Does previous laparoscopic experience improve ability to perform single-incision laparoscopic surgery?
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- Lewis, T., Aggarwal, R., Kwasnicki, R. et al. Surg Endosc (2012) 26: 1214. doi:10.1007/s00464-011-2058-6
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Single-site laparoscopic surgery (SSLS) has been suggested as a safe and less invasive alternative to standard laparoscopic surgery (LAP). It is not clear whether previous laparoscopic experience influences the ability to perform SSLS. This study aimed to assess the impact of laparoscopic experience on the performance of SSLS.
For this study, 18 surgeons were recruited including 12 novice surgeons, four experienced laparoscopic surgeons (intermediate) and two experienced SSLS surgeons (expert). All these subjects completed four tasks from the validated Fundamentals of laparoscopic surgery (FLS) curriculum. The tasks were performed using both a LAP and an SSLS approach with a randomized crossover design. Assessment of the tasks was performed with standardized FLS metrics and dexterity analysis using the Imperial college surgical assessment device.
The novice group performed two tasks (precision cutting and intracorporeal suture) significantly better with a LAP approach than with an SSLS approach in all parameters (P < 0.05). The two other tasks (peg transfer and endoloop) were performed significantly better with LAP than with SSLS in terms of time and dexterity only (P < 0.05) but not in terms of error score. The intermediate and expert groups demonstrated no significant difference between their LAP and SSLS performances for any of the tasks in any parameter. Intergroup analysis of performance demonstrated construct validity of the SSLS tasks, with significant differences between novice and intermediate performances for three tasks (peg transfer, endoloop, and intracorporeal suture) (P < 0.05) and between novice and expert performances for three tasks (peg transfer, precision cutting, and intracorporeal suture) (P < 0.05).
This study demonstrated that previous laparoscopic experience improves ability to perform SSLS tasks. Some SSLS tasks do not show construct validity due to the complexity of the SSLS technique. It also is implied that current LAP technical skills training curricula are insufficient for teaching SSLS.
KeywordsLaparoscopic experienceSingle-site laparoscopic surgeryStandard laparoscopic surgery
Innovation in surgery is an important aspect of ensuring improvement in both quality of health care delivery and enhancement in surgical technology . The development of laparoscopic surgery in the early 1990s has been heralded as one of the most important advances in the surgical speciality, providing patients with the benefits associated with reduced tissue trauma . Findings have shown laparoscopic surgery to be an effective approach to many general surgery operations, resulting in smaller wounds, less postoperative pain, a shorter hospital stay, earlier return to normal function, and an improved cosmetic appearance [3−5].
Single-site laparoscopic surgery (SSLS) aims to enhance these effects by allowing access to the abdominal cavity through one single manufactured port placed in the umbilicus . It has been widely demonstrated that SSLS can be used for appendectomy, cholecystectomy, gastric banding, sleeve gastrectomy, and right hemicolectomy [6−10].
The technical skills required to perform traditional multiport laparoscopic surgery are different from those required for open surgery . When laparoscopic surgery was introduced, this resulted in the concept of the learning curve, whereby patients would be at the most risk as the surgeon learned the technical skills required to complete the operation [12, 13].
The introduction of SSLS provides surgeons with a similar challenge . The techniques used to perform SSLS differ from those required for traditional laparoscopic surgery . The SSLS techniques force the surgeon to pass all instruments through one port, which can make movements awkward and technically challenging. To overcome this, surgeons can operate using either one instrument or roticulating instruments that cross over . This can increase the challenge by reversing the orientation of the surgeon’s instruments such that his or her right hand controls the left instrument and vice versa. Both of these techniques are challenging and require considerable practice to be used confidently and safely on a patient. Therefore, it is suggested that there may be an SSLS learning curve similar to that seen at the advent of traditional laparoscopic surgery regardless of the open or laparoscopic experience of the surgeon [17, 18].
To overcome the inherent risks associated with a procedural learning curve, simulation has been recommended as an adjunct to traditional laparoscopic training such that a surgical trainee can learn basic technical skills in the safety of a skills laboratory [19, 20]. This allows a surgeon to learn, practice, and develop skills without detriment to the patient.
In the United States, the Fundamentals of Laparoscopic Surgery (FLS) has been developed as a technical skills training curriculum that allows surgical trainees to learn and develop technical skills in the skills laboratory. Proficiency-based performance parameters provide a goal for training such that the trainees must repeat tasks until they reach proficiency. This program enhances a trainee’s technical skill before he or she enters the operating room. The FLS is now mandatory for completion of a surgical residency program [21, 22].
Because SSLS provides a very different challenge in terms of the technical skills required, it could be suggested that specific and separate technical skills training programs should be available for surgeons that wish to learn SSLS at both a junior level and a senior level where an established surgeon aspires to extend his or her practice. Currently, no specific technical skills training programs for SSLS are available to all surgeons. Because FLS currently is the gold standard for teaching and training surgeons to perform laparoscopic surgery, potentially it could be modified for use as an appropriate training platform for learning SSLS skills.
This study aimed to investigate the impact that previous laparoscopic surgical experience has on ability to perform SSLS. The secondary aim was to investigate whether current laparoscopic technical skills training curricula can be modified and used to teach SSLS by demonstrating the construct validity of the modified FLS tasks.
Methods and materials
This study recruited 18 surgeons of varying laparoscopic and SSLS experience including 12 novice laparoscopic, novice SSLS surgeons (novice group: performed less than 5 laparoscopic or SSLS cholecystectomies), 4 experienced laparoscopic, novice SSLS surgeons (intermediate group: performed more than 25 laparoscopic but less than 5 SSLS cholecystectomies), and 2 experienced laparoscopic, experienced SSLS surgeons (experienced group: performed more than 25 laparoscopic and more than 25 SSLS cholecystectomies).
Technical skills assessment
All the participants were asked to complete the tasks using both a traditional multiport laparoscopic (LAP) approach and an SSLS approach. Standard and roticulating graspers, scissors, endoloops, and needleholders were supplied to the participants.
The study was designed using a randomized crossover procedure such that half of the participants performed the tasks using an SSLS approach first and half of the participants performed the tasks using a LAP approach first. This was done to alleviate any learning effect that could occur by repeating tasks.
Assessment of performance
The participants were assessed for quality of performance and for dexterity in performing the tasks. Quality was assessed using FLS performance parameters, with time and error scores for each task. Dexterity analysis was performed using the Imperial college surgical assessment device (ICSAD). The ICSAD requires motion-tracking sensors to be placed on the dorsum of the surgeon’s hands. These sensors can accurately measure a surgeon’s dexterity in performing a task, giving parameters for hand path length and the total number of hand movements. The ICSAD has been widely validated as a surgical assessment tool .
Statistical analysis was performed using the Statistical Package for the Social Sciences version 18.0 (SPSS, Chicago, IL, USA). The data analyzed were nonparametric. Unpaired data were assessed using the Mann–Whitney U test, and paired data were assessed using the Wilcoxon signed rank test.
The intermediate group demonstrated no significant difference in performance between use of a LAP approach and use of an SSLS approach for any of the four tasks in terms of time, dexterity analysis, or FLS error score (Figs. 2, 3, 4, 5). This was reciprocated by the experienced group, with no significant difference in performance between a LAP approach and an SSLS approach for any of the tasks in terms of any performance parameters (Figs. 2, 3, 4, 5).
To demonstrate construct validity, novice performance was compared with experienced performance. Three of the SSLS tasks demonstrated significant differences between the performances of novice and experienced surgeons (P < 0.05). The SSLS precision cutting task demonstrated significant differences in time (median, 191.9 vs. 609.5 s; P = 0.028) (Fig. 2), error score (median, 1.5 vs. 7.5; P = 0.027), and path length (median, 11.08 vs. 53.45 m; P = 0.028) but not in hand movements (P > 0.05) The SSLS peg transfer task demonstrated significant differences between novice and experienced surgeons performance in time (median, 180.9 vs. 462.4 s; P = 0.028) (Fig. 4) and path length (median, 14.96 vs. 34.99 m, P = 0.029) but not in error score or hand movements (P > 0.05). The SSLS intracorporeal suture task demonstrated significant differences in time (median, 709.9 vs. 992.1 s; P = 0.045) (Fig. 2) and error score (median, 0 vs. 7.5; P = 0.035) but not in path length or hand movements (P > 0.05). The SSLS endoloop task did not demonstrate construct validity. No differences were found between the novice and experienced groups in any parameter (P > 0.05) (Fig. 5).
Further intergroup analysis demonstrated significant differences in performance between the novice and intermediate groups for three SSLS tasks. The SSLS peg transfer showed significant differences in time only (median, 280.3 vs 462.4 s; p = 0.029), but not in error score, path length, or hand movements (P > 0.05). The SSLS endoloop task demonstrated a significant difference in time (median, 105.2 vs. 224.1 s; P = 0.018) and error score (median, 0 vs. 1.5; P = 0.018) but not in path length or hand movements (P > 0.05). The SSLS intracorporeal suture task demonstrated significant differences in time only (median, 661.5 vs 992.1 s; P = 0.045), but not in error score, path length, or hand movements (P > 0.05).
There was no significant difference in performance for any SSLS task in terms of any parameter between the intermediate and experienced groups.
In this study, we concluded that novice laparoscopic surgeons perform basic SSLS tasks worse than they perform basic laparoscopic tasks. However, as laparoscopic experience increases, surgeons can perform basic SSLS tasks to a level similar to their level of performing basic laparoscopic tasks. This implies that surgeons who are board certified and trained in advanced laparoscopic surgery can perform basic SSLS tasks to a level similar to their performance level for traditional laparoscopic tasks. In addition, they can perform basic SSLS tasks to a level similar to that of an experienced SSLS surgeon. This is an important finding because it provides evidence that despite the differences in technical skills required for traditional laparoscopic surgery and SSLS, the skills developed for the competent performance of laparoscopic surgery provide surgeons with the skills necessary to perform SSLS.
The secondary aim of this study was to analyze whether current laparoscopic training curricula may be used to learn SSLS. Before a simulator can be used for teaching and training, it must be validated. Construct validity, the most important validity required, demonstrates that a simulator can distinguish between the performances of novice and experienced surgeons. This allows proficiency criteria to be set, with novice surgeons practicing tasks until they can perform them to the level of an experienced surgeon.
This study demonstrated that construct validity has been established for three of the SSLS FLS tasks (peg transfer, endoloop, and intracorporeal suture), with significant differences demonstrated between novice and experienced performances of the tasks. This implies that with modification of the FLS box to allow entry of the SSLS port, the FLS tasks are valid for SSLS training. However, it must be mentioned that this would be appropriate only for inexperienced laparoscopic surgeons because findings clearly show that the benefit to experienced laparoscopic surgeons is minimal.
Previous research in this field demonstrates results that conflict with those demonstrated in this study. Santos et al.  performed a similar study to assess the impact that previous laparoscopic experience has on the ability to perform SSLS. Using medical students, surgical residents, and attending surgeons, their study analyzed laparoscopic performance followed by SSLS performance of the FLS tasks. Their findings demonstrated significant differences between SSLS and laparoscopic performance on all tasks.
The conclusions of Santos et al.  differ from those provided in the current study. This may be explained by the difference in participant selection. Their study analyzed only qualified surgical residents and attending surgeons. In addition, Santos et al.  analyzed only the total FLS score, whereas the current study also analyzed the dexterity required to perform the tasks. This also could explain the discrepancy in the findings.
The results of this study could suggest that the development of a dedicated SSLS training program is pointless because laparoscopic surgical training using current methods provides the technical skills required to perform SSLS. However, surgical trainees have already had a reduction in training opportunities available to them due to a reduction in their working hours. Therefore, as the number of SSLS cases increases, which would be limited to experienced laparoscopic surgeons, it will further decrease the number of potential training opportunities for traditional laparoscopic surgery available to surgical trainees. It is clear from this study that inexperienced surgeons perform SSLS tasks worse than they perform traditional laparoscopic tasks, and that as such, it is inappropriate for inexperienced surgeons to attempt SSLS procedures without prior SSLS training. Therefore, to increase the amount of training opportunities available to surgical trainees, it is vital to develop dedicated SSLS training curricula that allow enhancement of SSLS technical skills in the skills laboratory before entrance to the operating room.
Despite the positive finding in this study, a number of its limitations should be discussed. The study clearly demonstrated construct validity for three of the FLS tasks. However, this was based on an experienced group of only two surgeons, which was very small. At the time of data collection for the study, only two experienced SSLS surgeons were available at our institution. It would have been beneficial if more surgeons could have participated in the study, with potentially equal numbers of surgeons in each group. This could have increased the significance of the findings.
Another limitation of this study was the selection of tasks. One of the aims was to establish the construct validity of the FLS training tasks. However, the disadvantage of using the FLS tasks was that they are only basic laparoscopic tasks and may not provide a sufficient challenge to experienced laparoscopic surgeons. Although the intermediate group (experienced laparoscopic, inexperienced SSLS surgeons) performed laparoscopic tasks and SSLS tasks to similar levels, it could be suggested that increasing the complexity of the task would have begun to demonstrate differences between laparoscopic and SSLS performances. In addition, performing the FLS tasks is not as challenging as performing an SSLS cholecystectomy or appendectomy. Therefore, although this study concluded that experienced laparoscopic surgeons can perform laparoscopic and SSLS tasks to similar levels, it does not imply that they also can perform laparoscopic and SSLS cholecystectomies to similar levels.
An additional limitation of this study was the validation process for the tasks. Although the study established construct validity, it did not attempt to establish any other forms of validity. Content validity is an important form of validation established by experts that assesses the appropriateness of a simulator as a teaching modality. The FLS was designed for traditional laparoscopic surgery, and it may be that the individual tasks are not appropriate for SSLS. For example, intracorporeal suture may not be performed in an SSLS manner because specific suturing instruments may be used instead.
A further limitation was that this study analyzed only one attempt at the tasks. Therefore, it assessed only the ability to perform SSLS, with no conclusion about the possible learning potential. It would be useful to analyze the learning curves for the tasks, assessing how long and how often trainees should perform the tasks to reach the performance level of an experienced surgeon.
The SSLS approach is a new and innovative advancement in the provision of general surgery. The SSLS approach is challenging, and there are many differences between the technical skills required to perform traditional laparoscopic surgery and those used for SSLS procedures. Although experienced laparoscopic surgeons are able to perform basic SSLS tasks to a level similar to that for laparoscopic tasks, this is not the case for novice surgeons because inexperienced surgeons perform SSLS tasks worse than they perform laparoscopic tasks.
Simulation is used routinely for traditional laparoscopic surgical training to enhance skills in the skills laboratory and to make junior surgeons safer when they enter the operating room. This should be reciprocated for SSLS training. Therefore, if junior surgeons wish to take part in SSLS operations as the primary or assistant surgeon, it should be compulsory for them to complete some form of basic SSLS training.
In addition, this study demonstrated that three of the FLS tasks have construct validity and could be used for teaching and training. However, more work is needed to identify the key important techniques required to perform SSLS operations and to discover how they can be incorporated into a specific training curriculum. Additional future work also should investigate the impact on SSLS performance by experienced laparoscopic surgeons when the complexity of task and the learning curve are increased in the operating room.
Rajesh Aggarwal is funded by a Clinician Scientist Award from the National Institute for Health Research. Trystan Lewis, Richard Kwasnicki, Ara Darzi, and Paraskevas Paraskeva have no financial disclosures or financial ties to disclose.