Determining the Structure of Training Sessions for Laparoscopic Surgery: What Is Important?

Susannah M Wyles, MSc MRCS, Danilo Miskovic, MD FRCS, Roger Motson, MS FRCS, Robin H Kennedy, MS FRCS, Ara W Darzi, MD FRCS FMedSci, George B Hanna, PhD FRCS. Imperial College London, Colchester General Hospital, St Mark’s Hospital Harrow

Background
Training laparoscopic surgery is known to be difficult, and has different challenges for the teacher, particularly given the fact that contrary to open surgery, only one operator can really be “hands-on” at a time. Since training sessions are limited, these should be optimised. The aim of this study was to determine whether a structure could be defined through to create a standardised format for training laparoscopic surgery.

Methods
In order to develop the item lists for the Delphi process, the themes had to be established. Having made no assumptions regarding the educational model, forty-three semi-structured interviews were carried out by two interviewers (29 surgical trainers, 10 senior surgical trainees, and 4 educationalists). Interviews were transcribed and analysed by two raters using N-VIVO software. Free nodes were combined into tree nodes, and from these very detailed item lists were created. These items were loosely grouped into a logical temporal pathway for a typical theatre session. Using the Delphi method, item importance was ranked by 11 national training program laparoscopic trainers and 5 senior surgical trainees who all had laparoscopic experience, using a 7-point Likert scale (1=very unimportant, 4=undecided, 7=very important). Items scoring <4 were removed, those scoring >6 were considered to be essential, those 5- desirable. The reliability was evaluated by internal consistency (Cronbach’s alpha) and inter-rater agreement. Mann Whitney-U test was used to determine any specific difference of opinion.

Results
Consensus was reached through two rounds of the Delphi process for the trainers. Ninety-nine items regarding the training structure were extracted from the interviews. Reliability tests showed good consistency within the trainers (alpha=0.87), but due to the fact that two of five trainees returned insufficient data, this as yet could not be determined. However, there was good overall inter-rater agreement (0.891). All ninety-nine items were retained by the trainers, and thus far all have been by the trainees. Of these, 35 were deemed to be essential and 38 desirable features of training. Given the detail, these will be consolidated further. Although a more detailed Mann Whitney-U test was performed, due to the small numbers of the trainees, these results should be treated with caution until the dataset is complete.

Conclusions
This extensive consensus study has determined a framework to allow for the standardisation of laparoscopic training sessions. Further on-going work from this is the development of an assessment form, which could have a significant impact on the quality of training in the real-life operative and simulation course setting.