGROUND: The COVID-19 pandemic has had a negative effect on surgical education in Latin America, decreasing residents’ surgical training and supervised clinical practice. AIMS: This study aimed to identify strategies that have been proposed or implemented to adapt surgical training and supervised clinical practice to COVID-19-related limitations in Latin America. METHOD: A literature review was performed between April and May 2021, divided into two searches. The first one sought to identify adaptation strategies in Latin America for surgical training and supervised clinical practice. The second one was carried out as a complement to identify methodologies proposed in the rest of the world. RESULTS: In the first search, 16 of 715 articles were selected. In the second one, 41 of 1,637 articles were selected. Adaptive strategies proposed in Latin America focused on videoconferencing and simulation. In the rest of the world, remote critical analysis of recorded/live surgeries, intrasurgical tele-mentoring, and surgery recording with postoperative feedback were suggested. CONCLUSIONS: Multiple adaptation strategies for surgical education during the COVID-19 pandemic have been proposed in Latin America and the rest of the world. There is an opportunity to implement new strategies in the long term for surgical training and supervised clinical practice, although more prospective studies are required to generate evidence-based recommendations.

Introduction: Non-compressible torso hemorrhage currently has a high morbidity and mortality even in the most specialized referral centers. REBOA is an emerging tool that is used as early hemostatic control in this type of patient. Clinical Case: We present the case of a 25-year-old female patient who suffers severe pelvic trauma after falling from a height. He was admitted hemodynamically unstable, for which a massive transfusion protocol was activated and a right common femoral arterial access was performed. After presenting a transient response to resuscitation, a REBOA balloon was installed in zone 3, increasing systolic pressure up to 130 mmHg, later transferring to the operating room. Preperitoneal pelvic packing and external fixation were performed, deflating the balloon after 29 minutes in zone 3. The patient left the intensive care unit without vasoactive drugs, to complete surgery 48 hours later and definitive fixation 6 days later. The patient evolves in good general condition.

Resumen Introducción: La hemorragia no compresible de torso, actualmente tiene una alta morbimortalidad aún en los centros de referencia más especializados. El REBOA es una herramienta emergente que se utiliza como control hemostático precoz en este tipo de pacientes. Caso Clínico: Presentamos el caso de una paciente femenina de 25 años que sufre un trauma pélvico grave tras caer de altura. Ingresa hemodinámicamente inestable por lo cual se activa protocolo de transfusión masiva y realiza acceso arterial femoral común derecho. Al presentar una respuesta transitoria a la reanimación, se instala balón de REBOA en zona 3, logrando aumentar presión sistólica hasta 130 mmHg, trasladando posteriormente a quirófano. Se realiza packing pélvico preperitoneal y fijación externa, desinflando el balón después de 29 min en zona 3. La paciente sale a unidad de cuidados intensivos sin drogas vasoactivas, para completar cirugía a las 48 h y fijación definitiva 6 días después. La paciente evoluciona en buenas condiciones generales.

Aim: To describe the design and creation of a high-fidelity thoracic trauma surgery simulation model incorporating 3D printing technology using a cadaveric human torso as a model. Materials and Method: This is a descriptive study that aims to illustrate the creation process of a thoracic trauma surgery simulation model throughout the incorporation of prototypes and dynamic iteration technologies. Results: A high-fidelity reusable thoracic trauma surgery simulation model was created from the digitalization of a cadaveric torso using a computed tomography scan. Throughout digital reconstruction tools, the subcutaneous, muscular, and skeletal structures were modeled from images obtained before and after an anterolateral thoracotomy. Using 3D printing and synthetic materials, a high-fidelity thoracic cavity was built so that perfused and ventilated porcine heart and lungs could be placed. A thoracotomy patch for the anterolateral thoracotomy was designed in a reusable and low-cost fashion. This simulation model is suitable for high fidelity training in the surgical management of cardiopulmonary traumatic injuries. Conclusion: The described methodology allowed the creation of a simulation model for training and assessment of surgical skills in thoracic trauma. The main components of the simulation model are made from reusable materials, broadening access to low-cost, high fidelity training.

Resumen Objetivo: Presentar la elaboración de un simulador de trauma torácico de alta fidelidad elaborado mediante modelamiento e impresión 3D a partir de un torso humano cadavérico. Materiales y Método: Estudio descriptivo del desarrollo de un simulador de trauma torácico utilizando metodología centrada en el prototipado y la iteración basada en testeos. Resultados: Se elaboró un simulador reutilizable mediante la digitalización de un torso cadavérico utilizando tomografía computada. Se realizó una reconstrucción digital del torso diseñando los planos subcutáneos, muscular y óseo en base a las imágenes del paciente pre y postoracotomía anterolateral. Utilizando impresión 3D y materiales sintéticos, se elaboró la caja torácica para luego instalar un corazón y pulmón porcino ventilado y perfundido. Los parches de la toracotomía son reemplazables y de bajo costo. En conjunto, este simulador permite el entrenamiento en manejo de lesiones traumáticas cardiacas y pulmonares de alta fidelidad. Conclusión: La metodología presentada permite la creación de un modelo para el entrenamiento y evaluación de habilidades quirúrgicas en trauma torácico. Los elementos principales del simulador son reutilizables y permiten mantener bajos los costos del entrenamiento.

RESUMO Racional: Trauma é uma das principais causas de morte no mundo e cuidados cirúrgicos adequados são críticos para determinar a mortalidade. No Chile, morte associada a trauma é a primeira causa de mortalidade na população entre 20 e 59 anos. Para lidar com esses pacientes complexos, são necessárias habilidades cirúrgicas precisas para esses procedimentos. Autoconfiança de cirurgiões recentemente graduados na Residência em Cirurgia Geral para práticas de procedimentos de trauma no nosso país não tem sido reportada. Objetivo: Descrever nível de autoconfiança para lidar com procedimentos de trauma em cirurgiões recentemente graduados na residência de cirurgia geral. Método: Estudo transversal. Foi desenhada e aplicada uma enquete em 2015, 2016 e 2017 a cirurgiões recentemente graduados para pesquisar sobre autoconfiança e habilidades cirúrgicas para lidar com cenários de trauma. Foram avaliados 18 procedimentos cirúrgicos de trauma (incluindo procedimentos cervicais, torácicos, abdominais e vasculares) usando a 5-grade Likert Scale. O número total de procedimentos feitos durante a residência foi avaliado. Resultados: Foram incluídos 88 cirurgiões recentemente graduados. O nível de competência foi reportado como alto em procedimentos como trauma intestinal, onde 98% sentiu-se competente ou muito competente em sua reparação. Por outro lado, em traumas complexos como dano vascular maior, até 76% reportaram não se sentirem competentes. A autoconfiança nos procedimentos esteve diretamente associada com o número de procedimentos realizados. Conclusões: Cirurgiões recentemente graduados na residência de cirurgia geral reportam níveis altos de confiança para lidar com traumas de complexidade baixa e média, mas um nível menor de confiança para tratar casos de complexidade alta.

ABSTRACT Background: Trauma is one of the leading causes of death in the world and proper surgical care is critical to impact mortality. In Chile, trauma associated death ranks first as mortality cause in population between 20 and 59 years old. Appropriate surgical skills are required to deal with these complex patients. Self-confidence to practice trauma procedures after the General Surgery Residency have not been reported in our country. Aim: Describe the level of self-confidence to deal with trauma procedures of surgeons who recently graduated from a General Surgery Residency. Method: Descriptive cross-sectional study. We designed and applied a survey in 2015, 2016 and 2017 to recently graduated surgeons, to inquire about self-confidence of surgical skills to deal with trauma scenarios. Eighteen trauma surgery procedures (including cervical, thoracic, abdominal and vascular procedures) were evaluated using a 5-grade Likert scale. The number of procedures performed during the residency was also queried. Results: Eighty-eight recently graduated surgeons from 11 different training programs in Chile were included. The report of competencies was high in procedures such as intestinal injuries, were 98% felt competent or very competent in their repair. On the other hand, in complex traumas such as major vessel injury, up to 76% reported not being competent. Self-confidence on procedures was directly associated with the number of procedures performed during residency. Conclusions: Recently graduated surgeons from General Surgery Programs report high levels of confidence to deal with low and intermediate complexity traumas, but a lower level of confidence to treat high complexity cases.

RESUMO Racional: Os procedimentos pediátricos têm dificuldade de serem realizados em espaços reduzidos. O treinamento nesses espaços provou ser diferente em dificuldade em comparação aos endotrainers laparoscópicos adultos. Objetivo: Desenvolver e validar um novo endotrainer neonatal com espaço reduzido. Métodos: O simulador foi criado, testado e avaliado por usuários com diferentes níveis de habilidade e experiência em cirurgia pediátrica laparoscópica por meio de um questionário de oito itens. A validação do método foi determinada pela avaliação do desempenho de cada participante em nove exercícios. Resultados: Foi criado um simulador acrílico de 10,5 x 10 x 18 cm, com uma superfície de trabalho interna de 9 x 9 cm. Uma câmera HD foi incorporada com faixa de movimento de 0-180°. Todos os exercícios do Programa de Treinamento Laparoscópico Básico foram adaptados em escala de 1:0,5 para se ajustarem. Dos 49 participantes, 42 (85,71%) responderam à pesquisa; 80,5% consideraram que o simulador reproduz condições semelhantes às de procedimentos realizados em crianças menores de um ano; 61,1% consideraram que o simulador representa dificuldade semelhante aos procedimentos realizados em recém-nascidos; 73,7% consideraram que o simulador neonatal é mais difícil que o simulador adulto. Especialistas apresentaram desempenho significativamente melhor em todos os exercícios propostos. Conclusão: O simulador possui imagem de alta qualidade e design que permitem o treinamento com exercícios básicos. O aparelho permitiu discriminar entre os diferentes níveis de habilidade e foi bem avaliado por usuários com experiência cirúrgica diversificada.

ABSTRACT Background: Pediatric procedures have the difficulty of being performed in reduced spaces. Training in reduced spaces has proven to be different in complexity compared to adult laparoscopic endotrainers. Aim: To develop and validate a new neonatal/reduced-space endotrainer. Methods: The simulator was tested and assessed by users with different skill levels and experience in laparoscopic pediatric surgery through an 8-item questionnaire. Construct validity was determined by evaluating the performance of each subject on nine exercises. Results: A 10.5 x 10 x 18 cm acrylic simulator was created, with an internal working surface of 9 x 9 cm. An HD camera was incorporated, with a 0-180° range of movement. All exercises of a Basic Laparoscopic Training Program were adapted on a scale of 1:0.5 to fit in. From 49 participants, 42 (85.71%) answered the survey; 80.5% considered that the simulator reproduces similar conditions to procedures performed in children under one year of age; 61.1% thought that the simulator represents a difficulty identical to procedures performed in newborns; 73.7% considered that the neonatal simulator is more complicated than the adult simulator. Experts showed significantly better performance in all proposed exercises. Conclusion: The simulator has a high-quality image and design that allows training with basic tasks. The endotrainer permitted to discriminate between these different skill levels and was well evaluated by users with diverse surgical experience.

RESUMO Racional: Residência em Cirurgia Geral pode durar entre 2-6 anos, dependendo do país. Residência mais curta deve otimizar a exposição dos residentes às cirurgias. Sabe-se que o treinamento cirúrgico simulado encurta as curvas de aprendizado, mas a informação relacionada à como isso afeta a residência em relação à exposição clínica é escassa. Objetivo: Analisar o efeito da introdução de um programa de treinamento laparoscópico simulado validado em procedimentos abdominais realizados por residentes em um programa de Residência em Cirurgia Geral de três anos. Métodos: Um estudo de coorte não simultâneo foi desenhado. Quatro gerações (2012-2015) de cirurgiões graduados foram incluídos. Apenas os procedimentos abdominais em que os cirurgiões graduados foram o cirurgião principal foram descritos e analisados. O grupo controle foi de cirurgiões graduados de 2012 sem programa de treinamento laparoscópico simulado. Procedimentos cirúrgicos por ano de programa, técnica cirúrgica, intervenção de emergência ou eletiva e local do hospital (hospitais principais/comunitários) foram descritos. Resultados: Intervenções de 28 cirurgiões graduados foram analisadas (controle=5; programa de treinamento simulado=23). Os cirurgiões graduados realizaram média de 372 procedimentos abdominais, com maior número médio de procedimentos de médio a complexo no grupo de programa de treinamento simulado (48 vs. 30, p=0,02). Cirurgiões graduados treinados com programa de treinamento simulado realizaram número maior de procedimentos abdominais totais (384 vs. 319, p=0,04) e procedimentos laparoscópicos (183 vs. 148, p<0,05). Conclusões: A introdução do programa de treinamento laparoscópico simulado pode aumentar o número e a complexidade dos procedimentos totais e laparoscópicos na Residência em Cirurgia Geral de três anos.

ABSTRACT Background: A General Surgery Residency may last between 2-6 years, depending on the country. A shorter General Surgery Residency must optimize residents’ surgical exposure. Simulated surgical training is known to shorten the learning curves, but information related to how it affects a General Surgery Residency regarding clinical exposure is scarce. Aim: To analyze the effect of introducing a validated laparoscopic simulated training program in abdominal procedures performed by residents in a three-year General Surgery Residency program. Methods: A non-concurrent cohort study was designed. Four-generations (2012-2015) of graduated surgeons were included. Only abdominal procedures in which the graduated surgeons were the primary surgeon were described and analyzed. The control group was of graduated surgeons from 2012 without the laparoscopic simulated training program. Surgical procedures per program year, surgical technique, emergency/elective intervention and hospital-site (main/community hospitals) were described. Results: Interventions of 28 graduated surgeons were analyzed (control group=5; laparoscopic simulated training program=23). Graduated surgeons performed a mean of 372 abdominal procedures, with a higher mean number of medium-to-complex procedures in laparoscopic simulated training program group (48 vs. 30, p=0.02). Graduated surgeons trained with laparoscopic simulated training program performed a higher number of total abdominal procedures (384 vs. 319, p=0.04) and laparoscopic procedures (183 vs. 148, p<0.05). Conclusions: The introduction of laparoscopic simulated training program may increase the number and complexity of total and laparoscopic procedures in a three-year General Surgery Residency.

Background and Objective Traditionally, microsurgical training has been based on a face-to-face tuition. This presents certain limitations such as the shortage of instructors and the limited number of students per instructor. The aim of this study is to describe a method of training and acquisition of microsurgical skills based on an online curriculum and distance based evaluation. Methods Six medical students were trained through a progressive difficulty program based on non biological models and artery to artery anastomosis using a non living chicken thigh and wing. Using an online platform, the students reviewed the instructional videos for each training lesson, registered their progress and sent a video to the instructor for assessment. Corrections were delivered through the same platform. The initial and final sessions were compared using objective evaluation scales in order to assess the microsurgical skill acquisition. Results It is feasible to implement a remote evaluation system. All students increased their scores at the end of training. Conclusions Using instructional on line platforms, it’s possible to increase the microsurgical skill without the physical presence of an instructor, overcoming the limitations of the traditional model.

Resumen Introducción y Objetivo Tradicionalmente el entrenamiento microquirúrgico se basa en la tutela presencial de un instructor. Esto presenta ciertas limitantes como la escasez de instructores y el número limitado de alumnos por instructor. El objetivo del presente trabajo es describir un método de entrenamiento y adquisición de destrezas microquirúrgicas basado en un currículum en línea y evaluación dirigida por un instructor a distancia. Material y método Se entrenaron 6 alumnos de Medicina mediante un curso de dificultad progresiva basado en modelos inanimados y anastomosis arterial término-terminal en muslo y ala de pollo ex vivo. Los alumnos, mediante una plataforma en línea, recibieron vídeos instructivos antes de cada sesión, registraron su actividad y enviaron un vídeo de su entrenamiento al instructor. Las correcciones fueron entregadas a los alumnos por parte del instructor mediante la misma plataforma en línea. Comparamos la sesión inicial y final utilizando escalas de evaluación objetivas para investigar la adquisición de destrezas microquirúrgicas. Resultados Fue factible implementar un sistema de evaluación a distancia. Todos los alumnos incrementaron sus puntajes al final del entrenamiento. Conclusiones Mediante el uso de plataformas de formación en línea, es posible incrementar la destreza microquirúrgica sin la presencia física de un instructor, sobrellevando las limitaciones del modelo tradicional.

Background: Simulation is a useful training tool for undergraduate medical students. A valid instrument is needed to assess students’ perception of simulation workshops. Aim: To adapt and validate an instrument to assess the undergraduate medical student’s perception of simulation workshops of clinical procedures. Material and Methods: Delphi Methodology was used to adapt the instrument. Exploratory and confirmatory analyses were performed to determine the construct validity and Cronbach’s Alpha (0 to 1) for internal consistency of the instrument. Results: A Delphi panel of 10 experts adapted a seven-item questionnaire (Likert scale 1-5; ranging from 7 to 35) and four open-questions. After 3-delphi-rounds, the instrument was administered to 210 students in six simulation training programs (Paracentesis, Cardiopulmonary Resuscitation, Airway management, Sutures, Thoracentesis and Nursing Procedures). The instrument was considered unidimensional in the factorial analysis. The overall median (Q1-Q3) score was 34 ranging from 32 to 35 and the Cronbach Alpha coefficient was 0.72, indicating a good reliability. Conclusions: The perception questionnaire is a useful and reliable instrument to assess students’ perceptions of clinical simulations.

Clinical simulation is defined as a technique (not a technology) to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive fashion. Over the pastfew years, there has been a significant growth in its use, both as a learning tool and as an assessment for accreditation. Example of this is the fact that simulation is an integral part of medical education curricula abroad. Some authors have cited it as an unavoidable necessity or as an ethical imperative. In Chile, its formal inclusion in Medical Schools' curricula has just begun. This review is an overview of this important educational tool, presenting the evidence about its usefulness in medical education and describing its current situation in Chile.