Tokio, Japón (special for SIIC)

In the education of surgeons, clinical experience is thought to be more important than on-the-job training. With a view toward providing postgraduates with sufficient experience, the surgical residency program at our hospital requires that participants serve as the primary surgeon in 100 cases and as the first or second assistant in 500 cases. This is true for postgraduates rotating through our Department of Gynecology. Despite the hospital requirement, it is difficult for us to provide these early residents with sufficient opportunities to serve as operators, and it is equally difficult to provide them with sufficient opportunities to serve as assistants. There are two reasons for this. The first is that, because postgraduates must rotate between various departments within a short post-graduation period, their time spent in our department is only 2 months. Second, the hospital serves only a limited number of patients, so only a few doctors can benefit from our residency curriculum at any one time. To compensate, we use a dry lab, an animal lab, a simulation lab, and a cadaver lab, but the continual maintenance and costs associated with these facilities are problematic, so we have not yet been able to take full advantage of these resources. To address the problem, we recently experimented with a simple training system that provides for residents to simply hold the scope and observe surgeries during their 2-month basic residency so that they may learn laparoscopic skills.

We tested our new approach to gynecological surgery training in three right-handed early residents. They were not provided dry box or simulator training. However, they each participated in 40 laparoscopic surgeries as the second assistant and in 30 laparoscopic surgeries as the first assistant. The main work of the second assistant is to hold the scope, and the main work of the first assistant is to retract the small bowel and omentum away from the surgical field. Four operators, each with 10 or more years’ experience involving more than 1000 laparoscopic surgeries, served as the residents’ supervisors.

Of particular interest was residents’ camera manipulation skills, eye-hand coordination, two-handed maneuvers, and performance of adhesiolysis. We assessed these skills by recording the time required for each task and the lengths of the camera and forceps paths and then by comparing skills the residents demonstrated on a LAP Mentor virtual reality simulator before and after the 2-month training.

The mean time required for camera operation after the training was 162.5 ± 37.79 seconds, whereas that before the training was 137.0 ± 37.14 seconds, and the difference was not significant (p = 0.17). The mean time required for coordinated one-handed maneuvers was 68.5 ± 8.47 seconds vs. 51.8 ± 8.62 seconds, respectively, and the difference was significant (p < 0.001). That required for two-handed maneuvers was 200.5 ± 42.14 seconds vs. 138.3 ± 39.88 seconds, respectively, and this difference was also significant (p < 0.002). That required for adhesiolysis was 186.3 ± 62.0 seconds vs. 118.5 ± 44.74 seconds, respectively, and the difference was significant (p < 0.02).

The times required for the three of the four test manipulations, including adhesiolysis, were shortened by the training.

The mean path length for camera operation after the training was 391.9 ± 75.99 cm, whereas that before the training was 425.5 ± 139.5 cm, but the difference was not significant (p = 0.43). The mean instrument path length for coordinated one-handed (right hand) maneuvers was 137.8 ± 37.39 cm vs. 117.7 ± 34.84 cm, respectively, and the difference was significant (p < 0.04). That for left hand one-handed maneuvers was 109.1 ± 56.85 cm vs. 91.2 ± 40.65 cm, and the difference was not significant (p = 0.16). The mean instrument path length for two-handed maneuvers, with the instrument held in the right hand, was 372.7 ± 111.7 cm vs. 298.6 ± 107.7 cm, respectively, and the difference was significant (p < 0.05); that for two-handed maneuvers with the instrument held in the left hand was 338.6 ± 62.62 cm vs. 298.5 ± 102.6 cm, respectively, but the difference was not significant (p = 0.25). The mean instrument path length required for adhesiolysis was 390.5 ± 94.55 cm vs. 375.4 ± 82.96 cm, respectively, when the instrument was held in the right hand and 223.5 ± 194.0 cm vs. 104.1 ± 29.32 cm, respectively, when the instrument was held in the left hand. The differences were not significant (p = 0.64 and p = 0.13, respectively).

Instrument path length can be used to judge surgical efficiency. With training, the times required for coordinated one-handed maneuvers and two-handed maneuvers were shortened, but only for maneuvers performed with the dominant hand. However, the instrument path length in the performance of adhesiolysis, which is in some ways like a surgical operation, was not shortened.

Although statistical improvement was shown for some but not all skills tested in the three doctors, we can say with confidence that the tested skills of all three doctors improved markedly under the new training approach. It has been reported that surgical skills can be improved just by watching videos of surgery; however, in this study, we found that presence at actual surgeries lends real-life clinical experience, and this kind of experience improves early residents’ surgical skills. However, in the performance of adhesiolysis, which is very close to actual surgery, we found that the instrument path time was shortened but that the experience did not help the residents learn how to use forceps effectively. For this, we need a different training approach.

We conclude that our new training system, which does not include the actual performance of surgeries during the short residency period, can be used as an effective initial step toward early residents’ acquisition of necessary laparoscopic surgery skills.