{"paper_id":"27d4d359-2b86-4533-af3b-7fc3f191f34e","body_text":"Investigating the impact of the COVID-19 pandemic on postgraduate surgical technical skills training: a systematic review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Investigating the impact of the COVID-19 pandemic on postgraduate surgical technical skills training: a systematic review Aditi Siddharth, Nadia Muspratt Tucker, Hikari Sakurai, Debbie Aitken, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6938176/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Surgical training was significantly affected during the COVID-19 pandemic due to several factors, including the postponement of professional exams, fewer hands-on surgical training opportunities and redeployment. This systematic review aimed to explore the impact of the COVID-19 pandemic on post-graduate technical skills training in surgical specialities. Methods The systematic review was conducted following the guidelines set out by PRISMA with the inclusion of studies on surgical training from any of the 12 specialities. The studies were screened in duplicate. A thematic analysis was conducted on the extracted data. Results Fifty-three studies reported a significant impact on technical skills training due to the pandemic with statistically significant reduction in operating compared to before the pandemic. Only a few studies discussed the use of simulation, to which about 50% of the trainees had access, but was underutilised during the prolonged downtimes where trainees could not operate but could have practised in simulation. There was a lack of evidence regarding recovery planning, with only one study that discussed the use of the independent sector as a potential avenue to provide trainees with opportunities for technical skills training. Worries regarding progression, exam cancellations and loss of technical skills were reported by most of the studies in this review. Conclusion There is an opportunity for a paradigm shift in surgical training with technical skills simulation as an essential adjunct to learning in the operating theatre after the pandemic. These findings underscore the need for adaptable, equitable recovery measures to address training deficits. COVID-19 pandemic Surgical training Systematic review Technical skills Figures Figure 1 Figure 2 Background Surgical training was significantly affected during the pandemic due to several factors, including the postponement of professional exams, fewer hands on surgical training opportunities, cancelling of educational courses, reduced simulation training and redeployment and workforce restructuring 1 . The concerns trainees and educators had during the pandemic was reflected by the increase in publications related to surgical training. For example, when using the search terms “technical skills training” and “surgery” on PubMed, the number of publications per year showed an upward trend over the last two decades (Fig. 1 ) and reached a peak at the time of the pandemic 2 . There was also uncertainty about which educational interventions to use in recovery planning 3 , 4 . A few systematic reviews on surgical training from different surgical specialities were published during and immediately after the pandemic 5 – 7 . These reviews, however, either did not provide enough detail about technical skills training, did not include all 12 surgical specialities, had included medical students and residents, were geographically restricted or had too wide a range of outcome measures and weren’t specific enough about technical skills training. The purpose of this systematic review, therefore, was to provide an in-depth understanding of the impact of the pandemic on technical skills training for postgraduate doctors in all 12 surgical specialities, and provide insights on appropriate recovery efforts for local, regional and national training bodies and educators to implement. Methods The systematic review protocol was registered a priori with PROSPERO (registration number: CRD42022304218). The systematic review was conducted following the guidelines set out by PRISMA 8 . Inclusion criteria The study population for the included studies were doctors in post-graduate surgical training programmes, with studies published during the COVID-19 pandemic, from 2019 to 2021 and studies that investigated technical skills training in a surgical speciality. Though we did not specifically exclude studies based on the outcome measures, we anticipated that outcome measures must align with the learning and maintenance of technical skills to be included. This included outcome measures that involved time spent in the operating theatre, competencies achieved for the annual review of competency progression (ARCP) or equivalent measures of progression. Similarly, other outcome measures we considered were number of procedures, theatre log review, and training tools used for acquiring and maintaining technical skills including simulation. All study designs, including those that used quantitative, qualitative, or mixed methodologies (except letters, correspondence, and editorial reviews) were included. Search Strategy To develop the search strategy, we were assisted by a specialist librarian from the University of Oxford. The search strategy was developed after due consideration to Medical Subject Headings (MeSH) terms and synonyms that could be used for surgeons in training e.g. “trainee” and “resident” (box 1). A comprehensive search of MEDLINE and EMBASE was undertaken on 7th of January 2022, which included grey literature from conference abstracts. ENDNOTE X9 was used to store the search results and automatic de-duplication was performed. Further de-duplication was done by hand. Further attempts were made to identify grey literature by searching the theses databases via the Oxford University library search engine and handsearching reference lists. 1 exp Education, Medical, Graduate/ (76692) 2 ((Postgrad* or post grad*) adj3 (train* or learn* or educat* or teach*)).ti,ab. (10769) 3 ((Postgrad* or post grad*) adj3 (train* or learn* or educat* or teach*)).tw. (10769) 4 Residen*.tw. (274743) 5 Intern*.tw. (1011537) 6 Specialist trainee*.tw. (177) 7 Registrar*.tw. (4436) 8 1 or 2 or 3 or 4 or 5 or 6 or 7 (1309252) 9 exp Specialties, Surgical/ (210530) 10 (Surg* or operat* or procedur*).tw. (3649117) 11 Neurosurg*.tw. (53005) 12 Obstetric*.tw. (104282) 13 Gynaecolog*.tw. (22727) 14 Gynecolog*.tw. (83286) 15 ENT.tw. (14869) 16 Otolaryngol*.tw. (18495) 17 Orthopaedic*.tw. (44234) 18 Orthopedic*.tw. (50803) 19 Urolog*.tw. (59131) 20 Ophthalmol*.tw. (59053) 21 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 (3991156) 22 8 and 21 (253569) 23 COVID-19/ or Coronavirus/ or SARS-CoV-2/ (134011) 24 22 and 23 (2019) Box 1 Search terms used for the systematic review to understand the impact of COVID-19 pandemic on technical skills training in surgical specialities Screening process AS was the primary reviewer and screened all the abstracts and titles. NMT and HS acted as second reviewers, each reviewing half of the papers, and independently screening the papers identified after the initial search. Any disagreements regarding the inclusion or exclusion of papers was resolved after discussion and with the help of DA and HH who acted as the arbitrators. Full text reviews were also conducted in duplicate independently. Data extraction and analysis Three thousand two hundred and thirty-eight papers were screened by title and abstract and 385 papers underwent full text screening. Sixty-two studies fulfilled the inclusion criteria and data was extracted onto a Microsoft Excel™ spreadsheet. Information regarding the study design, the surgical speciality, participant population and demographics, the country the study was conducted in, the outcome measures used to describe technical skills, and a summary of the results and conclusions were noted. The extracted data was coded by AS with inductive coding keeping in mind the aim of the review which was to understand the impact of the COVID-19 pandemic on technical skills training. The codes were reviewed by the other reviewers (NMT and HS) and the supervisors to check they accurately represented the data. Themes were developed from the codes using an iterative process. A narrative synthesis and descriptive analysis was performed as the studies included in this review used a wide range of methodologies including quantitative, qualitative? and mixed methods. Appraisal of study quality Risk of Bias assessment was conducted using the NIH quality assessment tool for Observational, Cohort and Cross-sectional studies tool 9 and was recorded alongside in the data extraction Microsoft Excel spreadsheet. Changes to the registered protocol The scope of the systematic reviewed was narrowed exclusively to technical skills after discussion with surgical trainees and educators. Also, the tool for quality assessment was changed from the CASP checklist to the NIH quality assessment tool for Observational, Cohort and Cross-sectional studies tool 9 which was more suitable for the wide variation of methodologies of the included studies. Results The full texts of 385 studies were reviewed and 62 were found to meet the inclusion criteria of this systematic review (Fig. 2 ). The majority of studies were conducted in high income countries (71%). None of the studies were from low-income countries (Table 1 ). Table 1 Classification of countries where the studies were conducted by socio-economic status based on the World Bank world development indicators 10 There were five studies that were conducted globally and included multiple countries (Table 2 ). The countries represented in these studies were all from lower middle, upper middle- and high-income countries. The World Bank classification of countries The studies included in the systematic review (n = 62) High Income countries 44 (71%) Upper middle-income countries 7 (11%) Lower middle-income countries 6 (10%) Low-income countries 0 Global 5 (8%) Table 2 Details of the countries that were included in the global studies. Abbreviations: UK- United Kingdom, USA- United States of America The majority of papers are from general surgery (26%) and neurosurgery (21%) and none from vascular surgery (Table 3 ). Studies that were classified as global Countries where the study was conducted The World Bank classification of countries COVID-19 and cardiothoracic surgery: Effects on training and workforce utilisation in a global pandemic 11 USA, Canada, Columbia, Finland, Australia, South Korea, Nigeria High Income and lower middle income The effect of COVID-19 on trainee operative experience at a multihospital academic neurosurgical practise: A first look at case numbers 12 USA, Egypt High income and lower middle income The impact of COVID-19 on surgical training: a systematic review 5 France, UK, Canada, USA, Kuwait, Saudi Arabia, Serbia, Italy, Chile, India, Pakistan, Latin America High income, upper middle income, lower middle income Reshaping ophthalmology training after COVID-19 pandemic 13 Slovenia, Mexico, Argentina, Ukraine, Morocco, Croatia, Poland, India, France, USA, Israel, Turkey, Philippines, Spain, Netherlands, UK, Italy, Belgium, Chile, Germany, Latvia, Greece, Switzerland, Ireland, Jordan, Pakistan, Singapore, Austria, Bosnia, Herzegovina, Bulgaria, Estonia, Guatemala High income, upper middle income, lower middle income What is the impact of the COVID-19 pandemic on residency training: a systematic review and analysis 6 UK, USA, Italy, India, Saudi Arabia, Nigeria, Pakistan, Peru, Canada, Germany, Taiwan, South Korea High income, upper middle income, lower middle income Table 3 Analysis of the surgical specialities that are represented in the studies included in this review. Abbreviations: ENT- Otolaryngology, O&G- Obstetrics and Gynaecology, OMFS- Oral and Maxillofacial surgery Specialities The studies included in the systematic review (n = 62) Cardiothoracic surgery 2 (3%) General surgery 16 (26%) Neurosurgery 13 (21%) OMFS 1 (2%) ENT 3 (5%) Paediatric 1 (2%) Plastic surgery 1 (2%) Orthopaedics 4 (6%) Urology 8 (13%) Vascular surgery 0 O&G 1 (2%) Ophthalmology 8 (13%) Multiple surgical specialities 4 (6%) Methodology of the studies All but one of the studies included used quantitative methods to present their findings. Surveys were the most common method of data collection and was used in 60% (n = 37) of the studies. One study used a mixed methodology approach (Table 4 ). Table 4 Methodology and subgroup analysis of methodologies of the studies included in this review Methodology Studies included in this review (n = 62) Quantitative 61 (98%) Qualitative 0 Mixed Methodology 1 (2%) Subgroup analysis Quantitative methodology Self-reported data: Surveys 37 (60%) Non-self-reported data: Operative logs, workplace-based assessments, calculation of costs etc. 20 (32%) Both self-reported and non-self-reported data 3 (5%) Review of literature 1 (2%) Qualitative methodology Self-reported: Interviews etc 0 Review of literature 0 Mixed methodology review of literature 1 (2%) The impact of the COVID-19 pandemic on technical skills training for postgraduate surgical specialities The thematic analysis, which focussed on understanding the impact of the COVID-19 pandemic on technical skills training, described three key themes from the analysis of the data: Reduced operating, no change to operating or improved operating opportunities, with no impact to technical skills training Reduced operating opportunities with a moderate negative impact on technical skills training Reduced operating opportunities with a significant negative impact on technical skills training Reduced operating, no change to operating or improved operating opportunities, with no impact to technical skills training Table 5 shows the results from studies that reported no impact to technical skills or progression with either no change to operating, increased operating for a few residents or minimal reduction in operating during the pandemic with five papers (including one conference abstract) from general surgery, neurosurgery, and ENT. The studies showed that the operating volume either minimally reduced or did not change or for a small cohort of trainees, increased, thereby helping them continue with skill development and training during the pandemic. Three of the five papers in this theme were appraised as good quality with low risk of bias. Title, year, location, speciality, reference Study design, methodology Results Appraisal of quality using NIH assessment tool General surgery chief residents’ perspective on surgical education during the coronavirus disease 2019 (COVID-19) pandemic, 2020, USA, General Surgery, 14 A prospective cross-sectional survey of chief residents to evaluate recommendations from a previous study of programme directors. 62% (24/39) response rate 88% participants planned for a fellowship afterwards, 100% were concerned about delays in board examinations due to COVID with a delay in graduation date. 75% wanted to continue with planned graduation and move on to a fellowship as planned. Trainees had a loss of operative volume due to the pandemic, but this did not affect them achieving minimum requirements Good By the numbers analysis of effect of COVID-19 on a neurosurgical residency at the epicentre, 2020, USA, Neurosurgery, 15 A comparative analysis of operative volume between 2020 and 2019 (a 7-week period in each year) The case volume decreased from 530 operations in 2019 to 448 operations in 2020 and from 340 endovascular operation since 2019 to 253 in 2020. Though case volume was decreased, operative work continued through the pandemic at average 1.4 cases/day Poor Impact of COVID-19 on the surgical volume of general surgery residents as main surgeons in a National Training Program in Costa Rica, 2021, Costa Rica, General Surgery, 16 A comparative analysis of operative volume of 10 residents between March- June 2020 with December 2019- March 2020 Operative volume was 291 pre-pandemic and 241 procedures during the pandemic. Year 2 trainees had increased operating during the pandemic (pre-pandemic 19% vs pandemic 27%, p = 0.028). Year 3 trainees performed procedures during the pandemic in the breast and foregut unit that they had not performed before the pandemic. Year 4 trainees had a statistically significant increase in procedures in breast surgery (pre-pandemic 1% vs. pandemic 8%, p = .008) and surgical emergencies (pre-pandemic 27% vs. pandemic 51%, p < .001) Good A Tale of Two Cities: Residents’ Operative Experience in the United Kingdom and Germany During the Coronavirus Disease 2019 Pandemic, 2021, Germany and UK, Neurosurgery, 17 A comparative analysis of operative volume between 2 centres and between 2019 and 2020 (3-month period in each year) Statistically significant reduction in operative volume from the pre-COVID months to the COVID months in the UK centre (p < 0.001) but no significant difference in the operative volume in the German centre (p = 0.61). The average number of procedures performed by residents in the UK centre as the primary surgeon decreased from 82 cases pre-COVID to 72 cases per month during the pandemic whereas German residents’ operating volume increased from 68 to 89 per month (pre-COVID vs. COVID months) Good Effect of the COVID-19 Pandemic on Otorhinolaryngology Residency Training, 2021, conference abstract, USA, ENT, 18 A retrospective comparative analysis of operative volume between 2019 and 2020 (3 months in each year) From March 15, 2020, to May 31, 2020, residents participated with the primary surgeon in 331 procedures compared with 63 procedures between the same period in 2019, noting an increase in operating during the pandemic Poor Table 5 Thematic analysis based on impact of COVID on technical skill training. Theme: Reduced operating, no change to operating or improved operating opportunities, with no impact to technical skills training. Appraisal of study quality was carried out using - National Institutes of Health (NIH) quality assessment tool for Observational, Cohort and Cross-sectional studies tool 9 . Abbreviations: ENT- Otolaryngology, NIH- National Institutes of Health, UK- United Kingdom, USA- United States of America Reduced operating opportunities with a moderate negative impact on technical skills training All four studies included in this theme (from general surgery, neurosurgery, and ophthalmology) showed reduced operating opportunities during the COVID-19 pandemic, with a moderate negative impact on technical skills training (Table 6 ). These studies demonstrate a variable impact among the trainees (i.e., junior residents were less impacted compared to their senior counterparts), or only one type of surgical opportunity was reduced (e.g., medium complexity operations) or limited time where the operating was reduced (during the latter half of the study period or COVID-19 pandemic) in the hospitals where the studies were conducted. Half the studies in this theme were of good quality. Table 6 Thematic analysis based on impact of COVID on technical skill training. Theme: Reduced operating opportunities with moderately negative impact on technical skills training. Appraisal of study quality was carried out using - National Institutes of Health (NIH) quality assessment tool for Observational, Cohort and Cross-sectional studies tool 9 . Abbreviations: NIH- National Institutes of Health Title, year, location, speciality reference Study design, methodology Results Appraisal of quality using NIH assessment tool COVID-19 and neurosurgical training and education: an Italian perspective, 2020, Italy, Neurosurgery, 19 A prospective cross-sectional survey of neurosurgical residents about their training experience from March to May 2020. 58% response rate (192/331) 79% performed less operations and 16% did not perform any operations at all. 3 trainees reported increased surgical activity. Senior residents were more affected by the global reduction of neurosurgical activity as compared with year 1 and 2 residents Fair Impact of COVID-19 pandemic on general surgery training program: An Italian experience, 2020, Italy, General Surgery, 20 A comparative analysis of operative volume of postgraduate year 6 trainees between March to May 2020 to January to March 2020 Statistically significant decrease in operations performed during the second period of the study (p = 0.033), especially of medium-complexity surgeries usually performed by the year 6 residents as first operator Good Impact of COVID-19 on Saudi Neurosurgery Residency: Trainers’ and Trainees’ Perspectives, 2021, Saudi Arabia, Neurosurgery, 21 A prospective comparative survey of residents and programme directors of training during COVID and pre-COVID from March to May 2020. Response rate was 100% from programme directors and 95% from residents 59% agreed that resident surgical skills would be affected if the pandemic lasted 6 months or more. Before the pandemic, 53% of the residents were involved in 2–3 surgeries per week, but during the pandemic, 70% were attending 0–1 case per week, showing a loss of operative volume Fair Residents' Perceived Impact of COVID-19 on Saudi Ophthalmology Training Programs-A Survey, 2020, Saudi Arabia, Ophthalmology, 22 A prospective cross-sectional survey of residents in July 2020 about training during the COVID-19 pandemic compared to before the pandemic 61% reported an increase or same volume of emergency operating, though there was an 82% reduction of elective operating. Emergency operating was unaffected though elective office-based procedures was significantly reduced (p < 0.001) Good Reduced operating opportunities with a significant negative impact on technical skills training Fifty-three studies reported a significant impact on technical skills training due to the pandemic with statistically significant reduction in operating compared to before the pandemic (Table 7 ). Four of the included 53 studies were conference abstracts and two were systematic reviews. The studies were representative of all the surgical specialities except vascular surgery. All of the studies showed that majority of operating was suspended during the pandemic, with significant reduction in trainee operating. Four of the studies provided details about access to simulation, where about 50% of the participants had access to simulation 23 – 27 . Only one of the four studies indicated intentional use of the simulation where at least a third of the trainees found useful 25 . Three of the studies discuss the loss of confidence experienced by the majority of trainees due to the significant loss of operating experience during the pandemic 23 , 28 , 29 . Only one study had initiated recovery plans which focussed on giving nearly half the trainees access to operating at hospitals in the independent sector. Other potential recovery measures briefly discussed were extending training to compensate and pursuing fellowships after training. Trainees were first surgeons on four of the seven cases in each operating list, and 80% of the trainees considered the experience to be enjoyable with half the trainees achieving their training goals using this experience 30 . Twenty six of the 53 studies were of good quality. Table 7 Thematic analysis based on impact of COVID on technical skill training. Theme: Reduced operating opportunities with significantly negative impact on technical skills training. Appraisal of study quality was carried out using - National Institutes of Health (NIH) quality assessment tool for Observational, Cohort and Cross-sectional studies tool 9 . Abbreviations: AR- Augmented Reality, ARCP: Annual Review of Competency Progression, ENT- Otolaryngology, NIH- National Institutes of Health, SARS- Severe Acute Respiratory Syndrome, UK- United Kingdom, USA- United States of America, VR- Virtual Reality Title, year, location, speciality, reference Study design, methodology Results Appraisal of quality using NIH assessment tool Effect of SARS and COVID-19 outbreaks on urology practise and training, 2021, China, 31 A comparative study of data collected from a prospective cross-sectional survey of all residents from all the urology centres (n = 11) in Hong Kong (49% response rate) and a review of the operative logs The mean operating sessions before the COVID-19 pandemic and during the COVID-19 pandemic was significantly reduced (85 versus 51 procedures respectively, p = 0.005). The numbers of operating sessions was reduced by 41% across all of the reviewed centres. 53% had cancelled professional examinations with delays with progression in training Fair Impact of the COVID-19 pandemic on core surgical training, 2020, UK, 23 A prospective cross-sectional survey of core surgical trainees (64% response rate, 28/44) 71% reported fewer operative opportunities. None of the trainees had performed any form of endoscopy during the pandemic. 50% trainees had access to their own laparoscopic box trainer. 71% felt their confidence performing surgical skills had been negatively impacted by the pandemic in open, laparoscopic, and endoscopic surgery Fair Impact of COVID-19 on Neurosurgical Training in Southeast Asia, 2020, Indonesia, Malaysia, Philippines, Singapore, and Thailand, 32 A descriptive cross-sectional survey of residents from 33 training programmes in South-East Asia (298 responses, 63% response rate) Reduction in elective procedures ranged from 50% in Thailand to 100% in Indonesia and the Philippines, 92% in Malaysia and 70% in Singapore (statistically significant). 74% of the trainees believed pandemic had a negative impact on their overall neurosurgical training, Residents were most concerned marked decrease in their hands-on surgical experience, uncertainty about their board examination and potential delay in career advancement, increasing number of backlog cases Good Has 2020 been a lost year in orthopaedic surgery and trauma training? Residents’ perceptions, 2021, Spain, 33 A prospective cross-sectional survey of 307 orthopaedic residents in February 2021 70% of surgeries were suspended in 2020, with no operating for an average of 8 weeks, affecting 67% of the residents. 52% considered the impact of the pandemic as bad or very bad on their surgical training. Majority wanted extra training time to compensate for that lost year Good The impact of COVID-19 on surgical training at a tertiary hospital in Greece: a ‘hidden infectious enemy’ for junior surgeons?, 2021, Greece, 28 A prospective cross-sectional survey of all core general surgical trainees from one hospital about their operative experience during and before the pandemic (Sept- Nov 2019 and 2020). 94% response rate (16/17) All trainees performed almost 50% fewer cases during the pandemic. Senior trainees assisted in 37 cases during the pandemic compared to 90 before the pandemic. 63% trainees reported less confidence in the operating theatre because of the pandemic Good The Impact of the Coronavirus Pandemic on European Neurosurgery Trainees, 2021, Europe, 34 A prospective cross-sectional survey of all European neurosurgical residents about their operative exposure before and during the pandemic. 16% response rate (134/810) 93% of residents reported a reduction of hands-on surgical exposure. One-third of the participants were spending > 15 hours in the operating room pre-pandemic but 52 residents spent more than 10 hours in the operating room during the crisis, indicating a statistically significant decrease in operative exposure (p < 0.05). Some trainees estimated a whole year equivalent of hands-on training was lost Poor How the COVID-19 pandemic changed urology residency – a nationwide survey from the Portuguese resident’s perspective, 2021, Portugal, 35 A prospective cross-sectional survey of urology residents regarding their operative experience before and during the pandemic in May 2020. 54% response rate (43/79) 49% reported up to 100% reduction in minor operative procedures. 40% reported a > 50% reduction in major operative procedures. 54% of residents reported a reduction of robotic and laparoscopic procedures due to concerns about contamination during the COVID-19 pandemic. 72% of residents considered their training was very or extremely affected due to the COVID-19 pandemic. 33% of residents wanted to prolong their residency program Good The reduction in clinical and surgical exposure of trainees during COVID-19 and its impact on their training, 2021, Pakistan, 36 A comparative study of results from a prospective cross-sectional survey of general surgical trainees from one unit (18/24, 75% response rate) to the operative log from August 2019 to May 2020 The number of elective cases performed went down to 1,465 from 2,364 (p < 0.005) during COVID compared to pre COVID, corroborated by the logbook data. Major cases performed by trainees, pre-COVID was 332, during COVID reduced to 105. Minor cases pre-COVID was 113, during COVID was 55. Reduction in operative volume was similar across all training years, showing a significant impact on operative exposure Good Canadian ophthalmology resident experience during the COVID-19 pandemic, 2020, Canada, 37 A prospective cross-sectional survey of all residency programmes in May and June 2020. 47% response rate (102/217) 51% of residents were working at reduced volumes. 65% of residents on surgical rotations had not operated in the previous 2 weeks. 55% of residents were concerned about their surgical skills deteriorating owing to the shutdowns. 51% did not have access to a surgical simulator. Operative skill was affected but trainees didn’t feel it would affect long term competency Good COVID-19 and cardiothoracic surgery: Effects on training and workforce utilisation in a global pandemic, 2021, conference abstract, USA, Canada, Columbia, Finland, Australia, South Korea, Nigeria, 11 A prospective cross-sectional survey of cardiothoracic surgery trainees in June-August 2020 regarding their operative exposure during and before the pandemic. 22% response rate (126/748) 86% of the trainees reported a reduction in the operative volume of which 54% reported a > 50% reduction and 23% did not operate at all. 98% of the USA trainees and 80% of international trainees reported reduction of operative volume (statistically significant). 38% would not meet the minimum case requirements for progression Fair Impact of the COVID-19 Pandemic on Ophthalmology Residency Training in Portugal, 2020, Portugal, 38 A prospective cross-sectional survey conducted between March and April 2020 of all ophthalmology trainees in Portugal. 94% response rate (75/80) No department performed elective ophthalmology surgeries during the pandemic. Nearly half the residents participated in emergency surgery. 99% did not perform cataract operations during the pandemic compared to 8% before the pandemic Fair The Continuing Impact of Coronavirus Disease 2019 on Neurosurgical Training at the 1-Year Mark: Results of a Nationwide Survey of Neurosurgery Residents in Turkey, 2021, Turkey, 25 A prospective cross-sectional survey of neurosurgical residents from Turkey conducted in January and February 2021 about surgical training during and before the pandemic. 54% response rate (356/435) 50% reported a significant decrease of elective operating, 9% felt it was unchanged 4% felt it increased. Only 6% felt emergency operating considerably decreased. 25% considered the impact of the pandemic to be considerably negative with decreased operative case diversity, decreased operative volume, decreased weekly work hours, assignment in the COVID services, interrupted training due to COVID isolations, loss of motivation. Useful simulation practise: cadaveric practise 30% and VR/AR simulator 30%. 42% have increased concerns about the effect of the pandemic on surgical training with 31% preferring an extension of their training Fair Factors Associated With General Surgery Residents’ Operative Experience During the COVID-19 Pandemic, 2021, USA, 39 A comparative study of retrospective review of 1358 operative logs from 3 consecutive academic years (4 months in 2017–2018, 2018–2019, and 2019–2020) from 16 general surgery programmes and cross-sectional survey of programme directors from 16 general surgical programmes 771 resident case logs (57%) were from 8 university-based programs, 407 (30%) from 5 university affiliated programs, and 180 (13%) from 3 independent programs. Residents performed a mean of 68 major cases pre-pandemic compared with 45 cases during the pandemic (p < 0.001), with 34% reduction in operative volume during the pandemic. All training years were equally affected Good A Survey of the Impact of the COVID-19 Crisis on Skill Decay Among Surgery and Anaesthesia Residents, 2021, USA, 26 A cross sectional survey of surgical and anaesthetic residents and faculty from 2 large tertiary centres regarding training in 2019, 2020 and 2021. 53% response rate (91/173) Three chief residents did not meet defined minimum case log for general surgery in 2020. All surveyed residents felt that their training was significantly impacted due to COVID-19 pandemic. 82% reported a reduction in case volumes (p < 0.05). 64% perceived a reduction in technical operative skill and 75% of faculty perceived that residents experienced a reduction in technical skill. Re-deployed residents were more likely to report skill decay than residents who were not re-deployed (p < 0.05). Resident concerns included return to the operating room with worse skill, surgical skill acquisition for progression to the next clinical year, ability to practise independently as an attending physician, and achievement of required case numbers. 58% of residents did not utilise simulation to maintain their technical skills. 39% used suture kits, laparoscopic trainers (9%), robotic consoles (3%), mannequins (1%) and other specialty-specific trainers (3%) to maintain their operative skills Good The impact of COVID-19 related lockdown on ophthalmology training programs in India, 2020, India, 40 A cross sectional survey of ophthalmology residents via social media in April 2020. 716 responses received 81% reported a negative impact on their surgical training due to COVID lockdowns. 62% trainees reported a >/=50% reduction in operating Fair Impact of the COVID-19 pandemic on orthopaedic and trauma surgery training in Europe, 2020, Europe, 41 A cross sectional survey in May 2020 of 327 orthopaedic trainees in 23 European countries about training during the COVID pandemic compared to before During the pandemic, 57% of institutes allowed only emergency surgical procedures. 58% had significant concerns about the achievement of annual training goals. 46% believed they will not acquire the expected practical skills, 45% that they will not complete their logbook, and 16% that their final exams will be postponed. One fourth of the respondents believed an additional year of appropriate training would be necessary and 61% believed they will finish their rotation as planned. 55% stated orthopaedic training will be negatively affected by the COVID-19 crisis Fair Impact of Elective Case Postponement Secondary to COVID-19 on General Surgery Residents’ Experience: Operative Cases Logged at Three Academic Teaching Hospitals, 2021, USA, 42 A retrospective cohort study of operative logs of general surgical trainees from three academic hospitals, 81 residents pre-COVID and 77 residents during COVID Year 4 residents had a significant decrease in total cases, 759 procedures during the pandemic compared to 1010 total cases before (p = 0.005). There was no difference for year 5 residents Good Impact of the COVID-19 pandemic on surgical skills training in paediatric surgery residents, 2021, Argentina, 29 A descriptive retrospective study of surgical training in the paediatric surgery department of one tertiary centre from March to May 2020. Results were compared to the same trimester in 2018 and 2019 to quantify the impact of the pandemic, 100% response rate The average number of surgeries in 2015–2019 was 530 compared to 368 surgeries during the pandemic, a reduction of 31%. No changes in case complexity was noted. A statistically significant reduction in procedures performed by the residents as leading surgeons in 2020. 70% reported no improvement in surgical performance and 50% reported taking more time to operate. All trainees spent < 10 hours a month on simulation before the pandemic but 70% of trainees reported > 10 hours a month during the pandemic. 70% reported a decrease in confidence during surgery Good Access and feasibility of orthopaedic training in the independent sector- A Deanery's experience, 2021, UK, 30 A cross sectional survey of trainees who attended operative theatre sessions at independent hospitals between November and December 2020 to supplement their surgical training. 89% response rate (57/64) 44% of trainees had accessed the 12 independent sector hospitals, attending an average of 4 sessions, and were first surgeons on 4 of the 7 cases in each operating list. 20% reported reluctance to allow training and obstruction from theatre staff. 80% reported an enjoyable experience and 52% reported to have achieved their goals. Only 29% felt private sector operating would compensate for their loss of training Good The impact of COVID-19 on urology resident surgical experience: An analysis of national case logs, 2021, conference abstract, Canada, 43 A comparative analysis of the theatre log from 11 urology residency programmes for 20 common urologic procedures, comparing data from September 2019-March 2020 with March 2020 to September 2020 12,831 procedures were recorded over 12-months by 122 residents in 11 training programs. 7211 procedures were logged before the pandemic compared to 5620 procedures after. 82% of programs reported a reduction in surgical volume Good Effects of the COVID-19 Pandemic on Operative Volume and Residency Training at Two Academic Neurosurgery Centres in New Orleans, 2021, USA, 44 A retrospective review of operative log from two tertiary centres comparing March to June 2020 with March to June 2019 Pre-pandemic operative average was 58 procedures/week. 77% reduction in operative procedures in 2020 Good The effect of COVID-19 on trainee operative experience at a multihospital academic neurosurgical practise: A first look at case numbers, 2021, USA and Egypt, 12 A retrospective review of operative log for 54 days pre-lockdown to 54 days post lockdown to evaluate the impact of the pandemic on operating exposure of trainees (March-May 2020 compared to January -March 2020) Mean total cases per day in the pre-lockdown group were 12.26, compared to 7.78 in the post lockdown group (p = 0.01) Good Impact of COVID-19 on Academic Activities of Ophthalmology Postgraduates: A Cross-sectional Survey, 2021, India, 45 A cross sectional online survey of Indian ophthalmology trainees in January 2021 to evaluate the impact of the pandemic on surgical training compared to before the pandemic. 84 trainees responded A marked reduction in operative procedures performed independently per week. 32% noted an increase in intraoperative surgical time post the pandemic. 36% were not satisfied with their surgical performance, because 41% were nervous to start, 8% wanted to finish quickly and 36% were not comfortable with new protocols. 49% did not report a change in complication rate Fair Impact of COVID-19 pandemic on plastic surgery activities and residency programs in a tertiary referral centre in Iran, 2021, Iran, 46 A retrospective case study of logbooks in a six-month time frame comparing two consecutive years (during and before the pandemic) There was a 70% reduction in case volume in plastic surgery. The total number of surgeries decreased by an average of 24% in all the specialities after the COVID-19 outbreak (p < 0.05) Good Impact of COVID-19 on operative experience of junior surgical trainees, 2020, UK, 47 A comparative study of operative logbooks in a five-month time frame of March-July 2019 with 2020 16,729 operative procedures were recorded during the control period compared with 6223 procedures during the COVID period, demonstrating a 63% decrease, across all levels of complexity Good Decrease in operative volume in general surgery residents in Chile: effects of the COVID-19 pandemic, 2021, Chile, 48 A comparative study of the operative logbooks of eight postgraduate year 3 trainees in 2019 to 2020 Significant decrease in the total number of surgical procedures of 62% (p < 0.001), though some trainees had more thoracic surgery exposure than usual due to the changes in the rota Fair Impact of COVID-19 on ophthalmic specialist training in the United Kingdom—the trainees’ perspective, 2020, UK, 49 A cross sectional survey of UK ophthalmology trainees in March 2020. 111 trainees completed the survey 87% were concerned COVID-19 will impact their training. Acquiring competencies like cataract surgery and completing the logbook worried up to 81% of the trainees Poor The impact of COVID-19 on surgical training: a systematic review, 2021, Global, 5 A systematic review and qualitative synthesis of surgical training before and during the pandemic from January 2020 to August 2020. 29 included studies All of the studies reported a decrease in the number of operative cases or operative experience available to trainees, particularly medium complexity operations where trainees would usually be the first operator Good Riding the waves: the ongoing impact of COVID-19 on a national surgical training cohort, 2021, UK, 50 Two online surveys of surgical trainees in May 2020 and October 2020 comparing surgical training during the first wave of the pandemic to the second wave of the pandemic. 29% response rate (98/340), with 44% core surgical trainees and 46% higher surgical trainees All trainees experienced a statistically significant reduction in day case operating and endoscopic sessions. Core surgical trainees also experienced a statistically significant decrease in emergency sessions. Major elective and emergency session numbers returned to pre-COVID levels in the second survey Good Military Otolaryngology Residency Training and Practise impact Assessment During COVID-19, 2021, conference abstract, USA, 51 A cross sectional survey to assess the impact of the pandemic on ENT surgical training in the Defence Health Agency sites Time in the operating room (p < .001) decreased significantly for both residents and faculty. Most residents (53%) were concerned about meeting their minimum case requirements for graduation Poor Impact of Coronavirus Disease on the Ophthalmology Residency Training in Brazil, 2020, Brazil, 52 A cross sectional survey conducted in May-June 2020 the programme directors of ophthalmology training programmes in Brazil to evaluate the impact of the pandemic on training. 83% (79/95) response rate 54% reported that elective surgery was completely suspended and for 20%, it was drastically reduced. For emergency operating, 76% said it was reduced, drastically reduced, or suspended. 70% of the education coordinators had a strategy to recover training with 11% planning to extend the period for course completion. 26% intended to increase the residents’ workload Fair Advanced head and neck surgery training during the COVID-19 pandemic, 2020, USA, 53 A comparative study of operative logs (2020 to 2019 and 2018) and a cross-sectional survey of programme directors, trainees, and fellows. 97% (37/38) of programme directors and 39% (12/31) of trainees responded 70% reported a 50–90% reduction in the number of elective cases and 76% reduction in emergency operating at their institutions. 81% stated that their fellows were still participating in oncology cases and remained active in a variety of procedures Fair Perceived Impact of Urologic Surgery Training Program Modifications due to COVID-19 in the United States, 2020, USA, 54 A survey of programme directors and residents at urology centres in March-April 2020. 43% (55/127) of programme directors and 18% (23/127) trainees responded 80% indicated that program changes had negatively impacted surgical training. 51% reported increased anxiety about competency upon residency completion. 9% expressed a likelihood of fellowship training. 90% reported spending more time in self-directed learning and 77% had more time for research (77%). 83%- 100% reported decreased surgical volume. Least affected were emergency surgery and oncology Fair Reshaping ophthalmology training after COVID-19 pandemic, 2020, Global (32 countries), 13 A cross sectional survey of ophthalmology trainees from 32 countries in May 2020 Surgical activity massively decreased with 75% of trainees reported a reduction of > 75% of their surgical practise. Half of respondents declared that they have suspended surgical practise completely. 53% of residents and 34% of fellows reported that they were not able to perform cataract surgery routinely anymore. The impact of COVID-19 pandemic was described as “severe” by most trainees (55%) Fair Decrease in Neurosurgical Program Volume During COVID-19: Residency Programs Must Adapt, 2020, USA, 55 An operative log review of case volume from March to May 2019 and 2020 Elective surgery volume (53%) and total surgical procedures (42%) decreased during COVID. Thrombectomies had increased by 21%. Operative cranial traumas had decreased by 18% Poor Impact of the COVID-19 Pandemic on Surgical Training and Learner Well-Being: Report of a Survey of General Surgery and Other Surgical Specialty Educators, 2020, USA, 27 A cross sectional survey of programme directors. 21% (472/ 2196) response rate The volume of surgical procedures was severely reduced by the pandemic with 87% reduction of elective operating. Emergency operative volume reduced by 20%. There was a severe negative impact on expected progression of operative autonomy across all stages reported by 14–18% of respondents. Nearly 70% (266 of 388) of respondents indicated that no extra steps were taken to develop technical competencies beyond the available clinical opportunities during the pandemic. 44% indicated that simulation centres were inaccessible during the pandemic Fair COVID-19 pandemic effect on otolaryngology resident surgical case numbers, 2021, conference abstract, USA, 56 A retrospective analysis of surgical operative logs of all residents from a large residency programme comparing February to March 2019 and 2020 The total decrease in surgical case numbers was 46%. Junior residents had a 28% decrease, while senior residents had a 54% decrease Good Impact of COVID-19 on surgical training, 2021, UK, 57 A retrospective comparative analysis of operative theatre records in a large teaching hospital comparing April to June 2019 to 2020 An overall reduction in operative volume by 66% during the pandemic, with a 71% decrease in the registrars as first operators Good Neurosurgery training in India during the COVID-19 pandemic: straight from the horse’s mouth, 2020, India, 58 A cross sectional survey via social media of neurosurgical trainees in India in May 2020 68% reduction in surgeries performed by trainees since the onset of the COVID-19 pandemic- 39.86 surgeries per month decreased to 12.31 per month(p < 0.0001). The majority of respondents felt that the COVID-19 pandemic will hamper their operative and clinical skills. Fear of rescheduling or deferring of licensing examinations was significantly higher among those closest to the examination (p = 0.002) Fair Impact of COVID-19 on a urology residency program, 2021, Brazil, 59 A retrospective analysis of surgical operative logs of all 18 urology residents in the 3rd, 4th, and 5th year of training from February to May 2017, 2018, 2019, 2020. 118 residents from 29 neurosurgical training programs across 17 states/union territories responded Overall surgical volume significantly decreased in 2020, by 51%, compared to the previous three years (p < 0.001), affecting the third, fourth and fifth year of the residency program Good COVID-19 impact on Surgical Training and Recovery Planning (COVID-STAR) - A cross-sectional observational study, 2021, UK, 60 A national, collaborative, cross-sectional study involving 13 surgical trainee associations using a pan-surgical specialty questionnaire on the impact of COVID-19 on surgical training over 4 weeks in May 2020 The reported impact of COVID-19 on surgical training experience was very significant (average on Likert scale was 8.66), with no difference between training grades or specialities. 84–87% reported complete suspension of elective non-cancer surgery and elective endoscopy operating. 76% reported at least a > 50% loss of operating. 73% anticipated an impact on their ARCP. Only 19% of trainees intended to progress to the next stage of training at ARCP having gained all training opportunities Good COVID-19 Pandemic and the Lived Experience of Surgical Residents, Fellows, and Early-Career Surgeons in the American College of Surgeons, 2020, USA, 61 A cross sectional online survey of members of the Resident Associate Society and the Young Fellows Association. 5% (1160/21385) response rate of which 40% were residents and 60% were fellows and early career surgeons 96% reported a negative impact of the COVID-19 pandemic. 84% of residents reported a > 50% reduction in operative volume and inability to meet minimum case requirements. 84% reported a reduction of 50% of elective operating and 19% reported a decrease in emergency operating Good What is the impact of the COVID-19 pandemic on residency training: a systematic review and analysis, 2021, Global, 6 A systematic review of surgical training until November 2020 51(96%) of the included studies reported a reduced operative case volume Fair The impact of COVID-19 pandemic on orthopaedic resident education: a nationwide survey study in South Korea, 2020, South Korea, 62 An online survey of orthopaedic residents from 43 hospitals in South Korea. 229 residents completed the survey Working time in the operating room was significantly decreased (p < 0.001). 68% of residents participated in surgeries for more than 10 hours/week before the COVID-19 pandemic but 48% participated in surgeries for more than 10 hours/week during the COVID-19 pandemic (p < 0.001) Fair Impact of coronavirus 2019 (COVID-19) on training and well-being in subspecialty surgery: A national survey of cardiothoracic trainees in the United Kingdom, 2020, UK, 63 A cross sectional online survey of cardiothoracic surgical trainees about the impact of the pandemic. 64% (76/118) responded Trainees reported a significant deviation in their sessional activity in operating theatres (p < 0.0001). 63% of trainees report somewhat (25%, n = 19) or very (63%, n = 48) concerned about the impact of the pandemic on their learning and progression through structured training. There was no association between trainee seniority and declared concern Fair Early Changes to Neurosurgery Resident Training During the COVID-19 Pandemic at a Large U.S. Academic Medical Centre, 2019, USA, 64 A retrospective analysis of 24 trainee operative logbooks in a single residency programme from January 2019 to June 2020 comparing pre COVID to the effect of the pandemic An average of 15 fewer cases had been logged in April 2020 (p < 0.01) and 5 fewer cases (20%) had been logged in May 2020 (p = 0.01). A comparison of the institutional case numbers showed a significant reduction in the overall case numbers for April and May 2020 compared with the same months in 2019 (mean difference 21, p = 0.01) Fair The influence of the COVID-19 outbreak on European trainees in obstetrics and gynaecology: A survey of the impact on training and trainee, 2021, Europe, 65 An online survey of the European Obstetrics and Gynaecology trainees via social media regarding the impact of the pandemic on their training. 110 trainees from 25 countries responded 95% of trainees reported a negative effect on their training due to COVID-19. Training was interrupted for 21% and 65% were worried about their training. Surgical skills training decreased for 67% of trainees due to cancellation of surgeries. 5% met the goals for their surgical competencies. Gynaecological oncology was least affected Fair Effect of COVID-19 on Surgical Training Across the United States: A National Survey of General Surgery Residents, 2020, USA, 66 A cross sectional survey of general surgical residents in all general surgical residency programmes (260) across the USA. 1102 residents completed the survey 41% reported that they were not allowed in the operating room for cases considered high-risk for COVID-19 transmission. Case volume reduction was statistically significant (p < 0.01) Good Urology Residency Training at the Time of COVID-19 in Italy: 1 Year After the Beginning, 2021, Italy, 67 A cross sectional survey of surgical training from 27 urology training programmes comparing the long-term impact of the pandemic with the training received pre-pandemic. 53% (312/585) response rate The proportions of those experiencing a significant decrease of training exposure were 27%, 47%, 38%, and 33% (as compared with 82%, 70%, 60%, and 50% in the previous survey) for diagnostic procedures, endoscopic surgery, open surgery, and minimally invasive surgery, respectively. The most impactful reductions in training activities were reached by final-year residents Good Impact of the COVID-19 pandemic on Urology Residency Training in Italy, 2020, Italy, 68 A cross sectional survey of Italian urology residents one month after the start of the pandemic. 61% (351/577) response rate Before the COVID-19 pandemic, the proportion of residents routinely involved in “surgical” activities ranged from 49–74%. In the COVID-19 period, the proportion of residents experiencing a severe reduction (> 40%) or complete suppression (> 80%) of training exposure ranged between 44% and 62% for surgical activities. This reduction was even more pronounced for residents attending the final year of training. Statistically significant reduction in diagnostic and endoscopic procedures (p < 0.001) for residents in year 2,3, 4 and 5. For open surgery, year 5 had a statistically significant decline in involvement Fair Impact of COVID-19 pandemic on urology residency training, 2020, Saudi Arabia, 69 A cross sectional survey of all urology residents about the impact of the pandemic on surgical training. 38% (77/202) response rate Statistically significant decline in diagnostic procedures (p < 0.001), endoscopic surgeries (p < 0.001), minimallyinvasive surgeries (p < 0.001), and major open surgeries (p < 0.001) in comparison to before the COVID-19 pandemic Fair Early Effects of COVID-19 Pandemic on Neurosurgical Training in the United States: A Case Volume Analysis of 8 Programs, 2020, USA, 70 A comparative review of the operative log from eight residency programmes from 2019 to January to April 2020 Compared with 2019, mean operative volume declined 15% (p = 0.003) in March 2020 and 49% (p = 0.002) in April 2020, respectively, which was statistically significant, affecting all the training programmes included in this study Good Impact of the COVID-19 Pandemic on Surgical Residency Training: Perspective from a Low-Middle Income Countries, 2020, Nigeria, 71 A cross sectional online survey of surgical residents from July to August 2020. 83% (207/250) response rate 59% reported a decrease and 36% reported no change in emergency operating. 91% reported a decrease in elective surgery. 82% believed the pandemic had a negative impact on their training and professional growth. 59% felt the pandemic had elongated the duration of training and time of completion of residency training Fair Discussion Aim The aim of this systematic review was to explore the impact of the COVID-19 pandemic on technical skill training in post-graduate surgical specialities and study the recovery measures being considered. Overview of findings This systematic review presented evidence from 62 papers published during the COVID pandemic about technical skills training in surgical specialities. The majority of the studies (71%) were from high income countries. All surgical specialities except vascular surgery were represented in this review. There were no papers published from vascular surgery that fit within the inclusion criteria of this review. The majority of papers used quantitative methods (98%), and relied on self-reported data collected through surveys, limiting the methodological diversity of the review. A meta-analysis was not possible due to the heterogenous nature of the studies and hence a thematic analysis was performed where the majority,53 of the 62 included studies, described a significant negative impact of the pandemic on operating and technical skills training. Only a few studies discussed the use of simulation, to which about 50% of the trainees had access. Simulation-based education was underutilised during the prolonged downtimes where trainees could not operate but could have practised in simulation 23 – 27 . Additionally, there was a lack of evidence regarding recovery planning, with only one study that discussed the use of the independent sector as a potential avenue to provide trainees with opportunities for technical skills training 30 . Worries regarding progression, exam cancellations and loss of technical skills were reported by most of the studies in this review. Impact on technical skills training The development of surgical technical skills relies on the acquisition of knowledge (through formal educational activities and self-study) and the practice of motor-skills through deliberate practise (traditionally reliant on the experience gained through operating on patients on the job, and more recently through simulation) 72 – 74 . The COVID-19 pandemic significantly disrupted surgical training by drastically reducing hands on training opportunities in the operating theatre which is critical for the development of technical surgical skills 57 . Of course, the damage was further enhanced by the cancellation of exams, the cancellation of courses and the inadequate use of simulation during this time 5 . Hands on training is essential for technical skills development and centres where operating was preserved witnessed less impact on technical skills training than the many centres where operating was severely reduced. Though in the past changes to surgical training e.g. work hour restrictions, competency-based training, shift pattern working etc were viewed as events that had a negative impact, it is well recognised now that no other global event has had such a devastating impact on technical skills training as the COVID-19 pandemic 60 . Historical context In their paper titled “Lessons from Epidemics, Pandemics, and Surgery”, Nicholas Hakes et al discuss the historical changes to surgery that have occurred in the wake of epidemics and pandemics 75 . The examples they quote include the formalisation of surgical guilds after the Plague, incorporating hygiene practises due to the Spanish flu and more recently the systemic flexibility that was required to deal with the Severe Acute Respiratory Syndrome (SARS) outbreak 75 . Arguably, one of the biggest challenges faced by the surgical specialities during the COVID-19 pandemic was the deterioration of surgical training and therefore, it is a logical conclusion one can draw that the post pandemic era of surgical training must require foundational restructuring- with a combined reliance on simulation and real world operating to gain the technical skills, with the overarching view that technical skills training obtained in an operating theatre and non-operating theatre environments go hand in hand. Proposal for recovery of technical skills training The only recovery measure discussed in this systematic review was the outsourcing of technical skill training to the independent sector 30 . The independent healthcare section in the UK is not accessible for everyone 76 , 77 . Though independent sector operating provided a potentially effective resource to consider post pandemic training recovery, other modalities for recovery such as simulation, training only operating lists, mentorship, extensions to training time and funding fellowships should also be considered. Furthermore, any recovery measures must be accessible, sustainable, and equitable 78 – 80 . Considering several avenues for recovery as described above would provide educators globally the chance to understand their contexts, access to resources, their trainees’ needs and enable them to apply the recovery measures that are likely to be the most effective. The use of simulation for technical skills training is evidence based. However, both with the evidence presented in this review and established in literature, simulation is often poorly implemented and therefore does not fulfil its potential as an adjunct to traditional technical skills training. The inadequate implementation of simulation presents us with a large gap in research that requires further exploration 81 – 83 . Strengths and limitations The PRISMA statement and guidelines were adhered to when conducting the systematic review to minimise identification and selection bias. Any changes to the protocol were documented and reported, to maintain transparency. This review, unlike other systematic reviews published about the impact of COVID on surgical trainees, specifically focussed on technical skills training. Also, this review included a wider range of surgical specialities than other previously published reviews. These steps enhanced the richness of the results, improving the overall scope and insights gained from the review. Studies were included based on their relevance to the research question and aim of the systematic review, irrespective of their risk of bias. It is worth noting, however, that publications based on individual opinion were excluded from this review. This variation in bias should be considered when interpreting the results. A strength of this review is in the thematic analysis, where each theme has emerged from the analysis of multiple studies of varying methodologies. This co-construction helped to strengthen the findings. Changes were made during the process of conducting the review that deviated from the registered protocol, and these were documented and reported. The changes included the narrowing of the scope of the review (focussing on technical skills training only) and changing the tool used for risk of bias analysis. The studies could not undergo meta-analysis due to the nature of the results presented and the lack of RCTs. A pooled estimate of the findings could not be statistically shown, and qualitative methodologies were applied to make sense of the data. The lack of publications from low-income countries highlights a publication bias. This limits the applicability of the findings of the study and the findings may not be easily extrapolated to a low-income context. Conclusion The purpose of this systematic review was to understand the impact of the COVID-19 pandemic on technical skills training in surgical specialities, adding to the evidence that exists regarding the issues with technical skills training and presenting potential recovery opportunities. This review has practical implications for the post-COVID recovery of surgical training. The recovery planning is an opportunity for a paradigm shift in surgical training with technical skills simulation as an essential adjunct to learning in the operating theatre. The findings underscore the need for adaptable, equitable recovery measures to address training deficits. Declarations Author Contribution AS: Concept, Protocol development, data collection, data analysis, manuscript writing, manuscript editingNMT and HS: Data analysisDA and HH: Project supervisor, data analysis, manuscript editing Acknowledgement Mr Neal Thurley, a librarian from the Bodleian Health Care libraries, helped refine the search protocol and conduct the search Funding and conflict of interest declaration There are no conflicts of interest to declare. No funding was received for this study References Daodu O, Panda N, Lopushinsky S, Varghese TK Jr, Brindle M. COVID-19–considerations and implications for surgical learners. Ann Surg. 2020;272(1):e22–3. PubMed. Pubmed search using terms technical skills training and surgery to demonstrate trends in publishing https:// pubmed.ncbi.nlm.nih.gov/rss/search/1RukBFKPvabUOwpfaD_9dWw3njLbn4uDp4xp_91dx1x82I8ctC/?limit=100&utm_campaign=pubmed-2&fc=20241118055212 Davidson LJ, Chow KY, Jivan A, et al. 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Impact of COVID-19 on Academic Activities of Ophthalmology Postgraduates: A Cross-sectional Survey. J Clin Diagn Res. 2021;15(12). Kalantar-Hormozi A, Habibzadeh Z, Yavari M, et al. Impact of COVID-19 pandemic on plastic surgery activities and residency programs in a tertiary referral centre in Iran. Eur J Plast Surg. 2021;44(6):817–23. Joyce D, Ryan D, Kavanagh D, Traynor O, Tierney S. Impact of COVID-19 on operative experience of junior surgical trainees. Br J Surg. 2021;108(1):e33–4. Inzunza M, Besser N, Bellolio F. Decrease in operative volume in general surgery residents in Chile: effects of the COVID-19 pandemic. Br J Surg. 2021;108(6):e226–7. Hussain R, Singh B, Shah N, Jain S. Impact of COVID-19 on ophthalmic specialist training in the United Kingdom—the trainees’ perspective. Eye. 2020;34(12):2157–60. Hennessy O, Fowler AL, Hennessy C, et al. Riding the waves: the ongoing impact of COVID-19 on a national surgical training cohort. Ir J Med Sci (1971-). 2022;191(4):1823–9. Haltiner C, Bevans S, Ruhl D, Wirtz E, Hong S, Ambrosio A. Military otolaryngology residency training and practice impact assessment during COVID-19. Otolaryngology-Head and Neck Surgery . 2021:P323-P323. Gondim MPMC, Carneiro PH, Moreno R, Lynch MI. Impact of Coronavirus disease on the ophthalmology residency training in Brazil. Arquivos brasileiros de oftalmologia. 2021;84:297–8. Givi B, Moore MG, Bewley AF, et al. Advanced head and neck surgery training during the COVID-19 pandemic. Head Neck. 2020;42(7):1411–7. Fero KE, Weinberger JM, Lerman S, Bergman J. Perceived impact of urologic surgery training program modifications due to COVID-19 in the United States. Urology. 2020;143:62–7. Field NC, Platanitis K, Paul AR, Dalfino JC, Adamo MA, Boulos AS. decrease in neurosurgical program volume during COVID-19: residency programs must adapt. World Neurosurg. 2020;141:566. Duffy J, Cabrera-Muffly C, Mann S. COVID-19 pandemic effect on otolaryngology resident surgical case numbers. Otolaryngology-Head and Neck Surgery . 2021:P157-P157. Davis C, Hayes L, Dent N, Jennings I, Arumugasamy M, Walsh T. Impact of COVID-19 on surgical training. Br J Surg. 2021;108(5):e199–200. Dash C, Venkataram T, Goyal N, et al. Neurosurgery training in India during the COVID-19 pandemic: straight from the horse’s mouth. NeuroSurg Focus. 2020;49(6):E16. Danilovic A, Torricelli FCM, Anjos Gd, et al. Impact of COVID-19 on a urology residency program. Int braz j urol. 2021;47:448–53. Clements JM, Burke J, Nally D, et al. COVID-19 impact on Surgical Training and Recovery Planning (COVID-STAR)-A cross-sectional observational study. Int J Surg. 2021;88:105903. Coleman JR, Abdelsattar JM, Glocker RJ, et al. COVID-19 pandemic and the lived experience of surgical residents, fellows, and early-career surgeons in the American College of Surgeons. J Am Coll Surg. 2021;232(2):119–35. e20. Chang D-G, Park J-B, Baek GH, et al. The impact of COVID-19 pandemic on orthopaedic resident education: a nationwide survey study in South Korea. Int Orthop. 2020;44:2203–10. Caruana EJ, Patel A, Kendall S, Rathinam S. Impact of coronavirus 2019 (COVID-19) on training and well-being in subspecialty surgery: a national survey of cardiothoracic trainees in the United Kingdom. J Thorac Cardiovasc Surg. 2020;160(4):980–7. Burks JD, Luther EM, Govindarajan V, Shah AH, Levi AD, Komotar RJ. Early changes to neurosurgery resident training during the COVID-19 pandemic at a large US academic medical center. World Neurosurg. 2020;144:e926–33. Boekhorst F, Khattak H, Topcu EG, Horala A, Henriques MG. The influence of the COVID-19 outbreak on European trainees in obstetrics and gynaecology: A survey of the impact on training and trainee. Eur J Obstet Gynecol Reproductive Biology. 2021;261:52–8. Aziz H, James T, Remulla D, et al. Effect of COVID-19 on surgical training across the United States: a national survey of general surgery residents. J Surg Educ. 2021;78(2):431–9. Amparore D, Checcucci E, Serni S, et al. Urology residency training at the time of COVID-19 in Italy: 1 year after the beginning. Eur Urol Open Sci. 2021;31:37–40. Amparore D, Claps F, Cacciamani GE et al. Impact of the COVID-19 pandemic on urology residency training in Italy. Minerva Urol Nefrol. 2020:0–0. Alyami FA, Almuhaideb MA, Alzahrani MA, Sabr YS, Almannie RM. Impact of COVID-19 pandemic on urology residency training. Urol Annals. 2021;13(3):215. Aljuboori ZS, Young CC, Srinivasan VM, et al. Early effects of COVID-19 pandemic on neurosurgical training in the United States: a case volume analysis of 8 programs. World Neurosurg. 2021;145:e202–8. Adesunkanmi AO, Ubom AE, Olasehinde O, et al. Impact of the COVID-19 pandemic on surgical residency training: perspective from a low-middle income country. World J Surg. 2021;45:10–7. Vaporciyan AA. Teaching and learning surgical skill. Ann Thorac Surg. 2016;101(1):12–4. Korte W, Merz C, Kirchhoff F, et al. Train early and with deliberate practice: simple coronary surgery simulation platform results in fast increase in technical surgical skills in residents and students. Interact Cardiovasc Thorac Surg. 2020;30(6):871–8. Wollstein Y, Jabbour N. Building Surgical Expertise Through Deliberate Practice. Ear Nose Throat J. 2022;101(9suppl):S47–51. Hakes NA, Choi J, Spain DA, Forrester JD. Lessons from epidemics, pandemics, and surgery. J Am Coll Surg. 2020;231(6):770–6. Vaughan-Shaw P, Chiverton S, Rew D, Nichols P. The Impact of an Independent Sector Treatment Centre on Basic Surgical Training. Bull Royal Coll Surg Engl. 2012;94(8):276–8. Kolaityte V, El-Sayed C, Burke J. SP2. 2.18 UK Surgical Training in the Independent Sector During COVID-19–A Snapshot Survey. Br J Surg. 2021;108(Supplement7):znab361. Kwan JY, Long J, McClean A, Chetter I, Lockwood S, Yiasemidou M. FTP8. 1 International expert opinion on the mitigation of the effects of the COVID-19 pandemic on surgical training. Br J Surg. 2023;110(Supplement6):znad241. Zhao S, Rothnie A, Nanda A, Chouari T, Ashraf S, Vig S. Developing Bespoke High Volume Low Complexity (HVLC) Theatre Lists With a Focus on Training to Address the Impact of COVID-19: A Pilot Study. Cureus. 2023;15(11). Bodapati S, Gambhir RPS, Kimura S. TU6. 1 Tackling the training deficit due to COVID-19 disruptions. Br J Surg. 2022;109(Supplement5):znac248. Davids J, Manivannan S, Darzi A, Giannarou S, Ashrafian H, Marcus HJ. Simulation for skills training in neurosurgery: a systematic review, meta-analysis, and analysis of progressive scholarly acceptance. Neurosurg Rev. 2021;44(4):1853–67. Bjerrum F, Thomsen ASS, Nayahangan LJ, Konge L. Surgical simulation: current practices and future perspectives for technical skills training. Med Teach. 2018;40(7):668–75. Stefanidis D, Sevdalis N, Paige J, et al. Simulation in surgery: what's needed next? Ann Surg. 2015;261(5):846–53. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 15 Sep, 2025 Editor assigned by journal 15 Sep, 2025 Submission checks completed at journal 23 Jun, 2025 First submitted to journal 20 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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14:34:07\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":53062,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThe number of publications per year from PubMed using the search terms “technical skills training” and “surgery”. The data highlights an upward trend in publications from 1999 onwards, reflecting increasing research interest in this area. Notably, a peak is observed around the time of the COVID-19 pandemic, likely secondary to the sudden changes to the surgical service that negatively affected trainee education. The x axis shows the year of publication, and the y axis represents the number of publications (2)\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6938176/v1/142163627f01e764aa778bad.png\"},{\"id\":93340715,\"identity\":\"dcd52f61-fafe-462a-9138-68611a91ff09\",\"added_by\":\"auto\",\"created_at\":\"2025-10-12 14:34:07\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":121208,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThe PRISMA flowchart for the systematic review on impact of COVID on training in a surgical speciality (9). Reason for exclusion of full text- reason 1: Outcome measures are not technical skill related, reason 2: Outcome measures are not related to the relevant training outcomes, reason 3: Individual observation (e.g., letters, correspondence, and editorial reviews) with high risk of bias\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6938176/v1/fea118c3d6aedd6a024c1edc.png\"},{\"id\":93342207,\"identity\":\"42982e17-14f7-4dba-b703-d8858bf04eac\",\"added_by\":\"auto\",\"created_at\":\"2025-10-12 14:42:09\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":2042716,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6938176/v1/e772d445-3815-4f8a-b8bb-08d94ee16c23.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Investigating the impact of the COVID-19 pandemic on postgraduate surgical technical skills training: a systematic review\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eSurgical training was significantly affected during the pandemic due to several factors, including the postponement of professional exams, fewer hands on surgical training opportunities, cancelling of educational courses, reduced simulation training and redeployment and workforce restructuring \\u003csup\\u003e\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u003c/sup\\u003e. The concerns trainees and educators had during the pandemic was reflected by the increase in publications related to surgical training. For example, when using the search terms “technical skills training” and “surgery” on PubMed, the number of publications per year showed an upward trend over the last two decades (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e) and reached a peak at the time of the pandemic \\u003csup\\u003e\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e\\u003c/sup\\u003e. There was also uncertainty about which educational interventions to use in recovery planning \\u003csup\\u003e\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eA few systematic reviews on surgical training from different surgical specialities were published during and immediately after the pandemic \\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR6\\\" citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e–\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u003c/sup\\u003e. These reviews, however, either did not provide enough detail about technical skills training, did not include all 12 surgical specialities, had included medical students and residents, were geographically restricted or had too wide a range of outcome measures and weren’t specific enough about technical skills training.\\u003c/p\\u003e \\u003cp\\u003eThe purpose of this systematic review, therefore, was to provide an in-depth understanding of the impact of the pandemic on technical skills training for postgraduate doctors in all 12 surgical specialities, and provide insights on appropriate recovery efforts for local, regional and national training bodies and educators to implement.\\u003c/p\\u003e \"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003eThe systematic review protocol was registered a priori with PROSPERO (registration number: CRD42022304218). The systematic review was conducted following the guidelines set out by PRISMA \\u003csup\\u003e\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e\\u003ch3\\u003eInclusion criteria\\u003c/h3\\u003e\\u003cp\\u003eThe study population for the included studies were doctors in post-graduate surgical training programmes, with studies published during the COVID-19 pandemic, from 2019 to 2021 and studies that investigated technical skills training in a surgical speciality. Though we did not specifically exclude studies based on the outcome measures, we anticipated that outcome measures must align with the learning and maintenance of technical skills to be included. This included outcome measures that involved time spent in the operating theatre, competencies achieved for the annual review of competency progression (ARCP) or equivalent measures of progression. Similarly, other outcome measures we considered were number of procedures, theatre log review, and training tools used for acquiring and maintaining technical skills including simulation. All study designs, including those that used quantitative, qualitative, or mixed methodologies (except letters, correspondence, and editorial reviews) were included.\\u003c/p\\u003e\\u003ch2\\u003eSearch Strategy\\u003c/h2\\u003e\\u003cp\\u003eTo develop the search strategy, we were assisted by a specialist librarian from the University of Oxford. The search strategy was developed after due consideration to Medical Subject Headings (MeSH) terms and synonyms that could be used for surgeons in training e.g. “trainee” and “resident” (box 1). A comprehensive search of MEDLINE and EMBASE was undertaken on 7th of January 2022, which included grey literature from conference abstracts. ENDNOTE X9 was used to store the search results and automatic de-duplication was performed. Further de-duplication was done by hand. Further attempts were made to identify grey literature by searching the theses databases via the Oxford University library search engine and handsearching reference lists.\\u003c/p\\u003e\\u003cp\\u003e \\u003c/p\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003ctable float=\\\"No\\\" id=\\\"Taba\\\" border=\\\"1\\\"\\u003e\\u003ccolgroup cols=\\\"1\\\"\\u003e\\u003c/colgroup\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1 exp Education, Medical, Graduate/ (76692)\\u003c/p\\u003e \\u003cp\\u003e2 ((Postgrad* or post grad*) adj3 (train* or learn* or educat* or teach*)).ti,ab. (10769)\\u003c/p\\u003e \\u003cp\\u003e3 ((Postgrad* or post grad*) adj3 (train* or learn* or educat* or teach*)).tw. (10769)\\u003c/p\\u003e \\u003cp\\u003e4 Residen*.tw. (274743)\\u003c/p\\u003e \\u003cp\\u003e5 Intern*.tw. (1011537)\\u003c/p\\u003e \\u003cp\\u003e6 Specialist trainee*.tw. (177)\\u003c/p\\u003e \\u003cp\\u003e7 Registrar*.tw. (4436)\\u003c/p\\u003e \\u003cp\\u003e8 1 or 2 or 3 or 4 or 5 or 6 or 7 (1309252)\\u003c/p\\u003e \\u003cp\\u003e9 exp Specialties, Surgical/ (210530)\\u003c/p\\u003e \\u003cp\\u003e10 (Surg* or operat* or procedur*).tw. (3649117)\\u003c/p\\u003e \\u003cp\\u003e11 Neurosurg*.tw. (53005)\\u003c/p\\u003e \\u003cp\\u003e12 Obstetric*.tw. (104282)\\u003c/p\\u003e \\u003cp\\u003e13 Gynaecolog*.tw. (22727)\\u003c/p\\u003e \\u003cp\\u003e14 Gynecolog*.tw. (83286)\\u003c/p\\u003e \\u003cp\\u003e15 ENT.tw. (14869)\\u003c/p\\u003e \\u003cp\\u003e16 Otolaryngol*.tw. (18495)\\u003c/p\\u003e \\u003cp\\u003e17 Orthopaedic*.tw. (44234)\\u003c/p\\u003e \\u003cp\\u003e18 Orthopedic*.tw. (50803)\\u003c/p\\u003e \\u003cp\\u003e19 Urolog*.tw. (59131)\\u003c/p\\u003e \\u003cp\\u003e20 Ophthalmol*.tw. (59053)\\u003c/p\\u003e \\u003cp\\u003e21 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 (3991156)\\u003c/p\\u003e \\u003cp\\u003e22 8 and 21 (253569)\\u003c/p\\u003e \\u003cp\\u003e23 COVID-19/ or Coronavirus/ or SARS-CoV-2/ (134011)\\u003c/p\\u003e \\u003cp\\u003e24 22 and 23 (2019)\\u003c/p\\u003e \\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\u003cp\\u003e \\u003cem\\u003eBox 1 Search terms used for the systematic review to understand the impact of COVID-19 pandemic on technical skills training in surgical specialities\\u003c/em\\u003e \\u003c/p\\u003e\\u003ch3\\u003eScreening process\\u003c/h3\\u003e\\u003cp\\u003eAS was the primary reviewer and screened all the abstracts and titles. NMT and HS acted as second reviewers, each reviewing half of the papers, and independently screening the papers identified after the initial search. Any disagreements regarding the inclusion or exclusion of papers was resolved after discussion and with the help of DA and HH who acted as the arbitrators. Full text reviews were also conducted in duplicate independently.\\u003c/p\\u003e\\u003ch3\\u003eData extraction and analysis\\u003c/h3\\u003e\\u003cp\\u003eThree thousand two hundred and thirty-eight papers were screened by title and abstract and 385 papers underwent full text screening. Sixty-two studies fulfilled the inclusion criteria and data was extracted onto a Microsoft Excel™ spreadsheet. Information regarding the study design, the surgical speciality, participant population and demographics, the country the study was conducted in, the outcome measures used to describe technical skills, and a summary of the results and conclusions were noted.\\u003c/p\\u003e\\u003cp\\u003eThe extracted data was coded by AS with inductive coding keeping in mind the aim of the review which was to understand the impact of the COVID-19 pandemic on technical skills training. The codes were reviewed by the other reviewers (NMT and HS) and the supervisors to check they accurately represented the data. Themes were developed from the codes using an iterative process. A narrative synthesis and descriptive analysis was performed as the studies included in this review used a wide range of methodologies including quantitative, qualitative? and mixed methods.\\u003c/p\\u003e\\u003ch3\\u003eAppraisal of study quality\\u003c/h3\\u003e\\u003cp\\u003eRisk of Bias assessment was conducted using the NIH quality assessment tool for Observational, Cohort and Cross-sectional studies tool \\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/sup\\u003e and was recorded alongside in the data extraction Microsoft Excel spreadsheet.\\u003c/p\\u003e\\u003ch3\\u003eChanges to the registered protocol\\u003c/h3\\u003e\\u003cp\\u003eThe scope of the systematic reviewed was narrowed exclusively to technical skills after discussion with surgical trainees and educators. Also, the tool for quality assessment was changed from the CASP checklist to the NIH quality assessment tool for Observational, Cohort and Cross-sectional studies tool \\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/sup\\u003e which was more suitable for the wide variation of methodologies of the included studies.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eThe full texts of 385 studies were reviewed and 62 were found to meet the inclusion criteria of this systematic review (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). The majority of studies were conducted in high income countries (71%). None of the studies were from low-income countries (Table \\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eClassification of countries where the studies were conducted by socio-economic status based on the World Bank world development indicators\\u003c/em\\u003e \\u003csup\\u003e\\u003cem\\u003e\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u003c/em\\u003e\\u003c/sup\\u003e There were five studies that were conducted globally and included multiple countries (Table \\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). The countries represented in these studies were all from lower middle, upper middle- and high-income countries.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"2\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eThe World Bank classification of countries\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eThe studies included in the systematic review (n\\u0026thinsp;=\\u0026thinsp;62)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHigh Income countries\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e44 (71%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUpper middle-income countries\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e7 (11%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLower middle-income countries\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e6 (10%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLow-income countries\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGlobal\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5 (8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eDetails of the countries that were included in the global studies. Abbreviations: UK- United Kingdom, USA- United States of America\\u003c/em\\u003e The majority of papers are from general surgery (26%) and neurosurgery (21%) and none from vascular surgery (Table \\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e).\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"3\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eStudies that were classified as global\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCountries where the study was conducted\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eThe World Bank classification of countries\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCOVID-19 and cardiothoracic surgery: Effects on training and workforce utilisation in a global pandemic \\u003csup\\u003e\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUSA, Canada, Columbia, Finland, Australia, South Korea, Nigeria\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eHigh Income and lower middle income\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eThe effect of COVID-19 on trainee operative experience at a multihospital academic neurosurgical practise: A first look at case numbers \\u003csup\\u003e\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUSA, Egypt\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eHigh income and lower middle income\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eThe impact of COVID-19 on surgical training: a systematic review \\u003csup\\u003e\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eFrance, UK, Canada, USA, Kuwait, Saudi Arabia, Serbia, Italy, Chile, India, Pakistan, Latin America\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eHigh income, upper middle income, lower middle income\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eReshaping ophthalmology training after COVID-19 pandemic \\u003csup\\u003e\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSlovenia, Mexico, Argentina, Ukraine, Morocco, Croatia, Poland, India, France, USA, Israel, Turkey, Philippines, Spain, Netherlands, UK, Italy, Belgium, Chile, Germany, Latvia, Greece, Switzerland, Ireland, Jordan, Pakistan, Singapore, Austria, Bosnia, Herzegovina, Bulgaria, Estonia, Guatemala\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eHigh income, upper middle income, lower middle income\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eWhat is the impact of the COVID-19 pandemic on residency training: a systematic review and analysis \\u003csup\\u003e\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUK, USA, Italy, India, Saudi Arabia, Nigeria, Pakistan, Peru, Canada, Germany, Taiwan, South Korea\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eHigh income, upper middle income, lower middle income\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eAnalysis of the surgical specialities that are represented in the studies included in this review. Abbreviations: ENT- Otolaryngology, O\\u0026amp;G- Obstetrics and Gynaecology, OMFS- Oral and Maxillofacial surgery\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"2\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSpecialities\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eThe studies included in the systematic review (n\\u0026thinsp;=\\u0026thinsp;62)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCardiothoracic surgery\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2 (3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGeneral surgery\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e16 (26%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNeurosurgery\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e13 (21%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOMFS\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1 (2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eENT\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3 (5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePaediatric\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1 (2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePlastic surgery\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1 (2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOrthopaedics\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4 (6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUrology\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8 (13%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVascular surgery\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eO\\u0026amp;G\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1 (2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOphthalmology\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8 (13%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMultiple surgical specialities\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4 (6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e\\n\\u003ch3\\u003eMethodology of the studies\\u003c/h3\\u003e\\n\\u003cp\\u003eAll but one of the studies included used quantitative methods to present their findings. Surveys were the most common method of data collection and was used in 60% (n\\u0026thinsp;=\\u0026thinsp;37) of the studies. One study used a mixed methodology approach (Table \\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab4\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 4\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eMethodology and subgroup analysis of methodologies of the studies included in this review\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"2\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMethodology\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eStudies included in this review (n\\u0026thinsp;=\\u0026thinsp;62)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eQuantitative\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e61 (98%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eQualitative\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMixed Methodology\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1 (2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eSubgroup analysis\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eQuantitative methodology\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSelf-reported data: Surveys\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e37 (60%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNon-self-reported data: Operative logs, workplace-based assessments, calculation of costs etc.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e20 (32%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBoth self-reported and non-self-reported data\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3 (5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eReview of literature\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1 (2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eQualitative methodology\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSelf-reported: Interviews etc\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eReview of literature\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMixed methodology review of literature\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1 (2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e\\n\\u003ch3\\u003eThe impact of the COVID-19 pandemic on technical skills training for postgraduate surgical specialities\\u003c/h3\\u003e\\n\\u003cp\\u003eThe thematic analysis, which focussed on understanding the impact of the COVID-19 pandemic on technical skills training, described three key themes from the analysis of the data:\\u003c/p\\u003e \\u003cp\\u003e \\u003col style=\\\"list-style-type:lower-alpha;\\\"\\u003e\\n \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eReduced operating, no change to operating or improved operating opportunities, with no impact to technical skills training\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eReduced operating opportunities with a moderate negative impact on technical skills training\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eReduced operating opportunities with a significant negative impact on technical skills training\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003c/ol\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eReduced operating, no change to operating or improved operating opportunities, with no impact to technical skills training\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab5\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 5\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eshows the results from studies that reported no impact to technical skills or progression with either no change to operating, increased operating for a few residents or minimal reduction in operating during the pandemic with five papers (including one conference abstract) from general surgery, neurosurgery, and ENT. The studies showed that the operating volume either minimally reduced or did not change or for a small cohort of trainees, increased, thereby helping them continue with skill development and training during the pandemic. Three of the five papers in this theme were appraised as good quality with low risk of bias.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTitle, year, location, speciality, reference\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eStudy design, methodology\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eResults\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAppraisal of quality using NIH assessment tool\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGeneral surgery chief residents\\u0026rsquo; perspective on surgical education during the coronavirus disease 2019 (COVID-19) pandemic, 2020, USA, General Surgery, \\u003csup\\u003e\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA prospective cross-sectional survey of chief residents to evaluate recommendations from a previous study of programme directors.\\u003c/p\\u003e \\u003cp\\u003e62% (24/39) response rate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e88% participants planned for a fellowship afterwards, 100% were concerned about delays in board examinations due to COVID with a delay in graduation date. 75% wanted to continue with planned graduation and move on to a fellowship as planned. Trainees had a loss of operative volume due to the pandemic, but this did not affect them achieving minimum requirements\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBy the numbers analysis of effect of COVID-19 on a neurosurgical residency at the epicentre, 2020, USA, Neurosurgery, \\u003csup\\u003e\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA comparative analysis of operative volume between 2020 and 2019 (a 7-week period in each year)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eThe case volume decreased from 530 operations in 2019 to 448 operations in 2020 and from 340 endovascular operation since 2019 to 253 in 2020. Though case volume was decreased, operative work continued through the pandemic at average 1.4 cases/day\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePoor\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of COVID-19 on the surgical volume of general surgery residents as main surgeons in a National Training Program in Costa Rica, 2021, Costa Rica, General Surgery, \\u003csup\\u003e\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA comparative analysis of operative volume of 10 residents between March- June 2020 with December 2019- March 2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eOperative volume was 291 pre-pandemic and 241 procedures during the pandemic. Year 2 trainees had increased operating during the pandemic (pre-pandemic 19% vs pandemic 27%, p\\u0026thinsp;=\\u0026thinsp;0.028). Year 3 trainees performed procedures during the pandemic in the breast and foregut unit that they had not performed before the pandemic. Year 4 trainees had a statistically significant increase in procedures in breast surgery (pre-pandemic 1% vs. pandemic 8%, p\\u0026thinsp;=\\u0026thinsp;.008) and surgical emergencies (pre-pandemic 27% vs. pandemic 51%, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;.001)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eA Tale of Two Cities: Residents\\u0026rsquo; Operative Experience in the United Kingdom and Germany During the Coronavirus Disease 2019 Pandemic, 2021, Germany and UK, Neurosurgery, \\u003csup\\u003e\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA comparative analysis of operative volume between 2 centres and between 2019 and 2020 (3-month period in each year)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eStatistically significant reduction in operative volume from the pre-COVID months to the COVID months in the UK centre (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) but no significant difference in the operative volume in the German centre (p\\u0026thinsp;=\\u0026thinsp;0.61). The average number of procedures performed by residents in the UK centre as the primary surgeon decreased from 82 cases pre-COVID to 72 cases per month during the pandemic whereas German residents\\u0026rsquo; operating volume increased from 68 to 89 per month (pre-COVID vs. COVID months)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEffect of the COVID-19 Pandemic on Otorhinolaryngology Residency Training, 2021, conference abstract, USA, ENT, \\u003csup\\u003e\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA retrospective comparative analysis of operative volume between 2019 and 2020 (3 months in each year)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eFrom March 15, 2020, to May 31, 2020, residents participated with the primary surgeon in 331 procedures compared with 63 procedures between the same period in 2019, noting an increase in operating during the pandemic\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePoor\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eTable\\u0026nbsp;\\u003cspan refid=\\\"Tab5\\\" class=\\\"InternalRef\\\"\\u003e5\\u003c/span\\u003e \\u003cem\\u003eThematic analysis based on impact of COVID on technical skill training. Theme: Reduced operating, no change to operating or improved operating opportunities, with no impact to technical skills training. Appraisal of study quality was carried out using - National Institutes of Health (NIH) quality assessment tool for Observational, Cohort and Cross-sectional studies tool\\u003c/em\\u003e \\u003csup\\u003e\\u003cem\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/em\\u003e\\u003c/sup\\u003e. \\u003cem\\u003eAbbreviations: ENT- Otolaryngology, NIH- National Institutes of Health, UK- United Kingdom, USA- United States of America\\u003c/em\\u003e\\u003c/p\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eReduced operating opportunities with a moderate negative impact on technical skills training\\u003c/h2\\u003e \\u003cp\\u003eAll four studies included in this theme (from general surgery, neurosurgery, and ophthalmology) showed reduced operating opportunities during the COVID-19 pandemic, with a moderate negative impact on technical skills training (Table \\u003cspan refid=\\\"Tab6\\\" class=\\\"InternalRef\\\"\\u003e6\\u003c/span\\u003e). These studies demonstrate a variable impact among the trainees (i.e., junior residents were less impacted compared to their senior counterparts), or only one type of surgical opportunity was reduced (e.g., medium complexity operations) or limited time where the operating was reduced (during the latter half of the study period or COVID-19 pandemic) in the hospitals where the studies were conducted. Half the studies in this theme were of good quality.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab6\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 6\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eThematic analysis based on impact of COVID on technical skill training. Theme: Reduced operating opportunities with moderately negative impact on technical skills training. Appraisal of study quality was carried out using - National Institutes of Health (NIH) quality assessment tool for Observational, Cohort and Cross-sectional studies tool\\u003c/em\\u003e \\u003csup\\u003e\\u003cem\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/em\\u003e\\u003c/sup\\u003e. \\u003cem\\u003eAbbreviations: NIH- National Institutes of Health\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTitle, year, location, speciality reference\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eStudy design, methodology\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eResults\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAppraisal of quality using NIH assessment tool\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCOVID-19 and neurosurgical training and education: an Italian perspective, 2020, Italy, Neurosurgery, \\u003csup\\u003e\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA prospective cross-sectional survey of neurosurgical residents about their training experience from March to May 2020. 58% response rate (192/331)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e79% performed less operations and 16% did not perform any operations at all. 3 trainees reported increased surgical activity. Senior residents were more affected by the global reduction of neurosurgical activity as compared with year 1 and 2 residents\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of COVID-19 pandemic on general surgery training program: An Italian experience, 2020, Italy, General Surgery, \\u003csup\\u003e\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA comparative analysis of operative volume of postgraduate year 6 trainees between March to May 2020 to January to March 2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eStatistically significant decrease in operations performed during the second period of the study (p\\u0026thinsp;=\\u0026thinsp;0.033), especially of medium-complexity surgeries usually performed by the year 6 residents as first operator\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of COVID-19 on Saudi Neurosurgery Residency: Trainers\\u0026rsquo; and Trainees\\u0026rsquo; Perspectives, 2021, Saudi Arabia, Neurosurgery, \\u003csup\\u003e\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA prospective comparative survey of residents and programme directors of training during COVID and pre-COVID from March to May 2020. Response rate was 100% from programme directors and 95% from residents\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e59% agreed that resident surgical skills would be affected if the pandemic lasted 6 months or more. Before the pandemic, 53% of the residents were involved in 2\\u0026ndash;3 surgeries per week, but during the pandemic, 70% were attending 0\\u0026ndash;1 case per week, showing a loss of operative volume\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eResidents' Perceived Impact of COVID-19 on Saudi Ophthalmology Training Programs-A Survey, 2020, Saudi Arabia, Ophthalmology, \\u003csup\\u003e\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA prospective cross-sectional survey of residents in July 2020 about training during the COVID-19 pandemic compared to before the pandemic\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e61% reported an increase or same volume of emergency operating, though there was an 82% reduction of elective operating. Emergency operating was unaffected though elective office-based procedures was significantly reduced (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eReduced operating opportunities with a significant negative impact on technical skills training\\u003c/h2\\u003e \\u003cp\\u003eFifty-three studies reported a significant impact on technical skills training due to the pandemic with statistically significant reduction in operating compared to before the pandemic (Table \\u003cspan refid=\\\"Tab7\\\" class=\\\"InternalRef\\\"\\u003e7\\u003c/span\\u003e). Four of the included 53 studies were conference abstracts and two were systematic reviews. The studies were representative of all the surgical specialities except vascular surgery. All of the studies showed that majority of operating was suspended during the pandemic, with significant reduction in trainee operating.\\u003c/p\\u003e \\u003cp\\u003eFour of the studies provided details about access to simulation, where about 50% of the participants had access to simulation \\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR24 CR25 CR26\\\" citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e\\u003c/sup\\u003e. Only one of the four studies indicated intentional use of the simulation where at least a third of the trainees found useful \\u003csup\\u003e\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eThree of the studies discuss the loss of confidence experienced by the majority of trainees due to the significant loss of operating experience during the pandemic \\u003csup\\u003e\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e\\u003c/sup\\u003e. Only one study had initiated recovery plans which focussed on giving nearly half the trainees access to operating at hospitals in the independent sector.\\u003c/p\\u003e \\u003cp\\u003eOther potential recovery measures briefly discussed were extending training to compensate and pursuing fellowships after training. Trainees were first surgeons on four of the seven cases in each operating list, and 80% of the trainees considered the experience to be enjoyable with half the trainees achieving their training goals using this experience \\u003csup\\u003e\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e\\u003c/sup\\u003e. Twenty six of the 53 studies were of good quality.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab7\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 7\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eThematic analysis based on impact of COVID on technical skill training. Theme: Reduced operating opportunities with significantly negative impact on technical skills training. Appraisal of study quality was carried out using - National Institutes of Health (NIH) quality assessment tool for Observational, Cohort and Cross-sectional studies tool\\u003c/em\\u003e \\u003csup\\u003e\\u003cem\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/em\\u003e\\u003c/sup\\u003e. \\u003cem\\u003eAbbreviations: AR- Augmented Reality, ARCP: Annual Review of Competency Progression, ENT- Otolaryngology, NIH- National Institutes of Health, SARS- Severe Acute Respiratory Syndrome, UK- United Kingdom, USA- United States of America, VR- Virtual Reality\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTitle, year, location, speciality, reference\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eStudy design, methodology\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eResults\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAppraisal of quality using NIH assessment tool\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEffect of SARS and COVID-19 outbreaks on urology practise and training, 2021, China, \\u003csup\\u003e\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA comparative study of data collected from a prospective cross-sectional survey of all residents from all the urology centres (n\\u0026thinsp;=\\u0026thinsp;11) in Hong Kong (49% response rate) and a review of the operative logs\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eThe mean operating sessions before the COVID-19 pandemic and during the COVID-19 pandemic was significantly reduced (85 versus 51 procedures respectively, p\\u0026thinsp;=\\u0026thinsp;0.005). The numbers of operating sessions was reduced by 41% across all of the reviewed centres. 53% had cancelled professional examinations with delays with progression in training\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of the COVID-19 pandemic on core surgical training, 2020, UK, \\u003csup\\u003e\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA prospective cross-sectional survey of core surgical trainees (64% response rate, 28/44)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e71% reported fewer operative opportunities. None of the trainees had performed any form of endoscopy during the pandemic. 50% trainees had access to their own laparoscopic box trainer. 71% felt their confidence performing surgical skills had been negatively impacted by the pandemic in open, laparoscopic, and endoscopic surgery\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of COVID-19 on Neurosurgical Training in Southeast Asia, 2020, Indonesia, Malaysia, Philippines, Singapore, and Thailand, \\u003csup\\u003e\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA descriptive cross-sectional survey of residents from 33 training programmes in South-East Asia (298 responses, 63% response rate)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eReduction in elective procedures ranged from 50% in Thailand to 100% in Indonesia and the Philippines, 92% in Malaysia and 70% in Singapore (statistically significant). 74% of the trainees believed pandemic had a negative impact on their overall neurosurgical training, Residents were most concerned marked decrease in their hands-on surgical experience, uncertainty about their board examination and potential delay in career advancement, increasing number of backlog cases\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHas 2020 been a lost year in orthopaedic surgery and trauma training? Residents\\u0026rsquo; perceptions, 2021, Spain, \\u003csup\\u003e\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA prospective cross-sectional survey of 307 orthopaedic residents in February 2021\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e70% of surgeries were suspended in 2020, with no operating for an average of 8 weeks, affecting 67% of the residents. 52% considered the impact of the pandemic as bad or very bad on their surgical training. Majority wanted extra training time to compensate for that lost year\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eThe impact of COVID-19 on surgical training at a tertiary hospital in Greece: a \\u0026lsquo;hidden infectious enemy\\u0026rsquo; for junior surgeons?, 2021, Greece, \\u003csup\\u003e\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA prospective cross-sectional survey of all core general surgical trainees from one hospital about their operative experience during and before the pandemic (Sept- Nov 2019 and 2020). 94% response rate (16/17)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eAll trainees performed almost 50% fewer cases during the pandemic. Senior trainees assisted in 37 cases during the pandemic compared to 90 before the pandemic. 63% trainees reported less confidence in the operating theatre because of the pandemic\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eThe Impact of the Coronavirus Pandemic on European Neurosurgery Trainees, 2021, Europe, \\u003csup\\u003e\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA prospective cross-sectional survey of all European neurosurgical residents about their operative exposure before and during the pandemic. 16% response rate (134/810)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e93% of residents reported a reduction of hands-on surgical exposure. One-third of the participants were spending\\u0026thinsp;\\u0026gt;\\u0026thinsp;15 hours in the operating room pre-pandemic but 52 residents spent more than 10 hours in the operating room during the crisis, indicating a statistically significant decrease in operative exposure (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05). Some trainees estimated a whole year equivalent of hands-on training was lost\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePoor\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHow the COVID-19 pandemic changed urology residency \\u0026ndash; a nationwide survey from the Portuguese resident\\u0026rsquo;s perspective, 2021, Portugal, \\u003csup\\u003e\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA prospective cross-sectional survey of urology residents regarding their operative experience before and during the pandemic in May 2020. 54% response rate (43/79)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e49% reported up to 100% reduction in minor operative procedures. 40% reported a\\u0026thinsp;\\u0026gt;\\u0026thinsp;50% reduction in major operative procedures. 54% of residents reported a reduction of robotic and laparoscopic procedures due to concerns about contamination during the COVID-19 pandemic. 72% of residents considered their training was very or extremely affected due to the COVID-19 pandemic. 33% of residents wanted to prolong their residency program\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eThe reduction in clinical and surgical exposure of trainees during COVID-19 and its impact on their training, 2021, Pakistan, \\u003csup\\u003e\\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA comparative study of results from a prospective cross-sectional survey of general surgical trainees from one unit (18/24, 75% response rate) to the operative log from August 2019 to May 2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eThe number of elective cases performed went down to 1,465 from 2,364 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.005) during COVID compared to pre COVID, corroborated by the logbook data. Major cases performed by trainees, pre-COVID was 332, during COVID reduced to 105. Minor cases pre-COVID was 113, during COVID was 55. Reduction in operative volume was similar across all training years, showing a significant impact on operative exposure\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCanadian ophthalmology resident experience during the COVID-19 pandemic, 2020, Canada, \\u003csup\\u003e\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA prospective cross-sectional survey of all residency programmes in May and June 2020. 47% response rate (102/217)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e51% of residents were working at reduced volumes. 65% of residents on surgical rotations had not operated in the previous 2 weeks. 55% of residents were concerned about their surgical skills deteriorating owing to the shutdowns. 51% did not have access to a surgical simulator. Operative skill was affected but trainees didn\\u0026rsquo;t feel it would affect long term competency\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCOVID-19 and cardiothoracic surgery: Effects on training and workforce utilisation in a global pandemic, 2021, conference abstract, USA, Canada, Columbia, Finland, Australia, South Korea, Nigeria, \\u003csup\\u003e\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA prospective cross-sectional survey of cardiothoracic surgery trainees in June-August 2020 regarding their operative exposure during and before the pandemic. 22% response rate (126/748)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e86% of the trainees reported a reduction in the operative volume of which 54% reported a\\u0026thinsp;\\u0026gt;\\u0026thinsp;50% reduction and 23% did not operate at all. 98% of the USA trainees and 80% of international trainees reported reduction of operative volume (statistically significant). 38% would not meet the minimum case requirements for progression\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of the COVID-19 Pandemic on Ophthalmology Residency Training in Portugal, 2020, Portugal, \\u003csup\\u003e\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA prospective cross-sectional survey conducted between March and April 2020 of all ophthalmology trainees in Portugal. 94% response rate (75/80)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eNo department performed elective ophthalmology surgeries during the pandemic. Nearly half the residents participated in emergency surgery. 99% did not perform cataract operations during the pandemic compared to 8% before the pandemic\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eThe Continuing Impact of Coronavirus Disease 2019 on Neurosurgical Training at the 1-Year Mark: Results of a Nationwide Survey of Neurosurgery Residents in Turkey, 2021, Turkey, \\u003csup\\u003e\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA prospective cross-sectional survey of neurosurgical residents from Turkey conducted in January and February 2021 about surgical training during and before the pandemic. 54% response rate (356/435)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e50% reported a significant decrease of elective operating, 9% felt it was unchanged 4% felt it increased. Only 6% felt emergency operating considerably decreased. 25% considered the impact of the pandemic to be considerably negative with decreased operative case diversity, decreased operative volume, decreased weekly work hours, assignment in the COVID services, interrupted training due to COVID isolations, loss of motivation. Useful simulation practise: cadaveric practise 30% and VR/AR simulator 30%. 42% have increased concerns about the effect of the pandemic on surgical training with 31% preferring an extension of their training\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFactors Associated With General Surgery Residents\\u0026rsquo; Operative Experience During the COVID-19 Pandemic, 2021, USA, \\u003csup\\u003e\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA comparative study of retrospective review of 1358 operative logs from 3 consecutive academic years (4 months in 2017\\u0026ndash;2018, 2018\\u0026ndash;2019, and 2019\\u0026ndash;2020) from 16 general surgery programmes and cross-sectional survey of programme directors from 16 general surgical programmes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e771 resident case logs (57%) were from 8 university-based programs, 407 (30%) from 5 university affiliated programs, and 180 (13%) from 3 independent programs. Residents performed a mean of 68 major cases pre-pandemic compared with 45 cases during the pandemic (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), with 34% reduction in operative volume during the pandemic. All training years were equally affected\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eA Survey of the Impact of the COVID-19 Crisis on Skill Decay Among Surgery and Anaesthesia Residents, 2021, USA, \\u003csup\\u003e\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA cross sectional survey of surgical and anaesthetic residents and faculty from 2 large tertiary centres regarding training in 2019, 2020 and 2021. 53% response rate (91/173)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eThree chief residents did not meet defined minimum case log for general surgery in 2020. All surveyed residents felt that their training was significantly impacted due to COVID-19 pandemic. 82% reported a reduction in case volumes (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05). 64% perceived a reduction in technical operative skill and 75% of faculty perceived that residents experienced a reduction in technical skill. Re-deployed residents were more likely to report skill decay than residents who were not re-deployed (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05). Resident concerns included return to the operating room with worse skill, surgical skill acquisition for progression to the next clinical year, ability to practise independently as an attending physician, and achievement of required case numbers. 58% of residents did not utilise simulation to maintain their technical skills. 39% used suture kits, laparoscopic trainers (9%), robotic consoles (3%), mannequins (1%) and other specialty-specific trainers (3%) to maintain their operative skills\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eThe impact of COVID-19 related lockdown on ophthalmology training programs in India, 2020, India, \\u003csup\\u003e\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA cross sectional survey of ophthalmology residents via social media in April 2020. 716 responses received\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e81% reported a negative impact on their surgical training due to COVID lockdowns. 62% trainees reported a \\u0026gt;/=50% reduction in operating\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of the COVID-19 pandemic on orthopaedic and trauma surgery training in Europe, 2020, Europe, \\u003csup\\u003e\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA cross sectional survey in May 2020 of 327 orthopaedic trainees in 23 European countries about training during the COVID pandemic compared to before\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eDuring the pandemic, 57% of institutes allowed only emergency surgical procedures. 58% had significant concerns about the achievement of annual training goals. 46% believed they will not acquire the expected practical skills, 45% that they will not complete their logbook, and 16% that their final exams will be postponed. One fourth of the respondents believed an additional year of appropriate training would be necessary and 61% believed they will finish their rotation as planned. 55% stated orthopaedic \\u003c/p\\u003e \\u003cp\\u003etraining will be negatively affected by the COVID-19 crisis\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of Elective Case Postponement Secondary to COVID-19 on General Surgery Residents\\u0026rsquo; Experience: Operative Cases Logged at Three Academic Teaching Hospitals, 2021, USA, \\u003csup\\u003e\\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA retrospective cohort study of operative logs of general surgical trainees from three academic hospitals, 81 residents pre-COVID and 77 residents during COVID\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eYear 4 residents had a significant decrease in total cases, 759 procedures during the pandemic compared to 1010 total cases before (p\\u0026thinsp;=\\u0026thinsp;0.005). There was no difference for year 5 residents\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of the COVID-19 pandemic on surgical skills training in paediatric surgery residents, 2021, Argentina, \\u003csup\\u003e\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA descriptive retrospective study of surgical training in the paediatric surgery department of one tertiary centre from March to May 2020. Results were compared to the same trimester in 2018 and 2019 to quantify the impact of the pandemic, 100% response rate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eThe average number of surgeries in 2015\\u0026ndash;2019 was 530 compared to 368 surgeries during the pandemic, a reduction of 31%. No changes in case complexity was noted. A statistically significant reduction in procedures performed by the residents as leading surgeons in 2020. 70% reported no improvement in surgical performance and 50% reported taking more time to operate. All trainees spent\\u0026thinsp;\\u0026lt;\\u0026thinsp;10 hours a month on simulation before the pandemic but 70% of trainees reported\\u0026thinsp;\\u0026gt;\\u0026thinsp;10 hours a month during the pandemic. 70% reported a decrease in confidence during surgery\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAccess and feasibility of orthopaedic training in the independent sector- A Deanery's experience, 2021, UK, \\u003csup\\u003e\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA cross sectional survey of trainees who attended operative theatre sessions at independent hospitals between November and December 2020 to supplement their surgical training. 89% response rate (57/64)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e44% of trainees had accessed the 12 independent sector hospitals, attending an average of 4 sessions, and were first surgeons on 4 of the 7 cases in each operating list. 20% reported reluctance to allow training and obstruction from theatre staff. 80% reported an enjoyable experience and 52% reported to have achieved their goals. Only 29% felt private sector operating would compensate for their loss of training\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eThe impact of COVID-19 on urology resident surgical experience: An analysis of national case logs, 2021, conference abstract, Canada, \\u003csup\\u003e\\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA comparative analysis of the theatre log from 11 urology residency programmes for 20 common urologic procedures, comparing data from September 2019-March 2020 with March 2020 to September 2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e12,831 procedures were recorded over 12-months by 122 residents in 11 training programs. 7211 procedures were logged before the pandemic compared to 5620 procedures after. 82% of programs reported a reduction in surgical volume\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEffects of the COVID-19 Pandemic on Operative Volume and Residency Training at Two Academic Neurosurgery Centres in New Orleans, 2021, USA, \\u003csup\\u003e\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA retrospective review of operative log from two tertiary centres comparing March to June 2020 with March to June 2019\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePre-pandemic operative average was 58 procedures/week. 77% reduction in operative procedures in 2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eThe effect of COVID-19 on trainee operative experience at a multihospital academic neurosurgical practise: A first look at case numbers, 2021, USA and Egypt, \\u003csup\\u003e\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA retrospective review of operative log for 54 days pre-lockdown to 54 days post lockdown to evaluate the impact of the pandemic on operating exposure of trainees (March-May 2020 compared to January -March 2020)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eMean total cases per day in the pre-lockdown group were 12.26, compared to 7.78 in the post lockdown group (p\\u0026thinsp;=\\u0026thinsp;0.01)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of COVID-19 on Academic Activities of Ophthalmology Postgraduates: A Cross-sectional Survey, 2021, India, \\u003csup\\u003e\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA cross sectional online survey of Indian ophthalmology trainees in January 2021 to evaluate the impact of the pandemic on surgical training compared to before the pandemic. 84 trainees responded\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eA marked reduction in operative procedures performed independently per week. 32% noted an increase in intraoperative surgical time post the pandemic. 36% were not satisfied with their surgical performance, because 41% were nervous to start, 8% wanted to finish quickly and 36% were not comfortable with new protocols. 49% did not report a change in complication rate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of COVID-19 pandemic on plastic surgery activities and residency programs in a tertiary referral centre in Iran, 2021, Iran, \\u003csup\\u003e\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA retrospective case study of logbooks in a six-month time frame comparing two consecutive years (during and before the pandemic)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eThere was a 70% reduction in case volume in plastic surgery. The total number of surgeries decreased by an average of 24% in all the specialities after the COVID-19 outbreak (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of COVID-19 on operative experience of junior surgical trainees, 2020, UK, \\u003csup\\u003e\\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA comparative study of operative logbooks in a five-month time frame of March-July 2019 with 2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e16,729 operative procedures were recorded during the control period compared with 6223 procedures during the COVID period, demonstrating a 63% decrease, across all levels of complexity\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDecrease in operative volume in general surgery residents in Chile: effects of the COVID-19 pandemic, 2021, Chile, \\u003csup\\u003e\\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA comparative study of the operative logbooks of eight postgraduate year 3 trainees in 2019 to 2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eSignificant decrease in the total number of surgical procedures of 62% (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), though some trainees had more thoracic surgery exposure than usual due to the changes in the rota\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of COVID-19 on ophthalmic specialist training in the United Kingdom\\u0026mdash;the trainees\\u0026rsquo; perspective, 2020, UK, \\u003csup\\u003e\\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA cross sectional survey of UK ophthalmology trainees in March 2020. 111 trainees completed the survey\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e87% were concerned COVID-19 will impact their training. Acquiring competencies like cataract surgery and completing the logbook worried up to 81% of the trainees\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePoor\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eThe impact of COVID-19 on surgical training: a systematic review, 2021, Global, \\u003csup\\u003e\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA systematic review and qualitative synthesis of surgical training before and during the pandemic from January 2020 to August 2020. 29 included studies\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eAll of the studies reported a decrease in the number of operative cases or operative experience available to trainees, particularly medium complexity operations where trainees would usually be the first operator\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRiding the waves: the ongoing impact of COVID-19 on a national surgical training cohort, 2021, UK, \\u003csup\\u003e\\u003cspan citationid=\\\"CR50\\\" class=\\\"CitationRef\\\"\\u003e50\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTwo online surveys of surgical trainees in May 2020 and October 2020 comparing surgical training during the first wave of the pandemic to the second wave of the pandemic. 29% response rate (98/340), with 44% core surgical trainees and 46% higher surgical trainees\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eAll trainees experienced a statistically significant reduction in day case operating and endoscopic sessions. Core surgical trainees also experienced a statistically significant decrease in emergency sessions. Major elective and emergency session numbers returned to pre-COVID levels in the second survey\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMilitary Otolaryngology Residency Training and Practise impact Assessment During COVID-19, 2021, conference abstract, USA, \\u003csup\\u003e\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA cross sectional survey to assess the impact of the pandemic on ENT surgical training in the Defence Health Agency sites\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eTime in the operating room (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;.001) decreased significantly for both residents and faculty. Most residents (53%) were concerned about meeting their minimum case requirements for graduation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePoor\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of Coronavirus Disease on the Ophthalmology Residency Training in Brazil, 2020, Brazil, \\u003csup\\u003e\\u003cspan citationid=\\\"CR52\\\" class=\\\"CitationRef\\\"\\u003e52\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA cross sectional survey conducted in May-June 2020 the programme directors of ophthalmology training programmes in Brazil to evaluate the impact of the pandemic on training. 83% (79/95) response rate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e54% reported that elective surgery was completely suspended and for 20%, it was drastically reduced. For emergency operating, 76% said it was reduced, drastically reduced, or suspended. 70% of the education coordinators had a strategy to recover training with 11% planning to extend the period for course completion. 26% intended to increase the residents\\u0026rsquo; workload\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAdvanced head and neck surgery training during the COVID-19 pandemic, 2020, USA, \\u003csup\\u003e\\u003cspan citationid=\\\"CR53\\\" class=\\\"CitationRef\\\"\\u003e53\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA comparative study of operative logs (2020 to 2019 and 2018) and a cross-sectional survey of programme directors, trainees, and fellows. 97% (37/38) of programme directors and 39% (12/31) of trainees responded\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e70% reported a 50\\u0026ndash;90% reduction in the number of elective cases and 76% reduction in emergency operating at their institutions. 81% stated that their fellows were still participating in oncology cases and remained active in a variety of procedures\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePerceived Impact of Urologic Surgery Training Program Modifications due to COVID-19 in the United States, 2020, USA, \\u003csup\\u003e\\u003cspan citationid=\\\"CR54\\\" class=\\\"CitationRef\\\"\\u003e54\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA survey of programme directors and residents at urology centres in March-April 2020. 43% (55/127) of programme directors and 18% (23/127) trainees responded\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e80% indicated that program changes had negatively impacted surgical training. 51% reported increased anxiety about competency upon residency completion. 9% expressed a likelihood of fellowship training. 90% reported spending more time in self-directed learning and 77% had more time for research (77%). 83%- 100% reported decreased surgical volume. Least affected were emergency surgery and oncology\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eReshaping ophthalmology training after COVID-19 pandemic, 2020, Global (32 countries), \\u003csup\\u003e\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA cross sectional survey of ophthalmology trainees from 32 countries in May 2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eSurgical activity massively decreased with 75% of trainees reported a reduction of \\u0026gt;\\u0026thinsp;75% of their surgical practise. Half of respondents declared that they have suspended surgical practise completely. 53% of residents and 34% of fellows reported that they were not able to perform cataract surgery routinely anymore. The impact of COVID-19 pandemic was described as \\u0026ldquo;severe\\u0026rdquo; by most trainees (55%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDecrease in Neurosurgical Program Volume During COVID-19: Residency Programs Must Adapt, 2020, USA, \\u003csup\\u003e\\u003cspan citationid=\\\"CR55\\\" class=\\\"CitationRef\\\"\\u003e55\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eAn operative log review of case volume from March to May 2019 and 2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eElective surgery volume (53%) and total surgical procedures (42%) decreased during COVID. Thrombectomies had increased by 21%. Operative cranial traumas had decreased by 18%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePoor\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of the COVID-19 Pandemic on Surgical Training and Learner Well-Being: Report of a Survey of General Surgery and Other Surgical Specialty Educators, 2020, USA, \\u003csup\\u003e\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA cross sectional survey of programme directors. 21% (472/ 2196) response rate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eThe volume of surgical procedures was severely reduced by the pandemic with 87% reduction of elective operating. Emergency operative volume reduced by 20%. There was a severe negative impact on expected progression of operative autonomy across all stages reported by 14\\u0026ndash;18% of respondents. Nearly 70% (266 of 388) of respondents indicated that no extra steps were taken to develop technical competencies beyond the available clinical opportunities during the pandemic. 44% indicated that simulation centres were inaccessible during the pandemic\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCOVID-19 pandemic effect on \\u003c/p\\u003e \\u003cp\\u003eotolaryngology resident surgical case numbers, 2021, conference abstract, USA, \\u003csup\\u003e\\u003cspan citationid=\\\"CR56\\\" class=\\\"CitationRef\\\"\\u003e56\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA retrospective analysis of surgical operative logs of all residents from a large residency programme comparing February to March 2019 and 2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eThe total decrease in surgical case numbers was 46%. Junior residents had a 28% decrease, while senior residents had a 54% decrease\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of COVID-19 on surgical training, 2021, UK, \\u003csup\\u003e\\u003cspan citationid=\\\"CR57\\\" class=\\\"CitationRef\\\"\\u003e57\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA retrospective comparative analysis of operative theatre records in a large teaching hospital comparing April to June 2019 to 2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eAn overall reduction in operative volume by 66% during the pandemic, with a 71% decrease in the registrars as first operators\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNeurosurgery training in India during the COVID-19 pandemic: straight from the horse\\u0026rsquo;s mouth, 2020, India, \\u003csup\\u003e\\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA cross sectional survey via social media of neurosurgical trainees in India in May 2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e68% reduction in surgeries performed by trainees since the onset of the COVID-19 pandemic- 39.86 surgeries per month decreased to 12.31 per month(p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.0001). The majority of respondents felt that the COVID-19 pandemic will hamper their operative and clinical skills. Fear of rescheduling or deferring of licensing examinations was significantly higher among those closest to the examination (p\\u0026thinsp;=\\u0026thinsp;0.002)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of COVID-19 on a urology residency program, 2021, Brazil, \\u003csup\\u003e\\u003cspan citationid=\\\"CR59\\\" class=\\\"CitationRef\\\"\\u003e59\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA retrospective analysis of surgical operative logs of all 18 urology residents in the 3rd, 4th, and 5th year of training from February to May 2017, 2018, 2019, 2020. 118 residents from 29 neurosurgical training programs across 17 states/union territories responded\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eOverall surgical volume significantly decreased in 2020, by 51%, compared to the previous three years (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), affecting the third, fourth and fifth year of the residency program\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCOVID-19 impact on Surgical Training and Recovery Planning (COVID-STAR) - A cross-sectional observational study, 2021, UK, \\u003csup\\u003e\\u003cspan citationid=\\\"CR60\\\" class=\\\"CitationRef\\\"\\u003e60\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA national, collaborative, cross-sectional study involving 13 surgical trainee associations using a pan-surgical specialty questionnaire on the impact of COVID-19 on surgical training over 4 weeks in May 2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eThe reported impact of COVID-19 on surgical training experience was very significant (average on Likert scale was 8.66), with no difference between training grades or specialities. 84\\u0026ndash;87% reported complete suspension of elective non-cancer surgery and elective endoscopy operating. 76% reported at least a\\u0026thinsp;\\u0026gt;\\u0026thinsp;50% loss of operating. 73% anticipated an impact on their ARCP. Only 19% of trainees intended to progress to the next stage of training at ARCP having gained all training opportunities\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCOVID-19 Pandemic and the Lived Experience of Surgical Residents, Fellows, and Early-Career Surgeons in the American College of Surgeons, 2020, USA, \\u003csup\\u003e\\u003cspan citationid=\\\"CR61\\\" class=\\\"CitationRef\\\"\\u003e61\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA cross sectional online survey of members of the Resident Associate Society and the Young Fellows Association. 5% (1160/21385) response rate of which 40% were residents and 60% were fellows and early career surgeons\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e96% reported a negative impact of the COVID-19 pandemic. 84% of residents reported a\\u0026thinsp;\\u0026gt;\\u0026thinsp;50% reduction in operative volume and inability to meet minimum case requirements. 84% reported a reduction of 50% of elective operating and 19% reported a decrease in emergency operating\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eWhat is the impact of the COVID-19 pandemic on residency training: a systematic review and analysis, 2021, Global, \\u003csup\\u003e\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA systematic review of surgical training until November 2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e51(96%) of the included studies reported a reduced operative case volume\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eThe impact of COVID-19 pandemic on orthopaedic resident education: a nationwide survey study in South Korea, 2020, South Korea, \\u003csup\\u003e\\u003cspan citationid=\\\"CR62\\\" class=\\\"CitationRef\\\"\\u003e62\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eAn online survey of orthopaedic residents from 43 hospitals in South Korea. 229 residents completed the survey\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eWorking time in the operating room was significantly decreased (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). 68% of residents participated in surgeries for more than 10 hours/week before the COVID-19 pandemic but 48% participated in surgeries for more than 10 hours/week during the COVID-19 pandemic (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of coronavirus 2019 (COVID-19) on training and well-being in subspecialty surgery: A national survey of cardiothoracic trainees in the United Kingdom, 2020, UK, \\u003csup\\u003e\\u003cspan citationid=\\\"CR63\\\" class=\\\"CitationRef\\\"\\u003e63\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA cross sectional online survey of cardiothoracic surgical trainees about the impact of the pandemic. 64% (76/118) responded\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eTrainees reported a significant deviation in their sessional activity in operating theatres (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.0001). 63% of trainees report somewhat (25%, n\\u0026thinsp;=\\u0026thinsp;19) or very (63%, n\\u0026thinsp;=\\u0026thinsp;48) concerned about the impact of the pandemic on their learning and progression through structured training. There was no association between trainee seniority and declared concern\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEarly Changes to Neurosurgery Resident Training During the COVID-19 Pandemic at a Large U.S. Academic Medical Centre, 2019, USA, \\u003csup\\u003e\\u003cspan citationid=\\\"CR64\\\" class=\\\"CitationRef\\\"\\u003e64\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA retrospective analysis of 24 trainee operative logbooks in a single residency programme from January 2019 to June 2020 comparing pre COVID to the effect of the pandemic\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eAn average of 15 fewer cases had been logged in April 2020 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01) and 5 fewer cases (20%) had been logged in May 2020 (p\\u0026thinsp;=\\u0026thinsp;0.01). A comparison of the institutional case numbers showed a significant reduction in the overall case numbers for April and May 2020 compared with the same months in 2019 (mean difference 21, p\\u0026thinsp;=\\u0026thinsp;0.01)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eThe influence of the COVID-19 outbreak on European trainees in obstetrics and gynaecology: A survey of the impact on training and trainee, 2021, Europe, \\u003csup\\u003e\\u003cspan citationid=\\\"CR65\\\" class=\\\"CitationRef\\\"\\u003e65\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eAn online survey of the European Obstetrics and Gynaecology trainees via social media regarding the impact of the pandemic on their training. 110 trainees from 25 countries responded\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e95% of trainees reported a negative effect on their training due to COVID-19. Training was interrupted for 21% and 65% were worried about their training. Surgical skills training decreased for 67% of trainees due to cancellation of surgeries. 5% met the goals for their surgical competencies. Gynaecological oncology was least affected\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEffect of COVID-19 on Surgical Training Across the United States: A National \\u003c/p\\u003e \\u003cp\\u003eSurvey of General Surgery Residents, 2020, USA, \\u003csup\\u003e\\u003cspan citationid=\\\"CR66\\\" class=\\\"CitationRef\\\"\\u003e66\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA cross sectional survey of general surgical residents in all general surgical residency programmes (260) across the USA. 1102 residents completed the survey\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e41% reported that they were not allowed in the operating room for cases considered high-risk for COVID-19 transmission. Case volume reduction was statistically significant (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUrology Residency Training at the Time of COVID-19 in Italy: 1 Year After the Beginning, 2021, Italy, \\u003csup\\u003e\\u003cspan citationid=\\\"CR67\\\" class=\\\"CitationRef\\\"\\u003e67\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA cross sectional survey of surgical training from 27 urology training programmes comparing the long-term impact of the pandemic with the training received pre-pandemic. 53% (312/585) response rate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eThe proportions of those experiencing a significant decrease of training exposure were 27%, 47%, 38%, and 33% (as compared with 82%, 70%, 60%, and 50% in the previous survey) for diagnostic procedures, endoscopic surgery, open surgery, and minimally invasive surgery, respectively. The most impactful reductions in training activities were reached by final-year residents\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of the COVID-19 pandemic on Urology Residency Training in Italy, 2020, Italy, \\u003csup\\u003e\\u003cspan citationid=\\\"CR68\\\" class=\\\"CitationRef\\\"\\u003e68\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA cross sectional survey of Italian urology residents one month after the start of the pandemic. 61% (351/577) response rate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eBefore the COVID-19 pandemic, the proportion of residents routinely involved in \\u0026ldquo;surgical\\u0026rdquo; activities ranged from 49\\u0026ndash;74%. In the COVID-19 period, the proportion of residents experiencing a severe reduction (\\u0026gt;\\u0026thinsp;40%) or complete suppression (\\u0026gt;\\u0026thinsp;80%) of training exposure ranged between 44% and 62% for surgical activities. This reduction was even more pronounced for residents attending the final year of training. Statistically significant reduction in diagnostic and endoscopic procedures (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) for residents in year 2,3, 4 and 5. For open surgery, year 5 had a statistically significant decline in involvement\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of COVID-19 pandemic on urology residency training, 2020, Saudi Arabia, \\u003csup\\u003e\\u003cspan citationid=\\\"CR69\\\" class=\\\"CitationRef\\\"\\u003e69\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA cross sectional survey of all urology residents about the impact of the pandemic on surgical training. 38% (77/202) response rate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eStatistically significant decline in diagnostic procedures (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), endoscopic surgeries (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), minimallyinvasive surgeries (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), and major open surgeries (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) in comparison to before the COVID-19 pandemic\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEarly Effects of COVID-19 Pandemic on Neurosurgical Training in the United States: A Case Volume Analysis of 8 Programs, 2020, USA, \\u003csup\\u003e\\u003cspan citationid=\\\"CR70\\\" class=\\\"CitationRef\\\"\\u003e70\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA comparative review of the operative log from eight residency programmes from 2019 to January to April 2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCompared with 2019, mean operative volume declined 15% (p\\u0026thinsp;=\\u0026thinsp;0.003) in March 2020 and 49% (p\\u0026thinsp;=\\u0026thinsp;0.002) in April 2020, respectively, which was statistically significant, affecting all the training programmes included in this study\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eGood\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eImpact of the COVID-19 Pandemic on Surgical Residency Training: Perspective from a Low-Middle Income Countries, 2020, Nigeria, \\u003csup\\u003e\\u003cspan citationid=\\\"CR71\\\" class=\\\"CitationRef\\\"\\u003e71\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eA cross sectional online survey of surgical residents from July to August 2020. 83% (207/250) response rate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e59% reported a decrease and 36% reported no change in emergency operating. 91% reported a decrease in elective surgery. 82% believed the pandemic had a negative impact on their training and professional growth. 59% felt the pandemic had elongated the duration of training and time of completion of residency training\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFair\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eAim\\u003c/h2\\u003e \\u003cp\\u003eThe aim of this systematic review was to explore the impact of the COVID-19 pandemic on technical skill training in post-graduate surgical specialities and study the recovery measures being considered.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec15\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eOverview of findings\\u003c/h2\\u003e \\u003cp\\u003e This systematic review presented evidence from 62 papers published during the COVID pandemic about technical skills training in surgical specialities. The majority of the studies (71%) were from high income countries. All surgical specialities except vascular surgery were represented in this review. There were no papers published from vascular surgery that fit within the inclusion criteria of this review. The majority of papers used quantitative methods (98%), and relied on self-reported data collected through surveys, limiting the methodological diversity of the review.\\u003c/p\\u003e \\u003cp\\u003eA meta-analysis was not possible due to the heterogenous nature of the studies and hence a thematic analysis was performed where the majority,53 of the 62 included studies, described a significant negative impact of the pandemic on operating and technical skills training.\\u003c/p\\u003e \\u003cp\\u003eOnly a few studies discussed the use of simulation, to which about 50% of the trainees had access. Simulation-based education was underutilised during the prolonged downtimes where trainees could not operate but could have practised in simulation \\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR24 CR25 CR26\\\" citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eAdditionally, there was a lack of evidence regarding recovery planning, with only one study that discussed the use of the independent sector as a potential avenue to provide trainees with opportunities for technical skills training \\u003csup\\u003e\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eWorries regarding progression, exam cancellations and loss of technical skills were reported by most of the studies in this review.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec16\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eImpact on technical skills training\\u003c/h2\\u003e \\u003cp\\u003eThe development of surgical technical skills relies on the acquisition of knowledge (through formal educational activities and self-study) and the practice of motor-skills through deliberate practise (traditionally reliant on the experience gained through operating on patients on the job, and more recently through simulation) \\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR73\\\" citationid=\\\"CR72\\\" class=\\\"CitationRef\\\"\\u003e72\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR74\\\" class=\\\"CitationRef\\\"\\u003e74\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eThe COVID-19 pandemic significantly disrupted surgical training by drastically reducing hands on training opportunities in the operating theatre which is critical for the development of technical surgical skills \\u003csup\\u003e\\u003cspan citationid=\\\"CR57\\\" class=\\\"CitationRef\\\"\\u003e57\\u003c/span\\u003e\\u003c/sup\\u003e. Of course, the damage was further enhanced by the cancellation of exams, the cancellation of courses and the inadequate use of simulation during this time \\u003csup\\u003e\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eHands on training is essential for technical skills development and centres where operating was preserved witnessed less impact on technical skills training than the many centres where operating was severely reduced. Though in the past changes to surgical training e.g. work hour restrictions, competency-based training, shift pattern working etc were viewed as events that had a negative impact, it is well recognised now that no other global event has had such a devastating impact on technical skills training as the COVID-19 pandemic \\u003csup\\u003e\\u003cspan citationid=\\\"CR60\\\" class=\\\"CitationRef\\\"\\u003e60\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec17\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eHistorical context\\u003c/h2\\u003e \\u003cp\\u003eIn their paper titled \\u0026ldquo;Lessons from Epidemics, Pandemics, and Surgery\\u0026rdquo;, Nicholas Hakes et al discuss the historical changes to surgery that have occurred in the wake of epidemics and pandemics \\u003csup\\u003e\\u003cspan citationid=\\\"CR75\\\" class=\\\"CitationRef\\\"\\u003e75\\u003c/span\\u003e\\u003c/sup\\u003e. The examples they quote include the formalisation of surgical guilds after the Plague, incorporating hygiene practises due to the Spanish flu and more recently the systemic flexibility that was required to deal with the Severe Acute Respiratory Syndrome (SARS) outbreak \\u003csup\\u003e\\u003cspan citationid=\\\"CR75\\\" class=\\\"CitationRef\\\"\\u003e75\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eArguably, one of the biggest challenges faced by the surgical specialities during the COVID-19 pandemic was the deterioration of surgical training and therefore, it is a logical conclusion one can draw that the post pandemic era of surgical training must require foundational restructuring- with a combined reliance on simulation and real world operating to gain the technical skills, with the overarching view that technical skills training obtained in an operating theatre and non-operating theatre environments go hand in hand.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec18\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eProposal for recovery of technical skills training\\u003c/h2\\u003e \\u003cp\\u003eThe only recovery measure discussed in this systematic review was the outsourcing of technical skill training to the independent sector \\u003csup\\u003e\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e\\u003c/sup\\u003e. The independent healthcare section in the UK is not accessible for everyone \\u003csup\\u003e\\u003cspan citationid=\\\"CR76\\\" class=\\\"CitationRef\\\"\\u003e76\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR77\\\" class=\\\"CitationRef\\\"\\u003e77\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eThough independent sector operating provided a potentially effective resource to consider post pandemic training recovery, other modalities for recovery such as simulation, training only operating lists, mentorship, extensions to training time and funding fellowships should also be considered. Furthermore, any recovery measures must be accessible, sustainable, and equitable \\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR79\\\" citationid=\\\"CR78\\\" class=\\\"CitationRef\\\"\\u003e78\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR80\\\" class=\\\"CitationRef\\\"\\u003e80\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eConsidering several avenues for recovery as described above would provide educators globally the chance to understand their contexts, access to resources, their trainees\\u0026rsquo; needs and enable them to apply the recovery measures that are likely to be the most effective.\\u003c/p\\u003e \\u003cp\\u003eThe use of simulation for technical skills training is evidence based. However, both with the evidence presented in this review and established in literature, simulation is often poorly implemented and therefore does not fulfil its potential as an adjunct to traditional technical skills training. The inadequate implementation of simulation presents us with a large gap in research that requires further exploration \\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR82\\\" citationid=\\\"CR81\\\" class=\\\"CitationRef\\\"\\u003e81\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR83\\\" class=\\\"CitationRef\\\"\\u003e83\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec19\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStrengths and limitations\\u003c/h2\\u003e \\u003cp\\u003e The PRISMA statement and guidelines were adhered to when conducting the systematic review to minimise identification and selection bias. Any changes to the protocol were documented and reported, to maintain transparency. This review, unlike other systematic reviews published about the impact of COVID on surgical trainees, specifically focussed on technical skills training. Also, this review included a wider range of surgical specialities than other previously published reviews. These steps enhanced the richness of the results, improving the overall scope and insights gained from the review.\\u003c/p\\u003e \\u003cp\\u003eStudies were included based on their relevance to the research question and aim of the systematic review, irrespective of their risk of bias. It is worth noting, however, that publications based on individual opinion were excluded from this review. This variation in bias should be considered when interpreting the results. A strength of this review is in the thematic analysis, where each theme has emerged from the analysis of multiple studies of varying methodologies. This co-construction helped to strengthen the findings.\\u003c/p\\u003e \\u003cp\\u003eChanges were made during the process of conducting the review that deviated from the registered protocol, and these were documented and reported. The changes included the narrowing of the scope of the review (focussing on technical skills training only) and changing the tool used for risk of bias analysis. The studies could not undergo meta-analysis due to the nature of the results presented and the lack of RCTs. A pooled estimate of the findings could not be statistically shown, and qualitative methodologies were applied to make sense of the data.\\u003c/p\\u003e \\u003cp\\u003eThe lack of publications from low-income countries highlights a publication bias. This limits the applicability of the findings of the study and the findings may not be easily extrapolated to a low-income context.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eThe purpose of this systematic review was to understand the impact of the COVID-19 pandemic on technical skills training in surgical specialities, adding to the evidence that exists regarding the issues with technical skills training and presenting potential recovery opportunities. This review has practical implications for the post-COVID recovery of surgical training. The recovery planning is an opportunity for a paradigm shift in surgical training with technical skills simulation as an essential adjunct to learning in the operating theatre. The findings underscore the need for adaptable, equitable recovery measures to address training deficits.\\u003c/p\\u003e \"},{\"header\":\"Declarations\",\"content\":\"\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eAS: Concept, Protocol development, data collection, data analysis, manuscript writing, manuscript editingNMT and HS: Data analysisDA and HH: Project supervisor, data analysis, manuscript editing\\u003c/p\\u003e\\u003ch2\\u003eAcknowledgement\\u003c/h2\\u003e\\u003cp\\u003eMr Neal Thurley, a librarian from the Bodleian Health Care libraries, helped refine the search protocol and conduct the search\\u003c/p\\u003e\\u003cp\\u003e \\u003cb\\u003eFunding and conflict of interest declaration\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eThere are no conflicts of interest to declare. 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COVID-19 pandemic effect on otolaryngology resident surgical case numbers. \\u003cem\\u003eOtolaryngology-Head and Neck Surgery\\u003c/em\\u003e. 2021:P157-P157.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDavis C, Hayes L, Dent N, Jennings I, Arumugasamy M, Walsh T. Impact of COVID-19 on surgical training. Br J Surg. 2021;108(5):e199\\u0026ndash;200.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDash C, Venkataram T, Goyal N, et al. Neurosurgery training in India during the COVID-19 pandemic: straight from the horse\\u0026rsquo;s mouth. NeuroSurg Focus. 2020;49(6):E16.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDanilovic A, Torricelli FCM, Anjos Gd, et al. Impact of COVID-19 on a urology residency program. Int braz j urol. 2021;47:448\\u0026ndash;53.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eClements JM, Burke J, Nally D, et al. COVID-19 impact on Surgical Training and Recovery Planning (COVID-STAR)-A cross-sectional observational study. Int J Surg. 2021;88:105903.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eColeman JR, Abdelsattar JM, Glocker RJ, et al. COVID-19 pandemic and the lived experience of surgical residents, fellows, and early-career surgeons in the American College of Surgeons. J Am Coll Surg. 2021;232(2):119\\u0026ndash;35. e20.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChang D-G, Park J-B, Baek GH, et al. The impact of COVID-19 pandemic on orthopaedic resident education: a nationwide survey study in South Korea. Int Orthop. 2020;44:2203\\u0026ndash;10.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCaruana EJ, Patel A, Kendall S, Rathinam S. Impact of coronavirus 2019 (COVID-19) on training and well-being in subspecialty surgery: a national survey of cardiothoracic trainees in the United Kingdom. J Thorac Cardiovasc Surg. 2020;160(4):980\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBurks JD, Luther EM, Govindarajan V, Shah AH, Levi AD, Komotar RJ. Early changes to neurosurgery resident training during the COVID-19 pandemic at a large US academic medical center. World Neurosurg. 2020;144:e926\\u0026ndash;33.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBoekhorst F, Khattak H, Topcu EG, Horala A, Henriques MG. The influence of the COVID-19 outbreak on European trainees in obstetrics and gynaecology: A survey of the impact on training and trainee. Eur J Obstet Gynecol Reproductive Biology. 2021;261:52\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAziz H, James T, Remulla D, et al. Effect of COVID-19 on surgical training across the United States: a national survey of general surgery residents. J Surg Educ. 2021;78(2):431\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAmparore D, Checcucci E, Serni S, et al. Urology residency training at the time of COVID-19 in Italy: 1 year after the beginning. Eur Urol Open Sci. 2021;31:37\\u0026ndash;40.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAmparore D, Claps F, Cacciamani GE et al. Impact of the COVID-19 pandemic on urology residency training in Italy. Minerva Urol Nefrol. 2020:0\\u0026ndash;0.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAlyami FA, Almuhaideb MA, Alzahrani MA, Sabr YS, Almannie RM. Impact of COVID-19 pandemic on urology residency training. Urol Annals. 2021;13(3):215.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAljuboori ZS, Young CC, Srinivasan VM, et al. Early effects of COVID-19 pandemic on neurosurgical training in the United States: a case volume analysis of 8 programs. World Neurosurg. 2021;145:e202\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAdesunkanmi AO, Ubom AE, Olasehinde O, et al. Impact of the COVID-19 pandemic on surgical residency training: perspective from a low-middle income country. World J Surg. 2021;45:10\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eVaporciyan AA. Teaching and learning surgical skill. Ann Thorac Surg. 2016;101(1):12\\u0026ndash;4.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKorte W, Merz C, Kirchhoff F, et al. Train early and with deliberate practice: simple coronary surgery simulation platform results in fast increase in technical surgical skills in residents and students. Interact Cardiovasc Thorac Surg. 2020;30(6):871\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWollstein Y, Jabbour N. Building Surgical Expertise Through Deliberate Practice. Ear Nose Throat J. 2022;101(9suppl):S47\\u0026ndash;51.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHakes NA, Choi J, Spain DA, Forrester JD. Lessons from epidemics, pandemics, and surgery. J Am Coll Surg. 2020;231(6):770\\u0026ndash;6.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eVaughan-Shaw P, Chiverton S, Rew D, Nichols P. The Impact of an Independent Sector Treatment Centre on Basic Surgical Training. Bull Royal Coll Surg Engl. 2012;94(8):276\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKolaityte V, El-Sayed C, Burke J. SP2. 2.18 UK Surgical Training in the Independent Sector During COVID-19\\u0026ndash;A Snapshot Survey. Br J Surg. 2021;108(Supplement7):znab361.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKwan JY, Long J, McClean A, Chetter I, Lockwood S, Yiasemidou M. FTP8. 1 International expert opinion on the mitigation of the effects of the COVID-19 pandemic on surgical training. Br J Surg. 2023;110(Supplement6):znad241.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eZhao S, Rothnie A, Nanda A, Chouari T, Ashraf S, Vig S. Developing Bespoke High Volume Low Complexity (HVLC) Theatre Lists With a Focus on Training to Address the Impact of COVID-19: A Pilot Study. Cureus. 2023;15(11).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBodapati S, Gambhir RPS, Kimura S. TU6. 1 Tackling the training deficit due to COVID-19 disruptions. Br J Surg. 2022;109(Supplement5):znac248.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDavids J, Manivannan S, Darzi A, Giannarou S, Ashrafian H, Marcus HJ. Simulation for skills training in neurosurgery: a systematic review, meta-analysis, and analysis of progressive scholarly acceptance. Neurosurg Rev. 2021;44(4):1853\\u0026ndash;67.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBjerrum F, Thomsen ASS, Nayahangan LJ, Konge L. Surgical simulation: current practices and future perspectives for technical skills training. Med Teach. 2018;40(7):668\\u0026ndash;75.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eStefanidis D, Sevdalis N, Paige J, et al. Simulation in surgery: what's needed next? Ann Surg. 2015;261(5):846\\u0026ndash;53.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"current-surgery-reports\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"surg\",\"sideBox\":\"Learn more about [Current Surgery Reports](http://link.springer.com/journal/40137)\",\"snPcode\":\"40137\",\"submissionUrl\":\"https://submission.nature.com/new-submission/40137/3\",\"title\":\"Current Surgery Reports\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"COVID-19 pandemic, Surgical training, Systematic review, Technical skills\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-6938176/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-6938176/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003eSurgical training was significantly affected during the COVID-19 pandemic due to several factors, including the postponement of professional exams, fewer hands-on surgical training opportunities and redeployment. This systematic review aimed to explore the impact of the COVID-19 pandemic on post-graduate technical skills training in surgical specialities.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003e The systematic review was conducted following the guidelines set out by PRISMA with the inclusion of studies on surgical training from any of the 12 specialities. The studies were screened in duplicate. A thematic analysis was conducted on the extracted data.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eFifty-three studies reported a significant impact on technical skills training due to the pandemic with statistically significant reduction in operating compared to before the pandemic. Only a few studies discussed the use of simulation, to which about 50% of the trainees had access, but was underutilised during the prolonged downtimes where trainees could not operate but could have practised in simulation. There was a lack of evidence regarding recovery planning, with only one study that discussed the use of the independent sector as a potential avenue to provide trainees with opportunities for technical skills training. Worries regarding progression, exam cancellations and loss of technical skills were reported by most of the studies in this review.\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e \\u003cp\\u003eThere is an opportunity for a paradigm shift in surgical training with technical skills simulation as an essential adjunct to learning in the operating theatre after the pandemic. These findings underscore the need for adaptable, equitable recovery measures to address training deficits.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Investigating the impact of the COVID-19 pandemic on postgraduate surgical technical skills training: a systematic review\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-10-12 14:26:03\",\"doi\":\"10.21203/rs.3.rs-6938176/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2025-09-15T19:31:39+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-09-15T19:31:08+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-06-24T01:58:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Current Surgery Reports\",\"date\":\"2025-06-20T10:42:02+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"current-surgery-reports\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"surg\",\"sideBox\":\"Learn more about [Current Surgery Reports](http://link.springer.com/journal/40137)\",\"snPcode\":\"40137\",\"submissionUrl\":\"https://submission.nature.com/new-submission/40137/3\",\"title\":\"Current Surgery Reports\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"f62872cf-7c35-423d-8c0e-5e95e483ee36\",\"owner\":[],\"postedDate\":\"October 12th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-10-12T14:26:03+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-10-12 14:26:03\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-6938176\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-6938176\",\"identity\":\"rs-6938176\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}