Abstract
Objective
Simulation is an increasingly important component of surgical training that often involves time-limited in-person sessions. The aim of this study is to assess the influence of a surgical simulation model used in a hybrid learning environment, including supervised and self-directed practice and to evaluate its effect on the development of technical skills in thoracic surgery trainees practicing pulmonary artery and bronchial anastomoses.
Methods
Sixteen postgraduate year 6 and 7 trainees participated. The group was split into 2 training sessions: part A, dedicated to the pulmonary artery anastomosis technique, and part B, focused on the bronchial anastomosis. Participants attended an in-person demonstration followed by a hands-on practice session led by an experienced thoracic surgeon. Participants then completed an anastomosis and were assessed independently by 2 thoracic surgeons. Time to task completion (TTC), technical skill scores, and watertightness test results were recorded. Subsequently, trainees performed 10 self-directed practice sessions using the simulation model at home, documenting the results of their TTC and watertightness tests. Upon the completion of independent practice sessions, trainees were evaluated by the same 2 raters during in-person assessments.
Results
The performance evaluation included a task-specific checklist, an overall impression of ability, an independent performance rating, and recorded TTC. In part A (n = 9), average task-specific checklist scores improved from 3.9 out of 7 to 6.3 out of 7 (62%; P = .016). In part B (n = 5), task-specific checklist scores improved from 4.1 out of 6 to 5.5 out of 6 (34%; P = .059). The overall impression of ability score averages increased from 3.1 out of 5 to 4.4 out of 5 (part A, 42%; P = .008) and 2.6 out of 5 to 4.7 out of 5 (part B, 81%; P = .039), whereas the independent performance rating scores improved from 2.7 out of 5 to 4.5 out of 5 (part A, 67%; P = .011) and 2.6 out of 5 to 4.7 out of 5 (part B, 81%; P = .018). Average TTC decreased by 1:47 minutes (part A, P = .119) and 4:15 minutes (part B, P = .005). All participants achieved watertight anastomoses by the end of training.
Conclusions
Hybrid simulation training is a feasible and effective method for refining and mastering surgical skills. Study participants demonstrated statistically significant performance improvements in almost all categories. A reduction in TTC and an ability to achieve a watertight anastomosis were noted, indicating an anticipated positive trend toward skill mastery. Hybrid simulation training is an effective educational approach that can help address the shortage of hands-on training opportunities among thoracic surgery trainees by providing added flexibility for practice at their own convenience.
Key Words: skill, education, surgery, simulation, technique, training
Graphical Abstract
Portable Marshall III lung transplant anastomosis simulation model.
Central Message.
A structured hybrid simulation training approach that combines supervised and self-directed practice enhances the acquisition of technical skills and promotes mastery among specialized surgical trainees.
Perspective.
Mastery of complex technical skills can't be achieved through a single training session. We tested a hybrid training model that integrates an introductory in-person workshop with repeated self-guided practice on a surgical anastomosis simulator. This framework produced measurable gains in both technical proficiency and learner confidence, supporting the role of hybrid training in surgical education.
Simulation-based training has become an important component of surgical education, increasing opportunities for skill development outside of the operating room.1, 2, 3, 4 This approach addresses variability in operative exposure, a critical challenge in surgical training. Hands-on training opportunities differ widely across institutions depending on hospital case volumes, number of active trainees, and the constraints of duty-hour restrictions.5,6 These factors directly influence the amount of active participation in intraoperative time available to trainees.
Although technical skill proficiency is a critical determinant of surgical outcomes, achieving and maintaining competency remains challenging in a resource-limited training environment. Educational opportunities vary considerably in their frequency and delivery format, including single- and multiday sessions that vary from high-intensity supervised to low-intensity self-directed learning. Many training programs rely on brief exposure formats, which may be insufficient for developing and retaining complex technical skills.7 There is an opportunity to evaluate the benefits of prolonged, distributed hands-on practice, delivered in a combination of supervised and self-directed learning environments.8
The goal of this study was to evaluate the influence of simulation-based hybrid training that integrates supervised in-person instruction with repeated self-directed practice. We believe that this approach would significantly enhance technical skills, improve learner confidence, and promote mastery.
Materials and Methods
This study was conducted at a quaternary care teaching hospital in Toronto, Ontario, Canada. The simulation training model used in this study is Marshall III: Universal Surgical Anastomosis Training Tool. Consisting of a modular design that is easy to assemble, it includes a mounting box and 3-dimensionally printed threaded peg components that can be paired with silicone tubes that mimic vascular structures in feel, circumference, and wall thickness (Figure 1).9 The design of this portable simulation tool further allows trainees to test the quality of their anastomosis by injecting fluids to confirm watertightness. Research ethics board approval was obtained from the Toronto General Hospital, University Health Networks (22-5944.2). All recruited participants provided consent for participation, data collection, analysis, and dissemination protocols.
Figure 1.
Marshall III: Universal Surgical Anastomosis Simulation Training Tool. A, List of included components. B, Assembled model.
The study was structured in 2 parts: part A addressed pulmonary artery (PA) anastomosis, whereas part B addressed bronchial anastomosis. For both part A and part B, all participants attended an in-person demonstration followed by a hands-on practice session led by 2 staff thoracic surgeons. Following the demonstration, participants had time for hands-on practice during which they received structured feedback. At the end of the session, each participant completed an independent anastomosis attempt, which was assessed by the 2 instructing surgeons.
For parts A and B, time to task completion (TTC) and technical skill performance evaluations were recorded. Additionally, part A included a collection of anastomosis watertightness test results. The technical skill performance evaluations were split into 3 categories, including a task-specific checklist (TSC), overall impression of ability (OIA), and independent performance rating (IPR).10 The TSC is a consensus-derived checklist that consists of 7 parameters, including proper placement of corner stitches, use of adequate distance between stitches, use of adequate distance from the edge of tissue, use of appropriate stitch size correction to account for size mismatch, securing of corner stitches, watertight seal (PA, not applicable to bronchus), ability to avoid purse-stringing of the completed anastomosis. A 5-point Likert scale (from poor 1, 2, 3, 4, 5 to excellent) was used to determine OIA, whereas the IPR scores were used to assess the matter of trust in independent performance. The thoracic surgery staff raters were asked to rate “How likely they were to trust the participant to do the PA or bronchial anastomosis independently?” with a score of 1 indicating “I would have to help them with every step” and 5 indicating “I would not need to be there.” The TSC and user instructions provided to all participants are in Appendix E1 and E2, respectively.
After the initial in-person training and evaluation, participants were provided with the anastomosis model kit and asked to complete 10 self-directed practice sessions over 6 weeks before returning for the final in-person evaluation. Secondary outcomes, including TTC and watertight anastomosis test results, were recorded by the participants throughout their independent practice. The final in-person assessment was conducted by the same 2 staff thoracic surgeons who performed the first assessments. Participant feedback was collected to gain further insight into the training model's functionality and effectiveness. Data collection was conducted sequentially, with part A (PA anastomosis) training completed before part B (bronchial anastomosis) training began. This was done intentionally to allow participants to focus on the development of 1 technical skill at a time and to provide sufficient instructor support during the in-person training and assessment sessions.
Statistical Analysis
All analyses were conducted using the IBM SPSS Statistics version 28.01.01 (IBM Corp). Graphs were generated using GraphPad Prism version 10.4.2. Data distribution normality testing for part A and part B was assessed using the Shapiro-Wilk test.
In part A, the distribution of TSC, OIA, and IPR scores indicated deviation from normality (P < .05). In part B, total before and after scores for TSC and OIA were found to be nonnormally distributed (P < .05), and the total scores for IPR were found to be normally distributed (P > .05). The distribution of TTC was normal in both part A and B of the study. A 2-tailed significance level of α = 0.05 was used for all tests.
Based on these findings, a combination of nonparametric and parametric methods were employed in the evaluation. Total mean pre- and postintervention scores for TSC, IPR, and OIA were compared using the Wilcoxon signed-rank test. For the analysis of nonparametric data comparing pre- and postintervention performance in individual subskills in parts A and B of the TSC scores, the McNemar test was used. Because the scores used as a measure of IPR for part B were normally distributed, paired t tests were used for these comparisons. Similarly, a paired t test was applied to evaluate the significance level of the recorded pre- and posttraining TTC values.
To visualize the final pre- and posttraining performance metrics, GraphPad column statistics analysis was used to compute descriptive statistics and to compare the mean and median averages of the group's performance. All missing data were handled by authors KK and HK, ensuring paired comparisons included only participants with complete data.
Results
A total of 14 participants were included in the study, with 9 in the PA anastomosis group and 5 in the bronchial anastomosis group Table 1. In the PA group, 56% of participants had 5 to 10 years of thoracic surgery training, whereas 22% had <1 year and 22% had 3 to 5 years of experience. The majority of participants in the bronchial anastomosis group (57%) had 5 to 10 years of training, and the remainder (43%) had 3 to 5 years. Participants in the PA group represented a wide range of training backgrounds, including Japan (45%), Canada (22%), Brazil (11%), Argentina (11%), and Mexico (11%). The bronchial group was predominantly trained in Japan (80%) and Mexico (20%). Regarding prior procedure experience, most participants in the PA group (67%) had performed the procedure on a porcine simulator, whereas 22% had performed fewer than 10 procedures in the operating room, and 11% had never performed the procedure. In contrast, 80% of the bronchial group had never performed the procedure, and 20% had completed fewer than 10 in the operating room, with none reporting prior simulator experience. In total, 10 participants were enrolled, and 9 participants completed training and assessment in part A. Of the 7 participants enrolled in part B, 5 have completed the training. All participating fellows were nonclinical at the time of the study.
Table 1.
Summary of participant cohort characteristics
| Cohort characteristics | PA anastomosis∗ (n = 9) |
Bronchial anastomosis∗ (n = 5) |
|---|---|---|
| Years of thoracic surgery training | ||
| ≤1 | 2 (22) | 0 |
| >1-3 | 0 | 0 |
| >3-5 | 2 (22) | 2 (42.9) |
| >5-10 | 5 (56) | 3 (57.1) |
| Country of training | ||
| Japan | 4 (45) | 4 (80) |
| Brazil | 1 (11) | 0 |
| Argentina | 1 (11) | 0 |
| Mexico | 1 (11) | 1 (20) |
| Canada | 2 (22) | 0 |
| Prior experience | ||
| Never done | 1 (11) | 4 (80) |
| Done <10 in the operating room | 2 (22) | 1 (20) |
| Done on simulator (porcine) | 6 (67) | 0 |
PA, Pulmonary artery.
Values are represented as n (%).
TSC Score
There was a statistically significant difference in pre- and postintervention average scores for part A (P = .016), whereas no statistical significance (marginal significance) was observed in part B (P = .059), suggesting that training made a positive difference in participants’ technical skills (Table 2).
Table 2.
Technical performance test summary for total mean pre- and postintervention pulmonary artery (PA) (study part A) and bronchial (study part B) anastomosis scores
| Metric | Initial average | Final average | Z value∗ | P value (2-sided)∗ |
|---|---|---|---|---|
| PA anastomosis | ||||
| Task-specific checklist | 3.9 | 6.3 | −2.398 | .016 |
| Overall impression of ability | 3.1 | 4.4 | −2.670 | .008 |
| Independent performance rating | 2.7 | 4.5 | −2.536 | .011 |
| Bronchial anastomosis | ||||
| Task-specific checklist | 4.1 | 5.5 | −1.890 | .059 |
| Overall impression of ability | 2.6 | 4.7 | −2.060 | .039 |
P values in boldface type are statistically significant. For nonparametric variables, Z value was based on negative ranks.
In part A, the average TSC scores of the 9 participants increased from 3.9 out of 7 to 6.3 out of 7 (62% improvement from baseline, P = .016) (Figure 2). There was significant posttraining improvement in individual subskills, including the adequate distance between stitches (P = .016), stitch distance from the tissue edge (P = .016), and watertightness (P = .016) (Table 3). In part B, the average TSC scores of the 5 participants increased from 4.1 out of 6 to 5.5 out of 6 (34% improvement from baseline; P = .059) (Figure 2). There was no statistically significant difference in the individual subskills, likely due to the small cohort size (Table 3).
Figure 2.
Performance assessment outcomes before and after training. A, Task-specific performance checklist scores for PA anastomosis. B, Task-specific performance checklist scores for bronchial anastomosis. C, Overall impression of ability scores for PA anastomosis. D, Overall impression of ability scores for bronchial anastomosis. E, Independent performance scores for PA anastomosis. F, Independent performance scores for bronchial anastomosis. PA, Pulmonary artery.
Table 3.
Part A subskill analysis for pulmonary artery (part A) and bronchial (part B) anastomosis
| Skill assessed | P value (2-sided)∗, part A | P value (2-sided)∗, part B |
|---|---|---|
| Corner stitch placement | .375 | .500 |
| Distance between stitches | .016 | 1.000 |
| Distance from edge | .016 | .125 |
| Stitch size | .250 | 1.000 |
| Secure corner stitch | .500 | 1.000 |
| Watertight | .016 | N/A |
| Absence of purse string | .625 | .500 |
N/A, Not available.
P values in boldface type are statistically significant.
OIA Score
In Part A, the average OIA scores of the 9 participants increased from 3.1 out of 5 to 4.4 out of 5 (42% improvement from baseline, P = .008) (Figure 2). In part B, the OIA scores of the 5 participants increased from an average of 2.6 out of 5 to 4.7 out of 5 (81% improvement from baseline, P = .039) (Figure 2).
IPR Score
In part A, the average IPR scores of the 9 participants increased from 2.7 out of 5 to 4.5 out of 5 (67% improvement from baseline, P = .011), (Figure 2). In part B, the average IPR scores of the 5 participants increased from 2.6 out of 5 to 4.7 out of 5 (81% performance improvement, P = .018) (Figure 2 and Table 4).
Table 4.
Analysis of the independent performance rating for bronchial anastomosis (part B)
| Skill assessed | t | P value (2-sided)∗ |
|---|---|---|
| Independent performance rating | −3.882 | .018 |
P values in boldface type are statistically significant.
TTC
The overall TTC showed an average reduction of 1 minute 47 seconds (part A, P = .119) and 4 minutes 15 seconds (part B, P = .005) (Figure 3). In part A, there was no statistically significant difference (P = .119) in the average TTC before and after training (Figure 3). In part B, a statistically significant difference was observed (P = .005) in the average TTC before and after training (Figure 3).
Figure 3.
Comparison of pre- and post-training median time-to-completion (TTC) for pulmonary artery (PA) and bronchial anastomosis. A, TTC for PA anastomosis. B, TTC for bronchial anastomosis.
Discussion
This study evaluated the effectiveness of a hybrid simulation training model that combines instructor-led workshops with self-directed practice using a portable synthetic simulator for PA and bronchial anastomosis. Across both phases of training, participants demonstrated improvements in technical performance, TTC, and independent procedure-related confidence, underscoring the value of structured simulation-based learning in thoracic surgery training.
In part A, PA anastomosis training was associated with significant gains in TSC scores and subskill proficiency, with notable improvements in stitch placement accuracy and watertightness. These findings align with previous work demonstrating that deliberate practice on structured simulators enhances technical precision and reduces error rates in vascular and airway surgery.11, 12, 13, 14 Although the bronchial anastomosis cohort (part B) showed a similar upward trend in TSC scores, the statistical significance threshold was not reached, likely due to the small sample size. Despite this limitation, both groups showed clear improvement in the OIA and IPR, suggesting that participants not only refined specific technical steps but also gained confidence and autonomy in task completion.
An additional strength of this training model was the observed improvement in task completion speed. Although PA training yielded modest, nonsignificant reductions in TTC, bronchial anastomosis training was associated with a statistically significant decrease of more than 4 minutes per procedure. This reduction indicates that, beyond improving technical accuracy, hybrid simulation-based practice may accelerate procedural flow, eliminate the need to provide technical skill onboarding in the operating room, and reduce overall operative time. This plays an important role because TTC is a critical factor in the clinical setting, where operative time contributes to patient outcomes, resource utilization, and hospital operational costs.
The hybrid structure of this program, combining initial supervised instruction with subsequent self-directed practice, addresses a key challenge in surgical education: Balancing limited faculty teaching time with the need for repetitive practice. Our findings align with Ericsson's framework of deliberate practice, which emphasizes not only structured, goal-oriented training but also the importance of feedback and progressive refinement of performance.15, 16, 17 In this study, feedback was provided as an integral part of the training process, supporting measurable improvements in technical skill acquisition, particularly in highly skill-dependent fields such as thoracic surgery. The study's success with a structured hybrid simulation program, combining feedback and independent learning, shows the benefits of goal-oriented learning. These results highlight the need to standardize technical skill acquisition education in thoracic surgery, with an emphasis on deliberate practice.
Limitations
This study has several limitations. First, the timing and format of training influenced participant completion rates. Scheduling conflicts related to clinical duties and on-call responsibilities led to dropouts, reducing the final sample size. We acknowledge that the hybrid training format may not be universally applicable because successful completion depends on individual motivation and alignment with personal training needs.
Second, the absence of a control group limited our ability to directly compare outcomes against traditional training methods. Given the small number of eligible participants, we opted for a single-subject design in which each trainee served as their own control. Although this approach allowed all interested participants to be included and ensured within-subject comparisons, it reduced the strength of causal inferences relative to randomized controlled designs.
Future Directions
Future studies should include larger trainee cohorts and longitudinal follow-up to evaluate skill retention and skill transfer to the operating room. Direct comparison of hybrid training with traditional apprenticeship models could further clarify its relative influence on learning efficiency. Expanding the use of portable simulators across a wider range of thoracic procedures may help standardize technical training, reduce dependence on animal or cadaver models, and ultimately improve patient safety.
Conclusions
This study supports the use of hybrid simulation training that combines instructor-led workshops with independent, unsupervised practice on portable synthetic trainers. This approach offers a scalable, learner-centered strategy to develop technical skills, confidence, and efficiency in thoracic anastomosis training, with the potential to complement and extend traditional operative learning opportunities.
Conflict of Interest Statement
The Marshall III: Surgical Simulation Training Tool is a patent-pending invention. Drs Marshall, Donahoe, Yasufuku, and Kazlovich are listed as inventors on the related patent application, registered with the University Health Network's Commercialization Office. The other author reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Footnotes
This study was approved on April 26, 2023, by the University Health Network's Research Ethics Board (22-5944.2) and conducted in accordance with the best practices.
Appendix E1
Assessment handout for bronchial and pulmonary artery (PA) anastomosis used to evaluate participant prior experience and provide ratings for the task-specific checklist, overall impression of ability, and independent performance.
Participant prior experience: Please check one that applies and indicate type of anastomosis (bronchial vs PA)
| Prior experience | Type of anastomosis (bronchial vs PA) |
|---|---|
| Never done before | |
| Done on a simulator | |
| Done <10 in the operating room | |
| Done >10 in the operating room |
Task-specific checklist for PA anastomosis
| Task description | Not done/done incorrectly | Done correctly |
|---|---|---|
| Places corner stitches properly | ||
| Uses adequate distance between stitches | ||
| Uses adequate stitch distance from the edge of the tissue | ||
| Uses appropriate stitch size correction to account for size mismatch | ||
| Secures corner stitches appropriately | ||
| Avoidance of purse stringing of completed anastomosis | ||
| Creates a watertight seal |
Time to complete anastomosis (min:sec)
Task-specific checklist for bronchial anastomosis
| Task description | Not done/done incorrectly | Done correctly |
|---|---|---|
| Places corner stitches properly | ||
| Uses adequate distance between stitches | ||
| Uses adequate stitch distance from the edge of the tissue | ||
| Uses appropriate stitch size correction to account for size mismatch | ||
| Secures corner stitches appropriately | ||
| Handles bronchial tissue appropriately |
Time to complete anastomosis (min:sec)
Overall impression of ability to complete anastomosis (circle one)
| Poor | Average | Excellent | ||
|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 |
Independent performance rating (circle one)
| How likely are you to trust this person to do this task independently? | ||||
|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 |
Where:
1 = “I would have to help them with every step”
2 = “I would have to talk them through”
3 = “I would have to direct them from time to time”
4 = “I would need to be available just in case”
5 = “I would not need to be there”
Appendix E2
Please fill out this performance tracking sheet while you are practicing performing pulmonary artery (PA) and bronchial anastomosis. If you started a practice round but didn't complete it, please make a note and indicate the reason in the comment section. An incomplete session does not count toward a full practice round. If you started but did not complete a practice round, please provide an explanation in the comment section. This round will not count towards your 10 completed practice sessions. Please modify the sheet to add more rows as needed to accommodate incomplete practice rounds.
PA anastomosis tracking sheet example
| Practice | Time-to-completion (min: sec) | Have you completed the practice round? Please indicate with yes/no | Watertightness test. Did the anastomosis leak when injected with water? Please indicate with yes/no | Additional comments |
|---|---|---|---|---|
| First | ||||
| Second |
Bronchial anastomosis tracking sheet example
| Practice | Time-to-completion (min: sec) | Have you completed the practice round? Please indicate with yes/no | Additional comments |
|---|---|---|---|
| First | |||
| Second |
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