- Email: [email protected]
A comprehensive resident training program in operative endoscopy
Graduate Education A comprehensive resident training program in operative endoscopy Magdy Peter Milad, MD, and Stacy Tessler Lindau, MD We describe a structured and uniform resident experience in operative endoscopy and analyze the costs of implementing such a program at an urban academic medical center. The residency curriculum at Northwestern Memorial Hospital incorporates a five-part approach to endoscopy training: weekly endoscopy rounds, an annual animal laboratory for residents, an individual animal laboratory, supervision by skilled endoscopic surgeons, and a laparoscopic training facility. Thirty-two residents have completed the training over 4 years. The annual cost of the entire program is $34,500, which can be offset partially by vendor support. A comprehensive and continuous endoscopic training program is an important and affordable part of resident education. (Obstet Gynecol 1998;92:148 –52. © 1998 by The American College of Obstetricians and Gynecologists.)
Twenty years ago, gynecologic procedures performed by endoscopy were limited to diagnostic procedures and tubal sterilizations. Since 1990, operative endoscopy has been used to treat an increasing variety of gynecologic conditions, resulting in shorter hospital stays and smaller, less painful abdominal incisions. The field of advanced operative laparoscopy is developing rapidly. Unfortunately, gynecologic resident training has not kept pace with these rapid changes in practice. Many established gynecologists responsible for resident teaching were not trained initially in advanced endoscopy themselves. As a result, there has been a proliferation of postgraduate courses to train attending physicians retroactively. Although such weekend courses are From the Section of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Northwestern University School of Medicine, Chicago, Illinois.
148 0029-7844/98/$19.00 PII S0029-7844(98)00119-7
also available to resident physicians, they may not contain adequate basic information for the novice. For this reason, the Council on Resident Education in Obstetrics and Gynecology developed a set of training modules to promote the inclusion of endoscopic surgery instruction in residency training programs.1 Using these modules as a foundation, we assembled an ad hoc committee that designed a comprehensive resident educational training curriculum in gynecologic endoscopy. The current program objectives are to provide 1) basic knowledge of endosurgical principles, 2) understanding of the equipment and technologies used in diagnostic and operative endoscopy, 3) information on minimization, early recognition, and treatment of endoscopic complications, and 4) hands-on experience in endoscopic and open procedures. The following five educational experiences are incorporated into the residency curriculum at Northwestern Memorial Hospital: 1) weekly endoscopy rounds, 2) a group animal laboratory for residents, 3) an individual animal laboratory, 4) supervision by skilled endoscopic surgeons, and 5) a laparoscopic training facility.
Weekly Endoscopy Rounds We hold endoscopy rounds weekly at our institution and publicize the session to all faculty and house staff. Discussions usually are researched and presented by residents, and topics are assigned at the start of each 6-week rotation. An experienced endoscopic surgeon is present to facilitate the discussion. Each year, fundamental topics are covered systematically to achieve uniformity in resident exposure and to establish a basic standard of endoscopic knowledge. However, to keep pace with changing technology and surgical advancements, the curriculum is flexible. The core curriculum follows, with a brief outline of our approach to some of these topics. Basic electrosurgical principles are discussed. The characteristics of monopolar and bipolar electrosurgery are demonstrated using uncooked chicken breast and an electrosurgical unit obtained from the operating room. The model allows demonstration of direct coupling, capacitative coupling, and stray current. Electrosurgical unit manuals and videos on electrosurgery are available in our laboratory. The hysteroscopic fluid media session is mainly didactic. Discussion includes a comparison of types of distention media,2 their physical properties and conductivity, relative advantages, disadvantages, risks, and cost. Fluid media samples and the hysteroscopy fluid management pump are brought to the session for demonstration. Instillation methods, intrauterine pressures in hysteroscopy, and troubleshooting with fluid
Obstetrics & Gynecology
distention problems also are addressed. Residents learn fluid monitoring methods and the prevention, diagnosis, and treatment of volume overload. To review equipment, we obtain operative laparoscopy, hysteroscopy, and resectoscope trays from surgical supply. Participants learn to identify, inspect, and assemble each of the tools. Residents are presented with operative scenarios and are asked to select appropriate instruments. Residents learn how to assemble electrosurgical cables with the corresponding instrumentation and irrigation fluid inflow and outflow attachments. Again, troubleshooting and injury prevention are important aspects of these discussions.3 Anesthetic complications are addressed also.4 Traditional methods of specimen removal such as the use of an endoscopic bag or extension of an abdominal incision are reviewed. Residents obtain hands-on experience in the laboratory working with the endoscopic bag as well as through assembly and use of the manual and electric morcellators. The method of performing laparoscopic colpotomy is discussed as are common problems encountered during this procedure. The basics of laser physics, laser safety, and lasertissue interactions are discussed.5 Applications of laser instruments in gynecology are reviewed, and the unique characteristics of a variety of laser tools are compared. Specific safety precautions, including protective eyewear and smoke evacuation, are covered. Laser tissue effects are demonstrated on chicken breast in the operating room. The mechanical properties of suture materials and thread-needle attachments are reviewed, and a variety of sutures and needles are brought for demonstration.6 Considerations unique to laparoscopy such as visibility, ergonomics, and limited access are discussed. The session covers principles and practice of basic endosurgical knots. Practical skill with knot-tying occurs in the laboratory. The hysterosalpingogram and sonohysterogram rounds session is structured around a set of slides collected by experienced clinicians. Residents are provided with pertinent clinical data and asked to interpret the films. Important concepts for hysterosalpingogram and sonohysterogram interpretation include recognition of uterine filling defects and structural abnormalities, diagnoses of intratubal architecture, and identification of technical error. Hysterosalpingogram technique and timing, patient care in preparation for and during the procedure, and counseling before and after hysterosalpingogram also is discussed. Management of allergic reaction to contrast media can be summarized briefly. Other topics that are discussed include the following: indications and techniques of cystourethroscopy,7,8 proctoscopy, and office hysteroscopy. Specific devices
VOL. 92, NO. 1, JULY 1998
such as the harmonic scalpel, balloon endometrial ablation, and hysteroscopic bipolar instruments are demonstrated. Pelvic anatomy is reviewed using slides and videos. The laparoscopic approach to ectopic pregnancy,9 hysterectomy,10 adhesion prevention, and complications of laparoscopy11,12 also are discussed.
Group Animal Laboratory Coming after at least 12 weeks of didactic training, the animal laboratory provides an ideal opportunity to develop familiarity with equipment and procedures, to develop technical skills and experience with vascular, bowel, and urinary tract injuries, and to learn from experienced endoscopists. A 12-hour course is provided annually for second- and fourth-year residents, so that each trainee experiences it twice during the residency. Second-year and senior residents work together in teams led by experienced surgeons. This promotes senior resident teaching skills and offers the opportunity for residents to learn from each other and a skilled endoscopist in an unrushed and controlled setting without prolonging surgery on a human patient. The course is divided into four half-day sessions, with brief didactic teaching in the morning and laboratory in the afternoon. Session I is an introduction to perioperative considerations including equipment, positioning, anatomic landmarks, and trocar placement. Emphasis is on endoscopic suturing, as this important skill is difficult for the novice to acquire. The practical session that follows (session II) reinforces endoscopic needle placement, suturing, and knot-tying skills using a pelviscopy trainer. Although the pelvic trainer is an excellent way to acquire basic skills, it cannot fully replicate the experience of working with live tissue. In preparation for the animate lab, session III covers common gynecologic and general surgical procedures as well as complications of operative laparoscopy. Experience in the animate model occurs during session IV. We have used porcine and canine models for teaching in vivo surgical skills. We have found the dog a superior model because the tissue texture is similar to human tissue. Also, the canine uterus better approximates the human fallopian tube, in contrast with the porcine uterus, which is akin to human bowel. Two or three residents and an experienced preceptor occupy each table. The following training procedures are included: an inferior epigastric vessel injury is secured using either a pediatric Foley bulb for tamponade, suture, or bipolar electrocoagulation. A loop of small bowel or the canine uterine horn is used to simulate an appendectomy. A cystotomy is performed with the bladder full and is repaired using extra- and
Milad and Lindau
Resident Endoscopic Training
149
Table 1. Annual Costs of Resident Endoscopy Training*
Endoscopy rounds
Animal laboratory
Individual animal laboratory Surgeon supervision Laparoscopy room
Administrative
Item
Quantity
Resterilization of trays Hysteroscopic fluid ESU pad/handpiece Tissue (chicken breast) Suture materials Coursebook Animal care† Endoscopic stations‡ Animal care
40 16 8 16 40 16 6 7 3
Videos Books Room (200 ft2) Pelviscopic equipment† Journals Society memberships
Fixed
Variable
Total (annual)
$20 $700 $400 $700
$400 $64 $48 $32 $80 $320 $4200 $2800 $2100
$10 $4 $6 $2 $2
$1000 $1000 $15,000 $6000 $500 $1000
$1000 $1000 $15,000 $6000 $500 $1000 $34,544
Totals
ESU 5 electrosurgical unit. * Based on 16 residents participating in the annual laboratory (seven dry stations and six animal stations) each year and three individual laboratories (a single animal station) per year. † Cost partially offset by vendor support. ‡ Supplied by vendors.
intracorporeal suturing. An incision is performed on a loop of small bowel and repaired in a transverse fashion using intracorporeal suturing techniques. A salpingoophorectomy is performed using bipolar electrosurgery as well as extracorporeal and intracorporeal suturing techniques. To mimic a retropubic urethropexy, the upper rectum is sutured to Cooper’s ligament after the obturator neurovascular bundle is identified. A large vascular structure such as the inferior mesenteric artery can be isolated and partially incised with scissors, and a clip applier can be used to secure the vessel proximally and distally. We regard the animal laboratory as an invaluable component of our endoscopic training program. In addition to the importance of using animals for preliminary surgical training, selection of the laboratory, acquisition of appropriate surgical and anesthetic equipment, and institutional support must be addressed carefully before a successful program can be initiated. Selection of the right veterinary laboratory must include evaluation of compliance with federal, state, and local regulations on animal use in research; the director’s experience with laparoscopy, veterinary anesthesia, euthanasia, and disposal techniques; and the experienced surgeon’s ability to operate safely and effectively in the laboratory environment. In addition, we strongly urge that the evaluation of an animal laboratory include review of multiple references and a trial run by operating in the laboratory. A qualified veterinary staff is critical; the need for proper anesthetic skills as well as an organized and professional environment cannot be overemphasized.
150 Milad and Lindau
Resident Endoscopic Training
Securing appropriate equipment can be formidable. Limited funding at most institutions will require procurement of instruments through multiple vendors. Obvious needs, in addition to basic endoscopic instruments, include a light source, camera, electrosurgical device, and a suction-irrigator apparatus. The latter two items are most often overlooked in establishing an endoscopy laboratory and are not substituted easily. The costs of establishing and maintaining an animal laboratory are difficult to quantify. Expenses include educational and surgical materials, finding and organizing the right laboratory, acquiring adequate equipment, and instructors’ time (Table 1). To justify these costs and garner ongoing support for the educational program, feedback about the laboratory experience and areas for improvement should be presented to the department on a regular basis.
Individual Animal Laboratory Ideally, a monthly or twice-monthly animal laboratory will provide more in-depth experience. Procedures can focus on gastrointestinal, urinary tract, and major vascular injuries and their repair by laparoscopy and laparotomy. Tissue reaction to various types of electrosurgical and laser injuries also can be demonstrated and management can be reviewed. Stapler devices, various clip appliers, and suture material can be used. Initially, this animal laboratory was provided for one or two residents each month. However, over the past year, financial constraints have limited the availability of this experience to only a few times a year.
Obstetrics & Gynecology
Supervision by Skilled Endoscopic Surgeons The daily interaction between faculty and resident is an essential component of resident teaching. It provides an opportunity to evaluate resident progress and individually correct deficiency. A core of qualified endoscopic surgeons was developed to supervise endoscopies performed by house staff and to assess resident performance. Surgeons who were “credentialled” for advanced endoscopic procedures following the Society of Reproductive Surgeons guidelines13 are used as preceptors for senior resident cases.
Laparoscopy Training Facility Operative laparoscopy training is carried out in dedicated space at the hospital and equipment out of service from the operating room is used. The room is equipped with an inanimate trainer and a range of suture materials, laparoscopic instruments (needle driver, tissue grasper, clips, staplers), and endoscopic loops. An endoscopy library in the same room comprises books, equipment manuals, videos, and a videocassette player. The facility has a combination-type lock and is well used in evenings and on weekends when residents take call. Endoscopy rounds are held in an adjoining conference room to promote hands-on learning.
Comment An important consideration in endoscopic training is the cost of maintaining the program. An analysis of the fixed and variable costs associated with this program is provided (Table 1). This does not include the time that is volunteered by the preceptors and facilitators. At first glance, costs may seen prohibitive, however, a large proportion is defrayed by vendor support. Nevertheless, corporate support may dwindle with increasing pressure to contain health care costs. There are few reports discussing endoscopic training for gynecologic residents. Fox et al14 reviewed the use of laparoscopic Pomeroy tubal ligation as a teaching tool for the acquisition of endoscopic skills during residency training. They found that five Pomeroy procedures were required to teach residents the skills necessary to reduce surgical time. In another retrospective study, Yeko et al15 found that as resident experience increased, mean operative times decreased. The minimum amount of supervised training necessary for gynecologic residents to safely and expeditiously treat ectopic pregnancies laparoscopically was five cases. However, a decrease in operating time does not necessarily represent an improvement in judgment. To measure comprehension, Stovall et al16 developed a
VOL. 92, NO. 1, JULY 1998
teaching module for gynecologic residents performing sterilization procedures. A 40-minute videotape and monograph were reviewed before a gynecologic surgery rotation. Resident performance on a post-test was significantly greater than on the pretest. Unfortunately, only tubal sterilizations were addressed, representing a small fraction of endoscopic surgical procedures. Sammarco and Youngblood17 described a training program using didactic sessions coupled with a series of inanimate models to mimic common gynecologic pathology without the use of a live animal laboratory. Cundiff18 described a 7-week program including didactic and practical sessions in the pelvic trainer and animal laboratory setting. Residents and faculty had an increase in self-assessed endoscopic competence when completing the course. Unfortunately, only 25% of residents (n 5 18) thought they were competent to manage a bowel injury, and 8% of residents thought they were able to manage a urinary tract injury after completing the course. The current report is distinctive in that unlike preceding reports, it describes an ongoing and comprehensive endoscopic training program. Throughout every year of the residency, we devote 1 hour a week to teaching and learning endoscopic issues. Basic principles are demonstrated and practiced in the pelviscopy training room, which can be used 24 hours a day. Simple tasks such as inspecting and assembling instruments and choosing electrosurgical power settings are taught in a hands-on approach in the intimate laboratory. Reinforcement takes place in the form of reading, videotapes, and the animal laboratories. Finally, graded preceptorship is performed in the operating room with highly skilled endoscopic surgeons. Our primary goal is to provide high-quality stepwise and uniform experience upon which graduating residents can continue to build. Apprenticeship during residency with a dedicated surgical endoscopist appears to have a significant positive impact on surgical skills19; however, broad-based and reinforcing extraoperative instruction provides the novice with a critical understanding of endoscopic surgical techniques and their limitations. Ultimately, our educational program strives to improve surgical judgment and patient care by cultivating residents’ ability to select appropriate surgical candidates, discern the correct surgical procedure and optimal approach, and accomplish procedures safely and expediently with the minimization, detection, and early treatment of complications. To make this happen, a single individual must coordinate the endoscopic training of residents. This person must have extensive endoscopic experience, a sufficient surgical load to put theory into practice, and, ideally, responsibility for operating room equipment purchases.
Milad and Lindau
Resident Endoscopic Training
151
Purchases are based primarily on the qualities of the specific instruments and are tried and approved by committee. However, by directing operating room purchases, the director of endoscopy has the ability to train residents in new endoscopic technologies before they are used in the operating room.
References 1. Council on Resident Education in Obstetrics and Gynecology. The advanced surgical syllabus. Washington, DC: CREOG, 1994. 2. Witz CA, Silverberg KM, Burns WN, Schenken RS, Olive DL. Complications associated with the absorption of hysteroscopic fluid media. Fertil Steril 1993;60:745–56. 3. Loffer FD. Contraindications and complications of hysteroscopy. Obstet Gynecol Clin North Am 1995;22:445–55. 4. Cunningham AJ. Laparoscopic surgery: Anesthetic implications. Surg Endosc 1994;8:1272– 84. 5. Sinai R. Laser physics and laser instrumentation. In: Donnez J, Nisolle M, eds. An atlas of laser operative laparoscopy and hysteroscopy. 1st ed. New York: The Parthenon Publishing Group, 1994:1–20. 6. Cuschierei A, Szabo Z. Tissue approximation in endoscopic surgery. 1st ed. Oxford, United Kingdom: Isis Medical Media Ltd., 1995. 7. Saidi MH, Sadler RK, Vancaillie TG, Akright BD, Farhart SA, White AJ. Diagnosis and management of serious urinary complications after major operative laparoscopy. Obstet Gynecol 1996;82: 272– 6. 8. Richardson DA. Cystourethroscopy in urogynecology. Obstet Gynecol Clin North Am 1989;16:817–25. 9. Penzias AS, Gutmann JN, Diamond MP. Laparoscopic management. In: Stovall TG, Ling FW, eds. Extrauterine pregnancy: Clinical diagnosis and management. 1st ed. St. Louis: McGrawHill, 1993:231– 48. 10. Chapron CM, Dubuisson JB, Ansquer Y. Is total laparoscopic hysterectomy a safe surgical procedure? Hum Reprod 1996;11: 2422– 4. 11. Jansen FW, Kapiteyn K, Trimbos-Kemper T, Hermans J, Trimbos JB. Complications of laparoscopy: A prospective multicenter observational study. Br J Obstet Gynaecol 1997;104:595– 600.
152 Milad and Lindau
Resident Endoscopic Training
12. Corfman RS, Diamond MP, DeCherney AH. Complications of laparoscopy and hysteroscopy. 2nd ed. Malden, Massachusetts: Blackwell Science, 1997. 13. Keye WR. Hitting a moving target: Credentialing the endoscopic surgeon. Fertil Steril 1994;62:1115–9. 14. Fox MD, Long CA, Meeks GR, Jutras ML, Cowan BD. Laparoscopic Pomeroy tubal ligation as a teaching model for residents. J Reprod Med 1994;39:862– 4. 15. Yeko TR, Villa A, Parsons AK, Maroulis GB. Laparoscopic treatment of ectopic pregnancy. Resident’s learning experience. J Reprod Med 1994;39:854 – 6. 16. Stovall TG, Ling FW, Lipscomb GH, Summitt RL Jr, Beckmann CR. A model for resident surgical training in laparoscopic sterilization. Obstet Gynecol 1994;833:470 –2. 17. Sammarco MJ, Youngblood JP. A resident teaching program in operative endoscopy. Obstet Gynecol 1993;81:463– 6. 18. Cundiff GW. Analysis of the effectiveness of an endoscopy education program in improving resident’s laparoscopic skills. Obstet Gynecol 1997;90:854 –9. 19. Cosgrove JM, Margolis IB, Riou JP, Wait RB. Formal endoscopy training for senior and junior house staff. J Laparoendosc Surg 1993;3:525–9.
Address reprint requests to:
Magdy Milad, MD Section of Reproductive Endocrinology Department of Obstetrics and Gynecology Northwestern University School of Medicine 333 East Superior Street, Suite 1504 Chicago, IL 60611 E-mail: [email protected]
Received November 24, 1997. Received in revised form February 18, 1998. Accepted March 12, 1998. Copyright © 1998 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
Obstetrics & Gynecology
Twenty years ago, gynecologic procedures performed by endoscopy were limited to diagnostic procedures and tubal sterilizations. Since 1990, operative endoscopy has been used to treat an increasing variety of gynecologic conditions, resulting in shorter hospital stays and smaller, less painful abdominal incisions. The field of advanced operative laparoscopy is developing rapidly. Unfortunately, gynecologic resident training has not kept pace with these rapid changes in practice. Many established gynecologists responsible for resident teaching were not trained initially in advanced endoscopy themselves. As a result, there has been a proliferation of postgraduate courses to train attending physicians retroactively. Although such weekend courses are From the Section of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Northwestern University School of Medicine, Chicago, Illinois.
148 0029-7844/98/$19.00 PII S0029-7844(98)00119-7
also available to resident physicians, they may not contain adequate basic information for the novice. For this reason, the Council on Resident Education in Obstetrics and Gynecology developed a set of training modules to promote the inclusion of endoscopic surgery instruction in residency training programs.1 Using these modules as a foundation, we assembled an ad hoc committee that designed a comprehensive resident educational training curriculum in gynecologic endoscopy. The current program objectives are to provide 1) basic knowledge of endosurgical principles, 2) understanding of the equipment and technologies used in diagnostic and operative endoscopy, 3) information on minimization, early recognition, and treatment of endoscopic complications, and 4) hands-on experience in endoscopic and open procedures. The following five educational experiences are incorporated into the residency curriculum at Northwestern Memorial Hospital: 1) weekly endoscopy rounds, 2) a group animal laboratory for residents, 3) an individual animal laboratory, 4) supervision by skilled endoscopic surgeons, and 5) a laparoscopic training facility.
Weekly Endoscopy Rounds We hold endoscopy rounds weekly at our institution and publicize the session to all faculty and house staff. Discussions usually are researched and presented by residents, and topics are assigned at the start of each 6-week rotation. An experienced endoscopic surgeon is present to facilitate the discussion. Each year, fundamental topics are covered systematically to achieve uniformity in resident exposure and to establish a basic standard of endoscopic knowledge. However, to keep pace with changing technology and surgical advancements, the curriculum is flexible. The core curriculum follows, with a brief outline of our approach to some of these topics. Basic electrosurgical principles are discussed. The characteristics of monopolar and bipolar electrosurgery are demonstrated using uncooked chicken breast and an electrosurgical unit obtained from the operating room. The model allows demonstration of direct coupling, capacitative coupling, and stray current. Electrosurgical unit manuals and videos on electrosurgery are available in our laboratory. The hysteroscopic fluid media session is mainly didactic. Discussion includes a comparison of types of distention media,2 their physical properties and conductivity, relative advantages, disadvantages, risks, and cost. Fluid media samples and the hysteroscopy fluid management pump are brought to the session for demonstration. Instillation methods, intrauterine pressures in hysteroscopy, and troubleshooting with fluid
Obstetrics & Gynecology
distention problems also are addressed. Residents learn fluid monitoring methods and the prevention, diagnosis, and treatment of volume overload. To review equipment, we obtain operative laparoscopy, hysteroscopy, and resectoscope trays from surgical supply. Participants learn to identify, inspect, and assemble each of the tools. Residents are presented with operative scenarios and are asked to select appropriate instruments. Residents learn how to assemble electrosurgical cables with the corresponding instrumentation and irrigation fluid inflow and outflow attachments. Again, troubleshooting and injury prevention are important aspects of these discussions.3 Anesthetic complications are addressed also.4 Traditional methods of specimen removal such as the use of an endoscopic bag or extension of an abdominal incision are reviewed. Residents obtain hands-on experience in the laboratory working with the endoscopic bag as well as through assembly and use of the manual and electric morcellators. The method of performing laparoscopic colpotomy is discussed as are common problems encountered during this procedure. The basics of laser physics, laser safety, and lasertissue interactions are discussed.5 Applications of laser instruments in gynecology are reviewed, and the unique characteristics of a variety of laser tools are compared. Specific safety precautions, including protective eyewear and smoke evacuation, are covered. Laser tissue effects are demonstrated on chicken breast in the operating room. The mechanical properties of suture materials and thread-needle attachments are reviewed, and a variety of sutures and needles are brought for demonstration.6 Considerations unique to laparoscopy such as visibility, ergonomics, and limited access are discussed. The session covers principles and practice of basic endosurgical knots. Practical skill with knot-tying occurs in the laboratory. The hysterosalpingogram and sonohysterogram rounds session is structured around a set of slides collected by experienced clinicians. Residents are provided with pertinent clinical data and asked to interpret the films. Important concepts for hysterosalpingogram and sonohysterogram interpretation include recognition of uterine filling defects and structural abnormalities, diagnoses of intratubal architecture, and identification of technical error. Hysterosalpingogram technique and timing, patient care in preparation for and during the procedure, and counseling before and after hysterosalpingogram also is discussed. Management of allergic reaction to contrast media can be summarized briefly. Other topics that are discussed include the following: indications and techniques of cystourethroscopy,7,8 proctoscopy, and office hysteroscopy. Specific devices
VOL. 92, NO. 1, JULY 1998
such as the harmonic scalpel, balloon endometrial ablation, and hysteroscopic bipolar instruments are demonstrated. Pelvic anatomy is reviewed using slides and videos. The laparoscopic approach to ectopic pregnancy,9 hysterectomy,10 adhesion prevention, and complications of laparoscopy11,12 also are discussed.
Group Animal Laboratory Coming after at least 12 weeks of didactic training, the animal laboratory provides an ideal opportunity to develop familiarity with equipment and procedures, to develop technical skills and experience with vascular, bowel, and urinary tract injuries, and to learn from experienced endoscopists. A 12-hour course is provided annually for second- and fourth-year residents, so that each trainee experiences it twice during the residency. Second-year and senior residents work together in teams led by experienced surgeons. This promotes senior resident teaching skills and offers the opportunity for residents to learn from each other and a skilled endoscopist in an unrushed and controlled setting without prolonging surgery on a human patient. The course is divided into four half-day sessions, with brief didactic teaching in the morning and laboratory in the afternoon. Session I is an introduction to perioperative considerations including equipment, positioning, anatomic landmarks, and trocar placement. Emphasis is on endoscopic suturing, as this important skill is difficult for the novice to acquire. The practical session that follows (session II) reinforces endoscopic needle placement, suturing, and knot-tying skills using a pelviscopy trainer. Although the pelvic trainer is an excellent way to acquire basic skills, it cannot fully replicate the experience of working with live tissue. In preparation for the animate lab, session III covers common gynecologic and general surgical procedures as well as complications of operative laparoscopy. Experience in the animate model occurs during session IV. We have used porcine and canine models for teaching in vivo surgical skills. We have found the dog a superior model because the tissue texture is similar to human tissue. Also, the canine uterus better approximates the human fallopian tube, in contrast with the porcine uterus, which is akin to human bowel. Two or three residents and an experienced preceptor occupy each table. The following training procedures are included: an inferior epigastric vessel injury is secured using either a pediatric Foley bulb for tamponade, suture, or bipolar electrocoagulation. A loop of small bowel or the canine uterine horn is used to simulate an appendectomy. A cystotomy is performed with the bladder full and is repaired using extra- and
Milad and Lindau
Resident Endoscopic Training
149
Table 1. Annual Costs of Resident Endoscopy Training*
Endoscopy rounds
Animal laboratory
Individual animal laboratory Surgeon supervision Laparoscopy room
Administrative
Item
Quantity
Resterilization of trays Hysteroscopic fluid ESU pad/handpiece Tissue (chicken breast) Suture materials Coursebook Animal care† Endoscopic stations‡ Animal care
40 16 8 16 40 16 6 7 3
Videos Books Room (200 ft2) Pelviscopic equipment† Journals Society memberships
Fixed
Variable
Total (annual)
$20 $700 $400 $700
$400 $64 $48 $32 $80 $320 $4200 $2800 $2100
$10 $4 $6 $2 $2
$1000 $1000 $15,000 $6000 $500 $1000
$1000 $1000 $15,000 $6000 $500 $1000 $34,544
Totals
ESU 5 electrosurgical unit. * Based on 16 residents participating in the annual laboratory (seven dry stations and six animal stations) each year and three individual laboratories (a single animal station) per year. † Cost partially offset by vendor support. ‡ Supplied by vendors.
intracorporeal suturing. An incision is performed on a loop of small bowel and repaired in a transverse fashion using intracorporeal suturing techniques. A salpingoophorectomy is performed using bipolar electrosurgery as well as extracorporeal and intracorporeal suturing techniques. To mimic a retropubic urethropexy, the upper rectum is sutured to Cooper’s ligament after the obturator neurovascular bundle is identified. A large vascular structure such as the inferior mesenteric artery can be isolated and partially incised with scissors, and a clip applier can be used to secure the vessel proximally and distally. We regard the animal laboratory as an invaluable component of our endoscopic training program. In addition to the importance of using animals for preliminary surgical training, selection of the laboratory, acquisition of appropriate surgical and anesthetic equipment, and institutional support must be addressed carefully before a successful program can be initiated. Selection of the right veterinary laboratory must include evaluation of compliance with federal, state, and local regulations on animal use in research; the director’s experience with laparoscopy, veterinary anesthesia, euthanasia, and disposal techniques; and the experienced surgeon’s ability to operate safely and effectively in the laboratory environment. In addition, we strongly urge that the evaluation of an animal laboratory include review of multiple references and a trial run by operating in the laboratory. A qualified veterinary staff is critical; the need for proper anesthetic skills as well as an organized and professional environment cannot be overemphasized.
150 Milad and Lindau
Resident Endoscopic Training
Securing appropriate equipment can be formidable. Limited funding at most institutions will require procurement of instruments through multiple vendors. Obvious needs, in addition to basic endoscopic instruments, include a light source, camera, electrosurgical device, and a suction-irrigator apparatus. The latter two items are most often overlooked in establishing an endoscopy laboratory and are not substituted easily. The costs of establishing and maintaining an animal laboratory are difficult to quantify. Expenses include educational and surgical materials, finding and organizing the right laboratory, acquiring adequate equipment, and instructors’ time (Table 1). To justify these costs and garner ongoing support for the educational program, feedback about the laboratory experience and areas for improvement should be presented to the department on a regular basis.
Individual Animal Laboratory Ideally, a monthly or twice-monthly animal laboratory will provide more in-depth experience. Procedures can focus on gastrointestinal, urinary tract, and major vascular injuries and their repair by laparoscopy and laparotomy. Tissue reaction to various types of electrosurgical and laser injuries also can be demonstrated and management can be reviewed. Stapler devices, various clip appliers, and suture material can be used. Initially, this animal laboratory was provided for one or two residents each month. However, over the past year, financial constraints have limited the availability of this experience to only a few times a year.
Obstetrics & Gynecology
Supervision by Skilled Endoscopic Surgeons The daily interaction between faculty and resident is an essential component of resident teaching. It provides an opportunity to evaluate resident progress and individually correct deficiency. A core of qualified endoscopic surgeons was developed to supervise endoscopies performed by house staff and to assess resident performance. Surgeons who were “credentialled” for advanced endoscopic procedures following the Society of Reproductive Surgeons guidelines13 are used as preceptors for senior resident cases.
Laparoscopy Training Facility Operative laparoscopy training is carried out in dedicated space at the hospital and equipment out of service from the operating room is used. The room is equipped with an inanimate trainer and a range of suture materials, laparoscopic instruments (needle driver, tissue grasper, clips, staplers), and endoscopic loops. An endoscopy library in the same room comprises books, equipment manuals, videos, and a videocassette player. The facility has a combination-type lock and is well used in evenings and on weekends when residents take call. Endoscopy rounds are held in an adjoining conference room to promote hands-on learning.
Comment An important consideration in endoscopic training is the cost of maintaining the program. An analysis of the fixed and variable costs associated with this program is provided (Table 1). This does not include the time that is volunteered by the preceptors and facilitators. At first glance, costs may seen prohibitive, however, a large proportion is defrayed by vendor support. Nevertheless, corporate support may dwindle with increasing pressure to contain health care costs. There are few reports discussing endoscopic training for gynecologic residents. Fox et al14 reviewed the use of laparoscopic Pomeroy tubal ligation as a teaching tool for the acquisition of endoscopic skills during residency training. They found that five Pomeroy procedures were required to teach residents the skills necessary to reduce surgical time. In another retrospective study, Yeko et al15 found that as resident experience increased, mean operative times decreased. The minimum amount of supervised training necessary for gynecologic residents to safely and expeditiously treat ectopic pregnancies laparoscopically was five cases. However, a decrease in operating time does not necessarily represent an improvement in judgment. To measure comprehension, Stovall et al16 developed a
VOL. 92, NO. 1, JULY 1998
teaching module for gynecologic residents performing sterilization procedures. A 40-minute videotape and monograph were reviewed before a gynecologic surgery rotation. Resident performance on a post-test was significantly greater than on the pretest. Unfortunately, only tubal sterilizations were addressed, representing a small fraction of endoscopic surgical procedures. Sammarco and Youngblood17 described a training program using didactic sessions coupled with a series of inanimate models to mimic common gynecologic pathology without the use of a live animal laboratory. Cundiff18 described a 7-week program including didactic and practical sessions in the pelvic trainer and animal laboratory setting. Residents and faculty had an increase in self-assessed endoscopic competence when completing the course. Unfortunately, only 25% of residents (n 5 18) thought they were competent to manage a bowel injury, and 8% of residents thought they were able to manage a urinary tract injury after completing the course. The current report is distinctive in that unlike preceding reports, it describes an ongoing and comprehensive endoscopic training program. Throughout every year of the residency, we devote 1 hour a week to teaching and learning endoscopic issues. Basic principles are demonstrated and practiced in the pelviscopy training room, which can be used 24 hours a day. Simple tasks such as inspecting and assembling instruments and choosing electrosurgical power settings are taught in a hands-on approach in the intimate laboratory. Reinforcement takes place in the form of reading, videotapes, and the animal laboratories. Finally, graded preceptorship is performed in the operating room with highly skilled endoscopic surgeons. Our primary goal is to provide high-quality stepwise and uniform experience upon which graduating residents can continue to build. Apprenticeship during residency with a dedicated surgical endoscopist appears to have a significant positive impact on surgical skills19; however, broad-based and reinforcing extraoperative instruction provides the novice with a critical understanding of endoscopic surgical techniques and their limitations. Ultimately, our educational program strives to improve surgical judgment and patient care by cultivating residents’ ability to select appropriate surgical candidates, discern the correct surgical procedure and optimal approach, and accomplish procedures safely and expediently with the minimization, detection, and early treatment of complications. To make this happen, a single individual must coordinate the endoscopic training of residents. This person must have extensive endoscopic experience, a sufficient surgical load to put theory into practice, and, ideally, responsibility for operating room equipment purchases.
Milad and Lindau
Resident Endoscopic Training
151
Purchases are based primarily on the qualities of the specific instruments and are tried and approved by committee. However, by directing operating room purchases, the director of endoscopy has the ability to train residents in new endoscopic technologies before they are used in the operating room.
References 1. Council on Resident Education in Obstetrics and Gynecology. The advanced surgical syllabus. Washington, DC: CREOG, 1994. 2. Witz CA, Silverberg KM, Burns WN, Schenken RS, Olive DL. Complications associated with the absorption of hysteroscopic fluid media. Fertil Steril 1993;60:745–56. 3. Loffer FD. Contraindications and complications of hysteroscopy. Obstet Gynecol Clin North Am 1995;22:445–55. 4. Cunningham AJ. Laparoscopic surgery: Anesthetic implications. Surg Endosc 1994;8:1272– 84. 5. Sinai R. Laser physics and laser instrumentation. In: Donnez J, Nisolle M, eds. An atlas of laser operative laparoscopy and hysteroscopy. 1st ed. New York: The Parthenon Publishing Group, 1994:1–20. 6. Cuschierei A, Szabo Z. Tissue approximation in endoscopic surgery. 1st ed. Oxford, United Kingdom: Isis Medical Media Ltd., 1995. 7. Saidi MH, Sadler RK, Vancaillie TG, Akright BD, Farhart SA, White AJ. Diagnosis and management of serious urinary complications after major operative laparoscopy. Obstet Gynecol 1996;82: 272– 6. 8. Richardson DA. Cystourethroscopy in urogynecology. Obstet Gynecol Clin North Am 1989;16:817–25. 9. Penzias AS, Gutmann JN, Diamond MP. Laparoscopic management. In: Stovall TG, Ling FW, eds. Extrauterine pregnancy: Clinical diagnosis and management. 1st ed. St. Louis: McGrawHill, 1993:231– 48. 10. Chapron CM, Dubuisson JB, Ansquer Y. Is total laparoscopic hysterectomy a safe surgical procedure? Hum Reprod 1996;11: 2422– 4. 11. Jansen FW, Kapiteyn K, Trimbos-Kemper T, Hermans J, Trimbos JB. Complications of laparoscopy: A prospective multicenter observational study. Br J Obstet Gynaecol 1997;104:595– 600.
152 Milad and Lindau
Resident Endoscopic Training
12. Corfman RS, Diamond MP, DeCherney AH. Complications of laparoscopy and hysteroscopy. 2nd ed. Malden, Massachusetts: Blackwell Science, 1997. 13. Keye WR. Hitting a moving target: Credentialing the endoscopic surgeon. Fertil Steril 1994;62:1115–9. 14. Fox MD, Long CA, Meeks GR, Jutras ML, Cowan BD. Laparoscopic Pomeroy tubal ligation as a teaching model for residents. J Reprod Med 1994;39:862– 4. 15. Yeko TR, Villa A, Parsons AK, Maroulis GB. Laparoscopic treatment of ectopic pregnancy. Resident’s learning experience. J Reprod Med 1994;39:854 – 6. 16. Stovall TG, Ling FW, Lipscomb GH, Summitt RL Jr, Beckmann CR. A model for resident surgical training in laparoscopic sterilization. Obstet Gynecol 1994;833:470 –2. 17. Sammarco MJ, Youngblood JP. A resident teaching program in operative endoscopy. Obstet Gynecol 1993;81:463– 6. 18. Cundiff GW. Analysis of the effectiveness of an endoscopy education program in improving resident’s laparoscopic skills. Obstet Gynecol 1997;90:854 –9. 19. Cosgrove JM, Margolis IB, Riou JP, Wait RB. Formal endoscopy training for senior and junior house staff. J Laparoendosc Surg 1993;3:525–9.
Address reprint requests to:
Magdy Milad, MD Section of Reproductive Endocrinology Department of Obstetrics and Gynecology Northwestern University School of Medicine 333 East Superior Street, Suite 1504 Chicago, IL 60611 E-mail: [email protected]
Received November 24, 1997. Received in revised form February 18, 1998. Accepted March 12, 1998. Copyright © 1998 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
Obstetrics & Gynecology