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Cross-Suturing is Effective for Teaching Suturing Skills: A Randomized, Controlled Trial

Published:October 05, 2022DOI:https://doi.org/10.1016/j.jss.2022.08.038

      Abstract

      Introduction

      Basic suturing is a skill expected from graduating medical students. A proposed concept to increase suturing competency is to integrate art by mixing cross-stitching with suturing. We hypothesize that students trained with “cross-suturing” would improve suturing performance.

      Methods

      We performed a randomized controlled trial of preclinical medical students using an art-based cross-stitching method intervention compared with conventional suturing. Both groups were provided with an introductory suturing video. Assessment of simple interrupted suturing were conducted preintervention and postintervention, and at 2-wk follow-up with a video review by blinded expert raters using the American College of Surgeons basic suturing and knot tying performance rating tool. Students completed a self-assessment of proficiency, confidence, and anxiety. Statistical analysis was performed using unpaired t-tests.

      Results

      A total of 16 preclinical medical students participated. Self-assessment and objective suturing performance were comparable in the preintervention measurements. The intervention group showed significant improvement compared to the control group with median (interquartile range) self-assessment scores 9 (8.5-9) compared with 6.5 (6-7.5) (P < 0.01) and objective performance scores of 25.25 (22.75-27) compared with 16.5 (14.5-18.5) (P < 0.01). The intervention group showed retained skills at the 2-wk follow up with no differences in self-assessment or objective suturing scores immediately postintervention compared with two-wk follow-up with self-assessment scores of 9 (8.5-9) versus 9 (8-9) at 2 wk (P = 0.16) and objective performance score of 25.25 (22.75-27) versus 24.75 (23.5-26.5) at 2 wk (P = 0.29).

      Conclusions

      The cross-suturing intervention improved suturing skills in this cohort. This low-cost approach to medical student surgical education should be explored on a larger scale.

      Keywords

      Introduction

      Medical students going into their third year clerkships are expected to perform basic surgical skills such as suturing. Suturing lacerations is considered a learning objective for medical student education before graduating. Although these skills are expected from medical students; they are infrequently incorporated into the medical school curriculum before the clinical years.
      Previous studies have demonstrated the advantages of early and frequent suturing workshops for medical students. Performance and self-confidence in suturing skills and procedural skills have been shown to improve with curated and directed skills modules.
      • Manning E.P.
      • Mishall P.L.
      • Weidmann M.D.
      • et al.
      Early and prolonged opportunities to practice suturing increases medical student comfort with suturing during clerkships: suturing during cadaver dissection.
      ,
      • Stewart R.A.
      • Hauge L.S.
      • Stewart R.D.
      • et al.
      A CRASH course in procedural skills improves medical students’ self-assessment of proficiency, confidence, and anxiety.
      Further, continued practice outside the clinical setting has been reported to help maintain suturing skills.
      • Routt E.
      • Mansouri Y.
      • de Moll E.H.
      • Bernstein D.M.
      • Bernardo S.G.
      • Levitt J.
      Teaching the simple suture to medical students for long-term retention of skill.
      Accordingly, early introduction through carefully curated modules as well as routine practice will improve confidence and retention of skills learned.
      Although suturing practice has many benefits, the task and the needed repetition to attain proficiency can be monotonous for medical students. A proposed idea is to integrate art into practice by mixing cross-stitching with suturing. This proposed “cross-suturing” method can be more engaging with students. Students will practice their skills by suturing through a design on a cross-stitching hoop leading a final end product of art.
      This study aims to measure students' skills after participating in a cross-suturing workshop. We aim to provide students with a training device that is easily accessible, low-cost, and engaging. We gathered junior medical students to assess the efficacy of cross-suturing in attaining and retaining basic suturing skills. We hypothesized that the cross-suturing workshop would increase suturing skill level and retention.

      Methods

      Workshop and assessment

      Preclinical medical students were recruited via email for this institutional review board-approved study. Students were randomly assigned to the control or intervention groups. All students were provided with a video of suturing techniques. Students in the intervention group participated in a cross-suturing workshop, while students in the control group were sent home with suturing supplies after assessing their technical skills and completing the surveys. The workshop lasted for 90 min. All students completed a three-question 4-point Likert scale assessment to gauge proficiency, confidence, and anxiety levels during three time periods: preintervention, postintervention, and 2-wk follow-up (Fig. 1). Students' technical skills were assessed through blinded video review by expert raters of five simple interrupted sutures with instrument ties on porcine feet during three time periods: preintervention, postintervention, and 2-wk follow-up. Video recording was done by stationary mounted recording equipment in high definition and high resolution. Students were required to wear nonsterile opaque gloves, and the video was zoomed in only to show their hands to aid in blinding. Videos were labeled using a code so that graders could not distinguish between intervention and control groups. Students were graded by two blinded expert raters (KRT, ALF) using the American College of Surgeons (ACS) basic suturing and knot tying performance rating tool and Global Rating Scale for a total of 30 points (Fig. 2, Fig. 3). Both raters individually graded each video, and the scores were averaged. Students were timed while completing five simple interrupted sutures. The time was started when the needle contacted the porcine skin and stopped once the fifth knot was cut. Statistical analysis was performed using Mann–Whitney U test for ordinal variables between groups, the Wilcoxon signed-rank test for ordinal variables within groups, and Student's t-test for continuous normally distributed variables. Normality was assessed with a Shapiro–Wilk W test (STATA, version 17, Statacorp, TX). A P-value of <0.05 was considered statistically significant.
      Figure thumbnail gr1
      Fig. 1Student self-assessment survey of proficiency and confidence in suturing with instrument tie.
      Figure thumbnail gr2
      Fig. 2American College of Surgeons performance rating tool: basic suturing.
      Figure thumbnail gr3
      Fig. 3American College of Surgeons performance rating tool: basic knot tying.

      Materials

      Fresh porcine feet were used during the initial study day and again at the 2-wk follow-up. Standard needle driver, Adson forceps, and scissors were provided to every student (Fig. 4). The recorded assessment used the porcine feet with a 5 cm incision, and a 3-0 polysorb braided absorbable suture on the GS-10 cutting ½ circle 26 mm needle (Covidien, Minneapolis, MN).
      Figure thumbnail gr4
      Fig. 4Fresh porcine foot and suturing material used for recorded assessment.
      Students in the intervention group were provided with cross-suturing materials. The cross-suturing training device consisted of an 8-inch round wooden embroidery hoop, a 14-count cross-stitch fabric aida cloth, and a cotton crochet thread of assorted colors. Richard-Allan Mayo Catgut 3/8th circle taper heavy needles were threaded and used (Aspen Surgical Products Inc, Caledonia, MI). A visual representation of the materials in use and students in the cross-suturing workshop are seen in Fig. 5, Fig. 6. Students in the intervention group were allowed to take the cross-suturing material and instruments home (Fig. 7). In contrast, those in the control group were provided with the 3-0 polysorb braided absorbable suture on the GS-10 cutting ½ circle 26 mm needle, standard needle driver, Adson forceps, and scissors to take home. Students in the control group were not provided with a suturing medium and were instead advised to use easily accessible materials at home such as cloth or fruit skins or commercially available products such as gel or foam suturing models or porcine feet.
      Figure thumbnail gr5
      Fig. 5Student completing the cross-suturing workshop.
      Figure thumbnail gr6
      Fig. 6Cross-suturing material in use during workshop.
      Figure thumbnail gr7
      Fig. 7Cross-suturing material provided for students in the intervention group.

      Results

      A total of 16 medical students were divided into a control and an intervention group, with eight in each group. Results of self-assessment Likert scales, ACS suturing and knot tying rating scales, and time to perform five sutures were compared between the two groups at three time points: preintervention, postintervention, and 2-wk follow-up. They were also compared within the groups themselves at each time point. The continuous variable of task completion time was normally distributed for the preintervention, postintervention, and 2-wk follow-up with P values for the Shapiro–Wilk W test all >0.05.

      Subjective data

      Based on the self-assessment Likert rating scale, the median (interquartile range) proficiency, confidence, and anxiety levels of the members of each group at the preintervention time point were similar with control 6 (4-6.5) versus intervention 6 (5.5-6), P = 0.77. During the postintervention time point, there was a statistically significant improvement in Likert scores in the intervention group compared to the preintervention scores: intervention pre 6 (5.5-6) versus intervention post 9 (8.5-9), P = 0.008. There was also a statistically significant difference in the intervention group's scores when compared to the control group at the postintervention time point: control 6.5 (6-7.5) versus intervention 9 (8.5-9), P = 0.0019. There was no difference in Likert scores within the control group between the preintervention and postintervention time points: control pre 6 (4-6.5) versus control post 6.5 (6-7.5), P = 0.06 (Table 1).
      Table 1Results preintervention versus postintervention.
      VariablePre-interventionPost-interventionP-value
      Subjective score: Likert rating scale, median (IQR)
       Control (n = 8)6 (4-6.5)6.5 (6-7.5)0.06
       Intervention (n = 8)6 (5.5-6)9 (8.5-9)0.008
      P-value0.770.0019
      Objective score: ACS, median (IQR)
       Control (n = 8)15.75 (13.5-17)16.5 (14.5-18.5)0.07
       Intervention (n = 8)19.25 (15-20.75)25.25 (22.75-27)0.01
      P-value0.110.0006
      Time (seconds), mean ± SD
       Control (n = 8)627.8 ± 137.3482.8 ± 107.20.034
       Intervention (n = 8)628.6 ± 217.7458.9 ± 80.80.057
      P-value0.9930.608
      Likert Rating Scale: Rating 1-4 measuring proficiency, confidence, and anxiety (12-points max) ACS: American College of Surgeons suturing and knot tying rating tool (30-points max).
      Bold items: Statistically significant with P-value < 0.05.
      IQR = interquartile range.

      Objective data

      Students' scores on the ACS suturing and knot tying rating scales were not significantly different between the two groups at the preintervention time point: control 15.75 (13.5-17) versus intervention 19.25 (15-20.75), P = 0.11. The control group did not show a statistically significant improvement in the ACS scores at the postintervention time point: control pre 15.75 (13.5-17) versus control post 16.5 (14.5-18.5), P = 0.07. Students in the intervention group did show statistically significant improvement at the postintervention time point: intervention pre 19.25 (15-20.75) versus intervention post 25.25 (22.75-27), P = 0.01. Students in the intervention group also scored higher than their peers in the control group at the postintervention time point: Control 16.5 (14.5-18.5) versus intervention 25.25 (22.75-27), P = 0.0006.

      Time

      There was no difference in the time needed to complete five simple interrupted sutures between the two groups. This was true for both the preintervention and postintervention timing (control pre 627.8 ± 137.3 versus intervention pre 628.6 ± 217.7, P = 0.993) and (control post 482.8 ± 107.2 versus intervention post 458.9 ± 80, P = 0.608), respectively. However, within the control group, the students were faster at the postintervention time point when compared to the preintervention time point (control pre 627.8 ± 137.3 versus control post 482.8 ± 107.2, P = 0.034). The intervention group also showed improvement within the preintervention and postintervention time points, although this did not achieve statistical significance (intervention pre 628.6 ± 217.7 versus intervention post 458.9 ± 80, P = 0.057).

      Retention rates

      Retention was assessed by comparing the results of the Likert, ACS, and time to perform the sutures for each group between the postintervention and at 2-wk follow-up time points (Fig. 8, Fig. 9, Fig. 10). At the 2-wk follow-up, two students in the intervention group and three in the control group were lost to follow-up. For the intervention group, there was no statistically significant decrease in scores between postintervention and the 2-wk follow-up (Likert: intervention post 9 (8.5-9) versus intervention 2-wk 9 (8-9), P = 0.16) and (ACS: intervention post 25.25 (22.75-27) versus intervention 2-wk 24.75 (23.5-26.5), P = 0.29) and (time: intervention post 457.9 ± 80.8 versus intervention 2-wk 389.0 ± 87.6, P = 0.153) (Table 2).
      Figure thumbnail gr8
      Fig. 8Likert rating scale rating 1-4 measuring proficiency, confidence, and anxiety (12 points max).
      Figure thumbnail gr9
      Fig. 9American College of Surgeons and Knot Tying Rating Tool (30 points max).
      Figure thumbnail gr10
      Fig. 10Time needed to complete 5 simple interrupted sutures with instrument tie (seconds).
      Table 2Retention rates results.
      Retention rates in intervention groupIntervention post-intervention (n = 8)Intervention 2-wk (n = 6)P-value
      Likert, median (IQR)9 (8.5-9)9 (8-9)0.16
      ACS, median (IQR)25.25 (22.75-27)24.75 (23.5-26.5)0.29
      Time (seconds), mean ± SD457.9 ± 80.8389.0 ± 87.60.153
      Retention rates in control groupControl post-intervention (n = 8)Control 2-wk (n = 5)P-value
      Likert, median (IQR)6.5 (6-7.5)8 (6-8)0.58
      ACS, median (IQR)16.5 (14.5-18.5)21.5 (20.5-21.5)0.08
      Time (seconds), mean ± SD482.8 ± 107.2513.0 ± 104.60.628
      Retention rates control versus InterventionControl 2-wk (n = 5)Intervention 2-wk (n = 6)P-value
      Likert, median (IQR)8 (6-8)9 (8-9)0.04
      ACS, median (IQR)21.5 (20.5-21.5)24.75 (23.5-26.5)0.004
      Time (seconds), mean ± SD513.0 ± 104.6389.0 ± 87.60.061
      Likert Rating Scale: Rating 1-4 measuring proficiency, confidence, and anxiety (12-points max) ACS: American College of Surgeons suturing and knot tying rating tool (30-points max).
      Bold items: Statistically significant with P-value < 0.05.
      The control group also did not show a change in scores for the Likert or the time it took to perform the suturing between the postintervention and 2-wk follow-up time points (Likert: control post 6.5 [6-7.5] versus control 2-wk 8 [6-8], P = 0.58) and time: control post versus control 2-wk 513.0 ± 104.6, P = 0.628. There were no differences in the control group for their ACS scores between the postintervention and the 2-wk follow-up time points (ACS: control post 16.5 [14.5-18.5] versus control 2-wk 21.5 [20.5-21.5], P = 0.08) (Table 2).
      The scores for the intervention group were higher than the control group at the 2-wk time point (control 21.5 (20.5-21.5) versus intervention 24.75 (23.5-26.5), P = 0.004). There was also a statistically significant difference in Likert scores between the intervention and control groups at the 2-wk time point (control 8 (6-8) versus intervention 9 (8-9), P = 0.04). When comparing the time taken to complete the sutures between the two groups, there was no statistically significant difference found at the 2-wk time point (control 513.0 ± 104.6 versus intervention 389.0 ± 87.6, P = 0.061) (Table 2).

      Discussion

      Suturing is considered a learning objective for medical students before graduation. Yet, several studies have demonstrated barriers for medical students in attaining adequate operating room skills.
      • Luhoway J.A.
      • Ryan J.F.
      • Istl A.C.
      • et al.
      Perceived barriers to the development of technical skill proficiency in surgical clerkship.
      ,
      • Moulton C.A.E.
      • Dubrowski A.
      • Macrae H.
      • Graham B.
      • Grober E.
      • Reznick R.
      Teaching surgical skills: what kind of practice makes perfect?: a randomized, controlled trial.
      As shown in previous studies, students need more opportunities to practice operative skills and become proficient in these skills before their clinical years and graduation.
      A 3D printed suturing trainer for medical students - Boyajian - 2020 - the clinical teacher - Wiley Online Library.
      ,
      • Vanyolos E.
      • Furka I.
      • Miko I.
      • Viszlai A.
      • Nemeth N.
      • Peto K.
      How does practice improve the skills of medical students during consecutive training courses?.
      In this study, we developed a novel suturing technique which combines cross-stitching and suturing to create cross-suturing. This technique succeeds in being affordable, easily attainable, and entertaining while demonstrating improved subjective and objective skill sets with skill retention at 2 wk.
      Students in the intervention cohort showed improved self-reported proficiency, confidence, and anxiety levels. It is important to note that scores were similar between cohorts during the pre-intervention time point, and only the intervention cohort showed an improvement in scores. Furthermore, no statistically significant difference in subjective scores was noted between the post-intervention time point and the 2-wk follow-up showing retained skillsets within the intervention group with no change in the self-reported skillset in the control group. These results demonstrate that participation in the cross-suturing workshop can increase students' confidence and proficiency while decreasing anxiety before entering an operative environment. Previous studies have shown that negative emotions and a lack of preparedness in the operating room could hinder students' learning experiences.
      • Bowrey D.J.
      • Kidd J.M.
      How do early emotional experiences in the operating theatre influence medical student learning in this environment?.
      ,
      The anxieties of new clinical students.
      Cross-suturing may better prepare students for a productive and educational surgical rotation while increasing interest in surgical fields.
      Students in the intervention cohort showed an improvement in objective skill set compared to students in the control group. The ACS performance rating tool for basic suturing and knot tying was used to grade students at three different time points. The ACS performance rating tool was developed jointly with the Association for Surgical Education for medical students' simulation-based surgical skills curriculum.
      ACS/ASE medical student simulation-based surgical skills curriculum.
      No statistically significant difference was noted between the intervention and control group at the preintervention time point (control 15.75 (13.5-17) versus intervention 19.25 (15-20.75), P = 0.11). Although no difference was shown at this time point, it is worth noting that the preintervention group had a higher score relative to the control group at both the preintervention and postintervention time points (intervention 19.25 [15-20.75] versus control preintervention 15.75 [13.5-17] and postintervention 16.5 [14.5-18.5]). Although this study would benefit from an increased cohort size and thus increased power, we believe in the results and objective improvement in the intervention cohort since statistical significance was achieved. The intervention group showed a statistically significant improvement in ACS scores during the postintervention time compared to the control group. Students in the intervention cohort also showed retained skills with no statistically significant difference between the postintervention time point and the 2-wk follow-up. Objectively, students who participated in the cross-suturing workshop demonstrated better skills and preparedness for their surgical rotations. Participating in suturing workshops has previously shown to improve student proficiency.
      • Emmanuel T.
      • Nicolaides M.
      • Theodoulou I.
      • Yoong W.
      • Lymperopoulos N.
      • Sideris M.
      Suturing skills for medical students: a systematic review.
      Although acquisition of skills is important, retention of skills is imperative for achieving a skillset that can be used in a surgical setting. Previous studies have shown a decay in skills following the end of the teaching intervention.
      • Routt E.
      • Mansouri Y.
      • de Moll E.H.
      • Bernstein D.M.
      • Bernardo S.G.
      • Levitt J.
      Teaching the simple suture to medical students for long-term retention of skill.
      ,
      • Porte M.C.
      • Xeroulis G.
      • Reznick R.K.
      • Dubrowski A.
      Verbal feedback from an expert is more effective than self-accessed feedback about motion efficiency in learning new surgical skills.
      • Brydges R.
      • Carnahan H.
      • Dubrowski A.
      Assessing suturing skills in a self-guided learning setting: absolute symmetry error.
      • Bekele A.
      • Wondimu S.
      • Firdu N.
      • Taye M.
      • Tadesse A.
      Trends in retention and decay of basic surgical skills: evidence from Addis Ababa University, Ethiopia: a prospective case-control cohort study.
      Skills are best retained through independent practice at home.
      • Routt E.
      • Mansouri Y.
      • de Moll E.H.
      • Bernstein D.M.
      • Bernardo S.G.
      • Levitt J.
      Teaching the simple suture to medical students for long-term retention of skill.
      Students in the intervention cohort were allowed to take the materials home which likely led to retained skills.
      Interestingly, the control group showed slightly improved skill level between the postintervention time point and the 2-wk follow-up, though this was not statistically significant. This improvement may have been due to continued practice by the students at home on their own time. When comparing the intervention group versus the control group at the 2-wk follow-up, the intervention group still showed a statistically significant higher score than the control group.
      Surprisingly, participation in the workshop showed no improvement in the time needed to complete five simple interrupted sutures. Notably, the only instance when students performed the task faster was seen in the control group between the preintervention and postintervention time points. Although the control group did complete the task more quickly, it is essential to note that their objective scores were lower than the intervention group. The intervention group approached but did not show a statistically significant improvement in time between the preintervention and postintervention time points. Other studies, with different interventions for suturing skill acquisition, were able to demonstrate an improvement in time between their control group and intervention group.
      • Ganier F.
      • de Vries P.
      Are instructions in video format always better than photographs when learning manual techniques? The case of learning how to do sutures.
      • Dubrowski A.
      • MacRae H.
      Randomised, controlled study investigating the optimal instructor: student ratios for teaching suturing skills.
      • Gershuni V.
      • Woodhouse J.
      • Brunt L.M.
      Retention of suturing and knot-tying skills in senior medical students after proficiency-based training: results of a prospective, randomized trial.
      • Brunt L.M.
      • Halpin V.J.
      • Klingensmith M.E.
      • et al.
      Accelerated skills preparation and assessment for senior medical students entering surgical internship.
      Importantly, these studies all had at least 10 participants in each cohort. It is possible that a statistically significant difference could be seen if the power of our study was increased and we recruited more participants.
      Our results indicate that the cross-suturing device proves to be an inexpensive and entertaining suturing practicing tool for junior medical students. The cross-stitching material, including the string, fabric, and oval, can easily be purchased at local craft stores or online. Although the Richard-Allan needles need to be ordered from a manufacturer, the durability of the heavy wire material and the ability to thread the needle countless times solves two critical problems: students no longer need to acquire expensive sutures or find suturing material in the hospital so that they can practice at home, and students do not need to worry about adequately disposing single use.
      Another advantage of the cross-suturing device is that the cross-stitching fabric is durable and does not tear when compared to silicone and sponge alternatives. In addition, the fabric pattern guides the students’ aim of their needles and allows them to practice their hand movement and torque to manipulate the position of the needle.
      The advantages of cross-suturing can be expanded to developing countries. Simulation-based training is an important aspect of surgical education.
      • Sutherland L.M.
      • Middleton P.F.
      • Anthony A.
      • et al.
      Surgical simulation: a systematic review.
      ,
      • Sturm L.P.
      • Windsor J.A.
      • Cosman P.H.
      • Cregan P.
      • Hewett P.J.
      • Maddern G.J.
      A systematic review of skills transfer after surgical simulation training.
      There is a need for surgical simulation devices in developing countries.
      • Hasan O.
      • Ayaz A.
      • Jessar M.
      • Docherty C.
      • Hashmi P.
      The need for simulation in surgical education in developing countries. The wind of change. Review article.
      Yet, simulation-based training is an uncommon component in developing countries.
      • Okrainec A.
      • Smith L.
      • Azzie G.
      Surgical simulation in Africa: the feasibility and impact of a 3-day fundamentals of laparoscopic surgery course.
      ,
      • Livingston P.
      • Bailey J.
      • Ntakiyiruta G.
      • Mukwesi C.
      • Whynot S.
      • Brindley P.
      Development of a simulation and skills centre in East Africa: a Rwandan-Canadian partnership.
      Efforts have been made to create low-cost surgical simulation for developing countries.
      • Parham G.
      • Bing E.G.
      • Cuevas A.
      • et al.
      Creating a low-cost virtual reality surgical simulation to increase surgical oncology capacity and capability.
      Cross-suturing should be considered in developing countries as a suturing simulation tool due to its attainability, durability, and cost-effectiveness.
      This study is not without limitations. Defining a control group was a challenging aspect of this experiment. While students in the intervention group were exposed to a 90-min workshop, those in the control group were sent home with standard suturing material after the assessment portion of the experiment. The control group was defined as having “no intervention” and thus no 90-min workshop because typically no suturing curriculum is provided to pre-clinical students. Since the cross-suturing device is 2-dimensional, it would be difficult for the student to practice advanced suturing techniques such as a subcuticular stitch which requires a 3-dimensional field. Variability in time spent practicing at home could have occurred between cohorts and could have led to differences in scores at the 2-wk time point. Potential selection bias can possibly be seen within our voluntary cohort. Finally, our study is limited due to a small sample size.

      Conclusions

      Cross-suturing proves to be an effective method for teaching medical students in their preclinical years basic suturing and knot tying skills. Both subjective and objective measurements were increased in the intervention group, and skills retention was maintained. Cross-suturing should be made widely available to medical students in their preclinical years as it is an entertaining, cost-effective, and productive method for learning suturing techniques.

      Author Contributions

      SLC created the idea from conception, wrote and submitted IRB, implemented research protocol, conducted statistical analysis, created figures and graphs, and wrote majority of the manuscript. TWC implemented research protocol, organized, and calculated averages on all data, administered surveys to students, and aided in writing manuscript. HHH aided in the creation of research idea, material acquisition, and manuscript revision. KRT graded student suturing assessment. SCF aided in the creation of research idea and manuscript revision. SLW aided in the creation of research idea. ALF contributed to study design, expert rater, abstract and manuscript preparation, and critical review.

      Acknowledgments

      Davis Global Center iEXCEL of the University of Nebraska Medical Center for the venue and technical support of video recording and storage.

      Disclosure

      Dr. Fingeret is an Associate Editor for the Journal of Surgical Research; as such, she was excluded from the entire peer-review and editorial process for this manuscript.

      Funding

      Financial support was provided through the University of Nebraska Medical Center Department of Surgery .

      References

      1. (Available at:)
        • Manning E.P.
        • Mishall P.L.
        • Weidmann M.D.
        • et al.
        Early and prolonged opportunities to practice suturing increases medical student comfort with suturing during clerkships: suturing during cadaver dissection.
        Anat Sci Educ. 2018; 11: 605-612
        • Stewart R.A.
        • Hauge L.S.
        • Stewart R.D.
        • et al.
        A CRASH course in procedural skills improves medical students’ self-assessment of proficiency, confidence, and anxiety.
        Am J Surg. 2007; 193: 771-773
        • Routt E.
        • Mansouri Y.
        • de Moll E.H.
        • Bernstein D.M.
        • Bernardo S.G.
        • Levitt J.
        Teaching the simple suture to medical students for long-term retention of skill.
        JAMA Dermatol. 2015; 151: 761-765
        • Luhoway J.A.
        • Ryan J.F.
        • Istl A.C.
        • et al.
        Perceived barriers to the development of technical skill proficiency in surgical clerkship.
        J Surg Educ. 2019; 76: 1267-1277
        • Moulton C.A.E.
        • Dubrowski A.
        • Macrae H.
        • Graham B.
        • Grober E.
        • Reznick R.
        Teaching surgical skills: what kind of practice makes perfect?: a randomized, controlled trial.
        Ann Surg. 2006; 244: 400-409
      2. A 3D printed suturing trainer for medical students - Boyajian - 2020 - the clinical teacher - Wiley Online Library.
        (Available at:)
        • Vanyolos E.
        • Furka I.
        • Miko I.
        • Viszlai A.
        • Nemeth N.
        • Peto K.
        How does practice improve the skills of medical students during consecutive training courses?.
        Acta Cirúrgica Bras. 2017; 32: 491-502
        • Bowrey D.J.
        • Kidd J.M.
        How do early emotional experiences in the operating theatre influence medical student learning in this environment?.
        Teach Learn Med. 2014; 26: 113-120
      3. The anxieties of new clinical students.
        (Available at:)
        https://pubmed.ncbi.nlm.nih.gov/1538650/
        Date accessed: February 24, 2022
      4. ACS/ASE medical student simulation-based surgical skills curriculum.
        (Available at:)
        • Emmanuel T.
        • Nicolaides M.
        • Theodoulou I.
        • Yoong W.
        • Lymperopoulos N.
        • Sideris M.
        Suturing skills for medical students: a systematic review.
        In Vivo. 2020; 35: 1-12
        • Porte M.C.
        • Xeroulis G.
        • Reznick R.K.
        • Dubrowski A.
        Verbal feedback from an expert is more effective than self-accessed feedback about motion efficiency in learning new surgical skills.
        Am J Surg. 2007; 193: 105-110
        • Brydges R.
        • Carnahan H.
        • Dubrowski A.
        Assessing suturing skills in a self-guided learning setting: absolute symmetry error.
        Adv Health Sci Educ Theory Pract. 2009; 14: 685-695
        • Bekele A.
        • Wondimu S.
        • Firdu N.
        • Taye M.
        • Tadesse A.
        Trends in retention and decay of basic surgical skills: evidence from Addis Ababa University, Ethiopia: a prospective case-control cohort study.
        World J Surg. 2019; 43: 9-15
        • Ganier F.
        • de Vries P.
        Are instructions in video format always better than photographs when learning manual techniques? The case of learning how to do sutures.
        Learn Instr. 2016; 44: 87-96
        • Dubrowski A.
        • MacRae H.
        Randomised, controlled study investigating the optimal instructor: student ratios for teaching suturing skills.
        Med Educ. 2006; 40: 59-63
        • Gershuni V.
        • Woodhouse J.
        • Brunt L.M.
        Retention of suturing and knot-tying skills in senior medical students after proficiency-based training: results of a prospective, randomized trial.
        Surgery. 2013; 154: 823-830
        • Brunt L.M.
        • Halpin V.J.
        • Klingensmith M.E.
        • et al.
        Accelerated skills preparation and assessment for senior medical students entering surgical internship.
        J Am Coll Surg. 2008; 206: 897-904
        • Sutherland L.M.
        • Middleton P.F.
        • Anthony A.
        • et al.
        Surgical simulation: a systematic review.
        Ann Surg. 2006; 243: 291-300
        • Sturm L.P.
        • Windsor J.A.
        • Cosman P.H.
        • Cregan P.
        • Hewett P.J.
        • Maddern G.J.
        A systematic review of skills transfer after surgical simulation training.
        Ann Surg. 2008; 248: 166-179
        • Hasan O.
        • Ayaz A.
        • Jessar M.
        • Docherty C.
        • Hashmi P.
        The need for simulation in surgical education in developing countries. The wind of change. Review article.
        JPMA. 2019; 69: S62-S68
        • Okrainec A.
        • Smith L.
        • Azzie G.
        Surgical simulation in Africa: the feasibility and impact of a 3-day fundamentals of laparoscopic surgery course.
        Surg Endosc. 2009; 23: 2493-2498
        • Livingston P.
        • Bailey J.
        • Ntakiyiruta G.
        • Mukwesi C.
        • Whynot S.
        • Brindley P.
        Development of a simulation and skills centre in East Africa: a Rwandan-Canadian partnership.
        Pan Afr Med J. 2014; 17: 315
        • Parham G.
        • Bing E.G.
        • Cuevas A.
        • et al.
        Creating a low-cost virtual reality surgical simulation to increase surgical oncology capacity and capability.
        Ecancermedicalscience. 2019; 13: 910