Surgical Endoscopy

, Volume 24, Issue 3, pp 616–623 | Cite as

Malpractice carrier underwrites Fundamentals of Laparoscopic Surgery training and testing: a benchmark for patient safety

  • Alexandre Y. Derevianko
  • Steven D. Schwaitzberg
  • Shawn Tsuda
  • Limaris Barrios
  • David C. Brooks
  • Mark P. Callery
  • David Fobert
  • Noel Irias
  • David W. Rattner
  • Daniel B. Jones



Fundamentals of Laparoscopic Surgery (FLS) is a validated program developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) to educate and assess competency in minimally invasive surgery (MIS). This study reports the first malpractice carrier–sponsored FLS course for surgeons in practice underwritten by the Controlled Risk Insurance Company of Harvard’s Risk Management Foundation (CRICO/RMF). The study investigated the participating surgeons’ pattern of MIS skills acquisition, subjective laparoscopic comfort level, operative activity, and perception of the FLS role in surgical education, credentialing, and patient safety.


A 1-day postgraduate continuous medical education (CME) course consisted of didactic presentations of the leading MIS faculty, proctored FLS hands-on training, psychomotor testing, and cognitive computer-based examination. Voluntary anonymous pre- and postcourse surveys were distributed to the participants at registration and at completion of both the didactic teaching and the skills modules of the program.


The course was attended by 37 practicing surgeons in the Harvard system, and 86% of the survey forms were returned. The major driving forces for attending the course were directive from the chief/chairman (50%), improvement in MIS didactic knowledge (56%), and the belief that FLS would become a standard such as advanced trauma life support (ATLS), advanced cardiac life support (ACLS), or the like (53%). Surgeons reported that the FLS exam content was appropriate (Likert 4.41 ± 0.91) and that mastery of the course material would improve safety (Likert 4.13 ± 0.79) and technical knowledge of MIS (Likert 4.03 ± 1.00).


This unique cooperative effort between a liability carrier, a professional surgical society, and proactive surgeons should be considered a model for advancing competency and patient safety. The survey results indicate a positive view of FLS in surgical training, safety, and MIS education.


Abdominal Clinical papers, trials, research Education Quality control Surgical Training, courses 


  1. 1.
    Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) (2007) Fundamentals of Laparoscopic Surgery (FLS) Program. SAGES, Los Angeles, CAGoogle Scholar
  2. 2.
    Peters JH, Fried GM, Swanstrom LL et al (2004) Development and validation of a comprehensive program of education and assessment of the basic fundamentals of laparoscopic surgery. Surgery 135(1):21–27CrossRefPubMedGoogle Scholar
  3. 3.
    Swanstrom LL, Fried GM, Hoffman KI, Soper NJ (2006) Beta test results of a new system assessing competence in laparoscopic surgery. J Am Coll Surg 202(1):62–69CrossRefPubMedGoogle Scholar
  4. 4.
    Fried GM, Feldman LS, Vassiliou MC et al (2004) Proving the value of simulation in laparoscopic surgery. Ann Surg 240(3):518–525 (discussion 525–528)CrossRefPubMedGoogle Scholar
  5. 5.
    Feldman LS, Hagarty SE, Ghitulescu G et al (2004) Relationship between objective assessment of technical skills and subjective in-training evaluations in surgical residents. J Am Coll Surg 198(1):105–110CrossRefPubMedGoogle Scholar
  6. 6.
    Stefanidis D, Sierra R, Korndorffer JR Jr et al (2006) Intensive continuing medical education course training on simulators results in proficiency for laparoscopic suturing. Am J Surg 191(1):23–27CrossRefPubMedGoogle Scholar
  7. 7.
    Ritter EM, Scott DJ (2007) Design of a proficiency-based skills training curriculum for the fundamentals of laparoscopic surgery. Surg Innov 14(2):107–112CrossRefPubMedGoogle Scholar
  8. 8.
    Fraser SA, Klassen DR, Feldman LS et al (2003) Evaluating laparoscopic skills: setting the pass/fail score for the MISTELS system. Surg Endosc 17(6):964–967CrossRefPubMedGoogle Scholar
  9. 9.
    McCluney AL, Vassiliou MC, Kaneva PA et al (2007) FLS simulator performance predicts intraoperative laparoscopic skill. Surg Endosc 21(11):1991–1995CrossRefPubMedGoogle Scholar
  10. 10.
    Stefanidis D, Korndorffer JR Jr, Markley S et al (2006) Proficiency maintenance: impact of ongoing simulator training on laparoscopic skill retention. J Am Coll Surg 202(4):599–603CrossRefPubMedGoogle Scholar
  11. 11.
    Scott DJ, Ritter EM, Tesfay ST et al (2008) Certification pass rate of 100% for fundamentals of laparoscopic surgery skills after proficiency-based training. Surg Endosc 22(8):1887–1893CrossRefPubMedGoogle Scholar
  12. 12.
    Fried GM (2006) Lessons from the surgical experience with simulators: incorporation into training and utilization in determining competency. Gastrointest Endosc Clin North Am 16(3):425–434CrossRefGoogle Scholar
  13. 13.
    Fraser SA, Feldman LS, Stanbridge D, Fried GM (2005) Characterizing the learning curve for a basic laparoscopic drill. Surg Endosc 19(12):1572–1578CrossRefPubMedGoogle Scholar
  14. 14.
    Dauster B, Steinberg AP, Vassiliou MC et al (2005) Validity of the MISTELS simulator for laparoscopy training in urology. J Endourol 19(5):541–545CrossRefPubMedGoogle Scholar
  15. 15.
    Derossis AM, Antoniuk M, Fried GM (1999) Evaluation of laparoscopic skills: a 2-year follow-up during residency training. Can J Surg 42(4):293–296PubMedGoogle Scholar
  16. 16.
    Derossis AM, Bothwell J, Sigman HH, Fried GM (1998) The effect of practice on performance in a laparoscopic simulator. Surg Endosc 12(9):1117–1120CrossRefPubMedGoogle Scholar
  17. 17.
    Derossis AM, Fried GM, Abrahamowicz M et al (1998) Development of a model for training and evaluation of laparoscopic skills. Am J Surg 175(6):482–487CrossRefPubMedGoogle Scholar
  18. 18.
    Fried GM, Derossis AM, Bothwell J, Sigman HH (1999) Comparison of laparoscopic performance in vivo with performance measured in a laparoscopic simulator. Surg Endosc 13(11):1077–1181 (discussion 1082)CrossRefPubMedGoogle Scholar
  19. 19.
    Vassiliou MC, Ghitulescu GA, Feldman LS et al (2006) The MISTELS program to measure technical skill in laparoscopic surgery: evidence for reliability. Surg Endosc 20(5):744–747CrossRefPubMedGoogle Scholar
  20. 20.
    Feldman LS, Sherman V, Fried GM (2004) Using simulators to assess laparoscopic competence: ready for widespread use? Surgery 135(1):28–42CrossRefPubMedGoogle Scholar
  21. 21.
    Fried GM (2005) The Steinberg-Bernstein Centre for minimally invasive surgery at McGill University. Surg Innov 12(4):345–348CrossRefPubMedGoogle Scholar
  22. 22.
    Gunther S, Rosen J, Hannaford B, Sinanan M (2007) The red DRAGON: a multimodality system for simulation and training in minimally invasive surgery. Stud Health Technol Inform 125:149–154PubMedGoogle Scholar
  23. 23.
    Hsu KE, Man FY, Gizicki RA et al (2008) Experienced surgeons can do more than one thing at a time: effect of distraction on performance of a simple laparoscopic and cognitive task by experienced and novice surgeons. Surg Endosc 22(1):196–201CrossRefPubMedGoogle Scholar
  24. 24.
    Keyser EJ, Derossis AM, Antoniuk M et al (2000) A simplified simulator for the training and evaluation of laparoscopic skills. Surg Endosc 14(2):149–153CrossRefPubMedGoogle Scholar
  25. 25.
    Korndorffer JR Jr, Dunne JB, Sierra R et al (2005) Simulator training for laparoscopic suturing using performance goals translates to the operating room. J Am Coll Surg 201(1):23–29CrossRefPubMedGoogle Scholar
  26. 26.
    Ritter EM, Kindelan TW, Michael C et al (2007) Concurrent validity of augmented reality metrics applied to the fundamentals of laparoscopic surgery (FLS). Surg Endosc 21(8):1441–1445CrossRefPubMedGoogle Scholar
  27. 27.
    Powers KA, Rehrig ST, Irias N et al (2008) Simulated laparoscopic operating room crisis: an approach to enhance the surgical team performance. Surg Endosc 22(4):885–900CrossRefPubMedGoogle Scholar
  28. 28.
    Stefanidis D, Acker C, Heniford BT (2008) Proficiency-based laparoscopic simulator training leads to improved operating room skill that is resistant to decay. Surg Innov 15(1):69–73CrossRefPubMedGoogle Scholar
  29. 29.
    Stefanidis D, Korndorffer JR Jr, Black FW et al (2006) Psychomotor testing predicts rate of skill acquisition for proficiency-based laparoscopic skills training. Surgery 140(2):252–262CrossRefPubMedGoogle Scholar
  30. 30.
    Stefanidis D, Korndorffer JR Jr, Scott DJ (2007) Psychomotor testing predicts rate of skill acquisition for proficiency-based laparoscopic skills training. Surgery 141(6):831–832CrossRefPubMedGoogle Scholar
  31. 31.
    Stefanidis D, Korndorffer JR Jr, Markley S et al (2007) Closing the gap in operative performance between novices and experts: does harder mean better for laparoscopic simulator training? J Am Coll Surg 205(2):307–313CrossRefPubMedGoogle Scholar
  32. 32.
    Stefanidis D, Korndorffer JR Jr, Sierra R et al (2005) Skill retention following proficiency-based laparoscopic simulator training. Surgery 138(2):165–170CrossRefPubMedGoogle Scholar
  33. 33.
    Stefanidis D, Scerbo MW, Korndorffer JR Jr, Scott DJ (2007) Redefining simulator proficiency using automaticity theory. Am J Surg 193(4):502–506CrossRefPubMedGoogle Scholar
  34. 34.
    Rehrig ST, Powers K, Jones DB (2008) Integrating simulation in surgery as a teaching tool and credentialing standard. J Gastrointest Surg 12(2):222–233CrossRefPubMedGoogle Scholar
  35. 35.
    Avgerinos DV, Goodell KH, Waxberg S et al (2005) Comparison of the sensitivity of physical and virtual laparoscopic surgical training simulators to the user’s level of experience. Surg Endosc 19(9):1211–1215CrossRefPubMedGoogle Scholar
  36. 36.
    Fried GM (2008) FLS Assessment of competency using simulated laparoscopic tasks. J Gastrointest Surg 12(2):210–212CrossRefPubMedGoogle Scholar
  37. 37.
    Parker WH, Johns A, Hellige J (2007) Avoiding complications of laparoscopic surgery: lessons from cognitive science and crew resource management. J Minim Invasive Gynecol 14(3):379–388CrossRefPubMedGoogle Scholar
  38. 38.
    Tsuda S, Scott D, Doyle J, Jones DB (2009) Surgical skills training and simulation. Curr Probl Surg 46(4):261–372Google Scholar
  39. 39.
    Fried GM (2008) FLS assessment of competency using simulated laparoscopic tasks. J Gastrointest Surg 12(2):210–212CrossRefPubMedGoogle Scholar
  40. 40.
    Holzman RS, Cooper JB, Gaba DM et al (1995) Anesthesia crisis resource management: real-life simulation training in operating room crises. J Clin Anesth 7(8):675–687CrossRefPubMedGoogle Scholar
  41. 41.
    Blum RH, Raemer DB, Carroll JS et al (2004) Crisis resource management training for an anaesthesia faculty: a new approach to continuing education. Med Educ 38(1):45–55CrossRefPubMedGoogle Scholar
  42. 42.
    Jenkins RC, Lemak CH (2007) Innovative teaching for health law: a case study of a hospital medical malpractice lawsuit simulation. J Health Adm Educ 24(1):43–57PubMedGoogle Scholar
  43. 43.
    Raborn GW, Carter RM (1999) Using simulation to evaluate clinical competence after impairment. J Can Dent Assoc 65(7):384–386PubMedGoogle Scholar
  44. 44.
    Berry W (2006) Surgical malpractice: myths and realities. J Med Pract Manage 22(1):50–51PubMedGoogle Scholar
  45. 45.
    Regenbogen SE, Greenberg CC, Studdert DM et al (2007) Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients. Ann Surg 246(5):705–711CrossRefPubMedGoogle Scholar
  46. 46.
    Dunkin B, Adrales GL, Apelgren K, Mellinger JD (2007) Surgical simulation: a current review. Surg Endosc 21(3):357–366CrossRefPubMedGoogle Scholar
  47. 47.
    Singh H, Thomas EJ, Petersen LA, Studdert DM (2007) Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Arch Intern Med 167(19):2030–2036CrossRefPubMedGoogle Scholar
  48. 48.
    Martin JA, Regehr G, Reznick R et al (1997) Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg 84(2):273–278CrossRefPubMedGoogle Scholar
  49. 49.
    Satava RM (2004) Disruptive visions: surgical education. Surg Endosc 18(5):779–781CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Alexandre Y. Derevianko
    • 1
  • Steven D. Schwaitzberg
    • 2
  • Shawn Tsuda
    • 3
  • Limaris Barrios
    • 2
  • David C. Brooks
    • 4
  • Mark P. Callery
    • 1
  • David Fobert
    • 1
  • Noel Irias
    • 1
  • David W. Rattner
    • 5
  • Daniel B. Jones
    • 1
  1. 1.Section of Minimally Invasive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical SchoolBostonUSA
  2. 2.Cambridge Health AllianceCambridgeUSA
  3. 3.University of Nevada School of MedicineLos VegasUSA
  4. 4.Brigham and Women’s HospitalBostonUSA
  5. 5.Massachusetts General HospitalBostonUSA

Personalised recommendations