- Email: [email protected]
Implementation of a Low-Cost Laparoscopic Skills Curriculum in a Third-World Setting
ORIGINAL REPORTS
Implementation of a Low-Cost Laparoscopic Skills Curriculum in a Third-World Setting Kristin L. Long, MD,* Carol Spears, MD,† Daniel E. Kenady, MD,* and John Scott Roth, MD* Department of General Surgery, University of Kentucky, Lexington, Kentucky; and †Department of Surgery, Tenwek Hospital, Bomet, Kenya *
BACKGROUND: Training outside the operating room has become a mainstay of surgical education. Laparoscopic training often takes place in a simulation setting. Advanced laparoscopic procedures are now commonplace, even in third-world countries with minimal hospital resources. We sought to implement a low-cost laparoscopic skills curriculum in a general surgery residency program in East Africa.
KEY WORDS: laparoscopic, curriculum, resident, surgical
education, international, Africa COMPETENCIES: Systems-Based Practice, Medical Knowl-
edge, Interpersonal and Communication Skills, PracticeBased Learning and Improvement
STUDY DESIGN: The laparoscopic skills curriculum created
and validated at the University of Kentucky was presented to the 10 general surgery residents at Tenwek Hospital. The curriculum and all materials were purchased for approximately $50 (USD). The residents in Kenya had access to laparoscopic trainer boxes and personal laptops to perform the simulations. Residents were timed on their performance at the initiation of the project and after 3 weeks of practice. RESULTS: Residents were tested on 3 separate tasks
(cannulation drill, peg board, and rope pass). At the initiation of the project, residents were unable to complete the 3 tasks chosen for timing without a critical error (i.e., dropping a peg out of view). After 3 weeks of independent practice, residents were able to successfully complete the tasks, nearing the time limits established in the curriculum manual. Additional practice and testing sessions are scheduled for the remainder of the year. CONCLUSIONS: Implementation of a low-cost laparo-
scopic skills curriculum in a third-world setting is feasible. This approach offers much-needed exposure and opportunities for residents with extremely limited resources and promises to be a vital aspect of the growing surgical residency training in third-world settings. ( J Surg 71:860C 2014 Association of Program Directors in Surgery. 864. J Published by Elsevier Inc. All rights reserved.)
Correspondence: Inquiries to Kristin L. Long, MD, Department of General Surgery, University of Kentucky, 800 Rose Street, Lexington, KY 40536; fax: (859) 323-6840; e-mail: [email protected] This work was presented at the American College of Surgeons Clinical Congress Surgical Forum, Global Health section, in Washington, DC, in October 2013.
860
INTRODUCTION Training outside the operating room has become a vital part of surgical education. With the advent of advanced laparoscopic procedures, simulation models have been developed to address skills required for the 2-dimensional operating, precise movements, and impaired tactile feedback of laparoscopy. Use of visual feedback based on monitors or other screens makes laparoscopy ideally suited for simulation training.1 Likewise, laparoscopic training using box models is known to significantly improve surgical dexterity and economy of movement.2 Improved operative performance after laparoscopic skills training has been widely reported.1,3,4 Participation in a formal skills curriculum produces dramatic improvement in residents’ performance, with novice learners showing the greatest improvement.5 Low-fidelity training models range from webcam use to a simple cardboard box to successfully simulate the laparoscopic environment and can be implemented in an office or home setting.6-8 Surgical residency programs now span the globe, and many of the lowest-resource areas struggle with providing advanced skills training, such as laparoscopy. Training programs have been successfully established in subSaharan Africa, where the need for surgeons is unparalleled. Across Africa, there are an average of 250,000 people for each surgeon and 2.5 million people per surgeon in the most rural areas.9 Integration of complete surgical training programs is a vital aspect of addressing Africa’s surgical workforce crisis.10 Isolated 3-day courses have attempted the Fundamentals of Laparoscopic Surgery course for surgeons in Africa, with
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.05.004
results showing that more than the single 3-day course is necessary for laparoscopic proficiency.11 Recognizing the dire need for consistent, early exposure to laparoscopic skills for Africa’s surgical trainees, we sought to introduce the laparoscopic skills curriculum used by the residents at the University of Kentucky (UK) to the residents in a thirdworld surgical training program. Our goal was to assess the feasibility of implementing a low-cost, formal training curriculum in this setting of minimal resources.
METHODS Following a protocol exempted by the UK’s institutional review board (12-1011-X3B), the laparoscopic skills curriculum and supplies used by the residents at this institution were presented to the 10 general surgery residents currently training at Tenwek Hospital in Bomet, Kenya. The initial instruction and training occurred over the course of a 3week period in January 2013 while a current postgraduate year-4 (PGY-4) resident from the UK was serving on a short-term surgical mission trip. Printed copies of the laparoscopic training manual used at UK were provided for reference by the local residents. Before beginning the study, each local resident was given a letter of consent and informed of his/her right to decline participation. All residents enthusiastically elected to participate. The 8 tasks of the first-year curriculum were discussed with the local residents (PGY-1 through PGY-4), and several were demonstrated using supplies brought from the United States (Fig. 1). Most of the supplies, however, are available locally in Kenya. Supplies for the curriculum instruction were purchased in the United States for approximately $50 (USD). These included pipe cleaners, small rubber tubing, small pegs, thin white rope, black markers, small blocks of wood with hooks, and plastic dishes. Several laparoscopic instruments (needle
FIGURE 2. Residents were able to perform simulation exercises using personal laptops and trainer boxes.
drivers, graspers, and scissors) were donated by Ethicon EndoSurgery. The local residents used previously available box trainers and their personal laptops to perform the timed tasks. Tasks chosen for initial instruction and timing included the cannulation drill, the peg board exercise, and the rope pass exercise. Local residents were timed by the visiting resident, as well as by their local faculty, while performing the tasks. The residents were given 3 weeks to practice independently and were timed once more before the end of the visiting resident’s stay in Kenya. Senior residents were also instructed in timing and future tasks to facilitate continued testing by the local team.
RESULTS
FIGURE 1. Residents at Tenwek Hospital are introduced to the laparoscopic trainer equipment.
On the first day of the study, the local residents were able to successfully use box trainers and webcams with personal laptops to set up the tasks (Fig. 2). All 10 of the general surgery residents at Tenwek Hospital were introduced to the laparoscopic curriculum. The first task introduced to the residents was the cannulation drill (Fig. 3). This drill was designed to mimic cannulation of a small duct, i.e., within the biliary system.
Journal of Surgical Education Volume 71/Number 6 November/December 2014
861
FIGURE 3. Pipe cleaners and rubber tubing used to simulation cannulation.
The goal of the task was to place a small pipe cleaner through a plastic tube from right to left, with the dominant hand. One dissector was used to manipulate the pipe cleaner, while a second dissector was used to stabilize the tubing. The task was then repeated using the nondominant hand. For each pass, the resident had 40 seconds to complete the task with no critical errors (bending the pipe cleaner). For the initial timing session, residents averaged a time of 110 seconds, with many having to abort the procedure secondary to errors (Table). After independent practice, most residents were able to successfully complete the task in an average of 80 seconds, with only 1 attempt aborted. The second timed task was the peg board exercise, which teaches precision with dissectors (Fig. 4). For this exercise, 10 small pegs were removed from a foam holder and placed in a small plastic dish. They were then returned to the foam holder. They were removed and replaced first with the dominant hand and then with the nondominant hand. The residents were given 4 minutes (4:00) for each section. The procedure was aborted if a peg was dropped out of the field of view. In the initial training session, times ranged from 2:18 to 7:16, and all attempts were aborted secondary
FIGURE 4. Pegs used for peg-pass exercise.
to dropped pegs. After practice, several residents were able to complete the task without a critical error, and times ranged from 4:00 to 5:00 (Table). The final task introduced to and practiced by the residents during this initial implementation project was the rope pass. The rope pass used a small white rope with sections of dark coloration. The rope was coiled in a circle, and the objective was to manipulate the length of rope by passing it from one hand to the other by touching only the white areas of the rope (Fig. 5). This mimics the technique used in running the bowel with 2 laparoscopic instruments. The residents were given 2 minutes for the task, and critical errors were defined by grasping the dark section of the rope. Owing to time constraints during the training session, formal timing of this last task was not completed. The residents were able to successfully pass the section of rope in practice, and it was recorded as pass/fail (Table).
DISCUSSION This study serves to confirm the feasibility of implementing a formal laparoscopic skills curriculum for residents in minimal-resource settings. Many of the larger referral
TABLE. Timing for Laparoscopic Skills Tasks Cannulation PGY
Peg Board
Rope Pass
Initial
Final
Initial
Final
Initial
Final
120 x x 95 110 115 110
60 x 100 90 90 60 80
x x x x x x x
x 247 x 240 300 260 261
x x x x x x x
Pass Pass Pass Pass Pass Pass Pass
1 2 2 3 4 4 Average time (seconds) x, task aborted because of critical error. 862
Journal of Surgical Education Volume 71/Number 6 November/December 2014
FIGURE 5. Rope drill using multicolored string to simulate running the bowel.
centers in third-world countries now offer laparoscopic surgical procedures; however, the equipment is often much older and less sophisticated than that used in the United States. Laparoscopic procedures are far less common in hospitals with minimal resources, and the need for exposure and simulation training outside of the operating room is even greater in these settings. The residents in these training environments must be familiar with laparoscopic concepts before entering the operating room, as there are very few opportunities for true “handson” practice. With older equipment and less reliable tools, the ability to troubleshoot and improvise is also essential. Of note, one of the PGY-4 residents in our study reported to have never seen a laparoscopic cholecystectomy before one that was performed during our stay. Many basic laparoscopic procedures have demonstrably shortened postoperative inpatient hospitalizations.12-14 Increased utilization of this technology would be of paramount importance in third-world hospitals with severe overcrowding. Outpatient laparoscopic surgery in these settings may be possible. This particular curriculum design is important in such an environment as well, owing to the low cost and the ability to be sustained with supplies purchased locally. The curriculum chosen, which was created and validated at the UK, has demonstrated the potential for robust training that is easily created and maintained with a minimal budget.15 Our study is limited by its small time period and small study population. The short time period of the initial study course may not accurately reflect the rate of improvement with independent practice. The local faculty have continued to encourage the curriculum and timing efforts. Strengths of this study include an extremely low-cost curriculum, highlighting resident enthusiasm in continued laparoscopic training, and development of educational opportunities in international resident rotations. Projects, such as this, offer an outstanding opportunity to foster international
resident exchanges with mutual educational benefit. Although the Kenyan residents learned the laparoscopic curriculum, the visiting resident was exposed to countless learning opportunities in the setting of third-world surgery. At 1-year follow-up, faculty from the local institution report several obstacles to full implementation of the curriculum. Most notably, and perhaps as expected, the utility of laparoscopic skills by these residents is minimal. Although the residents remain interested in the skills, the practical application and rare opportunities in the operating room have limited the use of the simulation techniques. Informal practice sessions are still available but structured continuing curriculum has yet to be adopted, which has clearly weakened the benefit. As reflected in the literature, skill retention for laparoscopic technique is highest in the setting of ongoing consistent training.16 Although skills can be retained after training periods of several months, we recognize the necessity of a sustainable curriculum structure that will continue after visiting teams leave host sites.17 Additionally, these difficulties highlight the importance of focusing on practical curriculum projects based on local needs, which was clearly underestimated in our initial study design and concept. Future projects will undoubtedly take these findings into consideration. The primary goal of our study was to assess feasibility of such a curriculum, which was accomplished. This approach offers much-needed exposure and opportunities for residents with extremely limited resources and promises to be an important aspect of the growing surgical residency training in third-world settings. Finally, this study highlighted the variety of learning opportunities, the potential for international educational exchanges, and the complexity of surgical outreach project implementation available to residents involved in global surgery experiences.
ACKNOWLEDGMENTS We gratefully acknowledge Ethicon EndoSurgery for their donation of training instruments. Jim Hoskins at the University of Kentucky Center for Advanced Training and Simulation was instrumental in providing the current curriculum manual and instructor information.
REFERENCES 1. Hyltander A, Liljegren E, Rhodin PH, Lonroth H.
The transfer of basic skills learned in a laparoscopic simulator to the operating room. Surg Endosc. 2002;16 (9):1324-1328. 2. Clevin L, Grantcharov T. Does box model training
improve surgical dexterity and economy of movement during virtual reality laparoscopy? A randomized trial. Acta Obstetricia Gynecol Scand. 2008;87(1):99-103.
Journal of Surgical Education Volume 71/Number 6 November/December 2014
863
3. Scott DJ, Bergen PC, Rege RV, et al. Laparoscopic
11. Okrainec A, Smith L, Azzie G. Surgical simulation in
training on bench models: better and more cost effective than operating room experience? J Am Coll Surg. 2000;191(3):272-283.
Africa: the feasibility and impact of a 3-day fundamentals of laparoscopic surgery course. Surg Endosc. 2009;23(11):2493-2498.
4. Whitted RW, Pietro PA, Martin G, Latchaw G,
12. Berggren U, Gordh T, Grama D, Haglund U,
Medina C. A retrospective study evaluating the impact of formal laparoscopic training on patient outcomes in a residency program. J Am Assoc Gynecol Laparosc. 2003;10(4):484-488.
Arvidsson D. Laparoscopic versus open cholecystectomy: hospitalization, sick leave, analgesia and trauma responses. Br J Surg. 1994;81(9):1362-1365.
5. Powers TW, Murayama KM, Toyama M, et al.
Housestaff performance is improved by participation in a laparoscopic skills curriculum. Am J Surg. 2002;184(6):626-630. 6. Chung SY, Landsittel D, Chon CH, Ng CS, Fuchs
13. Bingener J, Buck L, Richards M, Michalek J, Schwe-
singer W, Sirinek K. Long-term outcomes in laparoscopic vs open ventral hernia repair. Arch Surg. 2007;142(6):562-567. 14. Liu Z, Zhang P, Ma Y, et al. Laparoscopy or not: a
GJ. Laparoscopic skills training using a webcam trainer. J Urol. 2005;173(1):180-183.
meta-analysis of the surgical effects of laparoscopic versus open appendectomy. Surg Laparosc Endosc Percutan Tech. 2010;20(6):362-370.
7. Chandrasekera SK, Donohue JF, Orley D, et al. Basic
15. Hoskins JD, Iocono J, Roth JS. A cost efficient
laparoscopic surgical training: examination of a lowcost alternative. Eur Urol. 2006;50(6):1285-1291. 8. Kobayashi SA, Jamshidi R, O’Sullivan P, et al. Bring-
ing the skills laboratory home: an affordable webcambased personal trainer for developing laparoscopic skills. J Surg Educ. 2011;68(2):105-109. 9. Pollock JD, Love TP, Steffes BC, Thompson DC,
Mellinger J, Haisch C. Is it possible to train surgeons for rural Africa? A report of a successful international program World J Surg. 2011;35(3):493-499. 10. Ozgediz D, Kijjambu S, Galukande M, et al. Africa’s
neglected surgical workforce crisis. Lancet. 2008;371 (9613):627-628.
864
minimally invasive surgery skills curriculum. Phyllis D Saltzman, ed. Best Practices in Surgical Education. Cornelia, GA: Ethicon EndoSurgery, 2010;13.8-13.16. 16. Stefanidis D, Korndorffer JR, Markley S, Sierra R,
Scott DJ. Proficiency maintenance: impact of ongoing simulator training on laparoscopic skill retention. J Am Coll Surg. 2006;202(4):599-603. 17. Supe A, Prabhu R, Harris I, Downing S, Tekian A.
Structured training on box trainers for first year surgical residents: does it improve retention of laparoscopic Skills? A randomized controlled study. J Surg Educ. 2012;69(5):624-632.
Journal of Surgical Education Volume 71/Number 6 November/December 2014
Implementation of a Low-Cost Laparoscopic Skills Curriculum in a Third-World Setting Kristin L. Long, MD,* Carol Spears, MD,† Daniel E. Kenady, MD,* and John Scott Roth, MD* Department of General Surgery, University of Kentucky, Lexington, Kentucky; and †Department of Surgery, Tenwek Hospital, Bomet, Kenya *
BACKGROUND: Training outside the operating room has become a mainstay of surgical education. Laparoscopic training often takes place in a simulation setting. Advanced laparoscopic procedures are now commonplace, even in third-world countries with minimal hospital resources. We sought to implement a low-cost laparoscopic skills curriculum in a general surgery residency program in East Africa.
KEY WORDS: laparoscopic, curriculum, resident, surgical
education, international, Africa COMPETENCIES: Systems-Based Practice, Medical Knowl-
edge, Interpersonal and Communication Skills, PracticeBased Learning and Improvement
STUDY DESIGN: The laparoscopic skills curriculum created
and validated at the University of Kentucky was presented to the 10 general surgery residents at Tenwek Hospital. The curriculum and all materials were purchased for approximately $50 (USD). The residents in Kenya had access to laparoscopic trainer boxes and personal laptops to perform the simulations. Residents were timed on their performance at the initiation of the project and after 3 weeks of practice. RESULTS: Residents were tested on 3 separate tasks
(cannulation drill, peg board, and rope pass). At the initiation of the project, residents were unable to complete the 3 tasks chosen for timing without a critical error (i.e., dropping a peg out of view). After 3 weeks of independent practice, residents were able to successfully complete the tasks, nearing the time limits established in the curriculum manual. Additional practice and testing sessions are scheduled for the remainder of the year. CONCLUSIONS: Implementation of a low-cost laparo-
scopic skills curriculum in a third-world setting is feasible. This approach offers much-needed exposure and opportunities for residents with extremely limited resources and promises to be a vital aspect of the growing surgical residency training in third-world settings. ( J Surg 71:860C 2014 Association of Program Directors in Surgery. 864. J Published by Elsevier Inc. All rights reserved.)
Correspondence: Inquiries to Kristin L. Long, MD, Department of General Surgery, University of Kentucky, 800 Rose Street, Lexington, KY 40536; fax: (859) 323-6840; e-mail: [email protected] This work was presented at the American College of Surgeons Clinical Congress Surgical Forum, Global Health section, in Washington, DC, in October 2013.
860
INTRODUCTION Training outside the operating room has become a vital part of surgical education. With the advent of advanced laparoscopic procedures, simulation models have been developed to address skills required for the 2-dimensional operating, precise movements, and impaired tactile feedback of laparoscopy. Use of visual feedback based on monitors or other screens makes laparoscopy ideally suited for simulation training.1 Likewise, laparoscopic training using box models is known to significantly improve surgical dexterity and economy of movement.2 Improved operative performance after laparoscopic skills training has been widely reported.1,3,4 Participation in a formal skills curriculum produces dramatic improvement in residents’ performance, with novice learners showing the greatest improvement.5 Low-fidelity training models range from webcam use to a simple cardboard box to successfully simulate the laparoscopic environment and can be implemented in an office or home setting.6-8 Surgical residency programs now span the globe, and many of the lowest-resource areas struggle with providing advanced skills training, such as laparoscopy. Training programs have been successfully established in subSaharan Africa, where the need for surgeons is unparalleled. Across Africa, there are an average of 250,000 people for each surgeon and 2.5 million people per surgeon in the most rural areas.9 Integration of complete surgical training programs is a vital aspect of addressing Africa’s surgical workforce crisis.10 Isolated 3-day courses have attempted the Fundamentals of Laparoscopic Surgery course for surgeons in Africa, with
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.05.004
results showing that more than the single 3-day course is necessary for laparoscopic proficiency.11 Recognizing the dire need for consistent, early exposure to laparoscopic skills for Africa’s surgical trainees, we sought to introduce the laparoscopic skills curriculum used by the residents at the University of Kentucky (UK) to the residents in a thirdworld surgical training program. Our goal was to assess the feasibility of implementing a low-cost, formal training curriculum in this setting of minimal resources.
METHODS Following a protocol exempted by the UK’s institutional review board (12-1011-X3B), the laparoscopic skills curriculum and supplies used by the residents at this institution were presented to the 10 general surgery residents currently training at Tenwek Hospital in Bomet, Kenya. The initial instruction and training occurred over the course of a 3week period in January 2013 while a current postgraduate year-4 (PGY-4) resident from the UK was serving on a short-term surgical mission trip. Printed copies of the laparoscopic training manual used at UK were provided for reference by the local residents. Before beginning the study, each local resident was given a letter of consent and informed of his/her right to decline participation. All residents enthusiastically elected to participate. The 8 tasks of the first-year curriculum were discussed with the local residents (PGY-1 through PGY-4), and several were demonstrated using supplies brought from the United States (Fig. 1). Most of the supplies, however, are available locally in Kenya. Supplies for the curriculum instruction were purchased in the United States for approximately $50 (USD). These included pipe cleaners, small rubber tubing, small pegs, thin white rope, black markers, small blocks of wood with hooks, and plastic dishes. Several laparoscopic instruments (needle
FIGURE 2. Residents were able to perform simulation exercises using personal laptops and trainer boxes.
drivers, graspers, and scissors) were donated by Ethicon EndoSurgery. The local residents used previously available box trainers and their personal laptops to perform the timed tasks. Tasks chosen for initial instruction and timing included the cannulation drill, the peg board exercise, and the rope pass exercise. Local residents were timed by the visiting resident, as well as by their local faculty, while performing the tasks. The residents were given 3 weeks to practice independently and were timed once more before the end of the visiting resident’s stay in Kenya. Senior residents were also instructed in timing and future tasks to facilitate continued testing by the local team.
RESULTS
FIGURE 1. Residents at Tenwek Hospital are introduced to the laparoscopic trainer equipment.
On the first day of the study, the local residents were able to successfully use box trainers and webcams with personal laptops to set up the tasks (Fig. 2). All 10 of the general surgery residents at Tenwek Hospital were introduced to the laparoscopic curriculum. The first task introduced to the residents was the cannulation drill (Fig. 3). This drill was designed to mimic cannulation of a small duct, i.e., within the biliary system.
Journal of Surgical Education Volume 71/Number 6 November/December 2014
861
FIGURE 3. Pipe cleaners and rubber tubing used to simulation cannulation.
The goal of the task was to place a small pipe cleaner through a plastic tube from right to left, with the dominant hand. One dissector was used to manipulate the pipe cleaner, while a second dissector was used to stabilize the tubing. The task was then repeated using the nondominant hand. For each pass, the resident had 40 seconds to complete the task with no critical errors (bending the pipe cleaner). For the initial timing session, residents averaged a time of 110 seconds, with many having to abort the procedure secondary to errors (Table). After independent practice, most residents were able to successfully complete the task in an average of 80 seconds, with only 1 attempt aborted. The second timed task was the peg board exercise, which teaches precision with dissectors (Fig. 4). For this exercise, 10 small pegs were removed from a foam holder and placed in a small plastic dish. They were then returned to the foam holder. They were removed and replaced first with the dominant hand and then with the nondominant hand. The residents were given 4 minutes (4:00) for each section. The procedure was aborted if a peg was dropped out of the field of view. In the initial training session, times ranged from 2:18 to 7:16, and all attempts were aborted secondary
FIGURE 4. Pegs used for peg-pass exercise.
to dropped pegs. After practice, several residents were able to complete the task without a critical error, and times ranged from 4:00 to 5:00 (Table). The final task introduced to and practiced by the residents during this initial implementation project was the rope pass. The rope pass used a small white rope with sections of dark coloration. The rope was coiled in a circle, and the objective was to manipulate the length of rope by passing it from one hand to the other by touching only the white areas of the rope (Fig. 5). This mimics the technique used in running the bowel with 2 laparoscopic instruments. The residents were given 2 minutes for the task, and critical errors were defined by grasping the dark section of the rope. Owing to time constraints during the training session, formal timing of this last task was not completed. The residents were able to successfully pass the section of rope in practice, and it was recorded as pass/fail (Table).
DISCUSSION This study serves to confirm the feasibility of implementing a formal laparoscopic skills curriculum for residents in minimal-resource settings. Many of the larger referral
TABLE. Timing for Laparoscopic Skills Tasks Cannulation PGY
Peg Board
Rope Pass
Initial
Final
Initial
Final
Initial
Final
120 x x 95 110 115 110
60 x 100 90 90 60 80
x x x x x x x
x 247 x 240 300 260 261
x x x x x x x
Pass Pass Pass Pass Pass Pass Pass
1 2 2 3 4 4 Average time (seconds) x, task aborted because of critical error. 862
Journal of Surgical Education Volume 71/Number 6 November/December 2014
FIGURE 5. Rope drill using multicolored string to simulate running the bowel.
centers in third-world countries now offer laparoscopic surgical procedures; however, the equipment is often much older and less sophisticated than that used in the United States. Laparoscopic procedures are far less common in hospitals with minimal resources, and the need for exposure and simulation training outside of the operating room is even greater in these settings. The residents in these training environments must be familiar with laparoscopic concepts before entering the operating room, as there are very few opportunities for true “handson” practice. With older equipment and less reliable tools, the ability to troubleshoot and improvise is also essential. Of note, one of the PGY-4 residents in our study reported to have never seen a laparoscopic cholecystectomy before one that was performed during our stay. Many basic laparoscopic procedures have demonstrably shortened postoperative inpatient hospitalizations.12-14 Increased utilization of this technology would be of paramount importance in third-world hospitals with severe overcrowding. Outpatient laparoscopic surgery in these settings may be possible. This particular curriculum design is important in such an environment as well, owing to the low cost and the ability to be sustained with supplies purchased locally. The curriculum chosen, which was created and validated at the UK, has demonstrated the potential for robust training that is easily created and maintained with a minimal budget.15 Our study is limited by its small time period and small study population. The short time period of the initial study course may not accurately reflect the rate of improvement with independent practice. The local faculty have continued to encourage the curriculum and timing efforts. Strengths of this study include an extremely low-cost curriculum, highlighting resident enthusiasm in continued laparoscopic training, and development of educational opportunities in international resident rotations. Projects, such as this, offer an outstanding opportunity to foster international
resident exchanges with mutual educational benefit. Although the Kenyan residents learned the laparoscopic curriculum, the visiting resident was exposed to countless learning opportunities in the setting of third-world surgery. At 1-year follow-up, faculty from the local institution report several obstacles to full implementation of the curriculum. Most notably, and perhaps as expected, the utility of laparoscopic skills by these residents is minimal. Although the residents remain interested in the skills, the practical application and rare opportunities in the operating room have limited the use of the simulation techniques. Informal practice sessions are still available but structured continuing curriculum has yet to be adopted, which has clearly weakened the benefit. As reflected in the literature, skill retention for laparoscopic technique is highest in the setting of ongoing consistent training.16 Although skills can be retained after training periods of several months, we recognize the necessity of a sustainable curriculum structure that will continue after visiting teams leave host sites.17 Additionally, these difficulties highlight the importance of focusing on practical curriculum projects based on local needs, which was clearly underestimated in our initial study design and concept. Future projects will undoubtedly take these findings into consideration. The primary goal of our study was to assess feasibility of such a curriculum, which was accomplished. This approach offers much-needed exposure and opportunities for residents with extremely limited resources and promises to be an important aspect of the growing surgical residency training in third-world settings. Finally, this study highlighted the variety of learning opportunities, the potential for international educational exchanges, and the complexity of surgical outreach project implementation available to residents involved in global surgery experiences.
ACKNOWLEDGMENTS We gratefully acknowledge Ethicon EndoSurgery for their donation of training instruments. Jim Hoskins at the University of Kentucky Center for Advanced Training and Simulation was instrumental in providing the current curriculum manual and instructor information.
REFERENCES 1. Hyltander A, Liljegren E, Rhodin PH, Lonroth H.
The transfer of basic skills learned in a laparoscopic simulator to the operating room. Surg Endosc. 2002;16 (9):1324-1328. 2. Clevin L, Grantcharov T. Does box model training
improve surgical dexterity and economy of movement during virtual reality laparoscopy? A randomized trial. Acta Obstetricia Gynecol Scand. 2008;87(1):99-103.
Journal of Surgical Education Volume 71/Number 6 November/December 2014
863
3. Scott DJ, Bergen PC, Rege RV, et al. Laparoscopic
11. Okrainec A, Smith L, Azzie G. Surgical simulation in
training on bench models: better and more cost effective than operating room experience? J Am Coll Surg. 2000;191(3):272-283.
Africa: the feasibility and impact of a 3-day fundamentals of laparoscopic surgery course. Surg Endosc. 2009;23(11):2493-2498.
4. Whitted RW, Pietro PA, Martin G, Latchaw G,
12. Berggren U, Gordh T, Grama D, Haglund U,
Medina C. A retrospective study evaluating the impact of formal laparoscopic training on patient outcomes in a residency program. J Am Assoc Gynecol Laparosc. 2003;10(4):484-488.
Arvidsson D. Laparoscopic versus open cholecystectomy: hospitalization, sick leave, analgesia and trauma responses. Br J Surg. 1994;81(9):1362-1365.
5. Powers TW, Murayama KM, Toyama M, et al.
Housestaff performance is improved by participation in a laparoscopic skills curriculum. Am J Surg. 2002;184(6):626-630. 6. Chung SY, Landsittel D, Chon CH, Ng CS, Fuchs
13. Bingener J, Buck L, Richards M, Michalek J, Schwe-
singer W, Sirinek K. Long-term outcomes in laparoscopic vs open ventral hernia repair. Arch Surg. 2007;142(6):562-567. 14. Liu Z, Zhang P, Ma Y, et al. Laparoscopy or not: a
GJ. Laparoscopic skills training using a webcam trainer. J Urol. 2005;173(1):180-183.
meta-analysis of the surgical effects of laparoscopic versus open appendectomy. Surg Laparosc Endosc Percutan Tech. 2010;20(6):362-370.
7. Chandrasekera SK, Donohue JF, Orley D, et al. Basic
15. Hoskins JD, Iocono J, Roth JS. A cost efficient
laparoscopic surgical training: examination of a lowcost alternative. Eur Urol. 2006;50(6):1285-1291. 8. Kobayashi SA, Jamshidi R, O’Sullivan P, et al. Bring-
ing the skills laboratory home: an affordable webcambased personal trainer for developing laparoscopic skills. J Surg Educ. 2011;68(2):105-109. 9. Pollock JD, Love TP, Steffes BC, Thompson DC,
Mellinger J, Haisch C. Is it possible to train surgeons for rural Africa? A report of a successful international program World J Surg. 2011;35(3):493-499. 10. Ozgediz D, Kijjambu S, Galukande M, et al. Africa’s
neglected surgical workforce crisis. Lancet. 2008;371 (9613):627-628.
864
minimally invasive surgery skills curriculum. Phyllis D Saltzman, ed. Best Practices in Surgical Education. Cornelia, GA: Ethicon EndoSurgery, 2010;13.8-13.16. 16. Stefanidis D, Korndorffer JR, Markley S, Sierra R,
Scott DJ. Proficiency maintenance: impact of ongoing simulator training on laparoscopic skill retention. J Am Coll Surg. 2006;202(4):599-603. 17. Supe A, Prabhu R, Harris I, Downing S, Tekian A.
Structured training on box trainers for first year surgical residents: does it improve retention of laparoscopic Skills? A randomized controlled study. J Surg Educ. 2012;69(5):624-632.
Journal of Surgical Education Volume 71/Number 6 November/December 2014