Skills training in minimally invasive surgery in Dutch obstetrics and gynecology residency curriculum
© The Author(s) 2008
Received: 15 February 2008
Accepted: 15 April 2008
Published: 29 May 2008
The complexity of acquiring minimally invasive surgical (MIS) skills, combined with smaller case volumes for residents have pushed the development of skills training facilities on simulators outside the operating room (OR). Medico-legal and financial constraints have stimulated this development even more. However, the implementation of simulator training into a residency curriculum is shown to be troublesome. MIS skills training is organized in a uniform and easily applicable way in the Dutch obstetrics and gynecology residency curriculum. Every resident is obliged to attend the same basic surgical skills course, named Cobra-alpha course, intentionally during postgraduate year (PGY) 1 or 2. Furthermore, surgical skills are trained, evaluated and expanded on simulators in teaching hospitals. Additional to the Cobra-alpha course, residents may attend advanced training courses and congresses focusing on laparoscopy and hysteroscopy. This organization guarantees a uniform introduction to MIS skills training for every resident. However, preconditions for continuous training and evaluation after this introduction have to be optimized.
KeywordsSurgical skills Training Simulation Implementation Residency curriculum
Minimally invasive surgery (MIS) has evolved into a major surgical approach to treat a variety of gynecological disorders. This approach has considerable benefits for patients, such as a reduced morbidity, a shorter hospitalization, better cosmetic results, and an earlier return to normal activity .
However, acquiring MIS skills is more challenging than acquiring the skills necessary to perform conventional open surgical procedures. MIS poses specific demands on the surgeon. During MIS, the three-dimensional operating field has to be interpreted from a two-dimensional monitor display in which depth perception is altered. In addition, a surgeon has to manipulate long surgical instruments with diminished tactile feedback and fewer degrees of freedom, while adapting to the fulcrum effect [2, 3].
Apart from the complexity of acquiring MIS skills, a residency curriculum has to deal with smaller case volumes in the operating room (OR). This is due to a decrease in resident working hours and a declining trend in major gynecological surgical procedures in general [4, 5]. The smaller case volumes, combined with issues such as quality control, patient safety, efficiency and cost-effectiveness have led to an increasing interest in simulator training facilities outside the OR [3, 6]. Simulator training aims at progression along the learning curve by repetitive training of surgical skills with a lack a potential burden to patients in a pressure free environment. 
With regard to MIS training the implementation into residency programs is shown to be troublesome [7–9]. Even though basic laparoscopic procedures have well been incorporated in residency, more advanced procedures are not [5, 10]. Lack of adequate training during residency influences the subsequent use of a specific technique and ultimately may restrict the implementation of MIS in daily practice after completion of residency training [11, 12].
In this report, we present the organization of MIS skills training in the Dutch obstetrics and gynecology residency curriculum which has continuously been evaluated and improved over the past 15 years.
Surgical skills in the Dutch residency curriculum
The obstetrics and gynecology residency program lasts 6 years in the Netherlands. A basic surgical skill course, named Cobra-alpha course, was incorporated in the curriculum in 1992. It has been evaluated and improved ever since. In 1997, this course was made compulsory for every resident. Attendance to this course is mandatory for obstetrics and gynecology residents during postgraduate year (PGY) 1 or 2. One third of this two-day course is spent on theory, while the complementary two thirds are spent on hands-on training. The first day focuses on basic technical skills, like instrument handling and knot tying, for conventional surgery, while the second day concerns the basic skills required for MIS which is subdivided into laparoscopy and hysteroscopy. Two handbooks, focusing on the basics of surgery and laparoscopy, are used for study purposes and have been written for this course [13, 14].
The goal of the hands-on training in MIS during the Cobra-alpha course is to provide an introduction to simulator training for laparoscopic and hysteroscopic skills. Additionally, residents need to expand the acquired skills on simulators and have these skills evaluated by a mentor or MIS expert in their own clinic. Necessarily, time for training and evaluation has to be scheduled into the busy clinical practice of the residency program.
Prior to the start of hands-on training, the exercises are introduced and explained with the aid of audiovisual demonstration. Afterwards, the participants go through a rotation of simulators. The surgical performance is assessed by calculating a score that rewards precision and speed. In the validated exercises, the calculated individual scores are compared to a previously established performance standard . Training on the laparoscopic and hysteroscopic simulators is intensively supervised by experts in MIS. Regarding the number of participants attending the course, which varies from 32 to 36, each simulator is used by two or three residents and is supervised by one supervising expert.
In addition to the mandatory Cobra-alpha course which is mainly focused on basic skills, residents can apply to two advanced courses in MIS, a laparoscopy course and a hysteroscopy course. These courses can be attended on a voluntary basis. The advanced courses are more procedure orientated than the Cobra-alpha course. In spite of using simulators, life surgery is used for teaching purposes. Procedure-specific courses can further enhance skills and knowledge, like a sacrocolpopexy course and a course regarding laparoscopic adnex surgery. Besides, a variety of (inter)national congresses focuses on MIS are organized.
The mandatory Cobra-alpha course, advanced MIS courses and congresses form the training structure in the Dutch residency curriculum, combined with simulator training in the teaching hospitals during clinical rotation.
The Dutch obstetrics and gynecology residency curriculum has a clear structure regarding the training of MIS skills. A mandatory basic surgical skills course is established for residency training which is nationwide accepted and has a broad Dutch faculty. Intentionally, the course has to be attended during PGY 1 or PGY 2. Additionally, residents may attend advanced courses and congresses focusing on laparoscopy and hysteroscopy. This structure enhances the implementation of basic MIS skills training into the residency curriculum.
Basic MIS skills can be trained on simulators. Simulators have shown great potential for training and objectively assessing laparoscopic skills [17, 18]. The skills acquired are transferable to real operative procedures [19–21] and skills training is shown to decrease patient complications . For every resident, there is a learning curve to achieve proficiency in performing MIS. Presumably, acquiring basic MIS skills by simulator training leads to progression along the first part of this learning curve resulting in better prepared residents for the actual surgery. After achievement of the basic skills, more attention can be paid to the specific procedure during surgery on real patients. With the growing evidence of valuable aspects of MIS simulator training, we feel there is no excuse for depriving residents of this training.
The nationwide basic surgical skills course provides an introduction in simulator training for acquiring MIS skills. However, distributed practice is superior above massed practice, which is provided during a two-day course, for actually achieving these skills [23, 24]. Consequently, MIS skills can only be acquired if residents continue simulator training and evaluation in their own clinic. A first precondition for this continuance of training is the presence of simulator facilities in every cluster of teaching hospitals. A second precondition is that residents really do use these facilities. The first precondition is partially met. All 46 Dutch teaching hospitals are grouped in eight clusters and simulator training is offered in at least one teaching hospital of each cluster. However, the equipment varies widely among these hospitals. The advantage of training on the simulators used during the Cobra-alpha course is that these are easily fabricated and inexpensive. Besides, the exercises for the laparoscopic box trainer have been validated and a performance standard has been established. Regarding the second precondition, unfortunately, only one third of residents actually train on a simulator if training is offered on a voluntary basis . The fact that most residents do not voluntarily train is in contradiction with the residents’ opinion that simulator training is an important addition to their residency program . Hence, formal mandatory MIS training is urgently needed in every training hospital, which has to be scheduled in the busy practice of the residency program.
In spite of structured training, proper evaluation of skills contributes to the learning effect . However, the majority of residents’ surgical skills are evaluated informally and in a non-standardized fashion. There is a growing need for objective assessment tools. An example of such a tool is the Objective Structures Assessment of Technical Skills (OSATS). This evaluation method consists of a global rating scale and has proven high reliability and construct validity for simulators [25, 26].
Global rating scale for level of competence
Has theoretical knowledge
Is able to perform under strict supervision
Is able to perform under limited supervision
Is able to perform without supervision
Is able to supervise and educate others
Target numbers of MIS procedures required for certification
Target number (total)
Target number performed on competence level 4
Salpingectomy/salpingotomy (inclusive EP)
Resection myomas type 0–I
Resection myomas type II
Although some adaptations have to be made to incorporate continued training and evaluation in daily practice, a uniform introduction to MIS training on simulators is guaranteed for every resident in the Netherlands by a mandatory basic skills course, while advanced courses and congresses provide possibilities for enhanced education. Hopefully, this will facilitate and accelerate the implementation of MIS techniques in the gynecological surgical palette.
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- Darzi A, Mackay S (2002) Recent advances in minimal access surgery. BMJ 324:31–34PubMedView ArticleGoogle Scholar
- Gallagher AG, McClure N, McGuigan J, Ritchie K, Sheehy NP (1998) An ergonomic analysis of the fulcrum effect in the acquisition of endoscopic skills. Endoscopy 30:617–620PubMedView ArticleGoogle Scholar
- Munz Y, Kumar BD, Moorthy K, Bann S, Darzi A (2004) Laparoscopic virtual reality and box trainers: is one superior to the other? Surg Endosc 18:485–494PubMedView ArticleGoogle Scholar
- Blanchard MH, Amini SB, Frank TM (2004) Impact of work hour restrictions on resident case experience in an obstetrics and gynecology residency program. Am J Obstet Gynecol 191:1746–1751PubMedView ArticleGoogle Scholar
- Brolmann HA, Vervest HA, Heineman MJ (2001) Declining trend in major gynaecological surgery in The Netherlands during 1991–1998. Is there an impact on surgical skills and innovative ability? BJOG 108:743–748PubMedView ArticleGoogle Scholar
- Feldman LS, Sherman V, Fried GM (2004) Using simulators to assess laparoscopic competence: ready for widespread use? Surgery 135:28–42PubMedView ArticleGoogle Scholar
- Loh FH, Hameed N, Ng SC (2002) The impact of minimal access surgery on gynaecological surgery in a university gynaecological unit over a 10-year period from 1991 to 2000. Singap Med J 43:177–181Google Scholar
- Navez B, Penninckx F (1999) Laparoscopic training: results of a Belgian survey in trainees. Belgian Group for Endoscopic Surgery (BGES). Acta Chir Belg 99:53–58PubMedGoogle Scholar
- Nussbaum MS (2002) Surgical endoscopy training is integral to general surgery residency and should be integrated into residency and fellowships abandoned. Semin Laparosc Surg 9:212–215PubMedView ArticleGoogle Scholar
- Kolkman W, Wolterbeek R, Jansen FW (2005) Gynecological laparoscopy in residency training program: Dutch perspectives. Surg Endosc 19:1498–1502PubMedView ArticleGoogle Scholar
- Kolkman W, Wolterbeek R, Jansen FW (2006) Implementation of advanced laparoscopy into daily gynecologic practice: difficulties and solutions. J Minim Invasive Gynecol 13:4–9PubMedView ArticleGoogle Scholar
- Shay BF, Thomas R, Monga M (2002) Urology practice patterns after residency training in laparoscopy. J Endourol 16:251–256PubMedView ArticleGoogle Scholar
- Jansen FW, Trimbos-Kemper GCM (2006) Laparoscopy, the basics. Laurier, NoordwijkGoogle Scholar
- Trimbos JB (2007) Basics of Surgery, tools, techniques, attitude and expertise. Elsevier, AmsterdamGoogle Scholar
- Kolkman W, van de Put MAJ, Jansen FW (2008). Laparoscopic simulator: construct validity and performance standard. Gynecol Surg; in pressGoogle Scholar
- Kingston A, Abbott J, Lenart M, Vancaillie T (2004) Hysteroscopic training: the butternut pumpkin model. J Am Assoc Gynecol Laparosc 11:256–261PubMedView ArticleGoogle Scholar
- Lentz GM, Mandel LS, Lee D, Gardella C, Melville J, Goff BA (2001) Testing surgical skills of obstetric and gynecologic residents in a bench laboratory setting: validity and reliability. Am J Obstet Gynecol 184:1462–1468PubMedView ArticleGoogle Scholar
- Scott DJ, Young WN, Tesfay ST, Frawley WH, Rege RV, Jones DB (2001) Laparoscopic skills training. Am J Surg 182:137–142PubMedView ArticleGoogle Scholar
- Anastakis DJ, Regehr G, Reznick RK, Cusimano M, Murnaghan J, Brown M, Hutchison C (1999) Assessment of technical skills transfer from the bench training model to the human model. Am J Surg 177:167–170PubMedView ArticleGoogle Scholar
- Hyltander A, Liljegren E, Rhodin PH, Lonroth H (2002) The transfer of basic skills learned in a laparoscopic simulator to the operating room. Surg Endosc 16:1324–1328PubMedView ArticleGoogle Scholar
- Seymour NE, Gallagher AG, Roman SA, O’Brien MK, Bansal VK, Andersen DK, Satava RM (2002) Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg 236:458–463PubMedView ArticleGoogle Scholar
- Cadeddu JA, Wolfe JS Jr., Nakada S, Chen R, Shalhav A, Bishoff JT, Hamilton B, Schulam PG, Dunn M, Hoenig D, Fabrizio M, Hedican S, Averch TD (2001) Complications of laparoscopic procedures after concentrated training in urological laparoscopy. J Urol 166:2109–2111PubMedView ArticleGoogle Scholar
- Moulton CA, Dubrowski A, MacRae H, Graham B, Grober E, Reznick R (2006) Teaching surgical skills: what kind of practice makes perfect?: a randomized, controlled trial. Ann Surg 244:400–409PubMedGoogle Scholar
- Verdaasdonk EG, Stassen LP, van Wijk RP, Dankelman J (2007) The influence of different training schedules on the learning of psychomotor skills for endoscopic surgery. Surg Endosc 21:214–219PubMedView ArticleGoogle Scholar
- Reznick R, Regehr G, MacRae H, Martin J, McCulloch W (1997) Testing technical skill via an innovative “bench station” examination. Am J Surg 173:226–230PubMedView ArticleGoogle Scholar
- Goff BA, Nielsen PE, Lentz GM, Chow GE, Chalmers RW, Fenner D, Mandel LS (2002) Surgical skills assessment: a blinded examination of obstetrics and gynecology residents. Am J Obstet Gynecol 186:613–617PubMedView ArticleGoogle Scholar
- Park A, Witzke D, Donnelly M (2002) Ongoing deficits in resident training for minimally invasive surgery. J Gastrointest Surg 6:501–507PubMedView ArticleGoogle Scholar