- Email: [email protected]
Single incision laparoscopic proficiency correlates with residency training level
j o u r n a l o f s u r g i c a l r e s e a r c h j a n u a r y 2 0 1 8 ( 2 2 1 ) 2 1 1 e2 1 5
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Association for Academic Surgery
Single incision laparoscopic proficiency correlates with residency training level Maria Carmen Mora, MD,a,* Kaitlyn E. Wong, MD, PhD,a Gladys L. Fernandez, MD,a and Michael V. Tirabassi, MDb a b
Department of Surgery, Baystate Medical Center, UMass Medical School, Springfield, Massachusetts Department of Surgery, Baystate Children’s Hospital, UMass Medical School, Springfield, Massachusetts
article info
abstract
Article history:
Background: With experience, certain psychomotor skills should translate from standard
Received 10 February 2017
laparoscopy to single-incision laparoscopy (SIL). We proposed to compare all surgical
Received in revised form
postgraduate year (PGY) levels and determine if experience translated to improved SIL
29 July 2017
skills.
Accepted 30 August 2017
Methods: Surgical residents of all PGY levels (1-5) at our institution were included. Baseline
Available online xxx
surveys were obtained to determine resident level of exposure to both SIL and standard laparoscopic cases. Participants performed the following tasks: running of the bowel,
Keywords:
endoloop placement, extracorporeal suture tying, and intracorporeal suture tying. Tasks
Simulation
were performed on a commercially provided simulated inanimate organ model. Partici-
Single incision
pants were given 5 min to complete each task. Data were collected and analyzed by an
SIL
impartial-certified Fundamentals of Laparoscopic Surgery proctor.
FLS
Results: A total of 31 residents participated in the study. Overall, there was minimal SIL exposure among all residents. As expected, PGY level correlated with increased ability to complete assigned tasks within the allotted time. There was a statistically significant difference in the number of individuals able to complete a task based on PGY level for all given tasks (P ¼ 0.005). With increased difficulty, the percentage of higher level residents able to complete the task decreased (100% PGY5 completed running of bowel versus 0% intracorporeal knot tying). Conclusions: Certain psychomotor skills did appear to translate to SIL skills. However, further dedicated SIL training may help to better develop certain laparoscopic skills devoted to SIL. ª 2017 Elsevier Inc. All rights reserved.
Introduction Minimally invasive surgery has become the standard of care for a variety of surgical diseases. As time has passed we have migrated from multiport laparoscopy to single-incision
laparoscopy (SIL) for some surgical pathology.1-3 In an effort to “teach a standard set of cognitive and psychomotor skills to practitioners of laparoscopic surgery” the Society of American Gastrointestinal Endoscopic Surgery tasked a committee to develop the Fundamentals of Laparoscopic Surgery (FLS)
* Corresponding author. Department of Surgery, Baystate Medical Center, 759 Chestnut St, Springfield, MA, 01199. Tel.: þ1 413-794-5165. E-mail address: [email protected] (M.C. Mora). 0022-4804/$ e see front matter ª 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2017.08.050
212
j o u r n a l o f s u r g i c a l r e s e a r c h j a n u a r y 2 0 1 8 ( 2 2 1 ) 2 1 1 e2 1 5
program.4 With this program, surgeons are provided with the tools needed for cognitive knowledge, technical skills, and clinical judgment related to basic laparoscopic surgery.4 This program has been shown to be a reliable marker of performance in the operating room when compared to the performance in simulation. However, since the development of this program, SIL has been shown to be both safe and feasible for a wide variety of surgical diseases. The principles of SIL differ from standard multiport laparoscopy, and SIL has been shown to be more technically challenging.5 Despite the increased complexity of SIL, no validated program exists to evaluate associated skills and test proficiency. In addition, with increased regulation on duty hours, more emphasis is being placed on simulation for surgical training,6 as seen with Surgery Residency Review Committee milestones requisites for simulation-based education, FLS certification requirements and now the new incorporation of the Fundamentals of Endoscopic Surgery program. This raises the question as to whether an SIL program similar to FLS and the Fundamentals of Endoscopic Surgery should be incorporated into the surgical curriculum. Therefore, through this work we proposed comparing laparoscopic skills in all surgical postgraduate year (PGY) levels in several tasks and determine if experience translated to improved SIL skills using an inanimate organ models.
Methods Surgical residents of all PGY levels at our institution were recruited to participate in this study. After the Institutional Review Board approval, all residents were consented to participate in the study. A baseline survey was given to collect the following data: PGY level, hand dominance, number of basic laparoscopic cases performed (i.e. appendectomy, cholecystectomy, diagnostic laparoscopy and feeding tube), number of advanced laparoscopic cases performed (i.e. colectomy, lysis of adhesions, gastric bypass and inguinal hernia), number of basic SIL cases performed, number of advanced SIL cases performed, number of SIL cases assisted and FLS certification status. The residents had to have completed at least 80% of the operation to count the case as completed.
Tasks The residents were tested on four different surgical tasks consecutively in the following order: 1) running the bowel, 2) endoloop on appendix, 3) intracorporeal suture with extracorporeal knot tying and 4) intracorporeal suture with intracorporeal knot tying. The tasks were all performed on a commercially supplied inanimate organ model provided by
Figure e Innate organ model demonstrating the tasks. (A) Running the bowel with a tattooed area. (B-C) Dissection of the appendix and placement of the endoloop. (D) Intracorporeal suture of colotomy. (Color version of figure is available online.)
213
m o r a e t a l s i l p r o fi c i e n c y i n r e s i d e n t l e v e l
the company (Figure) (Applied Medical, Rancho Santa Margarita, CA). The FLS training box was modified to accommodate a single-access port. The small GelPOINT (Applied Medical, Rancho Santa Margarita, CA) was used as the access port for the procedure. The standard laparoscopic instruments used to perform the procedures were as follows: Maryland dissector, two hunters, endoloop (Ethicon, Cincinnati, OH), knot pusher and needle driver. All tasks were performed, collected and evaluated in person by an experienced impartial Society of American Gastrointestinal Endoscopic Surgeryecertified FLS proctor. The residents were given 5 min to complete each task; and all rules were explained by the proctor before each task.
Table 1 e Baseline characteristics. PGY5 n¼4
PGY4 n¼4
PGY3 n¼6
PGY2 n¼6
PGY1 n ¼ 11
4
4
6
5
10
3
2
1
0
0
1
2
3
1
0
Advanced SL cases >50
3
0
0
0
0
Advanced SL cases 25-50
0
1
0
0
0
Basic SIL cases 11-25
0
0
0
1
0
Basic SIL cases 1-10
2
2
4
3
1
Advanced SIL cases 1-10
1
2
0
0
1
4
3
0
0
0
Right hand dominant Performance* Basic SL cases >50
Running the bowel The residents were given two hunters and instructed to run the bowel from the ileocecal valve to the end of the small bowel and identify the number of tattoos marked on the bowel. Three areas were tattooed; however, this number was not disclosed to the residents. Time penalty was added for each missed tattoo.
FLS certified
Endoloop on appendix The resident was provided a hunter, scissors and one endoloop (Ethicon, Cincinnati, OH). The resident was tasked with freeing the appendix from its mesentery with scissors, placing an endoloop at the base of the appendix and then ligating the appendix. Time penalty was added if the appendix was avulsed, evidence of injury to surrounding structures was noted, if the endoloop was placed greater than 2 mm from the appendiceal base or if the appendix was divided greater than 5 mm from the endoloop.
Intracorporeal suture with extracorporeal knot tying The resident was provided with a needle driver, Maryland, scissors and one suture. The resident was instructed to close a colotomy with a single suture approximating the wound edges in equidistance. The knot was then tied extracorporeally with three square knots. Time penalty was added for inadequate full thickness bites and if the knot was not secure.
Intracorporeal suture with intracorporeal knot tying Similar to the extracorporeal knot tying task described previously, the resident was instructed to perform a colotomy closure, however, this time using an intracorporeal knot tie with three square knots. The same time penalties were added as the previously described task.
SL ¼ standard laparoscopy; SIL ¼ single-incision laparoscopy. * Resident performed > 80% of the operation.
complex tasks decreased (100% PGY5 residents completed running of bowel versus 0% intracorporeal knot tying). (Table 2). When accounting for accuracy of performance, the number of residents able to complete the task decreased across all levels. Skill completion did depend on task (Table 3). When running the bowel, the number of residents able to identify all three tattoo marks decreased across PGY levels; all three marks were identified by the following number of residents PGY5 n ¼ 2, PGY4 n ¼ 3, PGY3 n ¼ 3, PGY2 n ¼ 4 and PGY1 n ¼ 6 (noted as 50% for PGY5’s, 75% for PGY4’s, 50% for PGY3’s, 67% for PGY2’s and 55% for PGY1’s). In the endoloop group, appendectomy success improved with resident PGY level (PGY1 0%, PGY2e4 50%, PGY5 100%). It was noted that the PGY1s were only able to dissect the appendix and at the given time limit, none were able to attempt placement of the endoloop. Seventy-one percent of the senior residents (PGY3-5) had successful endoloop placement compared with 17% of the junior residents (PGY1-2).
Table 2 e Task completion. Task
PGY5 n¼4
PGY4 n¼4
PGY3 n¼6
PGY2 n¼6
Running of bowel
4
4
6
5
9
Endoloop placement
4
2
3
3
0
Extracorporeal tying
3
3
4
3
2
Intracorporeal tying
0
0
1
0
0
Results A total of 31 residents participated in the study with the following breakdown: PGY5 n ¼ 4, PGY4 n ¼ 4, PGY3 n ¼ 6, PGY2 n ¼ 6 and PGY1 n ¼ 11. Overall, there was minimal SIL exposure across all PGY levels. There was one outlier in the PGY3 class, having assisted in greater than 10 SIL cases. The baseline characteristics collected for the residents are noted in Table 1. PGY level did correlate with increased success rate in ability to complete the given task within the allotted 5 min time for all tasks provided (P ¼ 0.005). With increasing difficulty in task, the number of senior-level residents able to complete the more
PGY1 n ¼ 11
0.005* *
Chi-square analysis.
214
j o u r n a l o f s u r g i c a l r e s e a r c h j a n u a r y 2 0 1 8 ( 2 2 1 ) 2 1 1 e2 1 5
Table 3 e Resident who completed the task with ‡ one time penalty. Task
PGY5 n¼4
PGY4 n¼4
PGY3 n¼6
PGY2 n¼6
PGY1 n ¼ 11
Running of bowel
2
2
3
1
3
Endoloop placement
2
0
1
1
NA
Extracorporeal tying
2
3
3
2
2
Intracorporeal tying
NA
NA
1
NA
NA
NA ¼ not applicable as no resident completed task.
On evaluation of suturing, 71% of senior residents were able to place the suture and tie it extracorporeally. Twentynine percent of junior residents were able to place the suture; and only 23% could complete tying the knot within the allotted time. The proficiency of knot tying drastically changed between the extracorporeal and intracorporeal method for all PGY levels. The same percentage of senior versus junior residents was able to complete the placement of the suture in both methods (79% versus 29%, respectively); however, only one resident was able to complete the knot tying intracorporeally. Table 4, demonstrates the number of residents who received at least one time penalty during the task. Table 3, illustrates the number of residents with one or more penalties who completed the task. We noted that although a higher number of senior residents were completing the higher level tasks, the number of residents receiving penalties remained elevated in that group compared with the junior residents.
Discussion Since its introduction in the 1980s, minimally invasive surgery has grown significantly within the field of surgery. Dedicated surgical training for minimally invasive surgery has increased, as we have seen with the development of the FLS program. The utilization of multiple instruments through a single port has increased the technical difficulty of
Table 4 e All resident with ‡ one time penalty. Task
PGY5 n¼4
PGY4 n¼4
PGY3 n¼6
PGY2 n¼6
PGY1 n ¼ 11
Running of bowel
2
1
3
2
5
Endoloop placement
2
1
2
1
2
Extracorporeal tying
2
4
3
2
2
Intracorporeal tying
2
3
4
3
0
most procedures, including appendectomy. SIL has been found to be more technically challenging with a higher learning curve.5,7 Lewis et al.8 noted that in trained surgeons, expert laparoscopic surgeons had an easier time completing the SIL tasks compared to the novice. Although experience does improve SIL skills, the proficiency between standard laparoscopy and SIL is not equal. With increased number of SIL cases being performed, further training is required. Simulation training in multiport laparoscopy has been shown to correlate with operating room performance9,10; hence, we sought to evaluate the surgical residents at our institution to determine if proficiency correlated with resident PGY level. The baseline experience to SIL across the residency was minimal. Currently at our institution, residents participate in a formal curriculum in the simulation center for the progressive acquisition of skills in standard multiport laparoscopy with most of our residents becoming FLS certified during their fourth year. One year before the initiation of this project, SIL was implemented into surgical practice at our institution, and it is not clear if the skills taught by our simulation curriculum in standard multiport laparoscopy translated to performance in single-incision laparoscopic cases. With increasing resident duty-hour restrictions, further emphasizing inclusion of surgical simulation training in competency-based medical education,6 our institution focused on formulating a curriculum for residents in both standard laparoscopy and SIL. Standard laparoscopy skills have been shown to translate from the simulation center to the operating room9,10; as such, we expect skills acquired from a dedicated SIL simulation trainer to transfer to the operating room as well. Although senior surgical resident participants in this study had very limited exposure to SIL, they had more advanced standard laparoscopy exposure and many were FLS certified. As noted, these two factors likely improved their single-incision laparoscopic skills at baseline as compared with the junior residents. This correlates with others studies, which note that more experienced surgeons perform better on SIL at baseline.5,8 Of note, although the senior residents were more apt to complete the tasks assigned, the high rate of penalties received even by senior residents demonstrates, that further training is still needed to perform these tasks with better accuracy and competence. Although, basic psychomotor skills (such as depth/ visual perception, coordinated use of both dominant and nondominant hands, and transferring objects) transfer from standard laparoscopy to SIL, further dedicated training for intracorporeal suturing is still required. Santos et al.7 noted that SIL specific laparoscopic simulation trainers yielded better performance when compared to standard laparoscopic simulation trainers. The availability of a focused SIL training resource, along with a customized curriculum built upon a foundation of basic minimally invasive surgery skills training may prove to improve SIL skill transferability from simulation to the clinical setting. Our study does have several limitations to consider. First, the number of residents in the study yields a low power for analysis. Therefore, we were unable to perform multivariate analysis to determine if the number of cases, task
m o r a e t a l s i l p r o fi c i e n c y i n r e s i d e n t l e v e l
performance time, or hand dominance impacted the SIL skills. Second, we did not have an expert group to compare the residents’ performance, which would allow for better comparison of completion times and proficiency levels via expert referent analysis. Overall, our findings support that experience in standard multiport laparoscopy does correlate with higher success and improved proficiency in SIL. It appears that dedicated training in SIL is necessary, particularly if the resident is to participate in more advanced cases, such as those involving laparoscopic suturing. Based on our data, initiating a SIL training program between the PGY3- and PGY4-years may be optimal as these residents have gained experience in basic laparoscopy in simulation and in the clinical setting and are prepared for FLS certification. As these senior-level residents demonstrated greater ability to complete simple SIL tasks, they are also more likely ready for development of more advanced SIL skills. Given these early findings, we intend to implement a formal curriculum for training in the fundamentals of single-incision laparoscopic surgery.
Acknowledgment Author’s contributions: M.C.M. was involved with study design, data collection, data analysis, and manuscript writing. K.E.W. was involved with data collection and manuscript writing. G.L.F. was involved with study design and manuscript writing. M.V.T. is the principle investigator involved with study design and manuscript writing.
Disclosure The authors of this work have no relevant financial relationships to disclose.
215
references
1. Muensterer OJ, Perger L, Hansen EN, et al. Single-incision pediatric endosurgical nissen fundoplication. J Laparoendosc Adv Surg Tech A. 2011;21:641e645. 2. Muensterer OJ, Puga Nougues C, Adibe OO, et al. Appendectomy using single-incision pediatric endosurgery for acute and perforated appendicitis. Surg Endosc. 2010;24:3201e3204. 3. Van den Boezem PB, Velthuis S, Lourens HJ, et al. Single-incision and NOTES cholecystectomy, are there clinical or cosmetic advantages when compared to conventional laparoscopic cholecystectomy? A caseecontrol study comparing singleincision, transvaginal, and conventional laparoscopic technique for cholecystectomy. World J Surg. 2014;38:25e32. 4. Peters JH, Fired GM, Swanstrom LL, et al. Development and validation of a comprehensive program of education and assessment of the basic fundamentals of laparoscopic surgery. Surgery. 2004;135:21e27. 5. Santos BF, Enter D, Soper NJ, et al. Single-incision laparoscopic surgery (SILS) versus standard laparoscopic surgery: a comparison of performance using a surgical simulator. Surg Endosc. 2011;25:483e490. 6. Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty hour restrictions in surgery. Impact on resident wellness, training, and patient outcomes. Ann Surg. 2014;259:1041e1053. 7. Santos BF, Reif TJ, Soper NJ, et al. Effect of training and instrument type on performance in single-incision laparoscopy: results of a randomized comparison using a surgical simulator. Surg Endosc. 2011;25:3798e3804. 8. Lewis T, Aggarwal R, Kwasnicki R, et al. Does previous laparoscopic experience improve ability to perform singleincision laparoscopic surgery? Surg Endosc. 2012;26:1214e1219. 9. Boza C, Leon F, Buckel E, et al. Simulation-trained junior residents perform better than general surgeons on advanced laparoscopic cases. Surg Endsoc. 2017;31:135e141. 10. Al-Kadi AS, Donnon T, Oddone Paolucci E, et al. The effect of simulation in improving students’ performance in laparoscopic surgery: a meta-analysis. Surg Endosc. 2012;26:3215e3224.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Association for Academic Surgery
Single incision laparoscopic proficiency correlates with residency training level Maria Carmen Mora, MD,a,* Kaitlyn E. Wong, MD, PhD,a Gladys L. Fernandez, MD,a and Michael V. Tirabassi, MDb a b
Department of Surgery, Baystate Medical Center, UMass Medical School, Springfield, Massachusetts Department of Surgery, Baystate Children’s Hospital, UMass Medical School, Springfield, Massachusetts
article info
abstract
Article history:
Background: With experience, certain psychomotor skills should translate from standard
Received 10 February 2017
laparoscopy to single-incision laparoscopy (SIL). We proposed to compare all surgical
Received in revised form
postgraduate year (PGY) levels and determine if experience translated to improved SIL
29 July 2017
skills.
Accepted 30 August 2017
Methods: Surgical residents of all PGY levels (1-5) at our institution were included. Baseline
Available online xxx
surveys were obtained to determine resident level of exposure to both SIL and standard laparoscopic cases. Participants performed the following tasks: running of the bowel,
Keywords:
endoloop placement, extracorporeal suture tying, and intracorporeal suture tying. Tasks
Simulation
were performed on a commercially provided simulated inanimate organ model. Partici-
Single incision
pants were given 5 min to complete each task. Data were collected and analyzed by an
SIL
impartial-certified Fundamentals of Laparoscopic Surgery proctor.
FLS
Results: A total of 31 residents participated in the study. Overall, there was minimal SIL exposure among all residents. As expected, PGY level correlated with increased ability to complete assigned tasks within the allotted time. There was a statistically significant difference in the number of individuals able to complete a task based on PGY level for all given tasks (P ¼ 0.005). With increased difficulty, the percentage of higher level residents able to complete the task decreased (100% PGY5 completed running of bowel versus 0% intracorporeal knot tying). Conclusions: Certain psychomotor skills did appear to translate to SIL skills. However, further dedicated SIL training may help to better develop certain laparoscopic skills devoted to SIL. ª 2017 Elsevier Inc. All rights reserved.
Introduction Minimally invasive surgery has become the standard of care for a variety of surgical diseases. As time has passed we have migrated from multiport laparoscopy to single-incision
laparoscopy (SIL) for some surgical pathology.1-3 In an effort to “teach a standard set of cognitive and psychomotor skills to practitioners of laparoscopic surgery” the Society of American Gastrointestinal Endoscopic Surgery tasked a committee to develop the Fundamentals of Laparoscopic Surgery (FLS)
* Corresponding author. Department of Surgery, Baystate Medical Center, 759 Chestnut St, Springfield, MA, 01199. Tel.: þ1 413-794-5165. E-mail address: [email protected] (M.C. Mora). 0022-4804/$ e see front matter ª 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2017.08.050
212
j o u r n a l o f s u r g i c a l r e s e a r c h j a n u a r y 2 0 1 8 ( 2 2 1 ) 2 1 1 e2 1 5
program.4 With this program, surgeons are provided with the tools needed for cognitive knowledge, technical skills, and clinical judgment related to basic laparoscopic surgery.4 This program has been shown to be a reliable marker of performance in the operating room when compared to the performance in simulation. However, since the development of this program, SIL has been shown to be both safe and feasible for a wide variety of surgical diseases. The principles of SIL differ from standard multiport laparoscopy, and SIL has been shown to be more technically challenging.5 Despite the increased complexity of SIL, no validated program exists to evaluate associated skills and test proficiency. In addition, with increased regulation on duty hours, more emphasis is being placed on simulation for surgical training,6 as seen with Surgery Residency Review Committee milestones requisites for simulation-based education, FLS certification requirements and now the new incorporation of the Fundamentals of Endoscopic Surgery program. This raises the question as to whether an SIL program similar to FLS and the Fundamentals of Endoscopic Surgery should be incorporated into the surgical curriculum. Therefore, through this work we proposed comparing laparoscopic skills in all surgical postgraduate year (PGY) levels in several tasks and determine if experience translated to improved SIL skills using an inanimate organ models.
Methods Surgical residents of all PGY levels at our institution were recruited to participate in this study. After the Institutional Review Board approval, all residents were consented to participate in the study. A baseline survey was given to collect the following data: PGY level, hand dominance, number of basic laparoscopic cases performed (i.e. appendectomy, cholecystectomy, diagnostic laparoscopy and feeding tube), number of advanced laparoscopic cases performed (i.e. colectomy, lysis of adhesions, gastric bypass and inguinal hernia), number of basic SIL cases performed, number of advanced SIL cases performed, number of SIL cases assisted and FLS certification status. The residents had to have completed at least 80% of the operation to count the case as completed.
Tasks The residents were tested on four different surgical tasks consecutively in the following order: 1) running the bowel, 2) endoloop on appendix, 3) intracorporeal suture with extracorporeal knot tying and 4) intracorporeal suture with intracorporeal knot tying. The tasks were all performed on a commercially supplied inanimate organ model provided by
Figure e Innate organ model demonstrating the tasks. (A) Running the bowel with a tattooed area. (B-C) Dissection of the appendix and placement of the endoloop. (D) Intracorporeal suture of colotomy. (Color version of figure is available online.)
213
m o r a e t a l s i l p r o fi c i e n c y i n r e s i d e n t l e v e l
the company (Figure) (Applied Medical, Rancho Santa Margarita, CA). The FLS training box was modified to accommodate a single-access port. The small GelPOINT (Applied Medical, Rancho Santa Margarita, CA) was used as the access port for the procedure. The standard laparoscopic instruments used to perform the procedures were as follows: Maryland dissector, two hunters, endoloop (Ethicon, Cincinnati, OH), knot pusher and needle driver. All tasks were performed, collected and evaluated in person by an experienced impartial Society of American Gastrointestinal Endoscopic Surgeryecertified FLS proctor. The residents were given 5 min to complete each task; and all rules were explained by the proctor before each task.
Table 1 e Baseline characteristics. PGY5 n¼4
PGY4 n¼4
PGY3 n¼6
PGY2 n¼6
PGY1 n ¼ 11
4
4
6
5
10
3
2
1
0
0
1
2
3
1
0
Advanced SL cases >50
3
0
0
0
0
Advanced SL cases 25-50
0
1
0
0
0
Basic SIL cases 11-25
0
0
0
1
0
Basic SIL cases 1-10
2
2
4
3
1
Advanced SIL cases 1-10
1
2
0
0
1
4
3
0
0
0
Right hand dominant Performance* Basic SL cases >50
Running the bowel The residents were given two hunters and instructed to run the bowel from the ileocecal valve to the end of the small bowel and identify the number of tattoos marked on the bowel. Three areas were tattooed; however, this number was not disclosed to the residents. Time penalty was added for each missed tattoo.
FLS certified
Endoloop on appendix The resident was provided a hunter, scissors and one endoloop (Ethicon, Cincinnati, OH). The resident was tasked with freeing the appendix from its mesentery with scissors, placing an endoloop at the base of the appendix and then ligating the appendix. Time penalty was added if the appendix was avulsed, evidence of injury to surrounding structures was noted, if the endoloop was placed greater than 2 mm from the appendiceal base or if the appendix was divided greater than 5 mm from the endoloop.
Intracorporeal suture with extracorporeal knot tying The resident was provided with a needle driver, Maryland, scissors and one suture. The resident was instructed to close a colotomy with a single suture approximating the wound edges in equidistance. The knot was then tied extracorporeally with three square knots. Time penalty was added for inadequate full thickness bites and if the knot was not secure.
Intracorporeal suture with intracorporeal knot tying Similar to the extracorporeal knot tying task described previously, the resident was instructed to perform a colotomy closure, however, this time using an intracorporeal knot tie with three square knots. The same time penalties were added as the previously described task.
SL ¼ standard laparoscopy; SIL ¼ single-incision laparoscopy. * Resident performed > 80% of the operation.
complex tasks decreased (100% PGY5 residents completed running of bowel versus 0% intracorporeal knot tying). (Table 2). When accounting for accuracy of performance, the number of residents able to complete the task decreased across all levels. Skill completion did depend on task (Table 3). When running the bowel, the number of residents able to identify all three tattoo marks decreased across PGY levels; all three marks were identified by the following number of residents PGY5 n ¼ 2, PGY4 n ¼ 3, PGY3 n ¼ 3, PGY2 n ¼ 4 and PGY1 n ¼ 6 (noted as 50% for PGY5’s, 75% for PGY4’s, 50% for PGY3’s, 67% for PGY2’s and 55% for PGY1’s). In the endoloop group, appendectomy success improved with resident PGY level (PGY1 0%, PGY2e4 50%, PGY5 100%). It was noted that the PGY1s were only able to dissect the appendix and at the given time limit, none were able to attempt placement of the endoloop. Seventy-one percent of the senior residents (PGY3-5) had successful endoloop placement compared with 17% of the junior residents (PGY1-2).
Table 2 e Task completion. Task
PGY5 n¼4
PGY4 n¼4
PGY3 n¼6
PGY2 n¼6
Running of bowel
4
4
6
5
9
Endoloop placement
4
2
3
3
0
Extracorporeal tying
3
3
4
3
2
Intracorporeal tying
0
0
1
0
0
Results A total of 31 residents participated in the study with the following breakdown: PGY5 n ¼ 4, PGY4 n ¼ 4, PGY3 n ¼ 6, PGY2 n ¼ 6 and PGY1 n ¼ 11. Overall, there was minimal SIL exposure across all PGY levels. There was one outlier in the PGY3 class, having assisted in greater than 10 SIL cases. The baseline characteristics collected for the residents are noted in Table 1. PGY level did correlate with increased success rate in ability to complete the given task within the allotted 5 min time for all tasks provided (P ¼ 0.005). With increasing difficulty in task, the number of senior-level residents able to complete the more
PGY1 n ¼ 11
0.005* *
Chi-square analysis.
214
j o u r n a l o f s u r g i c a l r e s e a r c h j a n u a r y 2 0 1 8 ( 2 2 1 ) 2 1 1 e2 1 5
Table 3 e Resident who completed the task with ‡ one time penalty. Task
PGY5 n¼4
PGY4 n¼4
PGY3 n¼6
PGY2 n¼6
PGY1 n ¼ 11
Running of bowel
2
2
3
1
3
Endoloop placement
2
0
1
1
NA
Extracorporeal tying
2
3
3
2
2
Intracorporeal tying
NA
NA
1
NA
NA
NA ¼ not applicable as no resident completed task.
On evaluation of suturing, 71% of senior residents were able to place the suture and tie it extracorporeally. Twentynine percent of junior residents were able to place the suture; and only 23% could complete tying the knot within the allotted time. The proficiency of knot tying drastically changed between the extracorporeal and intracorporeal method for all PGY levels. The same percentage of senior versus junior residents was able to complete the placement of the suture in both methods (79% versus 29%, respectively); however, only one resident was able to complete the knot tying intracorporeally. Table 4, demonstrates the number of residents who received at least one time penalty during the task. Table 3, illustrates the number of residents with one or more penalties who completed the task. We noted that although a higher number of senior residents were completing the higher level tasks, the number of residents receiving penalties remained elevated in that group compared with the junior residents.
Discussion Since its introduction in the 1980s, minimally invasive surgery has grown significantly within the field of surgery. Dedicated surgical training for minimally invasive surgery has increased, as we have seen with the development of the FLS program. The utilization of multiple instruments through a single port has increased the technical difficulty of
Table 4 e All resident with ‡ one time penalty. Task
PGY5 n¼4
PGY4 n¼4
PGY3 n¼6
PGY2 n¼6
PGY1 n ¼ 11
Running of bowel
2
1
3
2
5
Endoloop placement
2
1
2
1
2
Extracorporeal tying
2
4
3
2
2
Intracorporeal tying
2
3
4
3
0
most procedures, including appendectomy. SIL has been found to be more technically challenging with a higher learning curve.5,7 Lewis et al.8 noted that in trained surgeons, expert laparoscopic surgeons had an easier time completing the SIL tasks compared to the novice. Although experience does improve SIL skills, the proficiency between standard laparoscopy and SIL is not equal. With increased number of SIL cases being performed, further training is required. Simulation training in multiport laparoscopy has been shown to correlate with operating room performance9,10; hence, we sought to evaluate the surgical residents at our institution to determine if proficiency correlated with resident PGY level. The baseline experience to SIL across the residency was minimal. Currently at our institution, residents participate in a formal curriculum in the simulation center for the progressive acquisition of skills in standard multiport laparoscopy with most of our residents becoming FLS certified during their fourth year. One year before the initiation of this project, SIL was implemented into surgical practice at our institution, and it is not clear if the skills taught by our simulation curriculum in standard multiport laparoscopy translated to performance in single-incision laparoscopic cases. With increasing resident duty-hour restrictions, further emphasizing inclusion of surgical simulation training in competency-based medical education,6 our institution focused on formulating a curriculum for residents in both standard laparoscopy and SIL. Standard laparoscopy skills have been shown to translate from the simulation center to the operating room9,10; as such, we expect skills acquired from a dedicated SIL simulation trainer to transfer to the operating room as well. Although senior surgical resident participants in this study had very limited exposure to SIL, they had more advanced standard laparoscopy exposure and many were FLS certified. As noted, these two factors likely improved their single-incision laparoscopic skills at baseline as compared with the junior residents. This correlates with others studies, which note that more experienced surgeons perform better on SIL at baseline.5,8 Of note, although the senior residents were more apt to complete the tasks assigned, the high rate of penalties received even by senior residents demonstrates, that further training is still needed to perform these tasks with better accuracy and competence. Although, basic psychomotor skills (such as depth/ visual perception, coordinated use of both dominant and nondominant hands, and transferring objects) transfer from standard laparoscopy to SIL, further dedicated training for intracorporeal suturing is still required. Santos et al.7 noted that SIL specific laparoscopic simulation trainers yielded better performance when compared to standard laparoscopic simulation trainers. The availability of a focused SIL training resource, along with a customized curriculum built upon a foundation of basic minimally invasive surgery skills training may prove to improve SIL skill transferability from simulation to the clinical setting. Our study does have several limitations to consider. First, the number of residents in the study yields a low power for analysis. Therefore, we were unable to perform multivariate analysis to determine if the number of cases, task
m o r a e t a l s i l p r o fi c i e n c y i n r e s i d e n t l e v e l
performance time, or hand dominance impacted the SIL skills. Second, we did not have an expert group to compare the residents’ performance, which would allow for better comparison of completion times and proficiency levels via expert referent analysis. Overall, our findings support that experience in standard multiport laparoscopy does correlate with higher success and improved proficiency in SIL. It appears that dedicated training in SIL is necessary, particularly if the resident is to participate in more advanced cases, such as those involving laparoscopic suturing. Based on our data, initiating a SIL training program between the PGY3- and PGY4-years may be optimal as these residents have gained experience in basic laparoscopy in simulation and in the clinical setting and are prepared for FLS certification. As these senior-level residents demonstrated greater ability to complete simple SIL tasks, they are also more likely ready for development of more advanced SIL skills. Given these early findings, we intend to implement a formal curriculum for training in the fundamentals of single-incision laparoscopic surgery.
Acknowledgment Author’s contributions: M.C.M. was involved with study design, data collection, data analysis, and manuscript writing. K.E.W. was involved with data collection and manuscript writing. G.L.F. was involved with study design and manuscript writing. M.V.T. is the principle investigator involved with study design and manuscript writing.
Disclosure The authors of this work have no relevant financial relationships to disclose.
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references
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