Abstract
Background
Americas Hepato-Pancreato-Biliary Association (AHPBA) established the Hepato-Pancreato-Biliary (HPB) ultrasound (US) and Advanced Technology Post-Graduate Course in 2012 in response to a perceived gap in training and practice.
Methods
The HPB US and Advanced Technology Post-Graduate Course consists of both didactic and hands-on skills sessions. The didactic sessions are divided into foundational, organ-focused, and application content. Hands-on sessions are constructed to immediately practice skills in the simulation setting which were taught during the didactic sessions. Course participant demographic data (practice location and practice type) and participant evaluations were reported.
Results
Since the first course in 2012, 298 participants have taken the post-graduate course. Most participants reported the content quality, delivery effectiveness, and practice relevance to be either excellent or above average (93.6 %, 91.1 %, 93.6 %, respectively). Participants' motivations to take the course included to enhance skills, knowledge, to incorporate US into practice, or to obtain formal training or qualification/certification, or to teach.
Conclusion
The HPB US and Advanced Technology Post-Graduate Course has filled a gap in HPB US training for practicing HPB surgeons. The annual course has been well-received by participants (Kirkpatrick Level 1 Program Evaluation) and will continue to fill the gap in training in operative US for the HPB surgeon.
Key message
Americas Hepato-Pancreato-Biliary Association established the HPB Ultrasound and Advanced Technology Post-Graduate Course in 2012. The Course has been well-received by participants and will continue to address a gap in surgical HPB training.
Keywords: Surgical education, HPB ultrasound
Highlights
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The HPB Ultrasound and Advanced Technology Course was developed to address a gap in training.
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Course quality, effectiveness and relevance were rated to be excellent/above average.
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The most common motivations to take the course were to enhance skills and/or knowledge.
Introduction
The use of ultrasound (US) in the operating room is a requirement for surgeons performing hepato-pancreato-biliary (HPB) procedures. Modern HPB surgical practices must include the use of surgeon-performed US in the operating room in order to adhere to the highest standards of safety and patient care. In 2012, a need for US training was identified based on informal interviews of surgeons performing HPB procedures (Ellen Hagopian, personal communication, January 30, 2023). These informal interviews concluded that surgeons performing HPB procedures did not consistently use operative US, despite its well-known applications and utility in the operating room [[1], [2], [3]].
Based on these informal interviews and the lack of structured US curricula during surgical residency or fellowship training, it was surmised that the lack of use of US during HPB procedures was due to a gap in surgical training. This led to the development of the HPB Ultrasound and Advanced Technology Post-Graduate Course through the Americas Hepato-Pancreato-Biliary Association (AHPBA). AHPBA, as a society, has shown a true commitment to the education and training of its membership and fellowship training programs. The institution of the HPB Ultrasound and Advanced Technology Post-Graduate Course is an example of the society's commitment. The first course was given in 2012, and since then, has been given nearly each year at the AHPBA Annual Meeting.
The aim of this paper is to provide a description and brief evaluation of the HPB Ultrasound and Advanced Technology Post-Graduate Course. The evaluation met criteria for exemption by the Hackensack University Medical Center Institutional Review Board (Pro2018-0616).
Methods
Curriculum framework
The overall goal of the HPB Ultrasound and Advanced Technology Post-Graduate Course (Course) is to provide practicing surgeons and surgical trainees (HPB, advanced gastrointestinal, minimally invasive, surgical oncology, transplantation) with advanced education and training in HPB US. The Course reviews the basic principles of US while providing in-depth instruction on the techniques of US in HPB surgery. Centering on intraoperative and laparoscopic approaches, the Course provides a comprehensive understanding of the anatomy of the HBP system in addition to US scanning techniques, methods, US guidance, and tumor ablation. The Course utilizes two pedagogies: large group learning sessions and hands-on skills sessions.
Large group sessions
Large group sessions are conducted using direct and case-based instruction. These sessions are divided into three major sections, including foundational, organ-specific US, and US application (Table 1, large group sessions). US principles, physics, and instrumentation constitute the foundational sessions. One of the most important learning curves in surgical US is image interpretation, which requires optimization of the US image. A solid understanding of US principles and physics provides the foundational knowledge of the US system to effectively adjust the US controls, such as frequency, gain, focus, and depth, to optimize the image. The functionality, use, and selection of the various US probes in transabdominal, open and laparoscopic approaches are detailed in the US instrumentation session. A session dedicated to US scanning techniques demonstrates foundational technical skills in transabdominal, open, and laparoscopic approaches and builds the surgeon's repertoire in image recognition. Organ-specific US sessions include Liver and Pancreatobiliary and focus on systematic approaches, scanning techniques, and normal and pathologic organ-specific imaging.
Table 1.
Curriculum framework.
| Instructional sessions (methods) | Course learning objectives |
|---|---|
| Large group sessions (direct; case-based) | 1. Define the principles of US physics. 2. Review open and laparoscopic scanning methods. 3. Describe HPB US normal anatomic and pathologic findings. 4. Distinguish the various liver ablation technologies. 5. Appraise the various uses of US in HPB surgery. |
| Foundational principles and technique | |
| US principles & instrumentation | |
| US scanning techniques | |
| Organ-specific US | |
| Liver US: Normal anatomy and pathologic findings | |
| Pancreatobiliary US: Normal anatomy and pathology | |
| US application | |
| Techniques in US guidance | |
| Methods of tumor ablation in HPB surgery | |
| Practical uses of US in HPB surgery | |
| Coding and billing | |
| Getting started | |
| Skills sessions (demonstration; guided practice) | |
| HBP US anatomy and technique | 6. Describe HPB US normal anatomic and pathologic findings. 7. Demonstrate intraoperative and laparoscopic US exams of the liver, pancreas, and biliary tree. |
| Image optimization | |
| Transabdominal US | |
| Intraoperative US anatomy and technique | |
| Open intraoperative US anatomy | |
| Laparoscopic US anatomy | |
| US guidance technique | 8. Demonstrate open and laparoscopic targeting methods in US guidance. 9. Distinguish the various liver ablation technologies. |
| Open intraoperative targeting | |
| Laparoscopic targeting | |
| Liver tumor ablation |
Note. US, ultrasound; HPB, hepatopancreatobiliary.
The foundational and organ-specific US sessions provide the basis for organ examination and the diagnosis of pathology. In the final section of the large group sessions, practical clinical uses (application) of US in the operating room are reviewed. US guidance techniques focuses on approaches in targeting in open and laparoscopic operative settings, and while an emphasis is placed on tumor targeting, the principles taught during this session are applicable to any targeting procedure. A session on Tumor ablation follows, where ablation technologies are discussed. Case-based presentations of US (Practical uses of US) have been recently added. During this session, faculty review operative HPB cases and show how US was used throughout specific operations in diagnosis, decision making, and procedural guidance. Other practical aspects, such as Coding and billing and Getting started using US in a HPB surgical practice, conclude the large group sessions. Large group sessions with linked course learning objectives are outlined in Table 1.
Skills sessions
The goal of the skills sessions is to continue instruction from the large-group sessions to hands-on practice in a supervised setting. Participants practice techniques in transabdominal, intraoperative, and laparoscopic US while gaining a comprehensive understanding of HPB ultrasound anatomy and performing US guidance procedures. A variety of models are utilized including human and phantom models for instruction in US technique and anatomy in addition ex-vivo organs (e.g., bovine liver) for practice in US guidance, targeting, and tumor ablation.
The first hands-on skills session immediately follows the large group foundational and organ-specific sessions (outlined above). During the HPB US Anatomy and Technique skills session (Table 1, Skills sessions), participants practice transabdominal US utilizing standardized human patients. The focus is on image (and anatomy) recognition in human models, while performing real-time image optimization to solidify understanding of US principles and physics. In more recent years, standardized patients have not been consistently used in instruction.
A transition to the use of inanimate models for anatomy instruction and ex-vivo organs for targeting occurs during the second hands-on skills session, which follows the large group US application section. Participants rotate through multiple stations, including Intraoperative US (open and laparoscopic), US guidance, and Liver tumor ablation (Table 1, Skills sessions, Intraoperative US anatomy and technique). At each station, techniques are demonstrated by expert faculty and participants have opportunities to practice open and laparoscopic US and targeting under direct faculty supervision. The learning objectives for the hands-on skills sessions are outlined in Table 2.
Table 2.
Hands-on skills learning objectives.
| HBP anatomy and technique |
|---|
|
| Techniques/technology in ultrasound guidance and HBP surgery |
|---|
|
In the recent years, the Course has transitioned to a “flipped” format (since 2021) whereby participants view pre-recorded videos in advance of the in-person course component. In this model, in-person instruction focuses on skills demonstration, mentored guided practice, and case-based discussions.
Evaluation framework
Kirkpatrick's four-level model is a simple and practical framework for program evaluation. The initial levels (steps) center on the learners, their satisfaction with the course (level 1), what they have learned (level 2), and how their behavior changed (level 3) after the course. The last level (level 4) measures the success, or outcomes, of the program and is arguably the culmination of the successes of all proceeding levels [4,5]. Table 3 outlines Kirkpatrick's four-level model and example measurements for the present Course. Kirkpatrick's framework was adopted for this brief evaluation, focusing on participants' “reactions” (level 1) to course content and delivery in addition to participants' motivations for coursework.
Table 3.
Kirkpatrick's four-level model [4] for HPB US program evaluation.
| Evaluation level | Description |
|---|---|
| Level 1 reaction | Measure of how participants feel about the coursework/training program. HPB US Course measure: Trained surgeons will report value in course completion. |
| Level 2 learning | Measure of the change in knowledge, skills, and/or attitudes following the course/training program. HPB US Course measure: Trained surgeons will report and demonstrate competent operative US skills. |
| Level 3 behavior | Measure of the extent to which participant change their behaviors after the course/training program. HPB US Course measure: Trained surgeons will actively use operative US in their practice. |
| Level 4 results | Measure of the success of the final results due to the coursework/training program. HPB US Course measure: Trained surgeons will have improved clinical and patient outcomes after incorporating operative US into their practice. |
Demographics
The Course administrative database was investigated to tally the yearly number of participants. Participant practice specialties and practice locations were collected and tabulated.
Survey
Immediately following each course, participants were requested to complete an anonymous course evaluation. Participants were asked to rate the course in terms of 1) quality of content, 2) effectiveness of delivery, and 3) relevance to practice using a 5-point scale (5, excellent; 4, above average; 3, average; 2, below average; 1, poor). Participants were also asked: Why did you take this abdominal ultrasound course? Responses to the open-ended query were reviewed to identify common themes using a grounded theory approach [6]. Each phrase was assigned a theme and the frequency of each theme determined, based on the total number of coded phrases. Exemplar quoted phrases were selected to illustrate themes. Descriptive statistics were applied to report participants' quantitative (scaled) and qualitative (open-ended) responses.
Results
Course participants
The Course has been offered each year since 2012 at the AHPBA Annual Meeting, except for 2016. Per course offering, an average of 30 (SD ± 5.37, range 20–35) surgeons participate, and since the initial offering, a total of 298 surgeons, including practicing surgeons and some trainees (fellows, residents) have completed the Course. Course participants represent an international community, although predominately from the United States and Latin America (Table 4). Participants' practice specialties span HPB, Transplantation, Surgical Oncology, General Surgery, and General Surgery with experience in HPB (i.e., HPB-experience despite no formal HPB training). A small number of non-surgical specialties also participated (e.g., Radiology, Gastrointestinal Endoscopy) (Table 4).
Table 4.
Course participant demographics (2012–2022).
| N (%) | |
|---|---|
| Practice location | |
| United States | 190 (63.76 %) |
| Latin America | 46 (15.44 %) |
| Canada | 19 (6.38 %) |
| Europe | 19 (6.38 %) |
| Asia | 18 (6.04 %) |
| Australia | 6 (2.01 %) |
| Practice specialty | |
| HPB | 89 (29.87 %) |
| Transplantation | 78 (26.17 %) |
| Surgical oncology | 67 (22.48 %) |
| General surgery | 36 (12.08 %) |
| General surgery with HPB experience | 25 (8.39 %) |
| Other (e.g., radiology) | 3 (1.01 %) |
| Total participants | 298 |
Note. Percentages (%) are based on the total participants across all years.
Post-course evaluation (Kirkpatrick level 1)
Content
Completed surveys were collected from 225 (75.5 % response rate) participants (data from 2013 was missing) and reflected a positive reaction to the course content (Table 5). Greater than 90 % of participants reported that the quality of content, effectiveness of delivery, and the relevance of content were either excellent or above average (Fig. 1).
Table 5.
Participants' reaction to course (Kirkpatrick Level 1).
| Content rating | Quality of content | Effectiveness of delivery | Relevance to practice |
|---|---|---|---|
| Excellent (5) | 145 (64.4 %) | 133 (59.3 %) | 172 (76.6 %) |
| Above average (4) | 66 (29.2 %) | 71 (31.8 %) | 38 (17.0 %) |
| Average (3) | 8 (3.5 %) | 13 (5.7 %) | 5 (2.2 %) |
| Below average (2) | 0 (0.0 %) | 2 (0.9 %) | 1 (0.5 %) |
| Poor (1) | 0 (0.0 %) | 0 (0.0 %) | 0 (0.0 %) |
| Missing data | 6 (2.67 %) | 5 (2.22 %) | 8 (3.56 %) |
Note. Percentages are based on 225 completed surveys (75.5 % response). Missing data refers to those missing from completed surveys. Survey data from 2013 were not collected.
Fig. 1.
Participants' reaction to course (Kirkpatrick Level 1).
Note. The majority of participants rated the Course as either excellent or above average (5/4, blue) in terms of relevance to practice, effectiveness of delivery and quality of content. Missing (green) data refers to those missing from completed surveys.
Motivation
A total of 230 phrases were coded in response to the question: Why did you take this abdominal ultrasound course? A total of 5 themes were identified. The most frequent themes found included the desire to enhance skills (38.7 %) and knowledge (29.6 %). Other less frequent themes identified included to incorporate US into practice (14.8 %), to obtain formal training (7.8 %), for qualification/certification (6.5 %), and to teach (2.6 %). Table 6 details themes identified with accompanying demonstrative quotes.
Table 6.
Participants' motivation for course (Kirkpatrick Level 1).
| Themes | Frequency (%) | Demonstrative quotes |
|---|---|---|
| Skills enhancement | 89 (38.7 %) | “Would like to improve US skills and techniques.” “To improve my ability and to offer to my patients better results.” “I wasn't using ultrasound to its potential. Wanted to feel more confident with targeting procedures and make a more comprehensive assessment of anatomy during resection procedures.” |
| Knowledge enhancement | 68 (29.6 %) | “Reinforce knowledge and learn the correct way to use the technology.” “Improve knowledge and comfort with US use.” “Better understanding of liver and pancreatic anatomy while performing laparoscopic ultrasound.” |
| Practice incorporation | 34 (14.8 %) | “To incorporate US into my practice.” “To gain more experience so I can incorporate it into my practice.” |
| Qualification and/or certification | 15 (6.5 %) | “For assistance with ultrasound privileging.” “To get a certificate for my hospital, documenting formal training course …” “For experience and certificate.” |
| Formal training | 18 (7.8 %) | “Had never taken a formal course before. I am glad I did.” “To get formal training to perform ultrasound by myself.” “Because I had never done a formal training in ultrasound.” |
| Teaching | 6 (2.6 %) | “To learn how to use it efficiently, and teach it.” “Extra training, and to learn about the course to be able to organize such a course … in the future myself.” “Review, be more effective, and to be able to teach residents more effectively.” |
Note. Frequency is based on a total of 230 coded phrases.
Discussion
The AHPBA HPB US and Advanced Technology Course is the first US course offered that focuses on HPB surgical US directed toward HPB surgeons. The range of content spans from foundational material to organ-specific examination (liver, pancreas and biliary) to finally application of surgical US in the clinical setting. There is an emphasis on skills, with dedicated laboratory time in diagnostic US, targeting, and tumor ablation with alongside expert faculty. Using Kirkpatrick's framework (level 1, participant reaction) of program evaluation, the Course performed extremely well, with the majority of participant ratings as excellent or above average. With the favorable evaluations and a consistent full annual subscription, the Course has demonstrated value among the HPB surgical community and will continue to fill a gap in training.
Gap in training
Motivations for the course work were varied, but most commonly participants sought to enhance their knowledge and skills. The Course was initially developed to fill a presumed gap in surgical training. The finding that the majority of participants' reasons to take the Course were to either enhance knowledge or skills (68.3 %) emphasizes this gap to be real, and not presumed. To address this gap, US training was intentionally incorporated into Fellowship Council-AHPBA (FC-AHPBA) accredited HPB fellowship training and minimal US case volumes are required for the AHPBA-awarded Certificate in HPB Surgery [7]. Other HPB training pathways also exist, including American Council of Graduate Education accredited Complex General Surgical Oncology and American Society Transplant Surgeons accredited Transplant fellowships [8]. The gap in general surgery training has been partially addressed by the development of resident training courses, such as the UltraSound Essentials for Residents (USER) Course developed by the National Ultrasound Faculty of the American College of Surgeons [9] and the incorporation of US into the Surgery Council on Resident Education (SCORE) Curriculum [10]. However, organ-specific diagnostic US is a not considered a core operation/procedure as liver, biliary tract, pancreas, thyroid, or vascular US are advanced, while the focused assessment with sonography for trauma (FAST) and US use for intravascular access are core operations/procedures [10]. Furthermore, the American Board of Surgery does not require applicants for board certification to have experience in ultrasound or have a defined minimum number of required US procedures [11,12]. The Surgery Review Committee of the ACGME refers to “diagnostic ultrasound” without further specification in the Program Requirements for General Surgery [12] but does not specify a minimum US case volume [13]. To ensure the gap in US is addressed in training, both diagnostic and procedural US should be incorporated into General Surgery training with a defined curriculum and required case volume minimum.
Transition to a flipped format
The Course was originally designed as a day-long, on-site course, with a mixture of large group sessions and hands-on skills sessions. However, in the past two years, the Course has been given as a “flipped” class, where participants learn foundational material in advance of the course. In this format, participants view on-demand videos to learn content normally delivered in the large group sessions (foundational, organ-specific, and selected application sessions). At the start of the on-site course a brief review of content is given, followed by the skills sessions (see Table 1). Emphasizing participants' skills development, the new format maximizes valuable time in direct instruction and saves classroom time for case-based discussions.
Opportunity for mentorship
The structure of the AHPBA-sponsored HPB US training for FC-AHPBA accredited HPB fellowships is similar to the Post-Graduate Course. Although the curriculum, including the large group and skills sessions are similar, a key difference between the two courses is in the follow-up mentored practice. Following on-site coursework, HPB fellows return to their home institution to practice US in the operative setting under the supervision of local faculty. In this setting, local faculty guide the practice in the clinical setting, acting as a resource for mentorship. The HPB US and Advanced Technology Post-Graduate Course does not have a formal, structured mentorship program for practicing surgeons completing this course. The creation of such a resource for surgeons who are actively incorporating US into their practices would be a valuable addition to the Course.
Conclusion
Operative ultrasonography is a mandatory tool for the HPB Surgeon. The AHPBA-sponsored HPB US and Advanced Technology Post-Graduate Course has been well-received by participants and fills a gap in surgical US training for practicing HPB surgeons.
Funding source
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sector.
Ethical approval statement
Exemption by the Hackensack University Medical Center Institutional Review Board (Pro2018–0616).
CRediT authorship contribution statement
Dr. Hagopian: study conception and design; data collection and analysis; interpretation of results; manuscript preparation
Dr. Adams: interpretation of results; manuscript preparation
Dr. Machi: interpretation of results; manuscript preparation.
All authors reviewed the results and approved the final version of the manuscript.
Conflict of interest
None.
Acknowledgments
We would like to express our deepest gratitude to the AHPBA, its membership and leadership, and our colleagues, who each year supports our HPB US course and truly believes in our charge to disseminate the practice of US in HPB surgery.
References
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