Minimally invasive surgery training in Canada: a survey of general surgery

Fundamentals of Arthroscopic Surgery Training and beyond: a reinforcement learning exploration and benchmark

PURPOSE

This work presents FASTRL, a benchmark set of instrument manipulation tasks adapted to the domain of reinforcement learning and used in simulated surgical training. This benchmark enables and supports the design and training of human-centric reinforcement learning agents which assist and evaluate human trainees in surgical practice.

METHODS

Simulation tasks from the Fundamentals of Arthroscopic Surgery Training (FAST) program are adapted to the reinforcement learning setting for the purpose of training virtual agents that are capable of providing assistance and scoring to the surgical trainees. A skill performance assessment protocol is presented based on the trained virtual agents.

RESULTS

The proposed benchmark suite presents an API for training reinforcement learning agents in the context of arthroscopic skill training. The evaluation scheme based on both heuristic and learned reward functions robustly recovers the ground truth ranking on a diverse test set of human trajectories.

CONCLUSION

The presented benchmark enables the exploration of a novel reinforcement learning-based approach to skill performance assessment and in-procedure assistance for simulated surgical training scenarios. The evaluation protocol based on the learned reward model demonstrates potential for evaluating the performance of surgical trainees in simulation.

Biomarker Identification in Membranous Nephropathy Using a Long Non-coding RNA-Mediated Competitive Endogenous RNA Network

PURPOSE

This study was aimed to identify biomarker associated with membranous nephropathy (MN) progression by integration of expression profiles and competitive endogenous RNA (ceRNA) network analysis.

METHODS

The gene (GSE108113) and microRNAs (miRNAs) expression profiles (GSE64306) were downloaded to identify the differentially expressed mRNAs, miRNAs and long non-coding RNAs (lncRNAs) between MN and control groups. The functions and pathways enriched by the differentially expressed mRNAs were analyzed. The mRNA-lncRNA co-expression network was constructed followed by and the ceRNA network construction.

RESULTS

Total 264 upregulated and 196 downregulated differentially expressed mRNAs, 79 upregulated and 4 downregulated lncRNAs, as well as 115 upregulated and 93 downregulated miRNAs were obtained between MN and control groups. After analysis, the differential mRNAs were significantly involved in multiple immune-related processes, and cell proliferation, apoptosis and differentiation processes, as well as pathways of taste transduction and lysosome. Finally, a ceRNA network consisting of 4 mRNAs (EPB41L5, FAM43A, PRKG1 and TTC14), 3 lncRNAs (LINC00052, LINC00641 and N4BP2L2-IT2) and 5 miRNAs (hsa-miR-145-5p, hsa-miR-3605-5p, hsa-miR-148a-3p, hsa-miR-497-5p and hsa-miR-148b-3p) was constructed.

CONCLUSION

Our study indicated dysregulation of immune- and apoptosis-associated functions and taste transduction and lysosome pathways may play important roles in MN progression. Deregulated ceRNAs, such as LINC00052-hsa-miR-145-5p-EPB41L5, LINC00052-hsa-miR-148a-3p-FAM43A and LINC00641-hsa-497-5p-PRKG1, may be associated with MN development.

Identification of Potential Biomarkers in Neonatal Sepsis by Establishing a Competitive Endogenous RNA Network

BACKGROUND

Neonatal sepsis is a serious and difficult-to-diagnose systemic infectious disease occurring during the neonatal period.

OBJECTIVE

This study aimed to identify potential biomarkers of neonatal sepsis and explore its underlying mechanisms.

METHODS

We downloaded the neonatal sepsis-related gene profile GSE25504 from the NCBI Gene Expression Omnibus (GEO) database. The differentially expressed RNAs (DERs) were screened and identified using LIMMA. Then, the functions of the DERs were evaluated using Gene Ontology (GO) and the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses. Finally, a competing endogenous RNA (ceRNA) network was constructed and functional analyses were performed.

RESULTS

The initial screening identified 444 differentially expressed (DE)-mRNAs and 45 DElncRNAs. GO analysis showed that these DE-mRNAs were involved in immune response, defense response, and positive regulation of immune system process. KEGG analysis showed that these DE-mRNAs were enriched in 30 activated pathways and 6 suppressed pathways, and those with the highest scores were the IL-17 signaling pathway and ribosome. Next, 722 miRNAs associated with the identified lncRNAs were predicted using miRWalk. A ceRNA network was constructed that included 6 lncRNAs, 11 mRNAs, and 55 miRNAs. In this network, HCP5, LINC00638, XIST and TP53TG1 were hub nodes. Functional analysis of this network identified some essential immune functions, hematopoietic functions, osteoclast differentiation, and primary immunodeficiency as associated with neonatal sepsis.

CONCLUSION

HCP5, LINC00638, TP53TG1, ST20-AS1, and SERPINB9P1 may be potential biomarkers of neonatal sepsis and may be useful for rapid diagnosis; the biological process of the immune response was related to neonatal sepsis.

Assessment of laparoscopic skills of Gynecology and Obstetrics residents after a training program

Objective

To evaluate laparoscopic skills of third-year Gynecology and Obstetrics residents after training at a training and surgical experimentation center.

Methods

Use of a prospective questionnaire analyzing demographic data, medical residency, skills, competences, and training in a box trainer and in pigs.

Results

After the training, there was significant improvement in laparoscopic skills according to the residents (before 1.3/after 2.7; p=0.000) and preceptors (before 2.1/after 4.8; p=0.000). There was also significant improvement in the feeling of competence in surgeries with level 1 and 2 of difficulty. All residents approved the training.

Conclusion

The training was distributed into 12 hours in the box trainer and 20 hours in animals, and led to better laparoscopic skills and a feeling of more surgical competence in laparoscopic surgery levels 1 and 2.

Broad-Based Fellowships: A Cornerstone of Minimally Invasive Surgery Education and Dissemination

Aware of the trends in surgery and of public demand, many residents completing a 5-year training program seek fellowships in minimally invasive surgery (MIS) because of inadequate exposure to advanced MIS during their residency. A survey was designed to evaluate the effectiveness of a broad-based fellowship in advanced laparoscopic surgery offered in an academic health science center. The questionnaire was mailed to all graduates. Data on demographics, comfort level with specific laparoscopic procedures, and opinions regarding the best methods of acquiring these skills were collected. Most of the surgeons entered the fellowship directly after residency. The majority of these surgeons are academic surgeons. Fellows performed a median of 187 cases by the end of their training and felt comfortable operating on foregut, hindgut, and end organ. A full year of training was found to be the best format for appropriate skill transfer. A broad-based MIS fellowship meets the needs of both academic and community surgeons desiring to perform advanced laparoscopic procedures.

Association between Fellowship Training, Surgical Volume, and Laparoscopic Suturing Techniques among Members of the American Association of Gynecologic Laparoscopists

Study Objective. To compare surgical volume and techniques including laparoscopic suturing among members of the American Association of Gynecologic Laparoscopists (AAGL) according to fellowship training status. Design. A web-based survey was designed using Qualtrics and sent to AAGL members. Results. Minimally invasive gynecologic surgery (FMIGS) trained surgeons were more likely to perform more than 8 major conventional laparoscopic cases per month (63% versus 38%, P < 0.001, OR [95% CI] = 2.78 [1.54–5.06]) and were more likely to perform laparoscopic suturing during these cases (32% versus 16%, P < 0.004, OR [95% CI] = 2.44 [1.25–4.71]). The non-fellowship trained (NFT) surgeons in private practice were less likely to perform over 8 conventional laparoscopic cases (34% versus 51%, P = 0.03, OR [95% CI] = 0.50 [0.25–0.99]) and laparoscopic suturing during these cases (13% versus 27%, P = 0.01, OR [95% CI] = 0.39 [0.17–0.92]) compared to NFT surgeons in academic practice. Conclusion. The surgical volume and utilization of laparoscopic suturing of FMIGS trained surgeons are significantly increased compared to NFT surgeons. Academic practice setting had a positive impact on surgical volume of NFT surgeons but not on FMIGS trained surgeons.

[Evaluation of residency training in general and digestive surgery in Tunisia]

Introduction

De nombreux moyens sont mis à disposition des résidents en chirurgie générale et digestive pour assurer leur formation théorique et pratique. Cependant, le niveau d'utilisation de ces différents outils et leur impact sur la formation des résidents n'ont jamais été évalués. L'objectif de notre étude était d’étudier l’état des lieux des moyens de formation utilisés par les résidents pour évaluer leurs degrés de satisfaction et leurs propositions en vue d'améliorer leur formation.

Méthodes

Un questionnaire anonyme a été distribué aux résidents de chirurgie générale et digestive de l'année 2012-2013. Ce questionnaire portait sur les caractéristiques démographiques, les ressources pédagogiques, ainsi que le cursus médical et universitaire. Une évaluation de la formation ainsi qu'un recueil des propositions faites en vue d'améliorer leurs formations étaient réalisées.

Résultats

Cinquante résidents sur 83 ont répondu au questionnaire. L'orientation de carrière la plus fréquente était l'hospitalo-universitaire dans 70% des cas. La pratique quotidienne et l'internet étaient les deux ressources pédagogiques les plus utilisées. La formation chirurgicale était jugée satisfaisante par seulement 10% des répondants. Parmi l'ensemble des propositions faites, l'apprentissage sur simulateur chirurgical, l'existence d'un ouvrage national de référence, et l'institution d'un tutorat par un chirurgien senior recueillaient plus de 80% d'avis favorable.

Conclusion

La majorité des résidents jugent leur formation non satisfaisante. Une meilleure information sur les ressources déjà existantes, un renforcement du compagnonnage et un accès plus large à un apprentissage sur simulateur chirurgical permettraient de diminuer ce sentiment d'insatisfaction.

The integration of minimally invasive surgery in surgical practice in a Canadian setting: results from 2 consecutive province-wide practice surveys of general surgeons over a 5-year period

BACKGROUND

Although minimally invasive surgery (MIS) has been quickly embraced, the introduction of advanced procedures appears more complex. We assessed the evolution of MIS in the province of Quebec over a 5-year period to identify areas for improvement in the modern surgical era.

METHODS

We developed, test-piloted and conducted a self-administered questionnaire among Quebec general surgeons in 2007 and 2012 to examine stated MIS practice, MIS training and barriers and facilitators to the use of MIS.

RESULTS

Response rates were 51.3% (251 of 489) in 2007 and 31.3% (153 of 491) in 2012. A significant increase was observed for performance of most advanced MIS procedures, especially for colectomy for benign (66.0% v. 84.3%, p < 0,001) and malignant diseases (43.3% v. 77.8%, p < 0,001) and for rectal surgery for malignancy (21.0% v. 54.6%, p < 0.001). More surgeons practised 3 or more advanced MIS procedures in 2012 than in 2007 (82.3% v. 64.3%, p < 0,001). At multivariate analysis, the 2007 survey administration was associated with fewer surgeons practising advanced MIS (odds ratio 0.13, 95% confidence interval 0.06-0.29). In 2012, more respondents stated they gained their skills during residency (p = 0.028).

CONCLUSION

From 2007 to 2012 there was a significant increase in advanced MIS procedures practised by general surgeons in Québec. This technique appears well established in current surgical practice. The growing place of MIS in residency training seems to be a paramount part of this development. Results from this study could be used as a baseline for studies focusing on ways to further improve the MIS practice.

Validation of virtual reality simulators: Key to the successful integration of a novel teaching technology into minimal access surgery

Minimal access surgery (MAS) requires additional training in the surgical curriculum, as skills needed to perform MAS are quite different from those used in open surgery. Moreover, residents do not seem to experience ample opportunity to gain such skills in the current surgical curriculum. Virtual reality (VR) simulation offers an interesting opportunity to train such skills in a safe, supporting environment. As with any new development, one should be careful about integrating costly technology into practice before it has been properly validated.This article outlines the requirements for a valid and integrated approach towards the integration of novel VR simulation systems in minimal access surgery.

Voluntary autonomous simulator based training in minimally invasive surgery, residents' compliance and reflection

BACKGROUND

Knot tying and suturing skills in minimally invasive surgery (MIS) differ markedly from those in open surgery. Appropriate MIS training is mandatory before implementation into practice. The Advanced Suturing Course (ASC) is a structured simulator based training course that includes a 6-week autonomous training period at home on a traditional laparoscopic box trainer. Previous research did not demonstrate a significant progress in laparoscopic skills after this training period. This study aims to identify factors determining autonomous training on a laparoscopic box trainer at home.

METHODS

Residents (n = 97) attending 1 of 7 ASC courses between January 2009 and June 2011 were consecutively included. After 6 weeks of autonomous, training a questionnaire was completed. A random subgroup of 30 residents was requested to keep a time log. All residents received an online survey after attending the ASC. We performed outcome comparison to examine the accuracy of individual responses.

RESULTS

Out of 97 residents, the main motives for noncompliant autonomous training included a lack of (training) time after working hours (n = 80, 83.3%), preferred practice time during working hours (n = 76, 31.6%), or another surgical interest than MIS (n = 79, 15.2%). Previously set training goals would encourage autonomous training according to 27.8% (n = 18) of residents. Thirty participants submitted a time log and reported an average 76.5-minute weekly training time. All residents confirmed that autonomous home practice on a laparoscopic box trainer is valuable.

CONCLUSIONS

Autonomous practice should be structured and inclusive of adequate and sufficient feedback points. A minimally required practice time should be set. An obligatory assessment, including corresponding consequence should be conducted. Compliance herewith may result in increased voluntary (autonomous) simulator based (laparoscopic) training by residents.

Resident perceptions of advanced laparoscopic skills training

BACKGROUND

The purpose of this study was to explore resident perceptions regarding four current models for teaching laparoscopic suturing and to assess the current quality of training in advanced minimally invasive surgical techniques at an academic teaching center.

METHODS

This study included 14 senior general surgery residents (PGY 3-5) participating in a workshop in advanced laparoscopy. Four training tools were used in the course curriculum: the Fundamentals of Laparoscopic Surgery (FLS) black box suturing model, a synthetic Nissen fundoplication model, a virtual reality (VR) simulator suturing task, and a porcine jejuno-jejunostomy model. After the workshop, residents were asked to complete a questionnaire relating to their experience with laparoscopic surgery, and their opinions regarding the four training models. Model rank was analyzed with one-way ANOVA, and χ(2) analysis with Fisher's exact test was used to analyze model effectiveness.

RESULTS

The majority of residents had strong experience in basic laparoscopic cases such as cholecystectomy and appendectomy; however, few participants had experience in advanced cases. As a group, the residents ranked the porcine model first (average 1.6, median 1), followed by the synthetic Nissen model (average 2.0, median 2), the FLS model (average 2.5, median 3), and the VR trainer (average 3.2, median 4). Finally, each resident was asked to rate the four models individually with respect to their educational value. Scores were on a Likert scale from 1 to 5. Nine of 11 (81.8%) residents rated the animal model as "extremely helpful" while only 3 of 14 (21.4%) participants rated the VR model as "extremely helpful" (p = 0.048).

CONCLUSIONS

This study demonstrates that operative experience in advanced laparoscopy for senior residents is suboptimal. Residents learning this skill in a simulated environment prefer animal or video-trainers as teaching models rather than virtual reality. This has implications when designing a curriculum for advanced endoscopy.

[Surgical resident training program in minimally invasive surgery experimental laboratory (CENDOS)]

INTRODUCTION

The rapid development of laparoscopic surgery makes resident training programmes necessary.

OBJECTIVE

To analyse the results of a structured programme of laparoscopic training in an experimental laboratory.

MATERIAL AND METHOD

From 2003 until 2007, we trained 11 general surgery residents for 20 h every 3 months, for three years. The practice consisted of suture and anastomosis in Endo-Trainer with animal organs, as well as laparoscopic techniques in live animals. In the Endo-Trainer practice we evaluated the time and quality of anastomosis performance. In laparoscopic techniques (cholecystectomy and anti-reflux surgery) a task table was evaluated, from 0 (no errors) to 100 (severe lesion).

RESULTS

In total, 314 anastomosis were performed by the 11 residents, with a median of 28.5 per resident (24-42). The mean time for the first gastro-jejunal anastomosis was 135 min (100-140) and 65 min (57.5-105) for the first jejunal-jejunal anastomosis. Maximum learning was achieved after 45 training hours. There were no appreciable differences between both types of anastomosis. There was inadequate anastomosis quality due to leakage in 17.1% during the learning period and 13.7% during the consolidation period. In the animal, 172 procedures were performed. In cholecystectomy and anti-reflux surgery the mean scores were 2.4 and 5.6 points, respectively. In the remaining procedures, subjectively evaluated by the monitors, the quality was adequate in 65%, deficient in 22% and highly deficient in 13%.

CONCLUSIONS

This structured programme of laparoscopic skills based on intestinal anastomosis allows for quicker resident training.

Implementation difficulties of advanced techniques in gynecological laparoscopy

Laparoscopic surgery has developed into an important part of the gynecological surgical pallet. Its implementation into daily practice has shown to be complex, especially the advanced procedures. The difficulties of implementation is multifactorial; however, the training of laparoscopy is one of the major issues of this subject. The adequate training of residents and gynecologists is essential for its optimal and safe implementation. Concerning the advanced procedures, the question raises as to who should be able to perform these procedures and how this is established. Causes, difficulties, and limitations of the implementation of advanced laparoscopy will be discussed in this paper.

Analysis of a structured training programme in laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is an established treatment for almost all gallbladder diseases with bile duct injury rates similar to open cholecystectomy. These laparoscopic skills must be passed on to junior surgeons without compromising patient safety.

MATERIALS AND METHODS

We analysed our structured training programme over 6years (May 2000 to May 2006) by following three trainee surgeons during their training and beyond. During this period, 1,000 laparoscopic cholecystectomies were carried out with five consultant surgeons supervising and three new trainees who completed their accreditation in laparoscopic cholecystectomy.

RESULTS

There were 694 patients operated on by consultant surgeons (Group 1), 202 by trainee surgeons (Group 2) and 104 by newly trained surgeons (Group 3). There were no differences between the groups in terms of age and gender. However, there was a significant difference in gallbladder disease among the three groups; Group 2 had more gallstone pancreatitis patients (P < 0.019). There were no differences among the three groups in conversion rates, bile duct injury rates, general complication rates or length of stay. However, the duration of operation in Group 2 was significantly longer compared to the other two groups (P < 0.0001).

CONCLUSION

This programme is effective in training junior surgeons and does not compromise patient safety.

Perceptions of surgical specialists in general surgery, orthopaedic surgery, urology and gynaecology on teaching endoscopic surgery in The Netherlands

BACKGROUND

Specific training in endoscopic skills and procedures has become a necessity for profession with embedded endoscopic techniques in their surgical palette. Previous research indicates endoscopic skills training to be inadequate, both from subjective (resident interviews) and objective (skills measurement) viewpoint. Surprisingly, possible shortcomings in endoscopic resident education have never been measured from the perspective of those individuals responsible for resident training, e.g. the program directors. Therefore, a nation-wide survey was conducted to inventory current endoscopic training initiatives and its possible shortcomings among all program directors of the surgical specialties in the Netherlands.

METHODS

Program directors for general surgery, orthopaedic surgery, gynaecology and urology were surveyed using a validated 25-item questionnaire.

RESULTS

A total of 113 program directors responded (79%). The respective response percentages were 73.6% for general surgeons, 75% for orthopaedic surgeon, 90.9% for urologists and 68.2% for gynaecologists. According to the findings, 35% of general surgeons were concerned about whether residents are properly skilled endoscopically upon completion of training. Among the respondents, 34.6% were unaware of endoscopic training initiatives. The general and orthopaedic surgeons who were aware of these initiatives estimated the number of training hours to be satisfactory, whereas the urologists and gynaecologists estimated training time to be unsatisfactory. Type and duration of endoscopic skill training appears to be heterogeneous, both within and between the specialties. Program directors all perceive virtual reality simulation to be a highly effective training method, and a multimodality training approach to be key. Respondents agree that endoscopic skills education should ideally be coordinated according to national consensus and guidelines.

CONCLUSIONS

A delicate balance exists between training hours and clinical working hours during residency. Primarily, a re-allocation of available training hours, aimed at core-endoscopic basic and advanced procedures, tailored to the needs of the resident and his or her phase of training is in place. The professions need to define which basic and advanced endoscopic procedures are to be trained, by whom, and by what outcome standards. According to the majority of program directors, virtual reality (VR) training needs to be integrated in procedural endoscopic training courses.

Implementation of hysteroscopic surgery in The Netherlands

OBJECTIVE

This study was conducted to assess the degree of diffusion of hysteroscopic surgery in gynaecological practice in The Netherlands in order to guide further implementation. The diffusion was objectified by defining the percentage of hospitals performing hysteroscopic procedures and the number of different procedures performed per gynaecologist.

STUDY DESIGN

In 2003 all Departments of Gynaecology (n=102) in The Netherlands were sent a questionnaire. The questionnaire addressed the number and type of all hysteroscopic procedures that were performed in each hospital in 2002. Data from this study were compared to previously published data from 1997.

RESULTS

Responses were received from 80% of all gynaecological departments in The Netherlands. Diagnostic hysteroscopy was performed in almost all hospitals in both 1997 and 2002. The percentage of hospitals that adopted polypectomy, myomectomy and endometrial ablation increased to more than 90% in 2002. The number of teaching hospitals that integrated diagnostic hysteroscopy, polypectomy and myomectomy (procedures required for graduation) into their operative spectrum increased to 100%.

CONCLUSION

This survey indicates a growing trend of the diffusion of diagnostic and "basic" therapeutic hysteroscopic procedures in The Netherlands. However, figures upon more advanced hysteroscopic surgery are less optimistic.

Simulators and Virtual Reality in Surgical Education

This article explores the pros and cons of virtual reality simulators, their abilities to train and assess surgical skills, and their potential future applications. Computer-based virtual reality simulators and more conventional box trainers are compared and contrasted. The virtual reality simulator provides objective assessment of surgical skills and immediate feedback further to enhance training. With this ability to provide standardized, unbiased assessment of surgical skills, the virtual reality trainer has the potential to be a tool for selecting, instructing, certifying, and recertifying gynecologists.

Implementation of advanced laparoscopy into daily gynecologic practice: Difficulties and solutions

BACKGROUND

The implementation of laparoscopy into Dutch gynecologic practice is slow. This study was conducted to assess the current state of laparoscopy, to identify factors influencing the implementation and to find solutions toward a better implementation.

METHODS

In 2003 a questionnaire was sent to all 151 gynecologists who finished residency within the previous 5 years. The questionnaire addressed practice demographics, performance of laparoscopy, factors influencing use of laparoscopy in practice and means of obtaining laparoscopic skills after residency.

RESULTS

Of 151 gynecologists, 124 (82%) responded, 46 (37%) male and 78 (63%) female. Mean age was 39 years (range 32-47 years). Respondents (73%) believed they were adequately trained during residency for basic laparoscopic procedures, but not for the more advanced procedures (82%). Lack of caseload, lack of being a primary surgeon, and lack of simulator training caused the deficiency of laparoscopic skills at the end of the residency. Causes of the slow implementation were long operating time, lack of attention for laparoscopy during residency, and budgetary problems, but not the financial compensation for gynecologists. In current practice, only 9% believed they reached their preferred level of competence. Hiring an advanced laparoscopic gynecologist was believed to be the best opportunity to reach the preferred level of competence. A minority of respondents supported a referral system or fellowship program.

CONCLUSIONS

Basic laparoscopy is sufficiently mastered during residency training; however, advanced laparoscopy is not. More emphasis should be placed on laparoscopic training of advanced procedures during residency and for gynecologists in practice. Hiring a gynecologist with advanced laparoscopic skills is expected to be the solution for this problem. However, a referral system or fellowship program is not.

Endoscopy teaching in Canada: A survey of obstetrics and gynecology program directors and graduating residents

OBJECTIVE

To examine the current state of basic and advanced gynecologic endoscopy teaching in Canadian Obstetrics and Gynecology (Ob/Gyn) residency programs.

METHODS

On Institutional Research Board approval, 2 pretested anonymous questionnaires were developed: one distributed to all Canadian Ob/Gyn program directors and a second to graduating residents (Canadian Task Force classification III). Two mailings were sent to maximize response, and some department chairs received personal telephone calls by the senior author to encourage participation. Residents on maternity leave were excluded from the study.

RESULTS

Fifteen of 16 (94%) program directors, and 47 of 62 (76%) residents participated. Directors expect all residents to be knowledgeable and competent performing basic endoscopic procedures on graduation. However, considerable variation exists among programs that teach advanced endoscopy. Some of the more important factors limiting integration of advanced endoscopic teaching include paucity of trained faculty, lack of attending interest, scarcity of operating time, and financial constraints. Most graduating residents consider undertaking additional gynecologic endoscopy fellowships.

CONCLUSION

Most Ob/Gyn program directors and graduating residents consider endoscopic surgery essential to contemporary practice. There is consensus to improve resident teaching in gynecologic endoscopy and commitment to better prepare future practitioners to ensure patient safety. Paucity of trained faculty and fiscal constraints appear to be important limiting factors.

Gynecological laparoscopy in residency training program: Dutch perspectives

BACKGROUND

Implementation of laparoscopy into residency training is difficult. This study was conducted to assess the current state of implementation of laparoscopic surgery into gynecological residency program, to identify factors influencing laparoscopic skills training, and to find solutions toward better training and implementation.

METHODS

In 2003 a questionnaire was sent to all 68 postgraduate year 5 and year 6 residents in obstetrics and gynecology in The Netherlands. The questionnaire addressed demographics, performance of laparoscopy, self-perceived competence, simulator training, and factors influencing laparoscopic training in residency.

RESULTS

Of the 68 residents, 60 (88%) responded; 46 (37%) were men and 78 (63%) women. Men showed significant higher mean self-perceived competence in some laparoscopic procedures than women. Of the respondents, 20% had no advanced laparoscopic gynecologist present in their teaching hospital. Residents felt that simulator training is important in relation to their performance in the operating room. Of all gynecological teaching hospitals in the Netherlands, 55% did not have the opportunity of simulator training. Of the respondents who had the possibility of simulator training, 33% did not use the simulator voluntarily. Residents who trained on a simulator felt training was significantly more important (p = 0.02) than residents who never practiced on a simulator. Respondents' laparoscopic skills were subjectively evaluated in the operating room (92%) or were evaluated based on the number of laparoscopic procedures performed as primary surgeon (49%). Of the respondents, 47% were satisfied with their current laparoscopic skills and 27% also felt prepared for the more advanced procedures. Not having been primary surgeon in nonacademic teaching hospitals and even more so in academic teaching hospitals (p < 0.05) was a limiting factor in acquiring laparoscopic skills.

CONCLUSIONS

Incorporation of basic laparoscopic procedures into residency training has been successful; however, advanced procedures are not. Simulator training is still in its infancy in The Netherlands, is not frequently used voluntarily, and should be mandatory during residency. Acquired laparoscopic skills on a simulator and in the operating room should be objectively assessed, and above all, training of trainers is imperative.

A global assessment tool for evaluation of intraoperative laparoscopic skills

BACKGROUND

There is a pressing need for an intraoperative assessment tool that meets high standards of reliability and validity to use as an outcome measure for different training strategies. The aim of this study was to develop a tool specific for laparoscopic skills and to evaluate its reliability and validity.

METHODS

The Global Operative Assessment of Laparoscopic Skills (GOALS) consists of a 5-item global rating scale. A 10-item checklist and 2 visual analogue scales (VAS) for competence and case difficulty were also used. During laparoscopic cholecystectomy, 21 participants were evaluated by the attending surgeon, by 2 trained observers and by self-assessment while dissecting the gallbladder from the liver bed.

RESULTS

The intraclass correlation coefficient (ICC) for the total GOALS score was .89 (95% confidence interval [CI] .74 to .95) between observers, .82 (95% CI .67 to .92) between observers and attending surgeons, and .70 (95% CI .37 to .87) between participants and attending surgeons. The ICCs (observers) for the VAS (competence) and the checklist were .69 and .70, respectively. The mean total GOALS score (observers) for novices (postgraduate years [PGYs] 1 through 3) was 13 (95% CI 10.3 to 15.7) compared with 19.4 (95% CI 17.2 to 21.5) for experienced (PGY 4 through attending surgeons, P = .0006). The VAS demonstrated a difference in scores between novice and experienced participants (P = .001); however, the task checklist did not (P = .09).

CONCLUSIONS

These data indicate that GOALS is feasible, reliable, and valid. They also suggest that it is superior to the task checklist and VAS for evaluation of technical skill by experienced raters. The findings support the use of GOALS in the training and evaluation of laparoscopic skills.

Minimal-access surgery training in the Netherlands: a survey among residents-in-training for general surgery

BACKGROUND

The purpose of this study was to assess the state of surgical training and its possible shortcomings in minimal-access surgery (MAS) among Dutch surgical residents.

METHODS

A pretested questionnaire was distributed to all residents-in-training for general surgery in The Netherlands.

RESULTS

The questionnaire was sent to 407 surgical residents. The response rate was 65%. Overall, 87.7% of all the responders were highly interested in the autonomous performance of laparoscopic surgery. Residents interested in gastrointestinal (GI) or oncologic surgery (n = 137) are significantly more interested than residents interested in non-GI/oncologic surgery. All the residents (100%) thought it was important to be able to perform the three basic MAS procedures (diagnostic laparoscopy, laparoscopic cholecystectomy, and laparoscopic appendectomy) autonomously at the end of their surgical training. Other MAS procedures were considered to be advanced procedures. Gastrointestinal/oncologic residents were most interested in performing advanced MAS procedures, although only 17.8% expected to be adequately prepared at the end of their surgical training. Most residents had the opportunity to attend MAS skills education. Irrespective of the format or training method, only 26.9% of residents stated their MAS skills training was objectively evaluated. The residents thought every surgical hospital department in the Netherlands should have a surgeon specialized in laparoscopic surgery (86.9%).

CONCLUSIONS

The current study showed that Dutch residents believe it is very important to perform basic MAS autonomously. Of the GI/oncologic-interested residents, the majority want to be able to perform advanced MAS, but expect to be unable to do so at the end of their training. They attribute this discrepancy to "not having enough chance to be the first operator" and to "lack of volume of procedures in the hospital." Specific and properly implemented, monitored, and evaluated MAS skills training programs in skills laboratory settings could offer a promising environment for overcoming this discrepancy.