Demonstrated Proficiency in Fundamentals of Laparoscopic Surgery Skills May Require Fewer Repetitions.

Albert Y Huang, MD, Victor Wilcox, MD, Brian Dunkin. Houston Methodist


We demonstrate that once achieving proficiency threshold in two consecutive attempts, surgery trainees practicing intracorporeal suturing in a FLS training box are able to reliably maintain adequate proficiency scores.

The current methodology for laparoscopic skills training is to have trainees reach a level of proficiency in large part based on a goal time frame in which to complete the target task. Following the UT Southwestern FLS training protocol, to successfully complete a task a trainee must do it within the goal time frame two times consecutively. This must be followed by 10 successful repetitions (nonconsecutive) for reinforcement (“2+10”). This is the standard sign-off for residents in general surgery as they practice for FLS certification.

Through our single-institution study, we show that once residents are able to achieve two consecutive proficiency scores, they are able to maintain that level of skill with few if any non-proficient scores on the following repetitions.

Methods and Procedures:

13 PGY 1 and 2 residents were voluntarily enrolled in the study and given the task of training to proficiency in intracorporeal suturing using the standardized FLS training box. The residents had little to no laparoscopic experience prior to the initiation of the study and so were truly learning as they performed the task.

Using the UT Southwestern FLS training protocol, the goal for each resident was to achieve a proficiency score of 112 seconds or less on two consecutive repetitions and then on 10 subsequent attempts (non-consecutive) to be considered proficient and to complete the task.

Anonymized demographic data such as laparoscopic experience and PGY level were collected on each participant. The time (in seconds) for each task attempt were recorded by a proctor.


Of the 13 trainees tested, 8 reached and maintained proficiency after achieving two consecutive successful attempts. 2 participants did not achieve proficiency during the study, 1 stopped after having two consecutive attempts below the goal time of 112 seconds and 2 did not complete the study.

4 of the 8 trainees that reached proficiency according to the UT Southwestern protocol continued to maintain scores of 112 seconds or less 90% of the time with 3 of those residents maintaining proficiency level 100% of the time. The remaining 4 trainees were able to maintain that score for 71-85% of the time.

Prior to completing two consecutive attempts below 112 seconds, the 4 trainees with the proficiency percentages in the 71-85% range after the two consecutive attempts below the goal time, two participants achieve a single time below 112 seconds. There was a significant increase in successful repetitions from the moment the two successful consecutive attempts were made.


Our observation shows that trainees consistently and reliably maintain adequate proficiency levels following achieving two consecutive proficient scores. We propose that trainees must demonstrate proof of proficiency retention through maintenance of proficient scores on another occasion separate from the day of reaching the consecutive proficient scores.

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