PETER D. VLAOVIC, MD, ERIC R. SARGENT, MD, JOHN R. BOKER, MD, FEDERICO A. CORICA, MD, DAVID S. CHOU, MD, COROLLOS S. ABDELSHEHID, BS, SHANNON M. WHITE, BS, LEANDRO G. SALA, MD, FRANK CHU, TODD LE, RALPH V. CLAYMAN, MD, ELSPETH M. MCDOUGALL, MD
INTRODUCTION
The acquisition of laparoscopic skills requires a longer learning curve than that of open surgery. To help postgraduate urologists acquire laparoscopic surgical skills, an intensive 5-day mini-residency (M-R) program was created at the University of California Irvine through a grant from Yamanouchi Pharma America (now Astellas Pharma Inc.).
PROGRAM DESIGN
A maximum of 2 urologists are accepted per week into the M-R program. The trainee chooses one of the following training modules: (1) ureteroscopy and percutaneous renal access; (2) laparoscopic renal ablative (radical nephrectomy); (3) laparoscopic renal reconstructive (partial nephrectomy and pyeloplasty); (4) and robot-assisted prostatectomy. The course includes 2 hours to 3 hours of didactic lectures, daily practice on pelvic trainers and virtual reality simulators, 1 to 2 porcine laboratories per week, and observation of cases in the operating room.
Skills testing (ST) simulating open, laparoscopic, and robot-assisted laparoscopic surgery is performed and evaluated by an experienced observer on training days 1 and 5. The tasks include ring transfer (placing and removing rings from pegs), suture threading (threading a 3-0 Prolene suture through loops), cutting (cutting along designated curved lines), and suturing (continuous running of a suture around a foam hexagon) (Figure 1). Mini-residents undergo ST with open surgical instruments (forceps, needle driver, and scissors) sitting at a table (open ST), with laparoscopic instruments (graspers, needle drivers, and shears) on the pelvic trainer (laparoscopic ST), and with robotic instruments (needle drivers and scissors) on the da Vinci Surgical System (robotic ST). The participants’ performance is graded with a validated Objective Structured Assessment of Technical Skill (OSATS) scoring system. The total score is a product of the quantity score (ie, how much of the task is completed in the specified period of time) and the quality score (ie, how accurately the skill task is performed). The data were analyzed by using the paired sample t test and analysis of variance at a confidence level of P<0.05.
Figure 1. The surgical skills tasks:
A. Participant removes all 6 rings and then places them back on pegs within a 2-minute timeframe.
B. Participant is given 2 minutes to thread a 2-0 Prolene suture through as many of the 11 loops as possible.
C. Participant is given 2 minutes to cut along the inner curved line.
D. Participant is given 3 minutes to run a 4-0 Vicryl suture on an RB-1 as close to the dots as possible.
RESULTS
Between July 2003 and June 2005, 101 urologists from 22 American states and 14 countries participated in the M-R experience. Mean participant age was 47 years (range, 31 to 70). Mean time from graduation from urology residency was 15 years (range, 1 to 42).
The M-R open, laparoscopic, and robotic ST scores for all of the participants on the first and fifth days of the course are shown in Table 1. On both the first and final days, the open ST scores are significantly higher than the robotic ST scores (P<0.0005), which are significantly higher than the laparoscopic ST scores (P<0.0005). This was the case for all of the ST scores, including the overall score. No significant difference existed between the ST scores on the first and final day for any of the open skills tasks. However, the robotic ST scores were significantly higher on the final day compared with scores on the first day.
The participants’ performance according to the M-R training module was also examined. Laparoscopic ablative and reconstructive renal module participants demonstrated significant improvement in laparoscopic and robotic ring transfer, suture threading, cutting, and suturing on day 5 compared with day 1 (P<0.05) (Table 2). However, none of this group’s open ST changed significantly from day 1 to day 5. In the robot-assisted prostatectomy module participants, significant improvement occurred in the quantity score for the cutting task and the quality score for suturing (P<0.05) (Table 3).
Increasing participant age tended to inversely correlate with some ST scores. Participants older than 54 years of age scored lower on day 1 for the open ring transfer and suture threading than did individuals aged 44 to 53 years (P=0.03) and <43 years (P=0.03). Moreover, the urologists >54 years of age scored significantly lower on open suture threading on day 5 (P=0.01). For the robotic ST scores, the >54-year-old group scored lower on suture threading on day 1 (P=0.004) and day 5 (P=0.017) and on suturing on day 5 (P=0.006). For robotic ring transfer ST scores, surgeons <43 years scored significantly better than the older participants (P=0.0004). The rest of the open and robotic ST scores and none of the laparoscopic ST scores were significantly different between the various age groups (P>0.05) (Table 4).
Skill task scores of participants who graduated from urology residency less than 10 years earlier were compared with those who graduated more than 10 years earlier (Table 5). The more recent graduates had significantly higher scores for robotic suture threading on day 1 (P=0.01), open suture threading on day 5 (P=0.03), and laparoscopic cutting on day 5 (P=0.01). No other ST scores differed significantly between the 2 groups.
DISCUSSION
The purpose of this study was to assess whether the course could develop participants’ basic laparoscopic and robotic skills, such as general coordination of instruments (ie, ring transfer and suture threading), and surgically oriented skills, such as cutting and suturing. The results show that laparoscopic and robotic ST scores significantly improve over the 5-day course while open ST scores do not. It would be expected that open ST scores would not improve following the M-R course, as these types of skills are not formally addressed during the course. The observation that robotic ST scores are significantly higher than the laparoscopic ST scores at the beginning and the end of the course reflects the greater degree of complexity associated with performing pure laparoscopic skills. As other investigators have demonstrated, basic robotic skills are more easily developed than are laparoscopic skills [1]. The robot facilitates the skill performance by providing an intuitive working format with more precise instrument movement, 3-dimensional visualization, and increased surgeon comfort at the master console. The counterintuitive, 2-dimensional working environment, long instruments fulcrumed at the abdominal wall, and magnification of the surgeon’s natural tremor all compound to make laparoscopy a challenging surgical technique [2].
There appears to be some correlation between ST scores and age, particularly the robot-assisted ST scores. Surgeons older than 54 years of age may have poorer fine motor coordination of instruments when using the robot and may have more difficulty learning robot-assisted suturing. These surgeons may require a longer training program to reach the same proficiency level as their younger counterparts, although this study was not able to assess this. Conversely, age does not appear to influence laparoscopic ST scores, including suturing. Time since graduation appears to have a less significant impact on ST scores than age does.
CONCLUSIONS
Laparoscopic and robotic skills are difficult to acquire, especially for urologists who were not exposed to the technique during residency training. It appears that the 5-day intensive M-R course improves both laparoscopic and basic robotic skills and thus represents a new paradigm in postgraduate surgical education.
Correspondence: Elspeth M. McDougall, MD, Department of Urology, University of California Irvine, Bldg 55, Rm 304, Rt 81, 101 The City Dr, Orange, CA 92868, USA. Telephone: 714 456 3429, Fax: 714 456 5062, E-mail: twatters@uci.edu
Federico Corica, MD, is a urologist in practice in Charleston, South Carolina.
Peter Vlaovic, MD, is a urologist in private practice in Toronto, Canada.
Eric Sargent, MD, is an Education Fellow in Minimally Invasive Urologic Surgery and a Clinical Instructor in the Department of Urology at the University of California, Irvine.
David Chou, MD, is a urologist in private practice in Honolulu, Hawaii (Pacific Urology, Inc.).
Corollos Abdelshehid, BS, is currently attending the American University of the Caribbean School of Medicine in St. Martin.
Shannon White, BS, is currently enrolled in the Master’s Program at the University of California, San Diego.
Leandro Sala, MD, is a urologist in private practice in Buenos Aires, Argentina.
Frank Chu is a student at the University of California, Irvine working towards his BS degree.
Todd Le is a student at the University of California, Irvine working towards his BS degree.
John Boker, PhD, is Vice President, Faculty and Curriculum Development Academic Affairs for Geisinger Health System in Danville, Pennsylvania.
Ralph V. Clayman, MD, is Professor and Chair, Department of Urology at the University of California, Irvine.
Elspeth M. McDougall, MD, FRCSC, is a Professor of Urology in the Department of Urology and the Director of the Minimally Invasive Surgery Education Center at the University of California, Irvine.
References
1. Kaul S, Shah NL, Menon M. Learning curve using robotic surgery. Curr Urol Rep. 2006;7(2):125-129.
2. Shalhav AL, Dabagia MD, Wagner TT, Koch MO, Lingeman JE. Training postgraduate urologists in laparoscopic surgery: The current challenge. J Urol. 2002;167:2135-2137.
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