The EAES Laparoscopic Surgical Skills programme

General outline
March 2011

Content - Introduction - Lay-out of the programme - Content of the LSS curriculum

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Introduction
Safety and quality of performance in surgery, in general but specifically in image-based procedures, remains a major concern for health care providers and authorities. The relative high rates of adverse advents should largely be avoided by taking proper preventive measures 1-3. Recently published reports on these issues, as for example by the World Health Organization, stress the urgent need for improvement of training, education, assessment and future accreditation for technology dependent surgical procedures such as laparoscopy 1-3. Although its importance is widely acknowledged, objective assessment of the acquisition of the required technical skills by trainees to perform laparoscopic surgery with the appropriate level of proficiency has been largely ignored in the past, sometimes with drastic consequences 4. Until now, relatively little attention has been given to the way in which the various skills thought to determine competency should be combined in one curriculum and how these might be brought to an optimum level of proficiency 5. When building such a curriculum, attention must first be paid to the validation studies comparing various training techniques, as a universal system providing optimal training of basic skills, component tasks and procedures is not yet available. Second, it seems wise to develop curricula stratified according to levels of experience, an unique idea we would like to underscore here. The use of a several simulators, ranging from basic bench box trainers to VR and augmented reality, can be recommended. Third, special attention must be paid to transferability of these acquired skills to clinical practice as well as retention of skills over time: this will be a major part of future research on simulation training. In particular, work is needed on the use of simulators for both assessing and accrediting surgeons. It is through the results of this type of research that authorities will understand why and become convinced that they should support the development and implementation of new training techniques 5. Thus we can conclude that there is a need for a comprehensive curriculum proficiency assessment tool that focuses on securing laparoscopic proficiency as a whole, incorporating all the related competencies and skills (cognitive, technical, and clinical/judgment).

Objectives
The objectives of this project are to develop, validate and implement a curriculum and proficiency assessment tool for laparoscopic surgery to be licensed and validated by the EAES. The curriculum and tool should become the golden standard within Europe to credential and recredential medical specialists to perform laparoscopic surgery.

Figure 1. Overview of the LSS curriculum per level.

Lay-out of the LSS programme

The EAES Laparoscopic Surgical Skills programme (curriculum and assessment) will consist of two grades. In Grade I consists of three levels which together cover all basic skills and fundamental laparoscopic surgical procedures. Grade II focuses on training and assessment of specific advanced laparoscopic procedures, such as colon surgery, bariatric surgery, and solid organ surgery. Later on, surgery specific training modules and selection of basic procedures will be elaborated for gynaecology, urology, and paediatric surgery.

General features of the LSS programme:

Training and objective assessment of laparoscopic skills separately and in a more comprehensive context Deliberate practise making use of a combination of different training/assessment modalities, making use of the best fitting modality for each task/skill. This enlarges the transferability of skills and adds to the engagement of trainees Goal-oriented and criterion-based training and assessment Close link between LSS curriculum and LSS assessment. The LSS assessment is an integral part of the LSS curriculum. In addition, the LSS assessment can function as separate examination of laparoscopic skills Dynamic programme: based on current knowledge and expertise extended by additional continuous research and development of training/assessment tools Admission requirements for each course to enlarge commitment of trainees, including: o successful completion of a knowledge test prior to each course o at start of each course verification of basic psychomotor skills acquired at home o portfolio requirements (>Grade I-2): total number and clinical performance assessment of index procedures, including major morbidity Examination by a combination of written knowledge tests, simulator assessment, and clinical performance assessment on index procedures For the clinical performance assessment on index procedures unedited video recordings will be assessed independently and blinded using the Competency Assessment Tool (CAT) complemented by Observational Clinical Humans Reliability Analysis (OCHRA) (for borderline and failed cases).

Figure 2. Several assessments are included in the programme for each level.

Laparoscopic Surgical Skills curriculum Grade 1: *

Divided in three levels, to be completed consecutively with a minimum interval of 6 months inbetween courses Theoretical information based on E-learning system and assessed by examination o Pre-assessment: before start of course on the E-learning system o Post-assessment: at the end of the course, for certification Practical skills during course and assessed based on proficiency benchmarks o The assessment benchmarks have to be reached, before receiving the certification and opportunity to enter in the following level.

Level 1: - two-day course - basic knowledge (pro/cons laparoscopy, use of instruments & equipment, OR set-up, electrosurgery principles, ergonomics, safe access, anatomical issues) - basic skills (e.g.: laparoscope navigation, translocation, tissue manipulation, dissection, clip&cut, ligation of vessels) on two different training modalities listed below: o Predefined validated tasks on a validated Virtual Reality (VR) simulator o Predefined validated tasks on a validated Augmented Reality (AR) simulator o Basic tasks on the box trainer - level 1 index procedure(s): diagnostic laparoscopy, cholecystectomy, appendectomy - training of procedural tasks and complete procedures on: o animal tissue/ artificial tissue model o VR/AR simulator/procedural training software - scenario based assessment - clinical performance assessment of unedited video registration of index procedure(s) Level 2: - two-day course or two one-day courses - refreshment and verification of basic knowledge & skills - suturing skills for procedures using physical training modality (AR/ box) (square, surgeons, tumble) level 2 index procedure(s): difficult cholecystectomy, incisional hernia repair, perforated duodenal ulcer, common bile duct (CBD) exploration tissue approximation techniques and anastomotic devices techniques of haemostasis training of procedural tasks and complete procedures on: o animal tissue/ artificial tissue model o VR/AR simulator/procedural training software scenario based assessment clinical performance assessment of unedited video registration of index procedure(s)

Level 3: - two-day course - refreshment and verification of basic knowledge & skills and suturing skills for procedures

the specific content of the levels and the indicated index procedure are still topic of discussion and could be subject of change 4

suturing (running, different planes) and advanced dissection skills on a physical training modality (AR/ box) stapled anastomosis techniques energised dissectors and vessel sealing techniques basics for LSS grade 2 speciality surgery (colonic surgery, obesity surgery, etc) level 3 index procedure(s): anti-reflux procedures (Nissen fundoplication), incisional hernia repair, laparoscopic common bile duct (CBD) exploration, laparoscopic splenectomy, inguinal hernia repair training of procedural tasks and complete procedures on: o animal tissue/ artificial tissue model o VR/AR simulator/procedural training software scenario based assessment clinical performance assessment of unedited video registration of index procedure(s)

Laparoscopic Surgical Skills curriculum Grade 2:

Laparoscopic procedural skills courses, to be completed by differentiating surgeons in training and laparoscopic surgeons Grade 1 has to be completed from level 1 to 4, before starting a course from grade 2. (or the trainee is already a general surgeon, before the LSS programme has started) Based on the different procedures or abdominal region, e.g.: o (Inguinal) hernia repair o Colon surgery o Obesity surgery o Solid organs Theoretical information based on E-learning system and assessed by examination Training of procedural tasks and complete procedures on: o animal tissue/ artificial tissue model o VR/AR simulator/procedural training software Clinical performance assessment of non-edited video registration of procedures Team training component including elements of Crew Resource Management (CRM) Scenario based assessment

Content of LSS curriculum

Grade 1: level 1
Targets theoretical knowledge: - Basics of laparoscopic procedures o Pros/cons, drawbacks of laparoscopic approach o Instrument use and knowledge o Electro-surgery in laparoscopy o Ergonomics in laparoscopic surgery/energised instruments o Safe access techniques - Laparoscopic cholecystectomy (LC) o Indications and contra-indications o Anatomy of gallbladder region/anatomy variations o Cholecystolithiasis, diagnosis and treatment options/ when to operate o Cholecystitis, diagnostics and treatment options/when to operate 5

o Complications of LC and treatment o Conversion Diagnostic laparoscopy o Knowledge of indication and diagnostic value o Procedural knowledge, with complications and contra-indication Laparoscopic appendectomy o Indications and contra-indications o Anatomy of appendix, with anatomic variations o Knowledge of appendicitis, diagnostics and treatment options o Procedural knowledge, with complications and treatment Scenario-based decision making

Targets practical skills: - Basic skills: trained on multimodality simulators o Camera navigation (30 degree angled scope) o Bimanual translocation of objects o Tissue manipulation o Dissection of tissues o Clip and Cut tasks - Basic suturing: trained on box trainers or Augmented Reality simulators o Ligation of vessels o Ligation of the base of appendix o Basics of intra corporal suturing knot-tying - Procedures: trained on multimodality simulators o Safe access techniques o Diagnostic laparoscopy o Laparoscopic cholecystectomy o Laparoscopic appendectomy

Grade 1: Level 2
Targets theoretical knowledge: - Basics of laparoscopic procedures o Advanced instrument use and knowledge o Position of patient, trocars and screens in the OR for different procedures - Laparoscopic suturing for procedures o Knowledge of steps in procedure of the laparoscopic square and surgeons knot o Knowledge of steps in procedure of the laparoscopic tumble knot o Which sutures and technique to use during laparoscopic suturing - Tissue approximation techniques and anastomotic devices - Techniques of haemostasis - Difficult laparoscopic cholecystectomy o Refreshing of theory from level 1 o Anatomical variations and what to do when encountered per-operative - Laparoscopic incisional hernia repair o Indications and contra indication o Procedural knowledge, complications and treatment - Laparoscopic repair of perforated duodenal ulcer o Indications and contra indication 6

o Procedural knowledge, complications and treatment Laparoscopic common bile duct exploration o Treatment of complicated cholelithiasis o Indications and contra indication o Procedural knowledge, complications and treatment Scenario-based decision making

Targets practical skills: - Basic skills: trained on multimodality simulators o Camera navigation (30 degree angled scope) o Bimanual translocation of objects o Tissue manipulation o Dissection of tissue o Clip and Cut tasks - Suturing: trained on box trainers or Augmented Reality simulators o Laparoscopic Surgeons knot o Laparoscopic Thumble knot - Procedures (if possible multimodality training, assessment on artificial/ animal models): o Laparoscopic cholecystectomy o Laparoscopic incisional hernia repair o Laparoscopic repair of perforated duodenal ulcer o Laparoscopic common bile duct exploration

Grade 1: Level 3
Targets theoretical knowledge: - Laparoscopic suturing o Refreshing of the steps in laparoscopic Square, Surgeons knot and Tumble knot o Knowledge on running sutures o Knowledge on suturing in different planes and difficulties of suturing of live organs, such as bowel for anastomoses and crura and stomach during laparoscopic Nissen Fundoplication - Stapled anastomosis techniques - Laparoscopic Nissen Fundoplication o Knowledge of pathology of Gastro-esophageal Reflux and treatment options o Anatomy of upper abdomen, with anatomical variations o Knowledge of indication for operative treatment, with contra-indications and complications o Step-by-step procedural knowledge, with knowledge of possible complications for each step/component tasks - Laparoscopic common bile duct exploration o Indications and contra indications o Refreshing of anatomy and anatomical variations o Intra-operative cholangiography and intra-operative ultrasonography o Knowledge of therapeutic value of CBD exploration versus ERCP o Procedural knowledge, complications and treatment - Laparoscopic incisional hernia repair o Indications and contra indication o Procedural knowledge, complications and treatment - Laparoscopic splenectomy 7

o Indications and contra indication o Procedural knowledge, complications and treatment Laparoscopic inguinal hernia repair o Indications and contra indication o Procedural knowledge, complications and treatment Basic knowledge for LSS grade 2 speciality surgery (colonic surgery, obesity surgery, etc) Scenario-based decision making

Targets practical skills: - Basic skills: trained on multimodality simulators o Advanced dissection of tissue in different planes o Use of energised dissectors and vessel sealing techniques - Suturing: trained on box trainers, Augmented Reality simulators, and animal/ artificial models o Refreshing of Square, Surgeons knot and Tumble knot o Suturing of crura under tension (like in Nissen Fundoplication) o Suturing of stapled bowel with the running suture (using animal or artificial models) o Procedural VR training - Procedures (if possible multimodality training, assessment on artificial/ animal models): o Laparoscopic Nissen Fundoplication o Laparoscopic CBD exploration o Laparoscopic incisional hernia repair o Laparoscopic splenectomy o Laparoscopic inguinal hernia repair