Fundamentals Of Laparoscopic Surgery Training Research Articles

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

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.

1966 Structured Teaching to Enhance Laparoscopy Learning

Study Objective To measure the impact of a standardized laparoscopic curriculum on knowledge and simulation skills assessment in Ob/Gyn residents Design Non-Randomized Control Trial Setting Three residency programs in Chicago, IL Patients or Participants Twenty-four residents Interventions A standardized laparoscopic curriculum was developed in accordance with Fundamentals of Laparoscopic Surgery (FLS) training guidelines. The educational program consisted of a didactic lecture with a written pre and post test and laparoscopic simulation training. Residents were trained in peg transfer and precision pattern cutting skills. A skills assessment was administered pre and post simulation training. This skills assessment measured time to completion of peg transfer and time to completion of precision cutting. Data points were assessed using a repeated measures analysis of variance. Measurements and Main Results The residents were evaluated with a significant improvement in knowledge score from 66.7% to 84.4% (p Conclusion Implementing a standardized curriculum improved resident knowledge and simulation skills in laparoscopic techniques. The program demonstrated an improvement in residency learning and could be applied to improve resident training in laparoscopy and FLS training.

Feasibility of adapting the fundamentals of laparoscopic surgery trainer box to endoscopic skills training tool.

The fundamentals of laparoscopic surgery (FLS) training box is a validated tool, already accessible to surgical trainees to hone their laparoscopic skills. We aim to investigate the feasibility of adapting the FLS box for the practice and assessment of endoscopic skills. This would allow for a highly available, reusable, low-cost, mechanical trainer. The design and development process was based on a user-centered design, which is a combination of the design thinking method and cognitive task analysis. The process comprises four phases: empathy, cognitive, prototyping/adaptation, and end user testing. The underlying idea was to utilize as many of the existing components of FLS training to maintain simplicity and cost effectiveness while allowing for the practice of clinically relevant endoscopic skills. A sample size of 18 participants was calculated to be sufficient to detect performance differences between experts and trainees using a two tailed t test with alpha set at 0.05, standard deviation of 5.5, and a power of 80%. Adaptation to the FLS box included two fundamental attachments: a front panel with an insertion point for an endoscope and a shaft which provides additional support and limits movement of the scope. The panel also allows for mounting of retroflexion tasks. Six endoscopic tasks inspired by FLS were designed (two of which utilize existing FLS components). Pilot testing with 38 participants showed high user's satisfaction and demonstrated that the trainer was robust and reliable. Task performance times was able to discriminate between trainees and experts for all six tasks. A mechanical, reusable, low-cost adaptation of the FLS training box for endoscopic skills is feasible and has high user satisfaction. Preliminary testing shows that the simulator is able to discriminate between trainees and experts. Following further validation, this adaptation may act as a supplement to the FES program.

Validation of the VBLaST pattern cutting task: a learning curve study.

Mastery of laparoscopic skills is essential in surgical practice and requires considerable time and effort to achieve. The Virtual Basic Laparoscopic Skill Trainer (VBLaST-PC©) is a virtual simulator that was developed as a computerized version of the pattern cutting (PC) task in the Fundamentals of Laparoscopic Surgery (FLS) system. To establish convergent validity for the VBLaST-PC©, we assessed trainees' learning curves using the cumulative summation (CUSUM) method and compared them with those on the FLS. Twenty-four medical students were randomly assigned to an FLS training group, a VBLaST training group, or a control group. Fifteen training sessions, 30min in duration per session per day, were conducted over 3weeks. All subjects completed pretest, posttest, and retention test (2weeks after posttest) on both the FLS and VBLaST© simulators. Performance data, including time, error, FLS score, learning rate, learning plateau, and CUSUM score, were analyzed. The learning curve for all trained subjects demonstrated increasing performance and a performance plateau. CUSUM analyses showed that five of the seven subjects reached the intermediate proficiency level but none reached the expert proficiency level after 150 practice trials. Performance was significantly improved after simulation training, but only in the assigned simulator. No significant decay of skills after 2weeks of disuse was observed. Control subjects did not show any learning on the FLS simulator, but improved continually in the VBLaST simulator. Although VBLaST©- and FLS-trained subjects demonstrated similar learning rates and plateaus, the majority of subjects required more than 150 trials to achieve proficiency. Trained subjects demonstrated improved performance in only the assigned simulator, indicating specificity of training. The virtual simulator may provide better opportunities for learning, especially with limited training exposure.

Convergent validation and transfer of learning studies of a virtual reality-based pattern cutting simulator.

Research has clearly shown the benefits of surgical simulators to train laparoscopic motor skills required for positive patient outcomes. We have developed the Virtual Basic Laparoscopic Skill Trainer (VBLaST) that simulates tasks from the Fundamentals of Laparoscopic Surgery (FLS) curriculum. This study aims to show convergent validity of the VBLaST pattern cutting module via the CUSUM method to quantify learning curves along with motor skill transfer from simulation environments to ex vivo tissue samples. 18 medical students at the University at Buffalo, with no prior laparoscopic surgical skills, were placed into the control, FLS training, or VBLaST training groups. Each training group performed pattern cutting trials for 12 consecutive days on their respective simulation trainers. Following a 2-week break period, the trained students performed three pattern cutting trials on each simulation platform to measure skill retention. All subjects then performed one pattern cutting task on ex vivo cadaveric peritoneal tissue. FLS and VBLaST pattern cutting scores, CUSUM scores, and transfer task completion times were reported. Results indicate that the FLS and VBLaST trained groups have significantly higher task performance scores than the control group in both the VBLaST and FLS environments (p<0.05). Learning curve results indicate that three out of seven FLS training subjects and four out of six VBLaST training subjects achieved the "senior" performance level. Furthermore, both the FLS and VBLaST trained groups had significantly lower transfer task completion times on ex vivo peritoneal tissue models (p<0.05). We characterized task performance scores for trained VBLaST and FLS subjects via CUSUM analysis of the learning curves and showed evidence that both groups have significant improvements in surgical motor skill. Furthermore, we showed that learned surgical skills in the FLS and VBLaST environments transfer not only to the different simulation environments, but also to ex vivo tissue models.

The Performance Gap for Residents in Transfer of Intracorporeal Suturing Skills From Box Trainer to Operating Room

Training on laparoscopic box trainer (BT) improves suturing skills in the operating room (OR). Optimal laboratory training should provide trainees with an adequate level of skills that can be transferred to the OR with no decline in performances. This study aimed to compare OR intracorporeal suturing performances of residents who trained with a fundamentals of laparoscopic surgery (FLS) BT vs. those of experienced laparoscopists. This was a prospective observational study. Residents received training with an FLS BT over a period of 4 months. Their performances with the BT and in the OR were then compared with those of experienced senior surgeons. OR assessment took place during a laparoscopic myomectomy. Performance evaluation was based on time taken and 2 validated qualitative assessment tools (GOALS and the Moorthy checklist). One academic tertiary care center, La Conception Hospital, Assistance Publique -Hopitaux de Marseille, Marseille, France, was involved. Twelve gynecology residents and 6 experienced laparoscopic surgeons. Following the FLS training period, performances of residents with the BT were equivalent to those of the experienced surgeons. When tested in the OR, the trained residents performed more slowly than experienced surgeons (279.75 vs. 159.75s; p = 0.001), and they obtained lower qualitative outcomes in terms of GOALS (13 vs. 16.75; p = 0.002) and checklist (18.25 vs. 21; p = 0.049). Transfer from the BT to the OR revealed an increase in time taken that was significantly higher for the trained residents' group than for the experienced group (137s vs. 49s; p < 0.001). A performance gap emerged between trained residents and experienced surgeons when transferring from the BT to the OR. Finding an intermediate training platform between the BT and independently suturing in the OR is hence warranted.

Training in Laparoscopic Surgery in Latin America

Introduction: The training of Residents and Surgeons in Laparoscopic Surgery in Latin America is performed in the OR (Operating Room) on the patient, which predisposes to the risk of many complications, both during learning as during the daily performance of this intervention. Objective: To evaluate the efficiency of the basic training program in Laparoscopic surgery in the development of cognitive and motor dexterities and skills. Methodology: CEPCEA (Center for Studies on Prevention and Correction of Abdominal Diseases) has developed a 5-day teaching system, based on the PBL (Problem-Based Learning) development of tests in manual skills on inanimate objects, biological and human tissue and permanent creation of easy to repeat tips, we combine the best of each continent: the American FLS (Fundamentals of Laparoscopic Surgery) Training, the Europeanoriginated Endotrainer and the Japanese KAIZEN. We took a pre-test and a practical post-test to the total cohort of trained surgeons during the period January-December 2016, tests which were based on time and on 20 theoretical questions with a value of 1 point per each correct answer. We used the SPSS v.21 as statistical software. Results: The population tested consisted of 55 trainees from different Latin-American countries who attended in groups of 4 to 6 participants of general surgery (32), gynecology (11), urology (3), surgery oncology (3), pediatric surgery (1), and others (5) who, on admission, had a mean of peg transfer time of 189.6 seconds, which at the end of their practical training of 4 days was of 68.4 seconds; while the results of the pretest and theoretical posttest showed a media of 5.8 And 14.9 points respectively. Conclusions: The CEPCEA teaching system is an efficient and necessary method for the development of manual and theoretical skills and dexterities in laparoscopic surgery in the various surgical specialties.

Cost Comparison of Fundamentals of Laparoscopic Surgery Training Completed With Standard Fundamentals of Laparoscopic Surgery Equipment versus Low-Cost Equipment

Training for the Fundamentals of Laparoscopic Surgery (FLS) skills test can be expensive. Previous work demonstrated that training on an ergonomically different, low-cost platform does not affect FLS skills test outcomes. This study compares the average training cost with standard FLS equipment and medical-grade consumables versus training on a lower cost platform with non-medical-grade consumables. Subjects were prospectively randomized to either the standard FLS training platform (n = 19) with medical-grade consumables (S-FLS), or the low-cost platform (n = 20) with training-grade products (LC-FLS). Both groups trained to proficiency using previously established mastery learning standards on the 5 FLS tasks. The fixed and consumable cost differences were compared. Training occurred in a surgical simulation center. Laparoscopic novice medical student and resident physician health care professionals who had not completed the national FLS proficiency curriculum and who had performed less than 10 laparoscopic cases. The fixed cost of the platform was considerably higher in the S-FLS group (S-FLS, $3360; LC-FLS, $879), and the average consumable training cost was significantly higher for the S-FLS group (S-FLS, $1384.52; LC-FLS, $153.79; p < 0.001). The LC-FLS group had a statistically discernable cost reduction for each consumable (Gauze $9.24 vs. $0.39, p = 0.002; EndoLoop $540.00 vs. $40.60, p < 0.001; extracorporeal suture $216.45 vs. $25.20, p < 0.001; intracorporeal suture $618.83 vs. $87.60, p < 0.001). The annual fixed and consumable cost to train 5 residents is $10,282.60 in the S-FLS group versus $1647.95 in the LC-FLS group. This study shows that the average cost to train a single trainee to proficiency using a lower fixed-cost platform and non-medical-grade equipment results in significant financial savings. A 5-resident program will save approximately $8500 annually. Residency programs should consider adopting this strategy to reduce the cost of FLS training.

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.

Investigating the Influence of Hand Dominance on Postural Sway During Traditional and Simulated Laparoscopic Surgical Skills Practice.

This study examined how hand dominance could influence postural sway during laparoscopic skills practice. Ten inexperienced medical trainees performed a peg transfer task using the Fundamentals of Laparoscopic Surgery (FLS) training box and the virtual reality (VR) trainer. Surface electromyographic recordings of upper and lower limb muscles were taken, while the postural sway was measured by a pressure mapping system. Skills performance using the non-dominant hand required more muscle effort and increased more postural sway. Compared with the FLS training box, training with VR decreased the use of muscle effort and could reduce the influence of hand dominance on the overall postural sway during laparoscopic surgical skills practice.

Ongoing Evaluation of Video-Based Assessment of Proctors’ Scoring of the Fundamentals of Laparoscopic Surgery Manual Skills Examination

In continued efforts to maintain standards required for high-stakes examination administration, Society of American Gastrointestinal and Endoscopic Surgeons' Fundamentals of Laparoscopic Surgery (FLS) program requires all prospective test proctors to complete the New FLS Proctor Workshop. As the FLS proctor pool and training evolves, the influence of experience on performance is not clear. In the previous work, we proposed that asynchronous web-based performances might be used to train proctors. In this study, we assessed the accuracy of proctors' ratings from asynchronous web-based performances by comparing the sensitivity and the specificity of ratings from proctors having varied experience levels. A sample of 42 (26% of all registered proctors) FLS proctors (recently trained novice, n = 15; intermediate, n = 20; and expert, n = 7) viewed 2 videotaped, laparoscopic-view FLS performances via the web. The first performance (error) contained 1 predetermined critical performance error in each of the 5 tasks (5 total errors), whereas the second performance (no error) contained no critical errors. For both the performances, participants noted time to complete each of the 5 tasks and any critical errors they observed (dichotomously scored). Participants also completed a demographic section that captured years of experience as a proctor. Using the Kruskal-Wallis test, we compared new trainee, intermediate, and expert proctors' recorded task times for both the performances. The sensitivity and the specificity values were also independently calculated using ratings from the error and the no error performances and then compared using the same test. There were no differences in recorded times across proctor groups for any of the tasks; p = 0.21 and 0.94. Rating sensitivity was 79% (novice), 75% (intermediate), and 83% (expert), with no significant differences across experience levels; p > 0.46. Following removal of the peg transfer task that had particularly low sensitivity, the sensitivity for the remaining 4 tasks increased [88% and 92%]. The specificity was 93% (novice), 86% (intermediate), and 100% (expert); p = 0.046. Comments from less-experienced proctors indicated that their focus on noncritical performance issues, such as "loop not on black line" and "air knot," were consistent with decreased specificity. Favorable results of this pilot study suggest that web-based FLS performances may be used for assessing FLS proctors' rating quality with adequate sensitivity and specificity. Decreased rating specificity from intermediate proctors indicates that these proctors would benefit from increased testing frequencies, updated training on current FLS proctoring standards, and ongoing performance review.

You Have a Message! Social Networking as a Motivator for FLS Training

Despite evidence supporting the value of the Fundamentals of Laparoscopic Surgery (FLS) curriculum, surgical educators still find it challenging to motivate residents to practice. Wiggio is an online networking and collaboration tool that allows learners to track performance, see what their peers are doing, and send and receive updates. The purpose of this study was to assess whether using Wiggio increases practice and improves performance of the FLS manual skills. After baseline FLS testing, residents were randomized into control (C) and Wiggio (W) groups. The practice events, time spent practicing, and best scores were recorded. Residents in the W group interacted with each other via the Wiggio website. The website moderator sent motivational messages, calendar reminders, and FLS-related articles. The best times and progress graphs for each resident were also posted online. After 4 weeks, all residents underwent final FLS testing and filled out a questionnaire. The study was performed in a tertiary care center, at the Steinberg-Bernstein Centre for Minimally Invasive Surgery at the Montreal General Hospital. Postgraduate year-1 and postgraduate year-2 general surgery residents with no or minimal FLS simulator experience were included. Of the 15 eligible residents, 14 participated, with 7 residents in each group. The FLS scores were similar at baseline (C = 56.9 [±14.2], W = 57. 6 [±14.7]; p = 0.93). During the study period, twice as many residents in the W group practiced compared with those in the C group (4 vs 2); W-group residents reported more practice events than the C-group residents did (14 vs 4) and spent more time practicing in the laboratory (1035 vs 480 minutes). These results did not reach statistical significance. During practice sessions, proficiency scores were achieved for 40% of the tasks in the W group compared with 8.6% in the C group; however, this difference was also not significant. There was no difference in the FLS scores in both groups at the end of the study. The moderator spent an average of 6.5 minutes per day sending messages and managing the Wiggio website. Participation in Wiggio seems to increase practice events and time spent training on FLS. Social networking may play a role in surgical education and learner motivation; however, the optimal use of Web 2.0 tools in resident education is not yet fully understood.

An automated system for video documentation of all instances of fundamentals of laparoscopic surgery training: feasibility and potential advantages of extended assessment

IntroductionDocumentation of the acquisition of surgical skills is mandated during and after training. Assessment-driven feedback interspersed during Fundamentals of Laparoscopic Surgery (FLS) training is expected to improve the quality of practice and increase skill acquisition. But the direct observation of FLS task performance by experts required to form this feedback is not feasible because of staffing and cost limits. Video recordings can reproduce a display of FLS task performance identical to the original camera view and can provide the critical observations needed for FLS assessment. MethodsWe report the design and operation of an automated system for the capture of digital video clips of all FLS practice trials and for the support of remote, distributed assessments. ResultsAdvantages included permanent documentation of performance, quality controlled assessment by non-Medical Doctor personnel, accurate quantification of practice frequency, and emergence of new observations on patterns of intermediate skill development. The completeness and accuracy of the dataset support analyses of group learning rates and lay the foundation for scientific training curriculum development. ConclusionsWe conclude that video documentation of FLS training is feasible and worthwhile.

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.

Construct Validity of a Novel Side-On Approach to Established Laparoscopic Simulation Curriculum

Fundamentals of Laparoscopic Surgery (FLS) has been validated and used by General Surgeons since 2008. Other subspecialties have implemented FLS training into their training. In the FLS curriculum, as in standard general surgery laparoscopic procedures, the surgeon operates from the midline, head-on, in axis with instrumentation and surgical field. In contrast, most gynecologic procedures are performed from side-on orientation with the operative field in line with the camera axis, but lateral to the surgeon.

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.

Does gender predict performance of novices undergoing Fundamentals of Laparoscopic Surgery (FLS) training?

BackgroundThis study was performed to assess the hypothesis that performance levels for Fundamentals of Laparoscopic Surgery (FLS) tasks were not dependent on trainee gender. MethodsInitial and final task completion times for 4 FLS tasks performed by 132 novices (4th-year medical students and 1st-year residents) were collated by task type and compared by gender. ResultsAll novices improved significantly with training (P > .001) on all tasks. Initial performance by men was better than by women but only reached significance for peg transfer and intracorporeal knot tying (P > .05). With training, women's performance became equivalent to that of men but showed a comparable or greater response to training. ConclusionsThe gender-related differences noted in initial FLS task performance disappeared after training. Gender displayed no effect on FLS training outcomes. The use of initial FLS task performance levels, seemingly objective selection criteria, would introduce gender bias into the ranking process.

The Case for Teaching Basic Surgical Skills in Medical School

The report by Edelman and colleagues [1] addresses an important and timely topic in the field of medical education. The authors describe the impact of fundamentals of laparoscopic surgery (FLS) training of fourth-year medical students on their subsequent performance as first-year surgery residents. The authors conclude that first-year surgery residents who had FLS training as students had better performance than first-year residents who did not have prior FLS training. The authors recommend integrating FLS training into medical school curricula.