Fundamentals Of Laparoscopic Surgery Certification Research Articles

What are essential laparoscopic skills these days? Results of the SAGES Fundamentals of Laparoscopic Surgery (FLS) Committee technical skills survey.

The Fundamentals of Laparoscopic Surgery (FLS) program tests basic knowledge and skills required to perform laparoscopic surgery. Educational experiences in laparoscopic training and development of associated competencies have evolved since FLS inception, making it important to review the definition of fundamental laparoscopic skills. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) assigned an FLS Technical Skills Working Group to characterize technical skills used in basic laparoscopic surgery in current practice contexts and their possible application to future FLS tests. A group of subject matter experts defined an inventory of 65 laparoscopic skills using a Nominal Group Technique. From these, a survey was developed rating these items for importance, frequency of use, and priority for testing for FLS certification. This survey was distributed to SAGES members, recent recipients of FLS certification, and members of the Association of Program Directors in Surgery (APDS). Results were collected using a secure web-based survey platform. Complete data were available for 1742 surveys. Of these, 1143 comprised results for post-residency participants who performed advanced procedures. Seventeen competencies were identified for FLS testing prioritization by determining the proportion of respondents who identified them of highest priority, at median (50th percentile) of the maximum survey scale rating. These included basic peritoneal access, laparoscope and instrument use, tissue manipulation, and specific problem management skills. Sixteen could be used to show appropriateness of the domain construct by confirmatory factor analysis. Of these 8 could be characterized as manipulative tasks. Of these 5 mapped to current FLS tasks. This survey-identified competencies, some of which are currently assessed in FLS, with a high level of priority for testing. Further work is needed to determine if this should prompt consideration of changes or additions to the FLS technical skills test component.

Residents perform better technically, have less stress and workload, and prefer robotic to laparoscopic technique during inanimate simulation.

With the widespread adoption of minimally invasive surgery, there is a growing need for surgical residents to be trained by a procedure-specific curriculum. This study aimed to evaluate the technical performance and feedback of surgical residents undergoing the robotic and laparoscopic hepaticojejunostomy (HJ) and gastrojejunostomy (GJ) biotissue modules. A total of 23 PGY-3 surgical residents participated in this study and performed the laparoscopic and robotic HJ and GJ drills, which were recorded and scored by two independent graders using the modified objective structured assessment of technical skills (OSATS). After completing each drill, all participants filled out the NASA Task Load Index (NASA-TLX), Borg Exertion Scale, and Edwards Arousal Rating Questionnaire. Twenty-two (95.7%) residents had already received fundamentals of laparoscopic surgery certification. Eighteen (78.3%) residents had robotic virtual simulation training and the median (range) number of robotic surgery console experience was 4 (0-30). In the HJ comparison of the six OSATS domains, the robotic system was superior in Gentleness (p = 0.031). In the GJ comparison, the robotic system was superior in Time and Motion (p < 0.001), Instrument Handling (p = 0.001), Flow of Operation (p = 0.002), Tissue Exposure (p = 0.013), and Summary (p < 0.001). Participants answered significantly higher demand scores for laparoscopy on all six facets of NASA-TLX for both HJ and GJ (p < 0.05). The Borg Level of Exertion was > 2 points higher for laparoscopic HJ and GJ (p < 0.001). Residents rated more Nervousness and Anxiety for laparoscopic compared to robotic (p < 0.05) HJ and GJ. Additionally, when asked to score preference for robotic and laparoscopic approach in terms of technique and ergonomics, residents scored robot as better (laparoscopy worse) for both HJ and GJ in both domains. The robotic surgical system provided a more favorable environment for trainees with less mental and physical burden for minimally invasive HJ and GJ curriculum.

Does the advanced training in laparoscopic suturing enhance laparoscopic suturing skill beyond fundamentals of laparoscopic surgery?

BackgroundLaparoscopic suturing is associated with a steep learning curve. Hence, many general surgery graduate residents entering fellowship have reportedly not been able to proficiently suture laparoscopically despite achieving Fundamentals of Laparoscopic Surgery certification. To address this deficiency, the Advanced Training in Laparoscopic Suturing curriculum was developed. This study aimed to compare the effectiveness of the Advanced Training in Laparoscopic Suturing curriculum in improving laparoscopic suturing skills compared with Fundamentals of Laparoscopic Surgery training. MethodsNovices were enrolled in a prospective randomized controlled study. All novices followed proficiency-based training on Fundamentals of Laparoscopic Surgery peg-transfer and intracorporeal suturing. Students were then stratified based on their peg-transfer performance and randomized into an Advanced Training in Laparoscopic Suturing or Fundamentals of Laparoscopic Surgery group. The Advanced Training in Laparoscopic Suturing group trained on 3 of the 6 Advanced Training in Laparoscopic Suturing tasks (needle handling, offset forehand suturing, confined space suturing), while the Fundamentals of Laparoscopic Surgery group was assigned more stringent suturing performance goals. Each group trained for an additional 6 hours, after which the laparoscopic suturing performance of the 2 groups was compared on a Nissen fundoplication porcine model. ResultsThirty-nine medical students were enrolled in the study; 17 (11 males and 6 females) completed the study protocol (44%). Controlling for confounders including the student suturing performance at the end of stage-1 training, the Advanced Training in Laparoscopic Suturing group at the porcine model was significantly faster/safer (coefficient = 102.7, P = .037), and more skilled (coefficient = 19.1, P = .048) compared with the Fundamentals of Laparoscopic Surgery group. ConclusionCompared with Fundamentals of Laparoscopic Surgery training alone the Advanced Training in Laparoscopic Suturing curriculum further enhances the laparoscopic suturing skill of novices. These findings support incorporating Advanced Training in Laparoscopic Suturing into existing skills curricula.

Learning Fundamentals of Laparoscopic Surgery Manual Skills: An Institutional Experience With Remote Coaching and Assessment.

ABSTRACTIntroductionCOVID-19 has altered the landscape of traditional surgical education. This is a pilot study of remote coaching and assessment of Fundamentals of Laparoscopic Surgery (FLS) manual skills in obstetrics and gynecology residents.Materials and MethodsPGY-3 obstetrics and gynecology residents participated in remote assessment of FLS manual skills using a live streaming platform. Learners who showed deficiencies in proficiency participated in live-streamed coaching sessions. The coaching sessions continued until the learner and coach mutually agreed that the learner was prepared for the skills portion of the FLS certification exam. The primary outcome was learner performance on skills assessment with external validation through the FLS manual skills exam pass rate.ResultsOne learner demonstrated proficiency at baseline and the remaining nine underwent remote coaching sessions. Learners received a mean of two coaching sessions to reach mutually agreed readiness for the FLS exam as per learner and coach. All residents performed significantly better at the conclusion of the remote coaching series (11.3 ± 0.82) as compared to their baseline scores (8.8 ± 2.82) (P < .03; 95% CI, 0.31-4.69). Proficiency was externally validated through the FLS exam taken by each resident 1-2 weeks following their final assessment, with all learners passing the manual portion. The average satisfaction of learners with remote coaching was 77/100 (range 50-100). 100% of learners felt prepared for their FLS certification exam and 100% would recommend this remote training program to a colleague.ConclusionRemote coaching and assessment of FLS skills yields similar results to traditional face-to-face instruction.

Fundamentals of Laparoscopic Surgery Exam: A Cross-Sectional Survey of in-Training Obstetricians and Gynecologists

Study ObjectivePhysicians seeking specialty certification in Obstetrics and Gynecology are now required to successfully complete the Fundamentals of Laparoscopic Surgery (FLS) exam in order to meet the American Board of Obstetrics and Gynecology (ABOG) certification requirement. We conducted a survey of U.S Obstetrics and Gynecology physicians in training in an attempt to assess their laparoscopic surgical training and perceived barriers and limitations to successfully obtain FLS certification.DesignObservational.SettingInternet-based survey of United States Obstetrics and Gynecology residency programs.Patients or ParticipantsU.S Obstetrics and Gynecology residents.InterventionsParticipants were asked to self-evaluate their confidence in conducting laparoscopic procedures.Measurements and Main ResultsOf the 237 U.S Obstetrics and Gynecology programs, 146 residents responded. Seventy-one (48%) respondents completed the FLS exam and reported a 93% pass rate. All those who did not pass reported poor performance on the manual skills portion. Sixty-six (93%) respondents felt the laparoscopic box trainer was most helpful in preparation for the FLS exam. Fifty-five (79%) respondents felt the cognitive portion of the exam was not at all or slightly representative of subjects taught in residency. Thirty-three (47%) respondents felt the skills portion was moderately reflective of laparoscopic skills needed in gynecologic surgery. Thirty-eight (54%) respondents felt preparing for this exam was not at all or slightly helpful in clinical or surgical practice.ConclusionThe laparoscopic box trainer appears to be most useful in preparation for the FLS exam. Most respondents agree the skills portion of the exam represents skills required in Obstetrics and Gynecology. Concern remains whether the cognitive portion of the exam is applicable to Obstetrics and Gynecology residents or if residency programs need to broaden their laparoscopic education. Alterations likely need to be made to the exam to more specifically evaluate fundamental laparoscopic surgical skills in gynecologic surgeons.

Use of Fundamentals of Laparoscopic Surgery Testing to Assess Gynecologic Surgeons: A Retrospective Cohort Study of 10-Years Experience

To compare the Fundamentals of Laparoscopic Surgery (FLS) exam scores between obstetrics and gynecology (OBGYN) and general surgery (GS) providers. This is a retrospective cohort study at a single institution from July 2007 to May 2018. Categorical and continuous variables were analyzed with χ2 test, t test, and Wilcoxon rank sum test. Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, a tertiary care academic medical center. All providers who took the FLS exam at the Carl J. Shapiro Simulation and Skills Center at BIDMC. FLS certification. A total of 205 BIDMC trainees and faculty took the FLS exam between July 2007 and May 2018, of which 176 were identified to be OBGYN or GS providers. The FLS certification pass rate was high for both specialties (97.0% OBGYN vs 96.1% sGS, p = .76). When comparing all providers, no significant difference was found in the mean manual skill test scores between surgical specialties (594.9 OBGYN vs 601.0 GS, p = .59); whereas, a significant difference was noted in the mean cognitive scores, with GS providers scoring higher than OBGYN providers (533.8 OBGYN vs 583.4 GS, p <.001). However, when adjusting for several variables in a multivariate linear regression model, surgical specialty was not a predictor for cognitive scores. In the multivariate analysis, age, sex, and test year were predictors for cognitive scores, with higher scores associated with younger age, male sex, and advancing calendar year. None of the variables were significant predictors of manual scores. Both OBGYN and GS providers had extremely high FLS pass rates. In the multivariate analysis, surgical specialty was not a predictor for higher FLS test scores for either manual or cognitive test scores. Although OBGYN residency programs offer fewer years of training, OBGYN trainees demonstrate the capacity to perform well on the FLS exam.

A Low-Cost Platform for Laparoscopic Simulation Training.

With the new requirement for Fundamentals of Laparoscopic Surgery certification among graduating obstetrics and gynecology residents, there has been an increased interest in simulation training. The Fundamentals of Laparoscopic Surgery curriculum uses a commercial laparoscopic box trainer to practice and assess laparoscopic skills. We created a low-cost, space-efficient, portable and versatile training platform that allows for the breakdown of complex tasks, and we studied its user acceptability. A rectangular piece of pine wood purchased at a hardware store was used as a base; metal eye hooks were used as ports, and a blueprint was created to simulate placement of Fundamentals of Laparoscopic Surgery inserts. In addition to the Fundamentals of Laparoscopic Surgery skills, this platform can be used for any laparoscopic task (such as hysterectomy or cuff closure). Additionally, this platform can be used with or without a camera to allow for task breakdown into simpler components for faster learning. A usability and acceptability survey was administered to a convenient sample of faculty and trainees. Trainees and faculty responded favorably to the model. Residents, fellows, and attendings felt that the laparoscopic platform closely simulated the feel of performing live laparoscopy surgery. This is a novel low-cost laparoscopic platform to add to the gynecologic surgical education simulation toolkit.

1846 Preparing for FLS: A Survey of Residents in Obstetrics and Gynecology

Study Objective Fundamentals of Laparoscopic Surgery (FLS) is a validated curriculum that uses laparoscopic simulation to prepare surgeons for the operating room. The American Board of Obstetrics and Gynecology has made FLS certification an eligibility requirement to take the certifying board exam for residents graduating in 2020 and onwards. The objective of this study is to describe the resident experience and to quantify test preparation for the FLS exam. Design This is a prospective observational study at a large academic medical center. Setting This study took place at UT Southwestern Medical Center between September 1, 2018 and March 31, 2019. Patients or Participants Second year residents in Obstetrics and Gynecology were invited to participate in the study if they had completed their initial FLS certification exam. Of 18 second year residents, 15 met eligibility criteria and all agreed to participate. Interventions Participants completed a two-page questionnaire about their preparation for the exam, including questions about practice time and repetitions for the five skills tasks and time spent watching the FLS-provided videos. Measurements and Main Results 15 residents completed the survey. Participants spent an average of 3 sessions practicing for an average of 2-3 hours per task. 11/15 residents rated the ligating loop the easiest task to master and 8/15 residents rated the precision cut most difficult. Residents viewed the training modules an average of 1.7 times. All 15 residents who took the exam passed. Conclusion FLS certification will soon be a requirement of all graduating US residents in Obstetrics & Gynecology. Residents and training programs will benefit from an understanding of the time and resources required to successfully take this exam. Our data suggests that residents spent upwards of 10 hours practicing to proficiency on the simulation tasks, in addition to viewing the training videos.

1216 Novel Laparoscopic Simulation Platform

Video Objective With the requirement for the Fundamentals of Laparoscopic Surgery certification amongst graduating OBGYN residents there has been increased interest in utilization of simulation to practice and improve laparoscopic skills. Currently FLS box trainers for practice and testing of FLS manual skills tasks are being sold. We aimed to create a low-cost, easy-to-make, and versatile laparoscopic training platform and studied its usability at our institution. Setting Academic Hospital, OBGYN Residency program Interventions A rectangular piece of sheet wood was used as a platform and a blueprint based on the official FLS box trainer dimensions was created with corresponding placement of ports and the camera on the board. A drill is used to create holes for the metal pegs with eyehooks that function as ports. Velcro is applied to the board to provide stability for FLS inserts. This model can be used for any laparoscopic set up including models for hysterectomy or colpotomy. Open design of the model allows for complex task breakdown to allow learners to master skills. Total cost of one model was $15-25 per platform and took 30 minutes to build. Conclusion A usability and acceptability survey was administered to a convenient sample of faculty and trainees. Trainees and faculty responded favorably to the model. 70% (7/10) residents and 86% (6/7) of attendings agreed the platform was easy to use. 100% (10/10) of residents and attendings (6/6) agreed the laparoscopic platform is useful for improving and practicing laparoscopic skills. 100% of attendings felt that the laparoscopic platform is useful for assessing the learners ability to perform laparoscopic skills prior to live surgery. 88% (8/9) of residents/fellows and 86% (6/7) of attendings felt that it closely simulated the feel of performing laparoscopy in live surgery. Novel laparoscopic platform model is an innovative low-cost teaching tool to add to the gynecologic surgical education armamentarium.

Association of Fundamentals of Laparoscopic Surgery Certification With Outcomes of Laparoscopic Cholecystectomy Performed by Surgical Residents

This study examines outcomes of laparoscopic cholecystectomies performed by surgical residents before and after mandatory implementation of Fundamentals of Laparoscopic Surgery certification to assess whether certification is associated with residence performance or patient outcome.

Retention of fundamentals of laparoscopic surgery (FLS) proficiency with a biannual mandatory training session.

The fundamentals of laparoscopic surgery (FLS) program was developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in 1997 with the goal of teaching surgeons the fundamental knowledge, judgment, and technical skills specific to laparoscopic surgery (Peters et al., Surgery JH 135:21-27, 2004; Soper et al., Bull Am College Surg NJ 93:30-32, 2008). This single academic institution observational study aimed to assess the effectiveness of a biannual FLS training curriculum on Post-Graduate Year [PGY] 1-5 proficiency levels, with a focus on one FLS task (PEG transfer). Previous studies have shown that obtaining expert FLS proficiency correlates with retaining proficiency in the future (Castellvi et al., Surgery 146:387-393, 2009). PGY 1-5 residents (n=28) at an academic general surgery residency program performed two timed PEG transfer tasks biannually. Participants were monitored by FLS certified examiners and standard FLS rules applied. Residents were expected to meet or exceed standards set by SAGES and FLS in consecutive timed PEG transfer trials (proficiency: <48s). Twenty-eight residents participated (PGY 1-5). Participants showed proficiency if they completed the PEG transfer task in less than 48s on two consecutive trials. None of the PGY 1 or PGY 2 residents completed two consecutive trials within the stated proficiency time, while the majority of the PGY 3-5 residents showed proficiency in the PEG transfer task. A biannual training session for FLS retains expert proficiency by PGY levels 4-5. Previous reports from our institution demonstrated that 95% of the residents did not practice this task between mandatory biannual sessions. This suggests that, in combination with standard residency training, biannual FLS sessions confer retained expert skills by PGY 4-5. As the FLS exam is generally taken by PGY 4 and 5 residents and is required for board certification, general surgery residents that participate in biannual training sessions will likely retain expert proficiency and achieve FLS certification.

Threefold increased bile duct injury rate is associated with less surgeon experience in an insurance claims database: more rigorous training in biliary surgery may be needed.

Bile duct injury (BDI) remains the dreaded complication of laparoscopic cholecystectomy (LC) over the last two decades. Although the Fundamentals of Laparoscopic Surgery (FLS) certification is now required for new applicants by the American Board of Surgery, the impact of FLS on procedure-specific outcomes is unknown. Moreover, the FLS content centers on fundamental education and not procedure-specific complication reduction such as BDI, magnifying the importance of understanding the educational impact of FLS on specific case types. This study reviewed the impact of FLS certification and other factors on the incidence of bile duct injury in a large insurance claims database. In total, 53,632 LCs were reviewed from July 2009 to December 2010 from a large private payer claims database. Surgeon National Provider Identifier (NPI), FLS certification status, International Classification of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) were available for each event. Each record was analyzed for evidence of any bile duct injury based on associated CPT or ICD-9 data in the claim record. Characteristics of the FLS+ and FLS- surgeon groups were analyzed by a separate reviewer blinded to clinical outcome on a large scale. A total of 53,632 LCs were reviewed; 1748 LC were performed by 441 FLS+ surgeons; and 58,870 LCs by 10,851 FLS- surgeons. (Some procedures involved more than one surgeon). Eighty-two BDIs were identified: 8 in the FLS+ and 74 in the FLS- group. The FLS+ group had a higher rate of BDI than the FLS- group (0.47 vs. 0.14 %, p = 0.0013); however, the FLS+ group was also younger (mean age 38.2 FLS+ vs. 50.4 years) and had significantly fewer years in practice (FLS+ = 6.1 vs. FLS- = 20.7, p = 0.0012). No other complications showed differences between the groups. NPI can be used as a linking intermediary between skills certification and outcomes on claims databases. FLS certification was not associated with a reduction in bile duct injury in this analysis, but FLS+ surgeons were also younger and less experienced overall. Since FLS lacks content specific to BDI, large-scale validated training and assessment programs targeted at BDI prevention are needed to impact the rate of this complication during cholecystectomy.

Gynecologic Trainee Opinions on the Fundamentals of Laparoscopic Surgery Curriculum

The Fundamentals of Laparoscopic Surgery (FLS) is a validated curriculum and exam used to assess laparoscopic knowledge and skills for general surgery residents. There are few studies evaluating the value of FLS in gynecology (Gyn) training. The objectives of this study were to: 1) evaluate resident and fellow opinions of FLS certification; and 2) assess if demographics affect FLS pass rates.

Ensuring competency: Are fundamentals of laparoscopic surgery training and certification necessary for practicing surgeons and operating room personnel?

Certification in fundamentals of laparoscopic surgery (FLS) is required by the American board of surgery for graduating residents. This study aimed to evaluate the feasibility and need for certifying practicing surgeons and to assess proficiency of operating room (OR) personnel. Through a patient safety and health care delivery effectiveness grant, investigators at four state medical schools received funding for FLS certification of all attending surgeons and OR personnel credentialed in laparoscopy. Data were voluntarily collected under an institutional review board-approved protocol. Surgeons performed a single repetition of the FLS tasks oriented to the FLS proficiency-based curriculum and online cognitive materials and were encouraged to self-practice. The FLS certification examination was administered 2 months later under standard conditions. Operating room nurses and scrub technicians were enrolled in a curriculum with cognitive materials and a multistation skills practicum. Baseline and completion questionnaires were administered. Performance was assessed using signed-rank and χ(2) analysis. The study aimed to enroll 99 surgeons. Subsequently, 87 surgeons completed at least one portion of the curriculum, 72 completed the entire curriculum (73% compliance), 83 completed the baseline skills assessment, and 27 (33%) failed. The self-reported practice time was 3.7 ± 2.5 h. At certification (n = 76), skills performance had improved from 317 ± 102.9 to 402 ± 54.2 (p < 0.0001). One surgeon (1.3%) failed the skills certification, and nine (11.8%) failed the cognitive exam. Remediation was completed by six surgeons. Of the 64 enrolled OR personnel, 22 completed the curriculum (34% compliance). All achieved proficiency at skills, and 60% passed the cognitive exam. This study demonstrated that FLS certification for practicing surgeons and proficiency verification for OR personnel are feasible. A baseline skills failure rate of 33% and a certification failure rate of 13% suggest that FLS certification may be necessary to ensure surgeon competency. Fortunately, with only moderate practice, significant improvement can be achieved.

Value of fundamentals of laparoscopic surgery training in a fourth-year medical school advanced surgical skills elective

BackgroundFew data are available describing the benefits of initiating fundamentals of laparoscopic surgery (FLS) training during medical school. We hypothesized that an intense 1-month surgical skills elective that included FLS task training for fourth-year medical students (MS4s) would result in performance levels indistinguishable from graduating chief residents (PGY5) who had received clinical skill training and access to self-guided FLS curriculum. MethodsFrom July 2007 through June 2011, 114 MS4s participated in a 1-month advanced surgical skills elective. The curriculum for the elective included cadaver dissections, patient management presentations, and surgical skill training (open surgical skills and basic laparoscopic skills modules performed on FLS trainers and virtual reality laparoscopic simulators). From June 2009 through June 2011, 21 PGY5s graduated who had never received formalized FLS skills training. These residents were tested on FLS by a certified proctor and the results recorded. The performance outcome measure was task completion time. Unpaired Student's t-test was used to compare the performance measures for each group. ResultsAll PGY5s achieved FLS certification on their first attempt and completed enough cases for graduation. The MS4 group showed significantly better performance than the PGY5 group in the peg transfer and circle cut (P < 0.05). No difference was seen in the knot tying tasks between the two groups (P > 0.05) ConclusionsIncorporating FLS training into a 1 month-long medical school surgery elective enabled MS4s to achieve FLS performance similar to, or better than, the performance achieved by PGY5 surgery residents. We support the integration of FLS skills task training as a standard part of the skills training curriculum for medical students.

Trends and results of the first 5 years of Fundamentals of Laparoscopic Surgery (FLS) certification testing

FLS is an educational program developed by the Society of American Gastrointestinal and Endoscopic Surgeons and endorsed by the American College of Surgeons. The goal of the FLS program is to teach and assess the basic cognitive and psychomotor skills required to perform laparoscopic surgery. The purpose of this study is to review the results from the first 5 years of FLS certification testing. FLS test data were prospectively collected for all participants taking the FLS certification examination since its inception. Deidentified data were reviewed and analyzed using standard descriptive statistics. The FLS examination was taken by 2,689 participants between October 2004 and December 2009. There was a yearly increase in the number of individuals seeking FLS certification. Complete demographic information was available for 1,882 participants: 12% were junior residents (PGY 1-3), 69% were senior residents (PGY 4-5) or fellows, and 19% were attending surgeons. A breakdown of participants by specialty revealed that 88% were general surgeons, 4% were gynecologists, 2% were urologists, and 6% were labeled as "other." The mean (standard deviation, SD) score on the cognitive examination was 519 (157), with a 93% pass rate. The mean score on the technical skills examination was 525 (117), with a 92% pass rate. After combining both scores, the overall FLS certification pass rate was 88%. The FLS certification examination has gained widespread acceptance among laparoscopic surgeons in training and practice, with a marked increase in testing since the American Board of Surgery mandate for certification was announced. The overall pass rate of 88% on the examination approaches the target pass rate of 90% established during the test-setting process.

FLS Skill Retention (Learning) in First Year Surgery Residents

Fundamentals of Laparoscopic Surgery (FLS) certification is reliable and valid; the American Board of Surgery requires FLS certification. Dynamics of skill retention after FLS training effect training schedules for residents. We hypothesized that the initial elevation of performance levels after FLS training would deteriorate predictably with time. FLS performance data on 16 new surgical residents (R01s) was examined retrospectively. These R01s trained at 16 weekly sessions. Training included 4 FLS tasks, VR simulator tasks, and open surgical skills. FLS skills were practiced weekly with feedback but no instruction. Performance was tested PRE, POST, and DELAY. Outcome metrics were task completion times (TCTs). POST TCTs were below PRE TCTs in all R01s for all FLS tasks (P < 0.05). No difference was seen between the DELAY TCT and POST TCT for peg transfer (P = 0.726) and pattern cut (P = 0.114). The DELAY TCTs were longer than POST TCTs for extra- and intra corporeal knot-tying (P < 0.0001 and P = 0.029). Relative retention was 103% for peg transfer, 85% for pattern cut, 47% for extracorporeal knot tying, and 59% for intracorporeal knot tying. However, many individual's displayed DELAY TCT equal to or lower than POST TCT implying full retention. This study extends the data on FLS skill retention to an actual "production" training curriculum. This FLS training provided effective learning in R01s. Although performance levels fell across these tasks on average and for the majority of individual R01s, significant skill retention remained at 7-8 months. Early training will enable R01s to maintain or elevate skill levels with additional training sessions.

Surgical simulation in Africa: the feasibility and impact of a 3-day fundamentals of laparoscopic surgery course

The use of laparoscopy in resource-restricted countries has increased in recent years. Although simulation is now considered an important adjunct to operating-room-based training for learning laparoscopic skills, there is very little literature assessing the use of simulation in resource-restricted countries. The purpose of this study was to determine the feasibility and impact of a 3-day Fundamentals of Laparoscopic Surgery (FLS) course in Botswana, Africa. A total of 20 surgeons and trainees participated in a 3-day FLS course. A pretest FLS score was obtained for each subject, followed by 2 days of practice with feedback. A final FLS posttest score was then obtained. Participants also watched the FLS instructional CD-ROM and took the written test on day 3. Mean posttest scores were significantly higher than pretest scores for each FLS task and for the total normalized FLS simulator score (285 +/- 94 versus 132 +/- 92, p < 0.001). The mean score on the written test was 242 (116). In total, only two surgeons achieved a passing score on both the cognitive and skills assessment required to obtain FLS certification. To our knowledge, this is the first time the FLS program has been taught in Africa. We have shown that giving the FLS course in a resource-restricted country is feasible and resulted in a significant improvement in FLS technical skills after 3 days. Most surgeons, however, still did not reach FLS passing scores, indicating that more than 3 days will be required in future courses to help surgeons obtain FLS certification.

Certification pass rate of 100% for fundamentals of laparoscopic surgery skills after proficiency-based training

The fundamentals of laparoscopic surgery (FLS) program has been extensively validated for use as a high-stakes examination for certification purposes, but optimal methods for its use in skills training have not been described. This study aimed to investigate the feasibility of implementing a proficiency-based FLS skills training curriculum and to evaluate its effectiveness in preparing trainees for certification. For this study, 21 novice medical students at two institutions viewed video tutorials, then performed one repetition of the five FLS tasks as a pretest. The pretests were scored using standard testing metrics. The trainees next practiced the tasks over a 2-month period until they achieved proficiency for all the tasks. A modified on-the-fly scoring system based on expert-derived performance was used. The trainees were posttested using the high-stakes examination format. No trainee passed the certification examination at pretesting. The trainees achieved proficiency for 96% of the five tasks during training, which required 9.7 +/- 2.4 h (range, 6-14 h) and 119 +/- 31 repetitions (range, 66-161 repetitions). The trainees rated the proficiency levels as "moderately difficult" (3.0 +/- 0.7 on a 5-point scale) and "highly appropriate" (4.7 +/- 0.1 on a 5-point scale). At posttesting, 100% of the trainees passed the certification examination and demonstrated significant improvement compared with pretesting for normalized score (468 +/- 24 vs 126 +/- 75; p < 0.001), self-rated laparoscopic comfort (89.4% vs 4.8%; p < 0.001), and skill level (3.6 +/- 0.9 vs 1.2 +/- 0.5; p < 0.001, 5-point scale). This proficiency-based curriculum is feasible for training novices and uniformly allows sufficient skill acquisition for FLS certification. Endorsed by the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), this curriculum is available for use as an optimal method for FLS skills training. More widespread adoption of this curriculum is encouraged.