Keywords
medical education - laparoscopic surgery - residency - training
Palavras-chave
educação médica - cirurgia laparoscópica - residência médica - treinamento
Introduction
Throughout past decades, laparoscopy (LP) became the first access choice for different
procedures and specialties, as it provides, among other advantages, faster recovery,
less pain and lower hospitalization length to the patients, in a way that there has
been an increase in the use of minimally invasive access routes in surgery.[1]
[2]
To be able to perform a laparoscopic surgery, a learning curve is required, as there
is a need to develop and improve nonintuitive psychomotor functions, such as performing
tasks under indirect vision and proprioception and handling with laparoscopic graspers.[3]
[4] It is crucial to all learning surgeons to practice these basic abilities before
applying them to their patients. Therefore, laparoscopic training courses have gained
great importance in the academic set.[1]
Different models are used during practice and some of them are low-cost models, such
as rubber models and indirect vision boxes; others have higher cost, such as animals,
virtual simulators and human cadavers. It seems to be consensus in the literature
that the most technological or complex ones are as effective as simpler models, when
the main objective is the development of the majority of the tasks, except for transferring
objects between graspers or reproducing realistic scenarios.[5]
[6]
[7]
As gynecology is considered a surgical specialty, residents need to learn LP skills
to keep up with current standards, so their training is extremely important for their
maturation as laparoscopic surgeons. The present study has the objective to expose
a laparoscopic multi-approach training course and to evaluate the improvement in laparoscopic
skills in obstetrics and gynecology (OBGYN) residents, after attending it.[8]
Methods
The present study is a transversal, observational and descriptive study, in which
24 residents were enrolled; 12 from the Hospital Israelita Albert Einstein (HIAE,
in the Portuguese acronym) and 12 from the Hospital do Servidor Público Estadual de
São Paulo (IAMSPE, in the Portuguese acronym). Students were selected according to
the following criteria:
-
Inclusion criteria: second and third year medical OBGYN residency students from the
HIAE and the IAMSPE, who completed the video-laparoscopic course from November 2017
to November 2018; with minimum attendance of 80%.
-
Exclusion criteria: first year OBGYN students from the HIAE and the IAMSPE; students
with absence of 20% or more during the 2-month course period; who were absent on test
application days; direct or indirect participants in the current study.
Between November 2017 and November 2018, all participants attended the LP course,
following the previously outlined medical residency schedule of the two institutions,
with 4 different participants every 2 months (i.e., 4 participants in November-December
2017; 4 participants in January-February 2018; and so on until September-October 2018).
The entire course was applied by the same instructors, all of them with previous training
in LP and technical proficiency in all skills taught.
Activities were developed at the Experimentation and Surgery Training Center (CETEC,
in the Portuguese acronym) of the Instituto Israelita Albert Einstein, following these
specifications: the same training was performed on 2nd and 3rd grade residents, with no progression of tasks; duration of 40 hours, divided into
weekly activities for 2 months: 4 theoretical lectures about equipment, instruments
and laparoscopic techniques, with a total length of eight hours; 16 hours of box-training;
8 hours of virtual laparoscopic simulator training; and 16 hours of animal model surgery
training performed on pigs.
At the end of the training, it was expected that the student should be able to name
the equipment needed for laparoscopic surgery and understand its basic operation and
parameter setting. Besides that, the student should have learned how to properly handle
the camera and optic, acquire spatial and proprioception notion while using graspers
and know how to perform the first punctures, as well as the abdominal inventory. All
these skills are compatible with the Brazilian Federation of Gynecology and Obstetrics
(FEBRASGO, in the Portuguese acronym)[9] competency matrix to a 2nd year resident. The 3rd year residents should even be able to perform simple animal model procedures.
During box training, students practiced camera proprioception exercises and visual-spatial
orientation with bean grains, elastics and matches. Participants were always encouraged
to use both hands and basic laparoscopic suture exercises were intensely practiced
(adjusting the needle in the laparoscopic needle holder inside the video box, cross
stitch and simple knot).
At the virtual simulator training, students had a sequence of programmed exercises,
which included proprioception techniques, cavity inventory using the camera, bimanual
skills, and surgical techniques for basic gynecological procedures such as tubal ligation.
Unfortunately, as there was only one simulator, the training time on it was reduced
in comparison to the other training modalities and, therefore, no specific evaluation
using it has been included in the present study.
Finally, in animal model practicing, groups of 4 participants performed laparoscopic
surgery on pigs. In this training, the tasks were: setting of the equipment and initial
puncture, pneumoperitoneum and access to the peritoneal cavity, cavity inventory,
surgical procedures such as lifting of the bladder, hysterectomy, bladder incision
and suture. To make the most of the animal model, lymphadenectomy and rectosigmoidectomy
were also performed, both focusing on the training of basic concepts and not the surgery
itself, with the main objective of gaining greater sensitivity with the mobilization
of living tissues using graspers.
The box used had the following specifications: 38.5 cm depth × 29.5 cm width (base),
32 cm (depth) × 29.5 cm width (top) × 20 cm height ([Fig. 1A]). Other equipment used consisted of 30° and 10 mm cameras, light source, LCD monitor,
rubber models ([Fig. 1B]) to practice suture and knots and the laparoscopic simulator used was the LapVR
laparoscopic surgical simulator (CAE Healthcare, Sarasota, FL, USA) .
Fig. 1 (A) “Black box” used for indirect vision training. (B) Rubber model for suture training.
All participants were evaluated individually using the same theoretical test (verbal
questionnaire) and practical test, which were applied on the first and last day of
the course (pre- and post-test, respectively). The students were not differentiated
or compared between them, the only comparison made was the student with himself in
the pre- and post-test.
The theoretical test consisted of two questions that included general knowledge about
instruments and surgical equipment used in laparoscopic surgeries. The first question
was: “What equipment and instruments need to be present in the operating room for
LP?”, and it comprised a checklist of 10 items. Participants verbally listed the items,
and for each correct answer in the checklist, the examiner granted them 1 point (maximum
score of 10 points).
The second theoretical question was to name five laparoscopic instruments placed on
a table ([Fig. 2]). For each correct answer, the participant received one point, with a maximum of
five points.
Fig. 2 Equipment to be nominated. 1. 10 mm trocater. 2. Veress needle. 3. Maryland or Dissecting laparoscopic forceps. 4. Laparoscopic needle holder. 5. Advanced bipolar.
The practical test evaluated assembly of the needle in the needle holder and surgical
suture, execution of a complete knot (three semi-knots) with needle support in a rubber
model and transfer of three small plaster cylinders from one nail to another (removal
of the cylinder from a nail with the laparoscopic grasper of the left hand, passing
it to the right hand grasper in the air and placing it on another nail).
Most practical training evaluation studies in the literature use time-based performance
to complete specific tasks known to analyze the skill level of the operator.[2]
[5] Measuring and comparing the performance time proved to be more effective and less
subjective than using the judgement of an experienced evaluator on the quality of
the task performed;[10] therefore, we decided to evaluate the practical tests by time performance.
To ensure the uniformity of the evaluation, the researchers followed a pre-established
checklist and were previously prepared on how to apply those tests, in a way that
they were homogeneously applied. The scores of the questionnaires and practical tests
were based on the number of correct answers and the time of completion of the proposed
tasks.
A maximum time for conclusion of each question was stablished to avoid the test from
becoming too extensive, and it was defined as ∼ 3 times the time spent by the course
professors to do the same tasks (120 seconds – for the first practical task, 180 seconds
for the second, and 300 seconds for the third). If the resident could not complete
the task within this time, it was used the maximum seconds possible to calculate the
results.
In addition, a global evaluation questionnaire of the course was applied on its final
day (8 multiple choice questions) to provide a qualitative analysis of the course
from the student perspective. The eight questions were:
-
Have you ever practiced LP in college or at any course in your life?
-
If yes: Have you practiced in simulators? Have you practiced in black boxes?
-
At the beginning of the course how would you rate your LP skills? Very poor, regular,
good or very good.
-
Now, at the end of the course how would you rate your LP skills? Very poor, regular,
good or very good.
-
How would you rate the course relevance to your LP learning ability? Irrelevant, slightly
relevant or very relevant.
-
How effective was the course for you learning? Not effective, slightly effective,
very effective.
-
How motivated have you been to practice LP after the course? Not motivated, slightly
motivated or very motivated.
-
How satisfied are you with the course? Not satisfied, slightly satisfied or very satisfied.
Results and scores obtained from the questionnaires and practical tests were compiled
and organized in specific tables, correlated by means of statistical analysis, with
a significance level (p) of 0,05. Comparisons between pre- and post-test questions were made through the
application of the Wilcoxon test.
The project was approved by the Ethics Committee for Research with Human Beings of
the institution (submission number CAAE: 75234817.2.0000.0071). The participants were
informed about the importance and purpose of the research and all those who agreed
to participate signed a consent form.
The animal procedures were performed in accordance with the Brazilian Society of Science
in Laboratory Animals norms, following the care recommended by the Assessment Association
and Laboratory Accreditation of Animal Care and the Normative Instruction No. 7 of
the Biosafety Commission. The release of animal use for this project by the Animal
Research Ethic Committee was linked to the prior release granted to the scheduled
LP course of the medical residency since 2015 and renewed annually by the Instituição
Israelita Albert Einstein.
Results
After applying the criteria, 24 students were included in the study and answered the
tests, but 3 of them were posteriorly excluded, 1 for being one of the authors of
the study, and 2 students due to absence in the post-course test; therefore, the final
analysis was conducted with a total of 21 participants, as shown in the workflow of
selection ([Fig. 3]).
Fig. 3 Participant selection workflow.
The participants were all female, with an average age of 27 years old, physicians
and OBGYN residents from the HIAE or the IAMSPE. The results showed improvement in
post-test compared with pretest from most students in almost all questions. The questions
made to students in the pre- and post-test are presented below:
-
Question 1 (Theoretical) - Which equipments and instruments need to be present in
the operating room for laparoscopy?
-
Question 2 (Theoretical) - Nominate the instruments placed on the table.
-
Question 3 (Practical) - Needle holder assembly and suture passage in rubber model.
-
Question 4 (Practical) - Performance of a laparoscopic knot (three semi knots).
-
Question 5 (Practical) - Transferring the cylindrical object from one nail to the
other, passing directly between the laparoscopic graspers for three consecutive times.
The mean score of the pre-test for the first theoretical question was 5.81, with a
median of 7.0, while the mean post test score was 8.45 with a median of 8.0. The difference
was statistically significant in the post test with p < 0.001.
The same occurred with the second theoretical question. The mean score of the pre-test
was 3.81 with a median of 4.0, compared with a mean post-test score of 4.76 and a
median of 5.00, a difference also statistically significant, with p = 0.001.
It was observed a reduction in the time to complete all practical questions whose
evaluations were time-based. The results were:
-
1) In question 3, we observed a statistically significant decrease of ∼ 44 seconds
in the needle holder assembly and suture passage time in the post-test (mean of 36.14
and median of 32 seconds) in relation to the pretest (mean of 80.05 and median of
74 seconds), with p < 0.001.
-
2) Question 4 showed a decrease of 46 seconds in the average time for performing a
complete laparoscopic node, with statistical significance (p < 0.001), comparing the pre-test (mean of 158.33 and median of 180 seconds) with the
post-test (mean of 112.71 and median of 109 seconds).
-
3) In question 5, there was a reduction of 63 seconds in the mean time required to
perform the task of transferring the cylindrical object. The pretest mean time was
213.81 seconds and median of 255 seconds, compared with the post-test (mean time of
150.29 seconds and median of 145 seconds), p = 0.048.
The mean, median and standard deviation (SD) that were calculated for each question
and the comparative results after the Wilcoxon paired test are shown in [Table 1]. The nonparametric Wilcoxon test is indicated to compare two groups of information
with numerical measurement level and paired samples, when we do not want to make assumptions
about the distribution of the analyzed samples. It is specially indicated for studies
with small samples.
Table 1
Statistical analysis with Wilcoxon Test
|
|
Pre
|
Post
|
Wilcoxon Test (p)
|
Results
|
|
Mean
|
5.81
|
8.48
|
|
|
|
Question 1
|
Median
|
7
|
8
|
< 0.001[*]
|
Pre < Post
|
|
Standard Deviation
|
2.34
|
0.87
|
|
|
|
n
|
21
|
21
|
|
|
|
Mean
|
3.81
|
4.76
|
|
|
|
Question 2
|
Median
|
4
|
5
|
0.001[*]
|
Pre < Post
|
|
Standard Deviation
|
1.08
|
0.44
|
|
|
|
n
|
21
|
21
|
|
|
|
Mean
|
80.05
|
36.14
|
|
|
|
Question 3
|
Median
|
74
|
32
|
< 0.001[**]
|
Pre > Post
|
|
Standard Deviation
|
39.8
|
21.77
|
|
|
|
n
|
21
|
21
|
|
|
|
Mean
|
158.33
|
112.71
|
|
|
|
Question 4
|
Median
|
180
|
109
|
< 0.001[**]
|
Pre > Post
|
|
Standard Deviation
|
36.88
|
52.16
|
|
|
|
n
|
21
|
21
|
|
|
|
Mean
|
213.81
|
150.29
|
|
|
|
Question 5
|
Median
|
255
|
145
|
0.048[**]
|
Pre > Post
|
|
Standard Deviation
|
90.42
|
83.83
|
|
|
|
n
|
21
|
21
|
|
|
* Questions with higher significantly post-test answers.
** Questions 3, 4 and 5 had significantly lower post-test responses.
In all questions, most of the participants got better results when comparing the post-test
with the pretest, except for questions 4 and 5, in which some students had worse results
at the post-test, as shown in [Fig. 4].
Fig. 4 Number of participants that were Better, Equal or Worse in each question comparing
post with pre tests.
Because the qualitative evaluation of the course was optional and was requested on
the last day of training, only 10 participants answered the questionnaire. Overall,
the answers given reflected a good acceptance of the course, with all students reporting
surgical improvement on their laparoscopic ability at the end of the training. Most
students classified the course as very relevant, and all of them answered that they
were more motivated to practice and improve their skills after it.
Discussion
In the present study, we evaluated the effectiveness of a laparoscopic training course
that complied with some pillars designed initially by Sun et al.[11] The authors established the following pillars for a favorable learning curve to
laparoscopic training: (a) laboratory skills training; (b) training in pelvic models
or black boxes; (c) animal models; (d) supervised clinical training; (e) selection
of cases to be treated first.
Following these principles, participants attended theoretical lectures, practical
activities in rubber models, training in black boxes and animal surgery, always supervised
by tutors and subsequently submitted to learning evaluation.[11]
The main results demonstrate a significant improvement in both theoretical and practical
skills of all students after a 2-month laparoscopic course, which is consistent with
similar results found in the literature for similar trainings.[12]
In the study by Derossis et al,[13] 4 out of 7 evaluated laparoscopic practice tasks had significantly better results
after developing a similar training with doctors. Andreatta et al[14] also presented better results when comparing interns who underwent virtual simulator
training with a control group not trained at all. The evaluation was applied after
a practice surgery on pigs, and the group that trained on the simulator achieved greater
accuracy on camera navigation and in the transfer of objects between graspers.[14]
Some literature studies compared educational techniques in LP, such as the one made
in the Hong Kong Academy of Medicine, that applied a course with different training
techniques, supposedly complementary, with the purpose to diversify and create a more
effective learning by stimulating different skills at the same time.[8]
[15]
The qualitative analysis of Ko et al,[8] conducted after the overall assessment of the students, showed a high satisfaction
rate with the course and a sense of technical improvement. However, there were no
significant differences between students who practiced in simulators with those who
practiced in black boxes.[8]
A Brazilian study conducted by the Universidade Federal de São Paulo/Escola Paulista
de Medicina (UNIFESP/EPM, in the Portuguese acronym), also demonstrated significant
improvement in the competence in students sense of competence to perform level 1 surgeries
(diagnostic LP and tubal ligation) and level 2 surgeries (ovarian biopsy, lysis of
adhesions, oophorectomy and ectopic pregnancy) after attending a practical course,
with an unanimous training approval.[16]
A strength of our study is that this training is inserted as a counterpoint to Brazilian
reality, as the country experiences contrasts in medical education, so that in one
hand, few large universities are able to invest sources in training to qualify their
students,[15] while in the other hand, others deal with lack of adequate institutional structure
and low quality technology, due to low funds.[1]
Following this scenario, it is erroneously believed that only high-tech and high-cost
courses would be suitable for learning. In our laparoscopic course, we managed to
combine purposely high-tech methods with low-cost and poor-technological models, to
reduce costs while maintaining quality. There are studies in the literature that explore
inexpensive models for successful surgical training, as the one developed by Sharma
et al,[4] in which the students performed self-LP-training by building black boxes using computer
cameras to develop basic skills, at a minimal cost.
Other new technologies are being studied to improve learning and reduce costs, such
as what has been demonstrated by Vyas et al[17] through the development of a laparoscopic simulator that uses cellphones and laptops
to train surgeons, with very satisfactory results. According to Chalhoub et al,[18] even cellphone applications can be used to improve laparoscopic skills.
In contrast, given the complexity of real-life surgeries, one of the limitations of
our study is that simple model training is not always enough for the formation of
the surgeon. An alternative to the animal model, known for being closer to reality,
are cadavers, an important complementary step before in vivo practice for enabling
and amplifying basic techniques.[19]
[20]
Another point that was not accomplished in the present study is the access to the
long-term knowledge retention of the students, as we apply the post-test as soon as
they finish the training; also, it is not possible to affirm the effectiveness of
the course for their application in vivo, because there was no evaluation on real
surgeries.
Different training courses are being developed with the proposal of improving the
long term learning retention of practical skills, as the “spaced learning training
in LP,” where the time training is broken with 20 minutes of active distractions,
and it showed improvement in time and quality of tasks, even after a long-term test,
when comparing spaced to traditional training. This can be a good alternative for
future studies.[21]
As limiting factors of the present study, we can highlight the absence of a control
group, a restricted number of students and an exclusive time performance evaluation
of practical skills, even though time is still an important parameter used in similar
studies.[22]
[23] Repeating the same previously familiar task may also have increased the chance of
correct answers in the post-test.
We know that training young surgeons is crucial to reduce errors and improve skills
that will be later used in our patients, so that a multi-approach training course,
like the one we presented, could maybe reduce costs without losing any quality on
teaching and become a model for universities and medical services that still do not
have this sort of training program on their residency schedule. Another important
key is to have an assessment tool like the pre and post-test to measure the student
improvement immediately after the course.
Conclusion
The study showed that the multiple-teaching approach to LP training resulted in a
significant technical improvement in students’ skills on the asked tasks. Theoretical
knowledge and practical skills were both improved through training, in accordance
with the literature, suggesting that this acquired learning can be expressed in the
future with the improvement of surgical ability and confidence in the execution of
surgical procedures in vivo.
