Formal Laparoscopic Training Research Articles

Advancing laparoscopic skills training in Namibia: Implementation of the Global Laparoscopic Advancement Program (GLAP)of the Society of American Gastrointestinal and EndoscopicSurgeons (SAGES).

In low- and middle-income countries (LMICs), laparoscopic surgery is challenging to implement due to limited resources and lack of expert surgeons as teachers. The Global Laparoscopic Advancement Program (GLAP) was developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) to deliver sustainable and effective methods for teaching safe laparoscopic surgery. GLAP aims to train surgical leaders and trainees with the goal of eventual in-country replication of GLAP programming. After successful implementation in Mexico and Costa Rica, this study evaluates the feasibility of a pilot training course in Namibia, Southern Africa. In December 2022 and September 2023, GLAP partnered with the Namibian Surgical Society and the College of Surgeons of East,Central,and Southern Africa (COSECSA) to administer 2 GLAP courses, with hands-on simulation practice and lectures on surgical education, training, and curriculum development. Participants completed surveys assessing their surgical background and experiences, their experience with simulation, and interest in curriculum development at their home institutions. Participants were also evaluated on their time to completion for the five FLS tasks during the initial and final days of the program. Over two GLAP courses, there were a total of 31 practicing general, gynecologic, and urologic surgeons from Namibia, Ethiopia, Malawi, Somali, and Zambia, taught by 5-7 GLAP faculty members. Overall, 35.5% had formal laparoscopic training during residency or fellowship, 16.13% had no experience with laparoscopy, and 77.42% learned laparoscopy through observation. Fifty-three percent of respondents had never practiced laparoscopy on a simulator before and 45% of respondents noted they did not have mentors to help them learn laparoscopic skills. Eighty percent of participants noted lack of equipment as the most important factor limiting the use of laparoscopy, followed by 76% noting lack of trained surgeons and 73% noting lack of formal training. The majority of respondents noted a very strong desire for formal training (61%), including additional short-term courses in laparoscopy (58%) and FLS skills testing opportunities (63%) in the future. For skills acquisition, there was a statistically significant reduction in the time to complete the circle cut task at the end of the course (359.2s vs 206s, p-value 0.016) across both years. There is limited adoption of laparoscopy in Namibia, hindered by lack of training, expert trainers, and equipment. Implementation of GLAP is feasible and offers an additional training opportunity to the region.

Effect of virtual reality training to enhance laparoscopic assistance skills

BackgroundWhile laparoscopic assistance is often entrusted to less experienced individuals, such as residents, medical students, and operating room nurses, it is important to note that they typically receive little to no formal laparoscopic training. This deficiency can lead to poor visibility during minimally invasive surgery, thus increasing the risk of errors. Moreover, operating room nurses and medical students are currently not included as key users in structured laparoscopic training programs.ObjectivesThe aim of this study is to evaluate the laparoscopic skills of OR nurses, clinical medical postgraduate students, and residents before and after undergoing virtual reality training. Additionally, it aimed to compare the differences in the laparoscopic skills among different groups (OR nurses/Students/Residents) both before and after virtual reality training.MethodsOperating room nurses, clinical medical postgraduate students and residents from a tertiary Grade A hospital in China in March 2022 were selected as participants. All participants were required to complete a laparoscopic simulation training course in 6 consecutive weeks. One task from each of the four training modules was selected as an evaluation indicator. A before-and-after self-control study was used to compare the basic laparoscopic skills of participants, and laparoscopic skill competency was compared between the groups of operating room nurses, clinical medical postgraduate students, and residents.ResultsTwenty-seven operating room nurses, 31 clinical medical postgraduate students, and 16 residents were included. The training course scores for the navigation training module, task training module, coordination training module, and surgical skills training module between different groups (operating room nurses/clinical medical postgraduate/residents) before laparoscopic simulation training was statistically significant (p < 0.05). After laparoscopic simulation training, there was no statistically significant difference in the training course scores between the different groups. The surgical level scores before and after the training course were compared between the operating room nurses, clinical medical postgraduate students, and residents and showed significant increases (p < 0.05).ConclusionOur findings show a significant improvement in laparoscopic skills following virtual surgery simulation training across all participant groups. The integration of virtual surgery simulation technology in surgical training holds promise for bridging the gap in laparoscopic skill development among health care professionals.

Trends in laparoscopic colorectal surgery over time from 2005-2014 using the NSQIP database

BackgroundLaparoscopy, originally pioneered by gynecologists, was first adopted by general surgeons in the late 1980s. Since then, laparoscopy has been adopted in the surgical specialties and colorectal surgery for treatment of benign and malignant disease. Formal laparoscopic training became a required component of surgery residency programs as validated by the Fundamentals of Laparoscopic Surgery curriculum; however, some surgeons may be more apprehensive of widespread adoption of minimally invasive techniques. Although an overall increase in the use of laparoscopy in colorectal surgery is anticipated over a 10-year period, it is unknown if a similar increase will be seen in higher risk or more acutely ill patients. MethodsUsing the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from 2005-2014, colorectal procedures were identified by Current Procedural Terminology codes and categorized to open or laparoscopic surgery. The proportion of colorectal surgeries performed laparoscopically was calculated for each year. Separate descriptive statistics was performed and categorized by age and body mass index (BMI). American Society of Anesthesiology (ASA) classification and emergency case status variables were added to the project to help assess complexity of cases. ResultsDuring the 10-year study period, the number of colorectal cases increased from 3114 in 2005 to 51,611 in 2014 as more hospitals joined NSQIP. A total of 277,376 colorectal cases were identified; of which, 114,359 (41.2%) were performed laparoscopically. The use of laparoscopy gradually increased each year, from 22.7% in 2005 to 49.8% in 2014. Laparoscopic procedures were most commonly performed in the youngest age group (18-49 years), overweight and obese patients (BMI 25-34.9), and in ASA class 1-2 patients. Over the 10-year period, there was a noted increase in the use of laparoscopy in every age, BMI, and ASA category, except ASA 5. The percent of emergency cases receiving laparoscopic surgery also doubled from 5.5% in 2005 to 11.5% in 2014. ConclusionsOver a 10-year period, there was a gradual increase in the use of laparoscopy in colorectal surgery. Further, there was a consistent increase of laparoscopic surgery in all age groups, including the elderly, in all BMI classes, including the obese and morbidly obese, and in most ASA classes, including ASA 3-4, as well as in emergency surgeries. These trends suggest that minimally invasive colorectal surgery appears to be widely adopted and performed on more complex or higher risk patients.

Simplifying laparoscopic nephrectomy: the inferior approach with en bloc stapling of the renal hilum.

Introduction:Laparoscopic nephrectomy (LN) is likely the most common laparoscopic procedure performed by general urologists without formal laparoscopic training. The traditional technique is cumbersome because it entails making an early approach to the hilum with the risk of bleeding and need for conversion. We perform a different technique that we believe is simpler to learn and to teach. It consists of a complete dissection of the inferior and posterior aspects of the kidney, followed by en bloc stapling of the renal hilum. The present report is a detailed description of our technique including outcomes and complications.Materials and Methods:Perioperative data of 129 consecutive patients who underwent LN between November 2003 and September 2007 were prospectively collected and retrospectively reviewed. Complications were reported using the Clavien classification system, and follow-up was performed according to our institution's protocol and included physical examination, blood count, blood chemistry, and renal function tests at every visit, in addition to abdominal computed tomography scan six months after surgery. Additional imaging was scheduled according to disease stage and grade.Results:Mean patient age, tumor size, and operative time were 63 ± 15.6 years, 6.3 ± 2.4 cm, and 128 ± 41.4 minutes, respectively. Median estimated blood loss was 0 mL (0.200). Conversion to open surgery occurred in 3.1% of patients, and 8% of the patients had a blood transfusion. Complications were recorded in 26% of the patients; 91% of them had Clavien grade scores of 1 or 2.Conclusion:We present a standardized technique for LN. Its main advantage is that postpones any manipulation of the hilum to a later step during the procedure when it is easy to identify and control. This decreases early bleeding and main vascular complications.

Contribution of Laparoscopic Training to Robotic Proficiency

Robotic surgical technology has been adopted by surgeons with and without previous standard laparoscopic experience. The necessity or benefit of prior training and experience in laparoscopic surgery is unknown. We hypothesized that laparoscopic training enhances performance in robotic surgery. Fourteen medical students with no surgical experience were instructed to incise a spiral using the da Vinci(®) surgical robot with time to completion and errors recorded. Each student was then trained for 1 month in standard laparoscopy, but with no further robotic exposure. Training included a validated laparoscopic training program, including timed and scored parameters. After completion of the month-long training, the students repeated the cutting exercise using the da Vinci robot as well as with standard laparoscopic instruments and were scored within the same parameters. The mean time to completely incise the spiral robotically before training was 16.72 min with a mean of 6.21 errors. After 1 month of validated laparoscopic training, the mean robotic time fell to 9:03 min (p=0.0002) with 3.57 errors (p=0.02). Laparoscopic performance after 1 month of validated laparoscopic training was 13.95 min with 6.14 errors, which was no better than pretraining robotic performance (p=0.20) and worse than post-training robotic performance (p=0.01). Formal laparoscopic training improved the performance of a complex robotic task. The initial robotic performance without any robotic or laparoscopic training was equivalent to standard laparoscopic performance after extensive training. Additionally, after laparoscopic training, the robot allowed significantly superior speed and precision of the task. Laparoscopic training may improve the proficiency in operation of the robot. This may explain the perceived ease with which robotics is adopted by laparoscopically trained surgeons and may be important in training future robotic surgeons.

The influence of a ‘take home’ box trainer on laparoscopic performance for gynaecological surgeons

Laparoscopic surgery requires a unique set of technical skills. There is emphasis on increasing patient safety, and therefore, a growing need to improve laparoscopic training. The aim of this study is to determine if the use of a ‘take-home’ box trainer would improve gynaecological surgeon performance. Thirteen obstetricians and gynaecologists (consultants and registrars) were enrolled to receive 6 months formal laparoscopic training using a ‘take-home’ box trainer. Laparoscopic skills were objectively assessed using a virtual reality haptic-enhanced simulator prior to commencement and at the completion of the course utilising three defined exercises (locating and coordinating, tissue manipulation and object positioning) where task duration, path length, economy of movement, hand dominance and overall score were assessed. Data is presented as mean ± SEM and differences between groups evaluated with ANOVA. All 13 gynaecologists completed the programme. For tissue manipulation, laparoscopic training using the box trainer reduced the task duration (214.8 ± 16.5 s vs. 147.7 ± 12.6 s, P = 0.04) and increased economy of movement (22 ± 7.1% vs. 78.9 ± 2.3%, P < 0.001) and overall score (11.7 ± 3.1% vs. 33.7 ± 1.8%, P < 0.001). For object positioning, laparoscopic training with the box trainer reduced task duration (280.1 ± 40.3 s vs. 106.6 ± 5.1 s, P < 0.001) and path length (825.3 ± 48.3 cm vs. 463.4 ± 16.8 cm, P < 0.001) and increased overall score (4.15 ± 1.7% vs. 15.2 ± 2%, P < 0.001). The box trainer did not significantly affect laparoscopic locating and coordinating or change hand dominance. Formal training and continuous practice using the box trainer model improves surgical skills required for laparoscopic surgery. The box trainer could be a more accessible and preferred tool for those training to become laparoscopic surgeons.

A collaborative approach reduces the learning curve and improves outcomes in laparoscopic nephrectomy

Despite the proven advantages of laparoscopic nephrectomy, the absence of local expertise and paucity of formal laparoscopic training in urology residencies has delayed the introduction of this technique into many institutions. We analyzed the impact of an initiative driven by the minimally-invasive division of the Department of Surgery on reducing the learning curve for hand-assisted laparoscopic nephrectomy (HALN) and maintaining good patient outcomes. A retrospective chart review was performed on all laparoscopic renal procedures performed at Greenville Memorial Hospital University Medical Center. A collaborative effort between an fellowship-trained laparoscopic surgeon and an urologist began in August 2005. The data from the first 25 procedures performed in collaboration with general surgery were compared to the first 25 cases by urology alone. The breakdown of cases was similar in the collaborative group (22 radical/3 partial) and the urology alone group (21 radical/4 partial). The indication for nephrectomy was cancer in the majority of cases. The operative times were longer in the collaborative group (236 v. 163 min; p < 0.001). With general surgery collaboration, estimated blood loss (107 v. 757 ml; p = 0.005), need for transfusion (2 v. 9 pts; p = 0.037), and conversion to open (1 pt v. 9 pts; p = 0.011) were all significantly reduced when compared to urologists alone. An initiative by general surgery to facilitate the introduction of laparoscopic renal surgery can result in substantial improvement in perioperative patient outcomes. Collaboration with urologists and laparoscopic surgeons allows for the introduction of advanced minimally invasive techniques with a reduced learning curve compared to urologists alone.

Proposal of a Formal Gynecologic Endoscopy Curriculum

As minimally invasive surgery becomes the standard of care in the United States and around the world, the formal training of endoscopic surgeons is an issue of growing concern. With the implementation of the American Association of Gynecologic Laparoscopists/Society of Reproductive Surgeons (AAGL/SRS)–sponsored fellowship training in gynecologic endoscopy and a growing number of hands-on courses, we have the challenge of credentialing and certifying future gynecologic endoscopists. The objective of this article is to propose and to illustrate a uniform standardized core curriculum for obstetrics and gynecology residents, fellows in AAGL/SRS-sponsored fellowship programs, and participants in postgraduate courses. Consisting of 3 discrete parts, this proposal addresses formal laparoscopic training for gynecologists, already implemented and available to general surgeons, and a novel proposition for core training in hysteroscopy. The curriculum is distributed in a quarterly system with specific educational objectives in each quarter. After quarters 1 and 2, an online examination is given; after quarter 3, participants are required to take and pass a hands-on examination at a specified testing facility; and at the end of quarter 4, participants must demonstrate leadership skills in the operating room and in a teaching capacity, and promote the principles of the AAGL.

Does Laparoscopy Beget Underuse of Partial Nephrectomy for T1 Renal Masses? Competing Treatment Decision Pathways May Influence Utilization

It has been suggested that renal laparoscopy has resulted in an underuse of partial nephrectomy (PN) for small renal masses in the U.S. In the absence of evidence-based medicine (EBM) guide-lines, multiple-perspective reasoning is required where complete v partial nephrectomy and the laparoscopic v the open surgical approach must be considered. We report on the PN rate in a contemporary laparoscopicera series of patients with T(1) renal masses and examine the potential influence of the management decision tree on the PN rate. An actively managed database of referred patients with T(1) renal masses was utilized retrospectively. All patients were evaluated by a single fellowship-trained urologic oncologist with formal laparoscopic training. Patients were presented with a management decision tree in which PN v total nephrectomy (TN) was the first decision node, laparoscopy v open surgery was the second decision node, and the actual PN rate was reported. We then constructed a hypothetical decision tree in which the first and second decision nodes were reversed and the criteria for performing laparoscopic nephrectomy remained constant. Seventy consecutive patients were entered during a 36-month period (July 2002-June 2005). The actual PN rate was 60%: 91% for lesions <2.0 cm, 68% for lesions 2.1 to 4.0 cm, and 33% for lesions 4.1 to 7.0 cm; and 62% of patients were treated laparoscopically. When the first and second decision nodes were reversed and this hypothetical model was applied to the study cohort, the projected PN rate was 23%, and 96% of the patients were treated laparoscopically. In the hypothetical model, the PN rate fell when patients who chose laparoscopy at the first decision node were excluded from PN at the second decision node if the criteria for laparoscopic PN were not met. Laparoscopy did not appear to result in underuse of PN. We explain this by suggesting that the PN rate may be influenced by variation in the decision tree itself. Such variation is inherent in complex clinical decision making where EBM guidelines are lacking.

A Retrospective Study Evaluating the Impact of Formal Laparoscopic Training on Patient Outcomes in a Residency Program

Study Objective To evaluate the impact of a formal laparoscopic training program on patient outcomes in an obstetrics and gynecology residency. Design Retrospective cohort study (Canadian Task Force classification II-1). Setting University-affiliated public hospital. Intervention Comparison of nonlaparoscopy-trained group (A) with a formally trained group (B). Subjects Three hundred sixty-eight women (group A) and 154 women (group B) undergoing operative laparoscopy. Measurements and Main Results Beginning October 1, 1999, residents, regardless of postgraduate year status, participated in six 4-hour sessions/year in a committed laparoscopic training program consisting of didactics, bench exercises (designed to mimic laparoscopic gynecologic technical skills), instrumentation instruction, animate tissue model surgery, and supervised gynecologic operating experience. Two certified gynecology laparoscopists facilitated each training session, and gynecologists with various laparoscopic skill levels supervised patient surgeries. Operating room time, blood loss, hospital stay, and conversion to laparotomy were less for group B than for group A, but the groups did not differ in complication rates. Adhesions and bleeding were the main reasons for conversion to laparotomy. Conclusion Formal laparoscopic training of gynecologic residents improved patient outcomes.

Mentored retroperitoneal laparoscopic renal surgery in children: a safe approach to learning.

To review the feasibility of introducing advanced retroperitoneal renal laparoscopic surgery (RRLS) to a paediatric urology division, using the mentorship-training model. Although the scope of practice in paediatric urology is currently adapting endoscopic surgery into daily practice, most paediatric urologists in North America have had no formal training in laparoscopic surgery. The study included four paediatric urologists with 3-25 years of practice; none had had any formal laparoscopic training or ever undertaken advanced RRLS. An experienced laparoscopic surgeon (the mentor) assisted the learning surgeons over a year. The initial phases of learning incorporated detailed lectures, visualization through videotapes and 'hands-on' demonstration by the expert in the technique of the standardized steps for each type of surgery. Over 10 months, ablative and reconstructive RRLS was undertaken jointly by the surgeons and the mentor. After this training the surgeons operated independently. To prevent lengthy operations, conversion to open surgery was planned if there was no significant progression after 2 h of laparoscopic surgery. Over the 10 months of mentorship, 36 RRLS procedures were undertaken in 31 patients (28 ablative and eight reconstructive). In all cases the mentored surgeons accomplished both retroperitoneal access and the creation of a working space within the cavity. The group was able to initiate ablative RRLS but the mentor undertook all the reconstructive procedures. After the mentorship period, over 10 months, 12 ablative procedures were undertaken independently, and five other attempts at RRLS failed. Although the mentored approach can successfully and safely initiate advanced RRLS in a paediatric urology division, assessing the laparoscopic practice pattern after mentorship in the same group of trainees is warranted. Ablative RRLS is easier to learn for the experienced surgeon, but reconstructive procedures, e.g. pyeloplasty, require a high degree of skill in laparoscopic technique, which may only be acquired through formal training focusing primarily on suturing techniques.

Retrospective study evaluating the early impact of a formal laparoscopic training program on the management of dermoid cysts

Objective: To evaluate outcomes of laparoscopic management of dermoid cysts after the institution of a formal laparoscopic training program at the University of Miami. Design: This is a retrospective comparative analysis of patients that had laparoscopic surgery at the University of Miami/Jackson Memorial Hospital from January 1998 to August 2001 for benign cystic teratomas. Materials and Methods: This is a retrospective study of 53 patients who had laparoscopic management of dermoid tumors at the University of Miami/Jackson Memorial Hospital from January 1998 to August 2001. In October 1999 an ongoing formal laparoscopic training program was instituted involving didactics, bench skills training, animate model surgery, and supervised surgery. Patients with a pre-operative diagnosis for suspected dermoid cyst were included in the study. Outcome variables measured included size of dermoid, spillage rates, estimated blood loss, operative time, hospital stay, complications, cost, resident training level and participation in formal training. Statitistical comparisons were made by Student’s t-tests, Chi square analysis, or Fisher’s exact tests. Statistical significance was defined as P-value <0.05. Results: Of the 250 patients who underwent surgical management of dermoid cyst, 197 (78.8%) were excluded because of concomitant major gynecologic surgery or laparotomy and the remaining 53 (21.2%) underwent dermoid management via laparoscopy. Of the 53 cases, 17 (32%) occurred prior to training and 36 (68%) after the institution of the formal training program. The size of dermoid cyst, spillage rates, estimated blood loss, operative time, hospital stay, complications, and hospital costs did not differ among both groups in this early analysis. Of the 9 patients that were converted to laparotomy due to size of the mass or dense adhesions, 8 (89%) were performed prior to the implementation of the training program (p<0.01). The resident training level and participation in formal training was equally distributed with third and fourth year residents performing most cases. The management of dermoids by laparoscopy was increased from 36% to 59% in the “formal training group” (p<0.05). Conclusions: A formal training program in laparoscopy impacts the conversion to laparotomy and the decision-making regarding surgical route of dermoid management.

Urological Laparoscopic Practice Patterns 1 Year After Formal Training

The long-term impact of laparoscopic training on urological surgical practice patterns is unclear. We assessed urologist practice patterns 1 year subsequent to a formal training course in urological laparoscopic surgery. Results were compared to findings from an identical study performed 3 months following training.On 5 dates between January and October 1991, a total of 163 urologists participated in a 2-day, university sponsored, laparoscopic surgery training seminar. At 3 months and 1 year following the course, participants were mailed a 20-question survey inquiring as to the interval laparoscopic experience. Multiple questions were designed for later correlation with participant use of laparoscopic surgery. Totals of 105 and 128 course participants (64% and 78.5%) responded to the questionnaire at 3 and 12 months, respectively. No significant differences in 3-month and 12-month demographics were demonstrated with respect to practice setting, practice focus or percentage undergoing additional training. Significant increases were noted between 3 and 12 months in the number of candidates identified per month (1.5 versus 2.4), proportion of surgical case load taken by laparoscopy (2.6% versus 4.1%), number of laparoscopic patient inquiries per month (0.25 versus 1.0) and number of laparoscopies performed per month (0.55 versus 0.78).Additional post-course training was significantly correlated with clinical use at 3 and 12 months. Of the 105 and 108 respondents 64 (61%) and 83 (65%) had engaged in some form of additional training by 3 months and 1 year after the course, respectively. Additional training as well as performance of laparoscopy proved to be independent of practice setting or practice focus at 3 and 12 months. Those who attended the course with a partner were significantly more likely to have performed laparoscopy at 1 year than those who attended alone. At 12 months following course completion 66% of the respondents believed that the year of laparoscopic experience was sufficient to maintain skills. This survey suggests that laparoscopic techniques are being used consistently by urologists subsequent to formal laparoscopic training courses.