Dmitry Nepomnayshy, MD, James Whitteledge, Richard Birkett, MD, Ted Delmonico, MD, Neal Seymour, MD. Lahey Clinic, Baystate Medical Center.
Since FLS represents a minimum proficiency standard for laparoscopic surgery, more advanced proficiency standards are required to address the need of current surgical training. We wanted to establish face and construct validity of a new set of skills building on the FLS model that would represent a more advanced proficiency standard – Advanced Laparoscopic Surgery (ALS) which addresses operating room challenges like off-set camera view, restricted space and difficult angles.
Prospective comparison of novice, (PGY 1-2), intermediate (PGY 3-4), and expert (PGY 5+) surgeons in the performance of FLS tasks – peg transfer (PT), circle cut (CC), intra-corporeal suture (ICS) and ALS tasks – Off-Set Camera PT and ICS, Vertical Plane PT and CC, Back-hand ICS, Confined Space ICS and Reverse Angle PT. To assess face validity, expert participants completed questionnaires. To assess construct validity, performance data on FLS and ALS were analyzed. Standard FLS errors were added to task time to create a composite time score which was used for comparison (lowest score is best).
Out of 48 participants, there were 15 (31%) attendings, 3 (6%) fellows and 30 (63%) residents which included 11 PGY1-2, 12 PGY3-4 and 7 PGY5. By specialty, 54% were General/MIS/Bariatric, (GMB), 10% were GYN, and 36% Urology. Majority of the respondents felt that ALS was a realistic task set, however not all the tasks were felt to be equally important. Offset Camera and Confined Space tasks were the best perceived while Reverse Angle was the worst. Initial analysis of composite data did not reveal statistically significant differences between novice, intermediate and experts. However, divided by specialty, GMB experts performed significantly better than other specialties on FLS and ALS. (TABLE 1 and 2 *)
In the GMB subset, there were significant difference in performance between experience levels on ALS, while there was no difference in performance on FLS (TABLE 1 and 2 ++). When looking at specific tasks, ALS suturing tasks (Backhand, Off-Set Camera and Confined Space) showed statistically significant improved performance in experts compared to novices while other tasks did not differentiate.
We were able to demonstrate face and construct validity of a series of advanced laparoscopic tasks (ALS) for General/MIS/Bariatric surgeons. This study may represent the first step in the development of an advanced laparoscopic skills curriculum. Given the high degree of specialization in surgery, different advanced skills curricula will need to be developed for each specialty.