Fundamentals Of Laparoscopic Surgery Exam Research Articles

Preparing for and passing the fundamentals of laparoscopic surgery (FLS) exam improves general surgery resident operative performance and autonomy.

The American Board of Surgery made the Fundamentals of Laparoscopic Surgery (FLS) exam a prerequisite for board certification in 2009. Some residency programs have questioned the need for a continued FLS testing mandate given limited evidence that supports the impact of FLS on intraoperative skills. The Society for Improving Medical Professional Learning (SIMPL) app is a tool to evaluate resident intraoperative performance. We hypothesized that general surgery resident operative performance would improve immediately after preparing for the FLS exam. The national public FLS data registry was matched with SIMPL resident evaluations from 2015 to 2021 and de-identified. SIMPL evaluations are scored in three categories: supervision required (Zwisch scale 1-4, 1 = show and tell and 4 = supervision only), performance (scale 1-5, 1 = exceptional and 5 = unprepared), and case complexity (scale 1-3, 1 = easiest and 3 = hardest). Statistical analyses compared pre and post-FLS exam resident average operative evaluation scores. There were a total of 76 general surgery residents, and 573 resident SIMPL evaluations included in this study. Residents required more supervision in laparoscopic cases performed before compared to after the FLS exam (2.84 vs. 3.03, respectively, p = 0.007). Residents performance scores improved from cases before compared to after the FLS exam (2.70 vs. 2.43, respectively, p = 0.001). Case complexity did not differ before versus after the FLS exam (2.13 vs. 2.18, respectively, p = 0.202). PGY level significantly predicted evaluation scores with a moderate correlation. A sub analysis grouped by PGY level revealed a significant improvement after the FLS exam in supervision among PGY-2 residents (2.33 vs. 2.58, respectively, p = 0.04) and performance among PGY-4 residents (2.67 vs 2.04, respectively, p < 0.001). Preparation for, and passing, the FLS exam improves resident intraoperative laparoscopic performance and independence. We recommend taking the exam in the first two years of residency to enhance the laparoscopic experience for the remainder of training.

Virtual fundamentals of laparoscopic surgery (FLS) boot-camp using telesimulation: an educational solution during the COVID-19 pandemic.

The Fundamentals of Laparoscopic Surgery (FLS) is an internationally recognized educational and certification program designed to teach the knowledge and skills required for basic laparoscopic surgery. Previously, our institution has organized an FLS boot-camp to teach PGY1 residents the FLS manual skills. During the COVID-19 pandemic, in-person sessions were not possible. The purpose of this study was to utilize telesimulation as an education solution for teaching FLS technical skills to PGY1 residents during the COVID-19 pandemic. A virtual FLS program was established. A complete, easily portable FLS kit was distributed to participantsand instructors to set up an FLS box and connect remotely using telesimulation. The program was delivered by three senior residents using the Zoom™ platform. Participants were split into groups of 3-4 individuals, each receiving three 1-h sessions. Sessions were structured with initial demonstration of tasks followed by individual coaching of participants in 'break-out' rooms. The official FLS exam was administered in-person on the 4th week. Pre- and post-course surveys were administered to participants gauging self-reported proficiency with FLS tasks and overall course feedback. Anonymized FLS exam results were collected. A total of 14 residents participated, and 11 responded to the survey. Participants reported that their overall FLS skills proficiency significantly improved on a 5-point likert scale from 1.5 ± 0.5 pre-course to 4.0 ± 0.5 post-course (mean ± SD). Participants unanimously stated that having the FLS box at home was valuable and enabled them to practice more. On the FLS exam, 13 of 14 participants passed the manual skills component. We developed a telesimulation hands-on FLS course as an alternative to in-person training. The course was practical and effective and was preferred to traditional methods by participants. With ever-expanding technological solutions, virtual telesimulation education is an attractive and underutilized tool, not only in the setting of COVID-19, but also more broadly across current educational programs.

8895 Fundamentals of Laparoscopic Surgery for Senior Medical Students Entering Surgical Residency

<h3>Study Objective</h3> The Fundamentals of Laparoscopic Surgery (FLS) is mandatory for OBSTETRICS AND GYNECOLOGY residency. We aimed to evaluate the usefulness of FLS for fourth year medical students to gain confidence and to determine quantitative improvement in FLS tasks and exam. <h3>Design</h3> On the first and last day of the course, students completed a Likert scale (1-10) self-assessment rating confidence in knowledge of laparoscopy, confidence in technical laparoscopic skills, and satisfaction with laparoscopic training during medical school. Students also completed the FLS written assessment. For two weeks, students had didactics and practiced the five practical tasks on FLS trainers: peg transfer, circle cutting, endoloop, extracorporeal and intracorporeal knot tying. Pre and post practice times were recorded. Students were evaluated by OBSTETRICS AND GYNECOLOGY faculty mentors with a pre and post validated global assessment tool per FLS task. <h3>Setting</h3> Fourth year medical school elective in an academic setting. <h3>Patients or Participants</h3> Sixteen fourth year medical students enrolled in the two-week FLS elective course over two years (2021-2022). <h3>Interventions</h3> Participants received daily didactic lessons taught by OBSTETRICS AND GYNECOLOGY faculty, as well as guided practice sessions utilizing laparoscopic task trainers. All interventions were measured pre and post didactic sessions. <h3>Measurements and Main Results</h3> Overall, students felt more confident in their combined laparoscopic knowledge, skills, and training assessment following the course (2.3 (1.7) vs. 6.1 (2.0), p<0.001). Students showed improvement on the written exam (.62 (.10) vs. .87 (.06), p<0.001). The mean time to complete all five of the FLS tasks decreased (seconds, 247 (135) vs. 143 (102), p<0.001). Finally, the average combined faculty global rating assessment of the students' performance improved (2.3 (0.4) vs. 3.9 (0.3), p<0.001). Feedback from students was universally positive. <h3>Conclusion</h3> Implementing the FLS curriculum for fourth year medical students increases confidence in laparoscopic knowledge and performance of technical skills prior to entering a surgical residency.

Preparing for the Fundamentals of Laparoscopic Surgery Exam: A Survey of Residents in Obstetrics & Gynecology

To describe the actual work-load and experience for first-time resident test takers preparing to meet the new high stakes cognitive and technical skills testing requirement for board certification in Obstetrics and Gynecology. A retrospective observational study. Participating residents completed a 2 page questionnaire about their preparation for the exam. Results are reported in aggregate. This study was conducted at the University of Texas Southwestern Medical Center, an academic medical school affiliated with both a private and public tertiary hospitals. Residents in obstetrics and gynecology who have completed their Fundamentals of Laparoscopic Surgery (FLS) certification exam between September 1, 2018 and September 31, 2019. Thirty-three PGY-2 and PGY-3 residents completed the survey. Participants spent an average of 6.7 ± 3.1 hours viewing online modules over an average of 3.6 ± 2.1 nonconsecutive days. Utilizing the campus simulation center, residents spent an average of 2.1 ± 2.1 hours on each of the 5 tasks to practice to the established proficiency score. Twenty-two out of 31 residents rated the ligating loop the easiest skill to master and 13/31 residents rated the precision cut the most difficult. The pass rate for the technical skills portion was 100% (33/33 residents) and for the cognitive portion was 93% (31/33 residents). Our data suggest that residents spent upward of 10 hours practicing to proficiency on the simulation tasks, in addition to time spent watching FLS-provided training videos. The 100% pass rate for the technical skills portion at our program may be impacted by a required technical skills curriculum that residents must complete prior to registering for the FLS exam. Obstetrics and gynecology residents and training programs will benefit from understanding the time and resources required for first-time resident test takers preparing to take the Fundamentals of Laparoscopic Surgery exam.

Implementing FLS Training Protocol for Minimally Invasive GYN Surgery Training

Study Objective The number of minimally invasive surgeries required for residents has increased alongside the requirement of passing the Fundamentals of Laparoscopic Surgery (FLS) program for board certification in Obstetrics and Gynecology (OBGYN) programs. Simulation training has been proposed as a method to increase the proficiency of training surgeons; however, no gynecologic simulation models have been validated. We hypothesized that 24-hour access to the FLS trainer would improve the residents’ times to complete the standardized FLS tasks and improve first time pass rates, and that increased training time would increase resident confidence. Design We performed an observational prospective study. Each resident was timed on the FLS tasks and surveyed to assess confidence each quarter. We compared first time pass rates of the FLS exam for residents who took the exam prior to having access to the trainer to the first-time pass rates of the residents who did have access to the trainer. Setting N/A. Patients or Participants 20 residents were enrolled. During the study period, 1 resident left the program. Interventions N/A. Measurements and Main Results There was no statistical significance between first time pass rates for the FLS exam. Paired t-test was used and found no significant differences in timed task completion or survey question. Conclusion Voluntary simulation-based training was not an effective way to improve gynecologic surgical skills during this study. We suspect this to be a result of lack of defined structure, limited free time, and challenges due to the COVID 19 pandemic. There were low compliance rates of the residents using the FLS trainer and no significant improvement in the time required to finish the standardized FLS tasks, first time pass rates on the FLS exam, or resident confidence levels measured by survey results. More research is needed to evaluate barriers to simulation training to improve minimally invasive surgical skills The number of minimally invasive surgeries required for residents has increased alongside the requirement of passing the Fundamentals of Laparoscopic Surgery (FLS) program for board certification in Obstetrics and Gynecology (OBGYN) programs. Simulation training has been proposed as a method to increase the proficiency of training surgeons; however, no gynecologic simulation models have been validated. We hypothesized that 24-hour access to the FLS trainer would improve the residents’ times to complete the standardized FLS tasks and improve first time pass rates, and that increased training time would increase resident confidence. We performed an observational prospective study. Each resident was timed on the FLS tasks and surveyed to assess confidence each quarter. We compared first time pass rates of the FLS exam for residents who took the exam prior to having access to the trainer to the first-time pass rates of the residents who did have access to the trainer. N/A. 20 residents were enrolled. During the study period, 1 resident left the program. N/A. There was no statistical significance between first time pass rates for the FLS exam. Paired t-test was used and found no significant differences in timed task completion or survey question. Voluntary simulation-based training was not an effective way to improve gynecologic surgical skills during this study. We suspect this to be a result of lack of defined structure, limited free time, and challenges due to the COVID 19 pandemic. There were low compliance rates of the residents using the FLS trainer and no significant improvement in the time required to finish the standardized FLS tasks, first time pass rates on the FLS exam, or resident confidence levels measured by survey results. More research is needed to evaluate barriers to simulation training to improve minimally invasive surgical skills

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.

Preparing OB/GYN Residents for the Fundamentals of Laparoscopic Surgery Exam

Study Objective Describe our experience preparing residents for the ABOG-required Fundamentals of Laparoscopic Surgery (FLS) exam. Design Survey. Setting Post-exam survey distributed May 2020 to evaluate curriculum. Patients or Participants OB/GYN residents. Interventions FLS proficiency-based curriculum was implemented. Proctored practice sessions were provided by faculty or MIGS fellow every 5 weeks. Measurements and Main Results Thirty residents across two programs took the 2019 FLS exam with 100% first attempt pass rate (20 PGY3, 10 PGY2). Survey response rate was 24/30 (80%). 100% reported they felt “very prepared” or “prepared” for the hands-on skill exam compared to 54.17% for the didactic portion. 95.8% viewed the didactic modules ≥ twice. A strong correlation was not observed between number of times modules viewed and feelings of preparedness for the didactic portion of the exam (ρ=-0.25). 95.8% reported practicing skills with faculty or MIGS fellow prior to their test and 100% found these sessions helpful. Most residents spent >5 hours practicing skills prior to their exam (50% practiced 5-10 hours, 33.3% practiced >10 hours). 87.5% noted >75% of practice time was in addition to protected teaching time. 95.8% reported FLS skills practice resulted in improved surgical skills, although 54.17% felt improvement was small. 83.3% felt taking the exam in the second year of residency was best in preparing them to get the most out of their OR experience while 12.5% felt like the first year would be a better year to take it. Residents reported improved access to equipment, more proctored sessions earlier in the year, and more protected time to independently practice would improve their exam preparation. Conclusion Implementation of the FLS proficiency based curriculum was successful across two OB/GYN residency programs with 100% pass rate and 100% of residents feeling very prepared/prepared to take the hands on portion of the FLS exam.

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.

Modification of Fundamentals of Laparoscopic Surgery Manual Skills Curriculum with Addition of a Vaginal Cuff Closure Task.

Study Objective Obstetrics and gynecology (OBGYN) residents are required to pass a Fundamentals of Laparoscopic Surgery (FLS) exam to qualify for written boards. FLS exam validity evidence has been questioned recently and concerns have been raised with its applicability to gynecologic surgical training. We present preliminary data from a pilot study which aims to correlate performance on FLS manual skills to a vaginal cuff closure model in a simulated setting. Design Prospective descriptive study Setting OBGYN residency program at a large urban academic medical center. Patients or Participants OBGYN residents in post-graduate year three. Interventions In addition to the standard five FLS tasks, participants are introduced to a previously studied vaginal cuff closure model during a teaching session. Before taking FLS exam, they are evaluated on a cuff closure using the modified Global Operative Assessment of Laparoscopic Skills (GOALS) and a task-specific checklist. After assessment, residents filled out a usability survey. Measurements and Main Results Seven residents participated between July and December 2019. The mean time to completion of the cuff closure was 14.6 minutes (SD= 2.2 minutes) and range of 12.5 to 18.5 minutes. In our sample size of 7, we did not detect a correlation between official composite FLS and vaginal cuff scores as measured with GOALS (rho = 0.1070, p = 0.819) or the checklist (rho = 0.359, p = 0.429). All residents found the cuff to be a useful addition to curriculum and preferred to replace an FLS task with the cuff model. We plan to continue enrollment of 11 residents per year for four years, to reach a sample size of 44. Conclusion In this preliminary analysis of a pilot study, we did not find a correlation between performance on a vaginal cuff task trainer and FLS manual skills. Residents preferred cuff closure to FLS tasks.

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.

Practice Patterns and Learning Curves of Obgyn Residents Preparing for the Fundamentals of Laparoscopic Surgery (FLS) Exam

Study Objective As of 2018, all graduating OBGYN residents are expected to complete and pass a Fundamentals of Laparoscopic Surgery (FLS) exam. Very few studies on FLS implementation in OBGYN residency programs exist. The aim of this study is to describe practice patterns and learning curves of OBGYN residents preparing for the manual skills portion of the FLS exam. Design Prospective cohort study. Setting OBGYN residency program at a large urban academic medical center. Patients or Participants 33 OBGYN residents, post-graduate years one (PGY1) to three (PGY3). Interventions An FLS curriculum, consisting of coached and self-practice sessions. Measurements and Main Results Residents recorded time spent on each training session, as well the type of trainer used and amount of supervision. For every task, residents recorded proficiency metrics, such as time to completion and penalties. Preliminary analysis of four PGY3 residents who took the exam showed that recorded number of repetitions for tasks 1-5 ranged from 1 to 22 and best time without penalties ranged from 30 to 315 seconds. Performance data and learning curves for each task will be presented for every resident. None of the residents met FLS suggested proficiency criteria for all tasks prior to the exam, and all residents passed the manual portion of FLS exam with wide margins (score range 527-673, with 356 as the national passing score). Correlational analyses of performance on each individual task with final exam score, as well as improvement in scores with each repetition, will be calculated when more participants complete training and have final exam scores available. Conclusion Our study compares FLS practice times, modality, and learning curves with final manual exam scores, which will be of great use to OBGYN residencies across the country as they implement FLS curricula into their programs.

1628 Use of Fundamentals Of Laparoscopic Surgery (FLS) Testing to Assess Gynecologic Surgeons: 10 Years of Experience

Study Objective To assess Fundamentals of Laparoscopic Surgery (FLS) exam scores among OBGYN and general surgery providers. Design This is a descriptive study of all FLS examinees in OBGYN and general surgery and at a single academic institution (Beth Israel Deaconess Medical Center [BIDMC], Boston, MA) from July 2007 to May 2018. We compared categorical and continuous variables with Chi-square, t, and Wilcoxon rank-sum tests. Setting N/A Patients or Participants N/A Interventions N/A Measurements and Main Results 205 BIDMC trainees and faculty took the FLS exam between July 2007 and May 2018 of which 176 were identified to be OBGYN or general surgery providers. The FLS pass rate was high for both specialties (98.7% OBGYN, 99.0% surgery, p= 0.42). When comparing providers in OBGYN and general surgery, no difference was found in manual skills score (mean 594.9 OBGYN vs 601.0 surgery, p=0.59), however, a significant difference was noted in the cognitive scores with surgery providers scoring higher than OBGYN providers (mean 533.8 OBGYN vs 583.4 surgery, p=0.0003). In a multivariate linear regression model adjusting for specialty, level of training, age, sex, and test year, none of the variables were significant predictors for manual scores. However, age, sex, and test year were predictors for cognitive scores with greater scores associated with younger age, male sex, and advancing calendar year. Surgical specialty was not a predictor for manual or cognitive scores. Conclusion Overall, both OBGYN and surgery residents had a high FLS pass rate. The manual skills test scores were comparable between specialties, but the cognitive scores were lower for OBGYN compared to surgery providers. Further investigation regarding validity of the cognitive component of the FLS exam for OBGYN providers may be warranted.

Fundamentals of Laparoscopic Surgery: Tutorial and Tips

Video Objective To provide a stepwise tutorial and task-specific tips for trainees preparing for the manual skills component of the Fundamentals of Laparoscopic Surgery exam. Setting The American Board of Obstetricians and Gynecologists announced that starting in 2020 all OB/GYN residents must pass the Fundamentals of Laparoscopic Surgery (FLS) test in order to be eligible for board certification. This initiative is part of an effort to standardize knowledge and skill across programs. Interventions The manual skills component of FLS consists of five tasks: peg transfer, precision cutting, ligating loop, extracorporeal suturing, and intracorporeal suturing. For the peg transfer, the rotating dial on the Maryland graspers should be used to optimize the position of the graspers and rotate the objects into an optimal position for transferring and placement. For precision cutting, if right-handed, consider starting to the right of the midline. The left hand provides traction on the gauze and directionality must be adjusted throughout the task. Rotate the scissors as necessary to match the curve of the circle pattern. For the ligating loop, use a locking grasper to free both hands to break the endoloop. Trainees should be familiar with the multiuse trainer loops. Extracorporeal suturing can be performed with either an open or closed knot pusher but should always be performed by pushing 90 degrees off of the knot. The knot pusher can be gently rotated to reduce twisted sutures, and tension should be released if the knot pusher slips off. For intracorporeal suturing, the needle can be rotated to optimize the suture loop. Additionally, the needle should be aligned parallel to the needle driver. Conclusion The FLS manual tasks can easily be completed by trainees with the assistance of the tips depicted in this video.

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.

Feasibility of remote administration of the fundamentals of laparoscopic surgery (FLS) skills test using Google wearable device.

The fundamentals of laparoscopic surgery (FLS) program is a simulation-based training program designed to teach and assess the basic skills necessary for laparoscopic surgery. Preliminary work has demonstrated the feasibility of using Skype™ as a telesimulation modality in reliably scoring the exam for remote centers. Google Glass (GG) (Mountain View, California) is referred to as a wearable computer containing a heads-up display and front-facing camera allowing point-of-view video transmission. The objective of this study was to evaluate the feasibility of GG in scoring the technical skills component of the FLS exam. Twenty-eight participants were asked to complete the peg transfer and intracorporeal knot tasks of FLS using both GG and Skype™ setups. GG employed a third-party HIPAA-compliant video software (Pristine; Austin, TX) for video transmission. Participants were alternated between setups and evaluated by onsite and remote proctors. Times and errors were recorded by both proctors. Interrater reliability of their FLS scores was compared using Intraclass Correlation Coefficients (ICCs). GG experience was evaluated based on participant survey responses using a 5-point Likert scale. Interrater reliability for GG demonstrated a statistically significant correlation between onsite (OP) and remote (RP) proctors with ICCs of 0.985 (95% Confidence Interval [CI], 0.969-0.993) and 0.997 (95% CI 0.993-0.998), respectively, for peg and suture tasks. Skype™ demonstrated ICCs of 1.0 (95% CI 1.0-1.0). Average Likert scale responses found GG to be distracting (2.71), obstructive of the view (2.79), and a limitation to task execution (2.75). Overall, there was no statistical difference in scores between GG and Skype™ setups for either the peg (t = 1.446, p = 0.154) or suture task (t = - 0.710, p = 0.480), only 1 participant found the use of GG superior to Skype™. Our findings suggest that although GG are feasible in remote assessment of FLS with strong interrater reliability (ICC > 0.95), Skype™ was the preferred modality.

Outcomes of Fundamentals of Laparoscopic Surgery (FLS) mastery training standards applied to an ergonomically different, lower cost platform.

Using previously established mastery learning standards, this study compares outcomes of training on standard FLS (FLS) equipment with training on an ergonomically different (ED-FLS), but more portable, lower cost platform. Subjects completed a pre-training FLS skills test on the standard platform and were then randomized to train on the FLS training platform (n=20) or the ED-FLS platform (n=19). A post-training FLS skills test was administered to both groups on the standard FLS platform. Group performance on the pretest was similar. Fifty percent of FLS and 32% of ED-FLS subjects completed the entire curriculum. 100% of subjects completing the curriculum achieved passing scores on the post-training test. There was no statistically discernible difference in scores on the final FLS exam (FLS 93.4, ED-FLS 93.3, p=0.98) or training sessions required to complete the curriculum (FLS 7.4, ED-FLS 9.8, p=0.13). These results show that when applying mastery learning theory to an ergonomically different platform, skill transfer occurs at a high level and prepares subjects to pass the standard FLS skills test.

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.

Feasibility of remote administration of the Fundamentals of Laparoscopic Surgery (FLS) skills test

Fundamentals of Laparoscopic Surgery (FLS) certification testing currently is offered at accredited test centers or at select surgical conferences. Maintaining these test centers requires considerable investment in human and financial resources. Additionally, it can be challenging for individuals outside North America to become FLS certified. The objective of this pilot study was to assess the feasibility of remotely administering and scoring the FLS examination using live videoconferencing compared with standard onsite testing. This parallel mixed-methods study used both FLS scoring data and participant feedback to determine the barriers to feasibility of remote proctoring for the FLS examination. Participants were tested at two accredited FLS testing centers. An official FLS proctor administered and scored the FLS exam remotely while another onsite proctor provided a live score of participants' performance. Participant feedback was collected during testing. Interrater reliabilities of onsite and remote FLS scoring data were compared using intraclass correlation coefficients (ICCs). Participant feedback was analyzed using modified grounded theory to identify themes for barriers to feasibility. The scores of the remote and onsite proctors showed excellent interrater reliability in the total FLS (ICC 0.995, CI [0.985-0.998]). Several barriers led to critical errors in remote scoring, but most were accompanied by a solution incorporated into the study protocol. The most common barrier was the chain of custody for exam accessories. The results of this pilot study suggest that remote administration of the FLS has the potential to decrease costs without altering test-taker scores or exam validity. Further research is required to validate protocols for remote and onsite proctors and to direct execution of these protocols in a controlled environment identical to current FLS test administration.

Data-based self-study guidelines for the fundamentals of laparoscopic surgery examination

In preparing for the fundamentals of laparoscopic surgery (FLS) exam, residents usually adopt a self-learning strategy where practice time can be managed with more flexibility. However, with this self-learning strategy, there is a lack of direct supervision from experts and residents risk understudying for this high-stakes exam. Our objective is to determine study goals for effective self-guided practice for the FLS manual skills tasks that will result in passing the examination. FLS manual skills data for all PGY-5 residents during 2009-2010 was supplied by the FLS administrative office. Descriptive statistics were performed, and data were regrouped by the pass/fail results of the exam. The minimum practice time requirement for passing each manual skills task is reported in order to guide practice. 1,047 proctored FLS exams were completed by 2009-2010 residents. Mean task time achieved by all residents was 84 ± 31 s for peg transfer, 139 ± 54 s for pattern cut, 78 ± 29 s for endoloop, 158 ± 66 s for extracorporeal suturing, and 168 ± 77 s for intracorporeal suturing. In the pass group (n = 988), mean time to complete each task was 80 s for peg transfer, 134 s for pattern cut, 75 s for endoloop, 148 s for extracorporeal suturing, and 160 s for intracorporeal suturing. Calculations suggest a self-study goal for each task of 53 s for peg transfer, 50 s for pattern cut, 87 s for endoloop, 99 s for extracorporeal suturing, and 96 s for intracorporeal suturing. If a resident can reliably achieve these results during self-study, they have an 84% chance of passing the exam. Residents preparing to take the FLS exam can refer to data presented in this study to set practice goals. Referring to these data-based practice goals will help residents to improve their chances of passing this high-stakes exam.

Malpractice carrier underwrites Fundamentals of Laparoscopic Surgery training and testing: a benchmark for patient safety

Fundamentals of Laparoscopic Surgery (FLS) is a validated program developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) to educate and assess competency in minimally invasive surgery (MIS). This study reports the first malpractice carrier-sponsored FLS course for surgeons in practice underwritten by the Controlled Risk Insurance Company of Harvard's Risk Management Foundation (CRICO/RMF). The study investigated the participating surgeons' pattern of MIS skills acquisition, subjective laparoscopic comfort level, operative activity, and perception of the FLS role in surgical education, credentialing, and patient safety. A 1-day postgraduate continuous medical education (CME) course consisted of didactic presentations of the leading MIS faculty, proctored FLS hands-on training, psychomotor testing, and cognitive computer-based examination. Voluntary anonymous pre- and postcourse surveys were distributed to the participants at registration and at completion of both the didactic teaching and the skills modules of the program. The course was attended by 37 practicing surgeons in the Harvard system, and 86% of the survey forms were returned. The major driving forces for attending the course were directive from the chief/chairman (50%), improvement in MIS didactic knowledge (56%), and the belief that FLS would become a standard such as advanced trauma life support (ATLS), advanced cardiac life support (ACLS), or the like (53%). Surgeons reported that the FLS exam content was appropriate (Likert 4.41 +/- 0.91) and that mastery of the course material would improve safety (Likert 4.13 +/- 0.79) and technical knowledge of MIS (Likert 4.03 +/- 1.00). This unique cooperative effort between a liability carrier, a professional surgical society, and proactive surgeons should be considered a model for advancing competency and patient safety. The survey results indicate a positive view of FLS in surgical training, safety, and MIS education.