Laparoscopic surgery is a relatively recently introduced method in medicine and beside its obvious advantages it comes with some difficulties caused by limited availability of both learning and training manual skills as so as just caused by the characteristics of the procedures. In recent years commonness of laparoscopic training stations has increased both in terms of their accessibility and range and variability of skills they develop. That’s why questions have been asked whether the training on such stations increases the adepts qualities and how does it affect the learning curve related to particular skills. Those questions we tried to answer, basing on the articles focused on the affects of training on the training stations as so as on the operating room, showing the most often used courses and parameters they measure.

Laparoscopy learning curve

Laparoscopic procedures learning curve requires certain number of surgeries performed before the surgeon archives proficiency in them. According to The Accreditation Council for Graduate Medical Education (ACGME) beginner of laparoscopy should perform 100 basic procedures which are diagnostic laparoscopy, cholecystectomy and appendectomy, 75 advanced procedures which comprise of any other types of procedures to consider their proficiency high enough to let them operate on their own. At the beginning trainee is responsible for camera guidance and the range of their range of duties gradually increases.

Standardized training programs: FLS and ATLAS

Among standardized learning programs aiming to increase basic laparoscopic skills FLS and its extended version – ATLAS – which creates more realistic procedurę conditions can be distinguished. Researches prove that instructions and feedback given by the teaching program have comparable value to the ones given by the tutor. Training programs value increased especially during COVID pandemic, when teaching in the classic maneer was vastly limited.

Blooms taxonomy in context of surgical skills development

Particular surgical skills should be divided by their potential level of difficulty which allows planning the learning path. Example of such evaluation is Blooms taxonomy which distinguishes 6 stages of achieving knowledge and abilities, starting from theoretical material learning, with performing and modifying the procedures on their own at the end. According to the surgery, the first step for the apprentice is to learn following steps of the procedure and their importance for the course of surgery, then uses collected information to do the procedurę on their own, sum up its results and detect the abilities that need to be improved. At the very end, owning both knowledge and skills, surgeon may try to invent new methods of dealing with problems they faced during the learning process. In order to objectively assess the results of learning several factors must be taken into consideration including operating time, hospital stay duration, blood loss, number of conversions, frequency of complications and morbidity. On the training stations surgeons effectiveness may be measured with analysis of task training time, instruments mobility, visibility and precision of performance parameters. It’s important to note that training enhances the management of new situations, because it trains general laparoscopic skills, not only ones connected with the course of some particular procedures. To maximize the effects of training three factors should be considered: defined expectations of progress in skills, intraoperative and simulation skills and parameters assessment, support and suggestions of an expert.

Skill assessment systems: GOALS and PBAs

Laparoscopic skills advancement validation system was designed in 2005 – Global Operative Assessment of Laparoscopic Skills evaluates five main parameters: depth perception, dexterity, efficiency of movement, tissue manipulation and independence in management. This system examines overall skills and does not relate to any particular procedure. To fulfill this need PBAs – Procedure-Based Assessments was designed. It examines particular steps of the procedure completion.

Turn in laparoscopic training: VR procedures

Simulations in virtual reality open new pathways of learning, enabling performance of the procedures in safe conditions – not limiting to theory only. This type of training allows trainees to observe the anatomy of operated region and enhance their surgical skills, which provides more effective preparation for the further surgeries. Research proves that virtual simulations shorten the learning curve and meaningfully improve the accuracy of surgery parameters, ergonomics and operating time. They also enable safe introduction of potential difficulties that trainee could meet during procedurę. For medical units additional advantage of virtual training is the tutoring cost reduction resulting from possibility to train without a supervisor and no requirement of animal specimens. In researches mentioned in bibliography proven that trainees using simulators quicker archive the proficiency close to specialists and perform better in the subsequent attempts to a given procedurę ( in this case cholecystectomy on porcine specimen), in addition they learned more advanced maneuvers quicker.

Summing up…

It should be noted that even though simulation trainings efficiently increase manual skills, they’re not able to substitute the training of communication, leadership and quick decisions in dynamic conditions. Those skills are also crucial for effective work on the operating room and can be developed only during real surgeries. Besides that, simulated training prepares adepts of surgery to use instruments, understand the course of procedures and manage the basic challenges of laparoscopic surgery. Summing up – training on laparoscopic simulator does not replace the participation in surgical procedures done on the patients, but allows trainees to quicker achieve proficiency and skills needed to do the surgeries on their own.

Author: Adam Hajdaniak

Bibliography

Brian R, Davis G, Park KM, Alseidi A. Evolution of laparoscopic education and the laparoscopic learning curve: a review of the literature. Laparosc Surg 2022;6:34. doi: 10.21037/ls-22-29

https://ls.amegroups.org/article/view/7650/html

Stefanidis, D., Hope, W. W., Korndorffer, J. R., Markley, S., & Scott, D. J. (2010). Initial Laparoscopic Basic Skills Training Shortens the Learning Curve of Laparoscopic Suturing and Is Cost-Effective. Journal of the American College of Surgeons, 210(4), 436–440. doi:10.1016/j.jamcollsurg.2009.12.015

Aggarwal, R., Ward, J., Balasundaram, I., Sains, P., Athanasiou, T., & Darzi, A. (2007). Proving the Effectiveness of Virtual Reality Simulation for Training in Laparoscopic Surgery. Annals of Surgery, 246(5), 771–779. doi:10.1097/sla.0b013e3180f61b09