Effect of Increasing Case Complexity On Fundamental Laparoscopic Skills: Understanding the Skill Set for Advanced Laparoscopy

Marilou Vaillancourt, MD, Melina C Vassiliou, MD, Simon Bergman, MD, Gerald M Fried, MD, Sebastian Demyttenaere, MD, Pepa Kaneva, MSc, Liane S Feldman, MD. Steinberg-Bernstein Centre for Minimally Invasive Surgery & Innovation, Department of Surgery, McGill University, Montreal, Canada

Introduction: The operating room is an ongoing learning environment for surgical trainees. However, very little standardized assessment of their operative performance occurs. The Global Operative Assessment of Laparoscopic Skills (GOALS) is a 5-domain non procedure-specific global rating scale evaluating fundamental laparoscopic skills with evidence supporting its reliability and validity. The aims of this study were (1) to establish a mechanism to track laparoscopic operative performance of general surgery residents as a first step towards incorporating performance metrics into our training program, and (2) to evaluate the impact of increasing case complexity on fundamental technical skills of general surgery trainees. Methods: We established a web-based data collection system allowing for convenient data input. Participating surgeons were emailed the evaluation forms the day before the scheduled cases and reminded the next day. 8 attending surgeons at three training sites evaluated laparoscopic operative performance of participating trainees after each case using GOALS. Participants who completed a gallbladder resection from the liver bed, a triangle of Calot dissection and one more advanced laparoscopic procedure within a two weeks period were included. Repeated measures ANOVA with Bonferroni post-hoc analysis was used to compare scores for the 3 case categories. Results: From October 2009 to September 2010, evaluations for 553 cases were sent and 213 complete evaluations were received for 24 residents. 14 residents completed procedures in the 3 case categories within 2 weeks. The advanced cases included inguinal and incisional hernia repair, gastrectomy and hemicolectomy. Total scores and scores for each item (except depth perception) declined with increasing case complexity (Table 1). Post-hoc analysis demonstrated significant deteriorations in total score, bimanual dexterity, efficiency and autonomy between cholecystectomy and advanced procedures. Conclusion: Systematic assessment of performance is feasible, although compliance remains an issue. Routine measurement of performance adds an important component to a training program and can provide formative feedback. In this study, we observed that laparoscopic operative performance of residents, as measured by GOALS, decreases as they face more advanced cases. Although depth perception is developed early and is preserved as case complexity increases, strategic use of both hands, the flow of the operation and autonomy decline when residents face an increase in cognitive load such as a less familiar procedure.

Table 1: Mean (SD) GOALS scores per item, maximum item score is 5, total score is 25
GOALS ItemsGallbladder bed dissectionTirangle of Calot dissectionAdvancced procedurep
1. Depth percetion4.2 (0.9)4.2 (0.9)4.1 (0.7)0.91
2. Bimanual dexterity3.9 (0.9)3.8 (1.0)3.3 (0.7)0.01*
3. Efficiency3.9 (0.9)3.8 (1.0)3.3 (0.7)0.04*
4. Tissue handling4.2 (0.8)3.9 (0.8)3.7 (0.8)0.03*
5. Autonomy4.1 (0.8)3.7 (1.0)3.1 (1.0)<0.01*
TOTAL20.4 (3.9)19.6 (4.2)17.7 (3.2)0.03*

*p ‹ 0.05

Session: PDIST
Program Number: P005
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