| >CYBER-BASED EDUCATION AND DISTANT LEARNING
TOP GUN LAPAROSCOPIC SUTURING PROGRAM Objective
Evaluation of a Laparoscopic Surgical Skill Program for Residents
and Senior Surgeons
James
C. Rosser, MD; Ludie E. Rosser, BSc; Raghu S. Savalgi, MD, PhD(Surg),
FRCS
This article reports
on the Yale Laparoscopic Skills and Suturing Program, a training method1-3
for objective evaluation of laparoscopic surgical skills including
intracorporeal suturing. Since
the introduction of laparoscopic general surgery, many courses to
retrain established surgeons have emerged.
However, objective parameters are not commonly used to assess
the outcome of courses.4-6 The safe and efficient inclusion of laparoscopic surgery as an integral
part of general surgery demands dissemination of laparoscopic surgical
skills among trained surgeons and residents with a common platform. An effective standardized skill-acquisition
course with objective evaluations can facilitate skill transfer for
the retraining of senior surgeons and establishing initial surgical
training in residents.7-9 Our aim was to evaluate the effectiveness of a method of teaching basic laparoscopic skills and suturing to trained surgeons and residents. A database with percentile graphs was created to allow valid comparison of the skills of the participants. (Figure 1) PARTICIPANTS
All 291 trained surgeons were
board eligible or board certified or had the equivalent qualifications
and experience. All were previously
certified to perform laparoscopic surgery in their hospitals. They attended a standardized training program
for 2-1/2 days, as described previously.1-3 All the trained surgeon participants performed
3 types of standardized drills (rope pass drill, triangle transfer
drill, and cup drop drill) 10 times each.
They were also trained in a standardized intracorporeal suturing
technique. The instructor-trainee
ratio was 1:4. Data were collected
by the instructors, who ensured the competency and timing of each
drill and suturing technique. All
exercises, including standardized intracorporeal anastomosis (8 cm
long, 2 layers), were performed within a laparoscopic trainer (Surgi
Trainer, US Surgical Corporation, Norwalk, CT) (Figure 1) using
a monitor (Trinitron model No. PVM-1943MD, Sony, Tokyo, Japan), and
a 0°,
10mm laparoscope (Stryker Endoscopy, Santa Clara, CA), and a 3-chip
medical video camera (model No. 777, Stryker Endoscopy). The participants performed 3 types of drills to improve their dexterity,
depth perception, instrument targeting accuracy, visual and spatial
abilities, and hand-eye coordination.
Use of the non-dominant hand was emphasized. These are generalized skill requirements, applicable not only to
laparoscopic surgery but also to other types of Endoscopic surgical
techniques. The drills are
subset tasks relevant to increasing efficiency in laparoscopic suturing. The steps involved in intracorporeal suturing
are described in detail elsewhere.1-6 A detailed suturing algorithm was developed and strictly
followed. The process was
broken into 3 phases: needle
positioning, tissue penetration, and knotting.
Only 1 practice drill was allowed, and thereafter all the exercises
were timed in a standardized fashion.
The participants performed the drills before the suturing exercises
on each day of the 2-1/2 day course.
The data collection for trained surgeons began in 1991 and
ended in 1994. The same course was conducted for residents at Yale University
School of Medicine over a 3-year period (from 1994-1996). The residents attended the course in batches
of 15 to 20 participants. The
courses were conducted during a weekend and were an essential requirement
of the residency training program.
At the end of the course, each resident was given an analysis
indicating the resident’s percentile performance compared with that
of the data bank of trained surgeons. The time required to perform each dexterity drill or suturing exercise
was documented in seconds. The
291 trained surgeons who performed 10 of each drill or suturing exercise
were included in the final analysis.
The total time required to perform the first 10 drills and
suturing exercises was calculated for each participant and used for
comparison with all the calculations.
This method yielded 1 value in seconds per participant per
drill or suturing exercise. Cumulative percentile graphs were prepared
for all the drills and suturing exercises.9,11 The comparisons of residents with trained surgeons and of
male with female participants were made with unpaired, 2-tailed t
tests. --------------------RESULTS--------------------
The total time in seconds required by 291
trained surgeons (268 male and 23 female) and 99 residents (78 male
and 21 female) to perform 10 drills and 10 suturing exercises of each
type is shown in Table 1. The resident group included 61 general surgical
residents and 19 gynecology residents across the spectrum from introduction
to chief residency, and 19 pre-residency participants. The senior surgeons
were older than the residents (mean ± SEM, 44±0.55 years vs 31±1.15 years, P<.001), as expected The container used to perform the cup drop
drill was changed to a porcelain cup with an aperture, as it was difficult
to obtain the former type of cup.
The alteration, however, increased the difficulty in performing
the cup drop drill, thus requiring a longer time to complete it.
Separate analysis was, therefore, performed for both old and
new cup drop drills. The drill
with the larger sample size was evaluated unless the amalgamation
of data did not influence the outcome of the analysis.
A comparison of time requirements for male and female residents
and for male and female trained surgeons is show in Table 2
and Table 3, respectively.
Each resident’s performance in drills and suturing exercises
was compared with the percentile rank for each resident was thus determined. The time required to perform 10 drills and
suturing exercises for the residents as a group and for the trained
surgeons are compared in Table 1.
Data of 3 catagories of residents are given separately, so
that the performance of these subgroups can be appreciated on their
own merit. Data of all the residents and data of their subgroups were compared
separately with the performance of the trained surgeons; P
values in Table 1 refer to these comparisons.
There was no significant difference in the time requirement
of residents and trained surgeons in performing the rope pass drill
and suturing exercises. Furthermore,
residents took significantly less time to perform the triangle transfer
drill. They required more time than the trained surgeons,
however, to perform the old cup drop drill, new cup drop drill, and
an 8-cm, 2-layer ananstamosis. Data
given in Table 1 for subgroups of residents are informative for evaluating
subgroup behavior in comparison with that of all of the residents
as a whole. The time requirements of male and female residents
and male and female trained surgeons are shown in Tables 2 and 3,
respectively. No significant
difference was noted in the performance of male and female residents. However, the trained female surgeons required
more time that the trained males to perform the rope pass drill and
suturing exercises. No significant
difference was found between the 2 groups in the time required to
perform the old cup drop drill and the triangle transfer drill. The times required to perform 10 drills and
10 suturing exercises were tested for correlation in the total study
population of 392 that included all the trained surgeons and all the
residents. A significant correlation was noted between
the time required for the suturing exercises and the time recorded
in all 3 drills (rope pass drill, n=352, r=0.51, P<.001,
Figure 2; triangle transfer drill, n=354, r=0.53, P<.001,
Figure 3; cup drop drill, n=354, r=0.51, P<.001,
Figure 4). The residents were younger than the trained
surgeons (mean ± SEM, 30.79±1.15 years vs 43.94±0.55 years, P<.001), as expected. The age of all the participants (41.46±0.58 years) including trained surgeons and residents
had very low correlation with the time required to perform 10 drills
and 10 suturing exercises (rope pass drill, n=274, r=0.17,
P<.005; triangle transfer drill, n=277, r=0.23, P<.005;
cup drop drill, n=278, r=0.07, P<.0001; suturing
exercises, n=244, r=0.27, P<.001). ------------------------COMMENT----------------------- Traditional educational strategies in surgery need to be altered to cope with recent developments in minimally invasive surgery. Current training systems are mainly dependent on subjective evaluation of trainee surgeons by the surgical preceptors, a loosely organized curriculum, and cognitive testing through multiple-choice questions. Very few training programs use objective tests of dexterity and surgical skills in their usual surgical training and evaluation methods. This is probably justified because the relationship between surgical skills and manual dexterity has been questioned. For example, some investigators did not find any difference in manual dexterity between physicians and surgeons.12 In addition, other13 did not find any correlation between surgical clinical proficiency and psychomotor skills. These studies, however, were not conducted in a laparoscopic environment and results cannot be extrapolated to laparoscopic surgery. It is agreed that performance in an objective evaluation should not be taken as the sole factor in judging the clinical or technical competency of a surgeon. Cognitive tests and objective evaluation of dexterity and psychomotor skills assess different characteristics of a surgeon. While tests of cognitive knowledge represent a valid measure of the retention of factual material, they cannot be used as the sole basis for assessing clinical competence in a residency program.14 Objective evaluations should be used in conjunction with subjective and cognitive tests and should not replace them. Correlation can be observed between the teaching of gross motor skill development by physical educators and the teaching of fine manual motor skills associated with surgical skill development.15 The need for a reliable method of skill acquisition was documented by a survey of 152 program directors in the United States,16 50% of whom felt that there was a need for improving the establishment of technical skill. No single method has been accepted as the best by any group, but many are being explored.17 The concept of skill labs is widely accepted,18 but curriculum content must dictate the effectiveness of these labs to affect skill transference. Minimal-access surgery demands high-quality assurance standards in order for patients to reap maximum benefits.19 Whatever transpires from the emerging technology, we must not overlook surgical principles governing operative intervention, which apply regardless of the approach and instrumentation. High performance standards with widespread availability cannot become a reality without the establishment of skills. Some programs have tried to introduce skill development more systematically than others.19,20 They did not, however, use objective parameters of laparoscopic skill, but only recorded an increase in the total number of laparoscopic cholecystectomies performed by the trainees in their hospitals. Coppola and Merrell21 discussed outcome reference points in their study on the effect of a laparoscopic skill-development regimen on a resident training program. After residents participated in this program, the academic level of the residents able to perform a laparoscopic cholecystectomy significantly decreased without extended operative times or increased complication rates. The objective evaluation of dexterity and skill can only become a reality if a large database is established. There are no such data banks in conventional surgery, but this database for laparoscopic surgery could prove very helpful in the development of a training system for laparoscopic surgery. A database provides a way for participants to know how successful their efforts are in attaining a level of competence. It gives them a performance reference point – the skill levels of trained surgeons – to try to achieve and to pass. It also helps to establish effective training countermeasures for participants who have difficulty. The relationship between dexterity drills and suturing techniques that was noted in our initial reports1-3 was also found in the current study (Figures 2-4). This strongly supports correlation between dexterity skills and a meaningful surgical task. It has been a commonly held assumption that younger surgeons have a natural advantage in the development of laparoscopic skills. Some authors reported that age influenced pure motor skills but neither age nor pure motor skills are necessarily important for operative skills. Age did not appear to play a dominant role in the outcome of our courses. All the participants who attended our courses, regardless of age, sex, and previous training, learned intracorporeal suturing and performed anastamosis. There was no participants whose performance did not improve. The correlation between age and the time required to perform the dexterity drills and intracorporeal suturing was very low. All the residents as a group took marginally longer to complete an anastamosis, although their suturing time was not significantly different from that of the trained surgeons. This difference may be due to a lack of experience in performing anastamosis rather than in suturing. Residents required more time that the trained surgeons to perform the cup drop drill, which requires considerable depth-perception compensation to the 2-dimensional environment. However, residents performed significantly better than the trained surgeons in the triangle transfer drill. It is possible that age and experience might influence some types of dexterity drills, but overall they do no seem to play a dominant role. Laparoscopic intracorporeal suturing is probably the most difficult exercise to master in the minimally invasive environment. The drills in this program were associated with mastery of the suturing process. Both the residents and the trained surgeons reached a comparable efficiency with the same educational program. It is notable that the residents were effectively taught intracorporeal suturing in the same training program as were the attending surgeons. The residents did not have the same experience as senior surgeons in constructing an intestinal anastamosis in the open environment. Although their anastamosis completion times were longer that those of the trained surgeons, they developed a foundation on which to competently build (Table 1). There was no significant difference (P<.00), however, between the intracorporeal suturing times of the residents as a group vs the trained surgeons. The residents’ performance is all the more noteworthy considering that 70% of board eligible, trained surgeons, before taking our course, could not complete a know in 5 minutes.1 Some authors reported that female residents scored better in cognitive
tasks but scored less well in visual motor tasks in comparison with
male residents. In our study
there does not appear to be a dominant influence on sex on laparoscopic
skill acquisition. No difference
was noted in the performance of male an female residents in performing
drills and suturing exercises. The
finding that trained females took a longer time to complete suturing
exercises and rope pass drills was only marginally significant (P<0.5). Hayward et al22 compared the abilities of male and female
residents in 6 areas: ethics, judgment, technical skills, knowledge,
interpersonal skills, and work habits.
A 5-piont scale was used for evaluation. They did not find any difference between male and female residents.
This finding was also consistent with our current study. ---------------------CONCLUSIONS-------------------- The Yale Laparoscopic Skills and Suturing Program is effective in
establishing laparoscopic and suturing skills in surgeons and residents
regardless of age or sex in a short time, resulting in greater teaching
efficiency. Because the database
generated by this study is applicable to a multilevel spectrum of
participants, comparison of skill levels of residents against the
percentile graphs derived from the performance of trained surgeons
is possible. Participants who finished this standardized curriculum can compare
their performance with that of trained surgeons, giving them an initiative
to practice and improve. ----------------------REFERENCES--------------------- (To follow) |
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