Fundamentals Of Laparoscopic Surgery Research Articles

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.

3005 Resident Versus Program Director Opinions on the Fundamentals of Laparoscopic Surgery Exam Requirement

Study Objective To determine opinions of both residents and program directors regarding the new American Board of Obstetrics and Gynecology Fundamentals of Laparoscopic Surgery (FLS) exam requirement Design Survey Setting Nation-wide Patients or Participants All OB/GYN residents and program directors (PD's) in the United States Interventions Nation-wide survey Measurements and Main Results 91 residents completed the survey while 27 program directors completed it. 71% of residents felt that they never used their simulation lab while 59% of PD's thought that residents used it 1-2 times a week. Of answers that scored the highest, 49% of residents felt that the main obstacle to simulation training was their resident work, while 31% of PD's felt that it was due to resident initiative. 75.4% of residents agreed with FLS requirement, whereas only 44.4% of PD's agreed. The majority of both residents and PD's agreed that the programs should pay for the test. Additionally, both residents and PD's equally felt that residents would be adequately prepared without additional resources (64.9% and 59.3% respectively). Conclusion Understanding both resident and PD viewpoints may be helpful in developing FLS residency curriculums.

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.

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.

17 Years of Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS): Where are Graduates Now?

Study Objective FMIGS graduates are imperative for the training of modern endoscopic surgery techniques to the next generation of gynecologic surgeons. The recent implementation of Fundamentals of Laparoscopic Surgery (FLS) for board certification and the recent approval of MIGS Focused Practice Designation by the American Board of Medical Specialties only further emphasizes the importance of FMIGS graduates to training institutions, yet the current distribution of FMIG graduates and their interactions with education is not well documented. Design An Internet based name search of 391 AAGL FMIG graduates from 2002-2018 conducted in April of 2019. Each physician's website was investigated for current practice type, setting, location, and interactions with residents and/or fellows and then analyzed. Setting Current, April 2019, Internet-based name search for practice website. Patients or Participants 391 AAGL FMIGS Graduates. Interventions N/A Measurements and Main Results Of the 391 AAGL FMIG graduates, 381 were searchable on the Internet. The breakdown were as follows- Gender: Male 30.5%, Female 69.5%, Practice Type: Private 53.3%, Academic 46.7%, Practice Setting: Urban 59.3%, Suburban 35.4%, Rural 5.2%, Location: NE 31.5%, SW 25.2%, SE 17.1%, MW 16.5%, NW 3.7%, and Out of States 6.0%. More than half of all FMIGS graduates were involved in residency or fellowship education. There has been a positive trend of FMIGS graduates practicing in both OB/GYN residency and fellowship programs as the fellowship has matured with over 58% of 2015-18 graduates involved with resident education and over 34% involved with fellowship education Conclusion The increasing trend of FMIGS graduates seeking job opportunities to educate residents and fellows supports the fellowships mission to train the next generation of minimally invasive gynecologic surgeons. The distribution and demographics of FMIGS graduates is not evenly distributed and this data may be utilized by the AAGL and prospective residents/fellows for decisions regarding future training and clinical practice location.

Basic Laparoscopic Skills Training is Equally Effective Using Either 2d or 3d Visualization: A Randomized Controlled Trial

Study Objective To assess whether basic laparoscopic skills (BLS) training on a standard laparoscopic box trainer using 2D visualization is at least equally effective compared to 3D. Design Randomized controlled trial. Setting Tertiary care center, Vienna, Austria. Patients or Participants A total of 32 medical students of the Medical University of Vienna were recruited. Interventions Participants were randomized to BLS training using either 2D or 3D visualization and trained four Fundamentals of Laparoscopic Surgery (FLS) tasks for one hour twice a week for four weeks. Baseline and post training tests were performed. Improvement in total test scores and the scores for the four individual FLS tasks within the assigned visualization modality was assessed. The non-inferiority margin was set as 10% of the mean improvement in the 3D group. Measurements and Main Results Data of 31 participants were analysed (n=16 in the 2D, n=15 in the 3D group, n=1 drop out). Baseline test scores did not differ significantly between groups except for the peg transfer task and total scores, where participants in the 3D group scored better than those in the 2D group. Total scores as well as the scores for all four tasks separately improved significantly in both groups. Post training test total and single task scores did not differ significantly between the groups. Non-inferiority of 2D compared to 3D training modality could be demonstrated for the improvement in total scores and in all individual FLS tasks, except for the suturing with extracorporeal knot tying task. Only the peg transfer task showed superiority in score improvement in the 2D compared to the 3D group. Conclusion Learning BLS using standard 2D visualization is at least equally effective as with 3D visualization. 3D visualization seems to offer a slight advantage at baseline testing, but does not translate to better test scores at post training testing.

Design of a Laparoscopic Curriculum for Obstetrics and Gynecology Residents

PROBLEM: The American Board of Obstetrics and Gynecology (ABOG) announced in January, 2018 it is requiring completion of the Fundamentals of Laparoscopic Surgery (FLS) program as prerequisite for board certification for residents graduating after May, 2020. Currently, our residency program has no formalized laparoscopic curriculum and has never required residents to participate in the FLS program. INTERVENTION: Needs assessment was performed to survey faculty in the residency program regarding residents’ current skill levels and faculty perspectives of level-appropriate laparoscopic skills by training year. A comprehensive laparoscopic curriculum was designed to support resident progression through different competency milestones required to ultimately be able to perform laparoscopic hysterectomies as the surgeon. The laparoscopic curriculum addresses a parallel group of requirements designed to assist residents in successful completion of the FLS curriculum. CONTEXT: The laparoscopic curriculum was designed in the context of an academically-based obstetrics and gynecology residency program. The residency program has 9 residents a year who rotate at 5 different clinical sites and work with over 50 faculty who perform laparoscopic procedures. OUTCOMES/LESSONS LEARNED: The curriculum will be implemented in July 2019 with the new academic year. The curriculum will be assessed in several ways: formal testing of residents with FLS skills by the program administration, time takes resident to progress through the competency milestones for laparoscopy, the FLS pass rate, and scores of our residents. Main lesson learned through the design process was how to manage the varying resident and faculty expectations for surgical skills training.

Development of a Low-Cost System for Laparoscopic Skills Training

Technological advancements in video equipment and biocompatible materials have enabled improvements in complex surgery through small incisions. The mastery of these laparoscopic surgical techniques is now a requirement for surgeons, however, the necessary skills are not intuitive and require hundreds of practice hours. The current state of surgical education includes animate models, inanimate physical models, and computer-based simulations, the latter of which are limited by cost, accessibility, and a lack of engagement. We propose a novel low-cost training interface that mimics the laparoscopic surgical environment using customized instruments whose movement and control are used as inputs for video games. The system is significantly less expensive than commercial systems and allows users freedom to select and play any game, enabling a take-home system with potential for higher levels of engagement, as well as familiarity and expertise with ambidextrous laparoscopic hand motion. A preliminary study compared performance on FLS (Fundamentals of Laparoscopic Surgery) testing before and after training. For a precision cutting task, groups that trained on a standard simulator or on the new system with either a noninverted or inverted hand-instrument mapping showed statistically significant improvements, warranting further investigation of training with this new system.

Correlation of surgical trainee performance on laparoscopic versus endoscopic simulation.

Both laparoscopy and endoscopy are image-based procedures, which are less intuitive than traditional open surgery and require extensive training to reach adequate proficiency. Currently, there is lack of understanding as to how the skills in one image-based procedure translate to another, such as endoscopy to laparoscopy and vice versa. The aim of our study was to explore the relationship between endoscopic and laparoscopic skills using a Fundamentals of Laparoscopic Surgery (FLS) trainer, a traditional virtual reality endoscopic trainer and a "desk-top" endoscopic physical simulator. Senior surgical residents from across Canada participating in an advanced laparoscopic foregut training course were enrolled in the study. Participants were assessed performing the FLS laparoscopic suturing task, the Endobubble 2 task (Simbionix, GI Mentor), and a forward viewing peg transfer on the novel Basics in Endoscopic Skills Training Box (BEST Box). There was significant correlation between the participant's skill in simulated laparoscopic suturing and simulated endoscopic skill using the BEST box (Pearson coefficient (r) was 0.551 (p = 0.033) and the coefficient of determination (r2) was 0.304). There was a trend towards correlation between laparoscopic suturing time and Endobubble 2 score, but this did not reach statistical significance (r = 0.458, p = 0.086; r2 = 0.210). Performance in the two physical simulators, laparoscopic suturing and simulated flexible endoscopy using the BEST box, showed a correlation. This study adds to the growing body of evidence that laparoscopic and endoscopic skills are complementary and has the potential to impact simulation training involving both skill sets.

Reliability testing of a modified MISTELS score using a low-cost trainer box

BackgroundTraining programs such as the fundamentals of laparoscopic surgery (FLS) that are based on simulation are being currently used in several western countries. FLS allows skill acquisition and evaluation of competency in laparoscopic surgery. On the practical side, evaluation is determined by the MISTELS metrics (MISTELS is the acronym for the McGill inanimate system for training and evaluation of laparoscopic skills).This training program may be modified so that it can be implemented in countries with limited resources using a low-cost trainer box. Would the use of a low-cost trainer box alter the reliability of the MISTELS score?Objective of studyThe aim of the study was to evaluate the reliability of a modified MISTELS using a low-cost trainer box.MethodsIt was a prospective study carried out at Habib Thameur hospital in Tunis (Tunisia), between April 2016 and August 2016. The study involved residents from different surgical specialties in the departments of general surgery and paediatric surgery of the hospital during 2015 and 2016.This study assessed the reliability of a modified MISTELS system (Only three tasks were performed out of the five tasks used in the original MISTELS system). Evaluation was based on Cronbach’s alpha and intraclass correlation coefficients (ICC).A low-cost trainer box was designed and constructed. The residents included in the study performed three series of three tasks using this trainer box. The first series was scored by two trained raters to evaluate inter-rater reliability. The two-other series were successively performed to evaluate test-retest reliability.ResultsThe internal consistency, assessed by Cronbach’s alpha, was at 0.929 which is an acceptable score. As for inter-rater and test-retest reliabilities that were assessed by ICCs, they yielded excellent scores that were at 1 and 0.95 (95% CI, 0.891–0.978) respectively.ConclusionsThe reliability of a modified MISTELS is not altered by the use of a low-cost trainer box. The score of the modified MISTELS is a reliable score for evaluating technical skills of surgical residents using a low-cost trainer box.

A "pickup" stereoscopic camera with visual-motor aligned control for the da Vinci surgical system: a preliminary study.

The current state-of-the-art surgical robotic systems use only a single endoscope to view the surgical field. Research has been conducted to introduce additional cameras to the surgical system, giving rise to new camera angles that cannot be achieved using the endoscope alone. While this additional visualization certainly aids in surgical performance, current systems lack visual-motor compatibility with respect to the additional camera views. We propose a new system that overcomes this limitation. In this paper, we introduce a novel design of an additional "pickup" camera that can be integrated into the da Vinci Surgical System. We also introduce a solution to work comfortably in the various arbitrary views this camera provides by eliminating visual-motor misalignment. This is done by changing the working frame of the surgical instruments to work with respect to the coordinate system at the "pickup" camera instead of the endoscope. Human user trials ([Formula: see text]) were conducted to evaluate the effect of visual-motor alignment with respect to the "pickup" camera on surgical performance. An inanimate surgical peg transfer task from the validated Fundamentals of Laparoscopic Surgery (FLS) Training Curriculum was used, and an improvement of 73% in task completion time and 80% in accuracy was observed with the visual-motor alignment over the case without it. Our study shows that there is a requirement to achieve visual-motor alignment when utilizing views from external cameras in current clinical surgical robotics setups. We introduce a complete system that provides additional camera views with visual-motor aligned control. Such a system would be useful in existing surgical procedures and could also impact surgical planning and navigation.

Career Interest and Psychomotor Aptitude Among Medical Students

The primary objective is to assess psychomotor aptitude of medical students interested in pursuing a procedural career. Secondary objectives include exploring the relationship between actual and perceived aptitude, and identifying predictors of superior aptitude. This is a cross-sectional, multisite study in which participants completed a paper survey, four visuospatial aptitude assessments, and a laparoscopic simulation modeled after the Fundamentals of Laparoscopic Surgery (FLS) peg transfer test (used as a proxy for psychomotor aptitude). Johns Hopkins University School of Medicine and Mayo Clinic School of Medicine. All second-year medical students who had not yet initiated clinical rotations were eligible. Sixty-four students participated. Students interested in a procedural career exhibited superior psychomotor aptitude (faster FLS task completion time), and a majority of these students correctly identified themselves as having above-average aptitude compared with peers. However, over one quarter of all students, regardless of career interest, incorrectly over- or under-rated their psychomotor aptitude. Upon completing their preclinical curriculum, a minority of students felt prepared to participate or assist in their surgical clinical rotations. Prior to embarking on their clinical rotations, over one quarter of medical students lack awareness of their psychomotor aptitude and many do not feel prepared to participate in the next phase of their training. Early aptitude testing and introduction to laparoscopic training may assist in career selection, preparedness, and success.

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.

Factors influencing amount of guidance in the operating room during laparoscopic cases

BackgroundIdentifying factors associated with resident autonomy may help improve training efficiency. This study evaluates resident and procedural factors associated with level of guidance needed in the operating room. MethodsIntraoperative performance and yearly performance on Fundamentals of Laparoscopic Surgery (FLS) tasks from 74 general surgery residents were retrospectively reviewed. The effect of post-graduate year (PGY), procedure complexity, case difficulty, intraoperative performance, and FLS task performance were analyzed using a mixed-effects model. ResultsPGY level, procedure complexity, case difficulty, operative technique, and operative knowledge were significantly associated with level of intraoperative guidance. In PGY2-4 residents, ratings of medical knowledge and communication were also significantly associated with guidance. There was no significant association between FLS performance and level of guidance for any PGY level. ConclusionsThe amount of intraoperative guidance is influenced by many factors, including resident performance and case characteristics. FLS tasks performance was not significantly associated with intraoperative guidance.

Performance variability during training on simulators is associated with skill transfer

BackgroundExpert performance is characterized by consistency. The degree of variability of performance from repetition to repetition during proficiency-based simulator training could potentially indicate acquisition of expertise. We hypothesized that learners with less variability in performance during simulator training would achieve greater performance at the end of training and improved transfer of skills to a live, anesthetized, porcine model. MethodsThe performance of 93 subjects (surgery residents and medical students) who had participated in 3 randomized controlled trials was analyzed for variability. All participants had trained in laparoscopic suturing on the Fundamentals of Laparoscopic Surgery (FLS) simulator. Their performance had been assessed on the simulator before (baseline) and after training (posttest) and on a live, anesthetized, porcine model (transfer test). We computed the coefficient of variations of suturing scores during training for each participant. Linear regression was used to assess whether variability in performance during training predicted posttest and transfer-test scores. ResultsDecreased practice variability in performance was associated with greater scores in posttests and transfer tests. For each percent decrease in variability performance, posttest scores increased by 3.8 points (P < .001) and transfer-test scores increased by 3.0 points (P < .001). Greater mean scores during practice were associated with greater scores on the transfer test (P < .001). ConclusionDecreased variability in performance during practice on simulators is associated with improved performance at the end of training and during transfer to a live, anesthetized, porcine model. These findings suggest that variability in performance during simulator training may be used to track the progress and readiness of a trainee for the clinical environment. Further studies are needed to verify the robustness of this potentially new metric of performance.

Suturing for FLS: A Practical Tutorial

Objective: The objective of this video is to demonstrate two of the five Fundamentals of Laparoscopic Surgery (FLS) manual skills, suturing with extracorporeal and intracorporeal knot tying.

Ergonomic analysis of laparoscopic and robotic surgical task performance at various experience levels.

Traditional laparoscopic surgery (TLS) has increasingly been associated with physical muscle strain for the operating surgeon. Robot-assisted laparoscopic surgery (RALS) may offer improved ergonomics. Ergonomics for the surgeon on these two platforms can be compared using surface electromyography (sEMG) to measure muscle activation, and the National Aeronautics and Space Administration Task Load Index (NTLX) survey to assess workload subjectively. Subjects were recruited and divided into groups according to level of expertise in traditional laparoscopic (TLS) and robot-assisted laparoscopic surgery (RALS): novice, traditional laparoscopic surgeons (TL surgeons), robot-assisted laparoscopic surgeons (RAL surgeons). Each subject performed three fundamentals of laparoscopic surgery (FLS) tasks in randomized order while sEMG data were obtained from bilateral biceps, triceps, deltoid, and trapezius muscles. After completing all tasks, subjects completed the NTLX survey. sEMG data normalized to the maximum voluntary contraction of each muscle (MVC%), and NTLX data were compared with unpaired t tests and considered significant with a p ≤ 0.05. Muscle activation was higher during TLS compared to RALS in most muscle groups for novices except for the trapezius muscles. Muscle activation scores were also higher for TLS among the groups with more experience, but the differences were less significant. NTLX scores were higher for the TLS platform compared to the RALS platform for novices. TLS is associated with higher muscle activation in all muscle groups except for trapezius muscles, suggesting greater strain on the surgeon. Increased trapezius muscle activation on RALS has previously been documented and is likely due to the position of the eye piece. The differences seen in muscle activation diminish with increasing levels of expertise. Experience likely mitigates the ergonomic disadvantage of TLS. NTLX survey data suggest there are subjective benefits to RALS, namely in the perception of temporal demand. Further research to correlate NTLX data and sEMG measurements, and to investigate whether these metrics affect patient outcomes is warranted.

Identifying the needs for teaching fundamental knowledge of laparoscopic surgery: a cross-sectional study in Japan.

Recently, laparoscopic surgery (LS) has become a more common procedure than traditional open surgery. Although LS-related adverse events have been reported, there is no formal, standardized curriculum to teach the fundamentals of LS in Japan. Understanding surgeons' knowledge regarding LS is crucial for developing an educational curriculum. The purpose of this study was to determine the baseline knowledge on LS of surgeons and surgical trainees in Japan. Participants completed 24 multiple-choice questions testing basic cognitive knowledge of LS and a questionnaire regarding the status of laparoscopic education. The examination was developed according to the 13 content domains of the Fundamentals of Laparoscopic Surgery (FLS) program. Scores were compared between post-graduate year (PGY) > 5 and PGY 1-5 participants. Data are expressed as median scores and interquartile ranges. Wilcoxon signed-rank test was used for statistical analysis. A total of 195 surgeons and surgical trainees from 10 teaching hospitals (PGY1-5: 66, PGY > 5: 129) across Japan completed the examination. The median score in the entire cohort was 75 [67; 83] %, with significantly higher scores in the PGY > 5 group compared to the PGY1-5 group (79 [75; 83] % vs. 67 [58; 75] %, p < 0.001). The differences in performance were due to better scores for PGY > 5 group on the sections "equipment," "patient considerations," "abdominal access," "tissue handling," "hemorrhage and hemostasis," "tissue approximation," and "exiting the abdomen." Overall, the median scores in the "energy sources" and "establishment and physiology of the pneumoperitoneum" subsections were lower than in other domains. All participants agreed on the need for fundamental knowledge and a formal educational curriculum. Compared to experienced surgeons, surgical trainees had lesser knowledge about performing LS. Regardless of the years of experience, there are crucial knowledge gaps in specific areas regarding safe LS that should be addressed by implementing an educational curriculum.

Development and face validation of a virtual camera navigation task trainer.

The fundamentals of laparoscopic surgery (FLS) trainer box, which is now established as a standard for evaluating minimally invasive surgical skills, consists of five tasks: peg transfer, pattern cutting, ligation, intra- and extracorporeal suturing. Virtual simulators of these tasks have been developed and validated as part of the Virtual Basic Laparoscopic Skill Trainer (VBLaST) (Arikatla et al. in Int J Med Robot Comput Assist Surg 10:344-355, 2014; Zhang et al. in Surg Endosc 27(10):3603-3615, 2013; Sankaranarayanan et al. in J Laparoendosc Adv Surg Tech 20(2):153-157, 2010; Qi et al. J Biomed Inform 75:48-62, 2017). The virtual task trainers have many advantages including automatic real-time objective scoring, reduced costs, and eliminating human proctors. In this paper, we extend VBLaST by adding two camera navigation system tasks: (a) pattern matching and (b) path tracing. A comprehensive camera navigation simulator with two virtual tasks, simplified and cheaper hardware interface (compared to the prior version of VBLaST), graphical user interface, and automated metrics has been designed and developed. Face validity of the system is tested with medical students and residents from the University at Buffalo's medical school. The subjects rated the simulator highly in all aspects including its usefulness in training to center the target and to teach sizing skills. The quality and usefulness of the force feedback scored the lowest at 2.62.

The Cost of Compliance: The Financial Burden of Fulfilling Accreditation Council for Graduate Medical Education and American Board of Surgery Requirements

There has been a significant increase in the number of regulatory requirements for general surgery graduate medical education (GME) programs over the last 20 years from the governing bodies of the American Board of Surgery (ABS) and the Accreditation Council of Graduate Medical Education (ACGME). We endeavored to calculate the cost to general surgery GME programs of regulatory requirements. We examined the requirements for General Surgery ABS Certification as well as the 2017 ACGME Program Requirements in General Surgery for all mandates that require funding by the surgery program to achieve. The requirements requiring funding include certification in Advanced Cardiac Life Support, Advanced Trauma Life Support, Fundamentals of Laparoscopic Surgery, Fundamentals of Endoscopic Surgery; access to medical references; simulation capability, program director protected time (30%); program coordinator salary (Association for Hospital Medical Education reported mean); and faculty time devoted to morbidity and mortality conference, journal club, Clinical Competency Committee, and Program Evaluation Committee. We then identified the cost of each mandate based on the average program in the United States of 5 residents per year in 5 clinical years. Total cost for the average program per year as the result of ABS or ACGME mandate equaled a minimum of $227,043. The ABS associated costs are $8900 per year. The ACGME associated costs are $218,143. The cost of program director and faculty time to meet the minimum ACGME requirements equaled $159,600. The most significant cost associated with mandates set forth by the ABS and ACGME are program director and faculty time devoted to resident education and evaluation. Recognition of this cost burden by institutions and policymakers for the allocation of funds is important to maintain strong general surgery GME programs.