Video-based microlearning improves vascular surgery resident proficiency in end-to-side anastomosis

Abstract

Objective

Effective and comprehensive surgical training poses a challenge for residency programs. Considering patient safety and limited work hours, training must be a time-efficient and effective use of simulation before practicing in the operating room. Therefore, we have integrated video-based microlearning for our surgical residents, focusing on end-to-side anastomosis techniques. By having three senior surgeons evaluate resident performance and give feedback to trainees, we aimed to validate the effectiveness of this educational approach.

Methods

Surgical residents were initially instructed to perform end-to-side anastomosis using a Penrose (simulating an artery) and 6-0 Prolene with minimal input. Subsequently, they were asked to review an 11-step procedure document and 10 video-based microlearning modules for end-to-side anastomosis techniques before performing their next anastomosis. Three senior vascular surgeons assessed the residents' practical skills. They provided feedback and assigned scores out of 17 based on the 8-item procedural checklist, including bite spacing, eversion, heel-toe evaluation, total time, back-walling, posterior wall cut, and several possible leaks.

Results

Trainee samples (n = 18 pairs) were continually graded and recorded. Feedback received from the participants highlighted the effectiveness of video-based microlearning. Paired t tests were conducted on participant samples, which showed an overall significant improvement in scores (P < .05) graded by the surgeons. The mean change in pretest vs post-test scores was 3.0 to 6.1 for surgeon 1, 3.6 to 7.4 for surgeon 2, and 7.6 to 9.6 for surgeon 3. The intraclass correlation coefficient for surgeon agreement was 0.93 to 1.00, indicating high reliability.

Conclusions

Our study aimed to highlight the feasibility of video-based microlearning as a valuable adjunct to traditional vascular surgery residency training. As surgical training continues to evolve, such innovative learning approaches promise to optimize surgical education and ultimately improve patient outcomes in vascular surgery. Further research is warranted to explore the long-term impacts and scalability across residency programs.

Surgical residency programs have incorporated competency-based training to equip residents with a diverse skill set to ensure proficient surgical practice.¹ Therefore, in the contemporary surgical education landscape, comprehensive training is imperative for the residents to be at par with the standard of care and to adapt to the evolving technological advancements in surgery.² Although traditional mentorship and one-on-one feedback are invaluable, they are increasingly constrained by the clinical and administrative burdens on attending surgeons.^3,4 This may impede attaining a well-rounded training experience, leading to potential gaps in training.

In recent years, video-based learning has emerged as an effective educational adjunct, supplementing the gaps in traditional methods owing to reproducibility and ease of adaptability.⁵ Furthermore, surgical simulation has grown as an essential component of modern surgical education by allowing residents to learn and refine their surgical skills in a risk-free environment.⁶ However, there is a lack of consensus regarding structured training for residents. The focus often lies predominantly on the end product for evaluation purposes, which may not always represent the most effective approach to learning. This method entails a thorough analysis of each step performed by the trainees, allowing for targeted feedback and gradual improvement.⁴ Such a segmented learning process encourages students to excel systematically, understanding and refining each skill component before moving to the next. This approach shifts the emphasis from merely achieving a final product to developing a deep, step-by-step mastery of skills from the outset, which is more effective and aligned with ethical teaching practices that emphasize skill acquisition in a nonoperative environment, thereby minimizing patient risk during early training.⁷ Therefore, our residency program developed and launched a combined video-based microlearning and surgical simulation approach.

Zhang and West⁷ define microlearning as “a form of e-learning delivered in small chunks, focused on delivering skill-based and just-in-time knowledge.” This educational strategy emphasizes concise, targeted learning modules that facilitate quick comprehension and the retention of specific skills and knowledge. The efficiency of microlearning lies in delivering focused content that can be revisited easily, thus reinforcing learning and aiding in the retention of complex surgical techniques. In vascular surgery, where precision and technical expertise are paramount, microlearning could be an excellent tool to supplement traditional training methods.

The adoption of microlearning in our program addresses the need for flexible, on-demand education that aligns with the demanding schedules of surgical residents. By breaking down intricate procedures into manageable segments, microlearning allows residents to absorb and practice each step of a surgical technique at their own pace, fostering autonomous skill development and continuous learning. This method not only enhances the acquisition of technical skills, but also supports cognitive understanding, which is critical for mastering vascular surgery procedures.

The introduction of this microlearning approach aligns with the growing body of evidence suggesting that microlearning can significantly impact knowledge retention and skill acquisition. Studies have shown that short, focused instructional content is more effective for long-term retention and practical application than traditional, lengthy training sessions.⁸ By leveraging the benefits of microlearning—short, focused, and specific instructional content—we aimed to bridge the training gaps and enhance the learning experience for residents.

This study was conducted to gauge the feasibility of integrating video-based microlearning and surgical simulation to establish its validity as a tool for improving surgical proficiency. Through rigorous evaluation of preintervention and postintervention performance, assessed by experienced surgeons, we sought to quantify the impact of this educational adjunct on the skillset of our residents, thereby underpinning its potential as a valuable component of modern surgical education, particularly in the specialized field of vascular surgery.

Methods

The Houston Methodist Institutional Review Board reviewed the study protocol (PRO00037147) and decided it was a quality improvement project, exempting it from the need for informed consent. The cohort included both medical students and surgical residents across different postgraduate years, aiming to evaluate the efficacy of a video-based microlearning environment on their end-to-side anastomosis skills. Although training level was recorded, the study was intentionally designed to provide the same microlearning intervention to all participants to minimize instructional bias, and performance was analyzed as within-participant improvement rather than stratified by training level. Participants were assessed both before and after participating in the training, which included one or more of the following components.

• 1.Didactic sessions by faculty members of the cardiovascular surgery department.
• 2.Educational videos demonstrating specific surgical techniques.
• 3.“On-the-job training” in the operating room for trainees rotating on the service.

Trainees on clinical rotations in the department were evaluated at the start and end dates of their rotations and at fixed intervals in between. We emphasized self-directed learning using instructional videos, considering this approach might enhance outcomes without continuous faculty involvement. The decision not to use the Objective Structured Assessment of Technical Skill was based on facilitating this model and addressing time constraints for attending physicians. Instead, we used a grading scale derived from validated skills assessment tools, namely the 10-Point Microsurgical Anastomosis Rating Scale.⁹

Initially, trainees were tasked with performing an end-to-side anastomosis using a Penrose (simulating an artery and a vein) and 6-0 Prolene with minimal input to establish baseline competency. Three senior vascular surgeons evaluated their attempts and provided feedback. Subsequently, they received 10 video-based micro-learning modules focusing on key surgical techniques and an 11-step procedure document for learning and review. Each video had an average duration of 2 minutes. They were asked to repeat the anastomosis after they had perused the materials. They were expected to continue practicing independently while gaining relevant exposure in the operating room. The second attempt was conducted 1 month after the first, which aligned with the typical duration of medical student and resident rotations on the vascular surgery service. This interval allowed consistent reassessment at the end of the rotation, ensuring that all participants were evaluated after completion of the microlearning modules within a standardized timeframe.

Participant performance was evaluated using an eight-item procedural checklist (Table I), which included criteria such as bite spacing, heel-toe alignment, eversion, leakage, back-walling, posterior wall cut, and total time. Three senior vascular surgeons assessed the residents' practical skills before and after completion of the learning modules and assigned scores out of 17 based on the procedural checklist. All study participants were requested to complete a survey (Table II) to provide feedback about the learning modules and the skills they acquired. The study workflow was structured as follows.

• •First attempt: Conducted in the resident room setting at the start of the rotation using a Penrose drain and 6-0 Prolene sutures. Participants submitted their anastomosis attempts to the designated office.
• •Microlearning modules: Participants reviewed 10 videos and the 11-step procedure document according to their schedule.
• •Second attempt: Conducted in the resident's room at the end of the rotation.
• •Evaluation: Three surgeons were involved in the grading process. Surgeon 2 conducted a comprehensive assessment, evaluating all available samples. Surgeons 1 and 3 assessed a subset of the samples; however, there was no overlap in the evaluated samples. This approach ensured a breadth of expert opinions while maintaining distinct, independent assessments from each participating surgeon.
• •Feedback: At the end of each attempt, participants were given feedback by the surgeons.
• •Survey: The participants were also sent a survey to gauge their feedback on the modules and their experience.

Table I.

Procedural checklist encompassing all key evaluation metrics

Item and description	Points	Score
Bites	Choose one
Consistent spacing/depth >75% of anastomosis	3
Consistent spacing/depth 50%-75%	2
Consistent spacing/depth <50%	0
		______/3
Heel	Cumulative
Edges correctly approximated	1
Three cardinal bites evenly spaced	1
		______/2
Toe	Cumulative
Edges correctly approximated	1
Three cardinal bites evenly space	1
		______/2
Eversion	Choose one
Eversion >75% of the anastomosis	2
Eversion 50%-75% of the anastomosis	1
Eversion <50% of anastomosis	0
		______/2
Leakage	Choose one
No additional stitch required	3
One additional stitch	2
Two additional stitches	0
Three or more additional stitches or suture noticeable loose	−3
		______/3
Time, minutes	Choose one
≤5	5
6-10	4
11-15	3
16-20	2
>20	1
Back-walling		______/5
Penalty for stitching the back-wall of anastomosis	−5
Posterior wall cut		______/−5
Penalty for cutting through the posterior wall	−2	______/−2
Total		_____/17

Table II.

Survey results distributed to the participants for feedback

Questions	Responses
	Strongly agree	Agree	Disagree	Neutral
1. Practicing anastomosis on a model positively impacted my competency with this procedure.	62.5	37.5	–
2. Practicing anastomosis on a model positively impacted my confidence with this procedure.	62.5	31.25	6.25
3. The written instructions were helpful in my understanding of the expectations for the task.	43.75	37.5	–	18.75
4. The videos were helpful in my understanding of how to complete an anastomosis correctly.	87.5	12.5	–	–
5. The feedback from faculty helped me improve my anastomosis skills.	56.25	18.75	6.25	18.75
6. The feedback from faculty provided me with actionable items I can improve on.	50	43.75	–	6.25

Values are percent.

This structured approach allowed for a comprehensive assessment of the impact of video-based microlearning on surgical skill acquisition.

Instructional video content

The instructional videos were meticulously crafted to enhance participants' understanding and proficiency in performing end-to-side anastomosis. The content was selected to address the same core technical domains evaluated by the study's eight-item procedural checklist, which was adapted from the validated Microsurgical Anastomosis Rating Scale. Each video focused on specific aspects of the procedure, providing detailed teaching points and guidance.

The first two videos covered the handling of the Castro needle holder. Participants were instructed to hold the Castro between their thumb and the second and third fingers, ensuring a gentle click to open and close it. The needle was to be loaded at the tip of Castro's beak, held two-thirds of the way from the needlepoint, and kept upright, with a slight tilt toward Castro's tip to facilitate precise bites.

A demonstration of the forehand suturing technique followed this in the third video. Participants learned to take perpendicular bites to the vessel wall, using an upward swinging motion of the wrist from pronation to supination. They were shown how to grab the needle with forceps without touching the needlepoint, release the Castro, and pull the needle out of the vessel wall before reloading it in the field of anastomosis. The importance of spacing bites evenly (2-3 mm) was emphasized to ensure uniform suturing.

The fourth video addressed the transition from forehand to backhand suturing. It detailed how to grab the needle with forceps, release the Castro, and pull the needle out of the vessel wall. After this, two additional videos demonstrated how to effectively alternate between forehand and backhand suturing, ensuring a smooth and continuous suturing process. Participants were taught to use the Castro to rotate the swaged end of the needle toward them, reload the needle with the tip pointing away, and take bites with an upward swinging motion from supination to pronation.

The final four video modules focused on assisting techniques. In the exposure section, participants were instructed to grab the graft or vein with forceps approximately opposite to the heel or about 1 cm from the tip, ensuring it was not too far or at the very tip. Gentle pulling on the graft opened the lumen during suturing. The following section highlighted how to manage the suture properly, advising participants to grab the suture between their thumb and index finger, maintaining tension, and pulling in the direction of the suture. They were cautioned against grabbing too close to the anastomosis to avoid leaving too much suture in the surgeon's way and to let go to allow the surgeon to reload the needle before grabbing it again for the next bite. A separate video available on YouTube highlighted the parachute technique, where sutures are placed circumferentially around the graft opening and sequentially tightened. These instructional videos provided a comprehensive guide, ensuring that the participants could develop the necessary skills and confidence to perform end-to-side anastomosis effectively.

Statistical analyses

The surgeons scored and tabulated performance metrics. We used various statistical methods to evaluate the effectiveness of the video-based microlearning approach. Paired sample t tests were conducted to analyze the pretraining and post-training scores for each resident, thus assessing individual improvements in performance. The Shapiro-Wilk test was used to examine the normality of the score distributions. Since the normality assumptions were satisfied for all score distributions, only parametric tests were applied.

In this study, the reliability of evaluative scores was assessed at two sample points: pre-intervention and postintervention. Intraclass correlation coefficients (ICCs) were calculated separately for each sample to gauge the consistency of evaluations before and after the intervention. The evaluative process involved three senior surgeons, with overlapping assessments as follows: surgeons 1 and 2 evaluated the same sets of preintervention and postintervention samples, allowing for continuous comparison across the intervention. Similarly, surgeons 2 and 3 evaluated overlapping sets of samples, but only surgeon 2 assessed both preintervention and postintervention samples for all participants. Surgeon 3 did not overlap with surgeon 1, providing distinct pairwise comparisons for reliability assessments.

The analysis of ICCs was stratified not only by the time of evaluation (preintervention vs postintervention), but also by the pairs of surgeons, to elucidate the consistency of scoring within and across different evaluative pairs. This approach allowed for a detailed examination of how the intervention might affect the evaluators' perceptions or scoring criteria differently, depending on their collaborative overlap. This measure of interrater reliability ensured that the assessment of residents' performance was robust and reliable. All tests were performed using Stata (version 17.0, StataCorp).

Results

A total of 18 pairs of samples were evaluated. All trainees demonstrated significant improvements in their scores after the video-based microlearning intervention. Paired t tests were conducted on participant samples, revealing overall significant improvements in scoring by the evaluators: surgeon 1 (P < .01), surgeon 2 (P < .01) and surgeon 2 (P = .03). Specifically, the mean change in scores between resident samples was 3.1 for surgeon 1, 3.8 for surgeon 2, and 2.0 for surgeon 3.

In evaluating the reliability of the surgical assessment scores between surgeon 1 and surgeon 2 and surgeon 2 and surgeon 3, a two-way mixed-effects model was used to compute the ICCs. ICCs for the evaluations conducted by surgeons 1 and 2 revealed high levels of agreement both before and after the intervention. Before the intervention, the individual and average ICCs were near perfect at 0.90 and 0.94, respectively. After the intervention, both the individual and average ICCs remained high at 0.87 and 0.88, reflecting robust consistency despite a slight decrease. The ICC values were supported by statistically significant F tests, confirming the reliability of the surgeons' evaluations across both time points (before the intervention, P < .001; after the intervention, P < .001). Similarly, reliability assessments for surgeons 2 and 3 demonstrated high consistency both before and after the intervention. Before the intervention, the ICCs indicated perfect agreement with individual and average ICCs, both recorded at 1.0. After the intervention, although the perfect agreement slightly decreased, it remained exceptionally high; the individual ICC was 0.98 and the average ICC was 0.97. These results, supported by a statistically significant F test (P = .009), confirm the robust agreement between the two surgeons across the evaluation periods, underscoring the effectiveness of the intervention in maintaining high evaluative standards.

Box plot comparisons of the presurgical and postsurgical scores for the three surgeons further illustrated a clear increase in median values postintervention, highlighting the overall improvement in participants' performance (Fig 1). Additionally, Figs 2 and 3 showcase an ideal sample with even bites and consistent spacing, contrasted with Figs 4 and 5, which demonstrate common errors such as eversion, inversion, uneven bites, and back-walling.

Fig 1.

Box plot depicting scores of paired samples as evaluated by the respective surgeons.

Fig 2.

Side view of ideal sample of end-to-side anastomosis.

Fig 3.

Heel view of ideal sample of end-to-side anastomosis.

Fig 4.

End-to-side anastomosis sample showcasing errors of inversion, eversion, and uneven bites.

Fig 5.

End-to-side anastomosis sample showcasing back-walling error.

Survey feedback from participants indicated a highly positive response to the training course (Table II). Regarding the impact on competency, all respondents (100%) agreed or strongly agreed that practicing anastomosis on a model positively influenced their competency. Similarly, most respondents (93.75%) reported increased confidence owing to model practice. The written instructions were well-received, with 81.25% finding them helpful. Notably, the video modules were particularly valued, with 100% of respondents affirming their usefulness (strongly agree, 87.5%; agree, 12.5%). Feedback from faculty was also perceived positively, with 75% of participants acknowledging it improved their anastomosis skills and 93.75% finding it actionable for further improvement. Overall, the participants' responses reflect substantial satisfaction and endorsement of the educational strategies implemented during the training course.

Discussion

This study aimed to evaluate the feasibility and effectiveness of integrating video-based microlearning into the vascular surgery residency program, specifically focusing on the end-to-side anastomosis technique. The results of this study emphasize the potential of video-based microlearning as a valuable adjunct in surgical training. Previous research has shown that microlearning, characterized by its content delivery in small, focused segments, can significantly enhance knowledge retention and skill acquisition.^7,10 Our study extends these findings by demonstrating the practical application of microlearning in a specialized surgical context, addressing specific procedural skills in vascular surgery. We compared preintervention and postintervention scores in trainees to assess the effectiveness of our approach, which demonstrated a mean change in scores between paired samples, which was 3.1 for surgeon 1, 3.8 for surgeon 2, and 2.0 for surgeon 3. The significant improvements in postintervention scores reflect this learning tool's efficacy in enhancing trainees' surgical skills. Notably, residents showed meaningful progress across several critical metrics evaluated by experienced surgeons, underscoring the educational intervention's practical effectiveness. These findings are consistent with existing literature that supports the utility of video-assisted and microlearning in medical education, which can complement traditional hands-on training methods.^5,11,12 The high interrater reliability (ICC = 0.89) between the three senior surgeons further validates the objectivity and consistency of the assessment criteria used to evaluate the residents' performance, strengthening confidence in the reported outcomes.

The implications of these findings for surgical training are substantial. Traditional mentorship and one-on-one feedback, although invaluable, are often constrained by the clinical and administrative demands placed on attending surgeons. Video-based microlearning offers a flexible and efficient alternative, allowing residents to learn and practice at their own pace. This approach not only complements traditional training methods, but also addresses potential gaps caused by time constraints and variability in mentorship quality. Although several studies have shown variable results in translating video-based learning into improved surgical skills, our results align in favor of video-based learning with substantial improvement in trainees' assessment scores.^5,11 Additionally, in terms of determining trainee confidence and satisfaction, our trainees provided reassuring feedback in terms of confidence and satisfaction. This finding corresponds with previous literature, with improved participant satisfaction and preference for video-based learning.13, 14, 15 Additionally, the structured, systematic nature of microlearning modules aligns well with ethical standards of medical training by providing a risk-free yet realistic practice environment, minimizing patient risk exposure during residents' early procedural skill development.

Nevertheless, our study is not without limitations. Although rigorous in methodology, the limited sample size and short duration of follow-up restrict the generalizability of these preliminary findings. Although the 1-month reassessment provided a standardized evaluation point across trainees, it does not fully control for skill gains that may have occurred from operative exposure during the rotation. Additionally, although we included both medical students and surgical residents across varying stages of training, our analysis did not stratify outcomes by training level. This uniform approach reflects the study design, but limits conclusions regarding differential improvement based on postgraduate year or stage of training. Operative experience during the rotation was not systematically documented or quantified. Variability in the amount and type of on-the-job exposure could have influenced skill improvement, representing a potential confounding factor in interpreting the effect of the microlearning intervention. In addition, our design did not include a control group that repeated the anastomosis without access to the microlearning modules. As a result, we cannot fully separate the effect of the videos from the potential benefit of simple repetition or from additional operative exposure during the rotation. Future studies with a parallel control arm—such as a group repeating the anastomosis without access to the microlearning modules—would better isolate the independent contribution of the educational intervention. Moreover, reliance on resident self-reported feedback may introduce subjective biases, and because our survey used only Likert scale responses, we were unable to capture qualitative feedback explaining why some participants rated the written instructions as neutral. Future studies could incorporate open-ended survey questions to better understand this feedback. Finally, owing to the study's design and logistical constraints, a complete overlap among surgeons' evaluations was not feasible, potentially limiting some analyses of inter-rater agreement. These limitations highlight the opportunities for potential future research.

Future studies should explore the long-term impacts of video-based microlearning on surgical proficiency and patient outcomes. It would also be beneficial to investigate the scalability of this approach across different residency programs and surgical specialties. Understanding how microlearning can be tailored to various educational contexts will be key to maximizing its potential benefits.

Conclusions

We have demonstrated that video-based microlearning is a feasible and valid approach to enhance surgical training. The significant improvement in surgical skills after the intervention, along with the high inter-rater reliability, emphasizes the platform's potential as a supplemental educational resource. In an era where the availability of senior surgeons for traditional mentorship is increasingly constrained, microlearning modules offer a scalable solution to support the continuous professional development of surgical residents. It is anticipated that the integration of such innovative learning tools will play a pivotal role in the future of surgical education, ultimately benefiting patient care by refining the skillset of emerging surgeons.

Funding

None.

Disclosures

None.