Significant Transfer of Surgical Skills Obtained With an Advanced Laparoscopic Training Curriculum; Feasibility of Learning Advanced Laparoscopy in a General Surgery Residency.

Julian Varas, MD, Ricardo Mejía, MD, Oslando Padilla, PhDS, Felipe Maluenda, MS, Napoleon Salgado, MD, Arnoldo Riquelme, MD, Jorge Martinez, MD, Nicolas Jarufe, MD, Rajesh Aggarwal, MBBS MA PhD FRCS, Camilo Boza, MD. Department of Digestive Surgery. Surgery Division. Pontificia Universidad Católica de Chile


INTRODUCTION: Currently, there is no valid competency based training programs to develop skills necessary to perform advanced laparoscopic procedures. Furthermore, there are no simulation programs proving that once advanced laparoscopic skills are obtained, they are transferred to more complex scenarios. Aim: To present an advanced simulation training program and to assess the transfer of skills to a live porcine model.

METHODS AND PROCEDURES: 23 first-year residents were assessed in a 14-session advanced laparoscopic training program, performing a laparoscopic hand-sewn Jejuno-jejunostomy on a modified validated bench model with ex-vivo bovine bowel. Procedures were recorded on video, and analyzed by 2 blinded experts using a validated global and specific rating scale (GRS, SRS); Operating time, anastomosis leakage and permeability, were assessed. In addition, a tracking motion system (ICSAD) was utilized in each evaluation. All results were then compared to those achieved by expert surgeons in the same model. Residents were then assessed performing a stapled Jejuno-jejunostomy in a live porcine model. Results were compared to those of 10 general-surgeons graduated from traditional residencies without any lab training program and 6 expert laparoscopic surgeons executing the same procedure.
Mann-Whitney and Kruskal-Wallis tests were used to compare each specific non-parametrical variable within each group. Wilcoxon test was used for pre-post Assessment. P value was considered as statistically significant when <0,05 .

RESULTS: Learning curves were achieved. Residents improved significantly their GRS and SRS score median (Q1-Q3) at the bench model. In addition, the total path lengths of both hands registered with ICSAD decreased more than a 65%. Results obtained at the bench model were comparable to those achieved by expert surgeons (Table1).

Table 1: Trainees Results obtained at the advanced laparoscopic training program (bench model).
  APrior to Training (n=23) BAfter Training
AB P value BC P value
GRS (min 5-max 25) 7(5-17) 23(21-25)  24(23-25) < 0,0001 0,0129
SRS (min 4-max 20) 7(4-12) 18(16-20) 19(18-20) < 0,0001 0,2252
% Permeable anastomosis with no Leak 25% 100% 100% < 0,0001  
Operative Time(s) 2609(1620-3808) 1110(810-1410) 720(685-800) < 0,001 0,0032
TPL(meters) 307(194-510) 115(74-152) 75(71-79) 0,0002 0,0313

AB p value: P values obtained when comparing columns A and B with Wilcoxon matched-pairs test
BC p value: P values obtained when comparing columns B and C with Mann Whitney.

In the live porcine model, trainees obtained significantly better results compared to those of general surgeons with no lab training (p=0.0002), and comparable to those achieved by experts (p=0,364). Trainees, general surgeons and experts GRS scores were: 21(16-21), 12(8-21), 24(23-25) respectively. SRS scores were: 18(16-18), 9.5(7-17), 19(16-20) respectively, p=0.0004. Total path lengths registered for residents were significantly lower compared to general surgeons (p<0.0001) and with no statistical difference compared to experts (p=0,299); 111.5m (70-208), 505.6m (190-880), 62.46m (41-154) respectively. Trainees operative times (in seconds) were faster than general surgeons: 1105(720-1384), 1392(1069-2336) p=0,0133; but slower than experts: 512(397-676).

CONCLUSIONS: Trainees significantly improved their advanced laparoscopic skills to a level compared to expert surgeons. More important, these acquired skills were transferred to a more complex live model.

Session Number: SS05 – Education
Program Number: S029

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