Impact of one-to-one tutoring on fundamentals of laparoscopic surgery (FLS) passing rate in a single center experience outside the United States: a randomized controlled trial

  • Federico Gheza
  • Paolo Raimondi
  • Leonardo Solaini
  • Federico Coccolini
  • Gian Luca Baiocchi
  • Nazario Portolani
  • Guido Alberto Massimo Tiberio



Outside the US, FLS certification is not required and its teaching methods are not well standardized. Even if the FLS was designed as “stand alone” training system, most of Academic Institution offer support to residents during training. We present the first systematic application of FLS in Italy.

Our aim was to evaluate the role of mentoring/coaching on FLS training in terms of the passing rate and global performance in the search for resource optimization.


Sixty residents in general surgery, obstetrics & gynecology, and urology were selected to be enrolled in a randomized controlled trial, practicing FLS with the goal of passing a simulated final exam. The control group practiced exclusively with video material from SAGES, whereas the interventional group was supported by a mentor.


Forty-six subjects met the requirements and completed the trial. For the other 14 subjects no results are available for comparison. One subject for each group failed the exam, resulting in a passing rate of 95.7%, with no obvious differences between groups. Subgroup analysis did not reveal any difference between the groups for FLS tasks.


We confirm that methods other than video instruction and deliberate FLS practice are not essential to pass the final exam. Based on these results, we suggest the introduction of the FLS system even where a trained tutor is not available. This trial is the first single institution application of the FLS in Italy and one of the few experiences outside the US.

Trial Number: NCT02486575 (


Laparoscopy FLS Training Randomized trial Tutoring Italy 



The authors are grateful to all the residents who participated in this TRIAL. We would like to express sincere gratitude to Luisa Ciullo, Director of the administrative operations at our Institution, for the coordination and the logistic support.


No funds received for this study.

Compliance with ethical standards


Federico Gheza, Paolo Raimondi, Leonardo Solaini, Federico Coccolini, Gian Luca Baiocchi, Nazario Portolani, and GuidoAlberto Massimo Tiberio have no conflicts of interest or financial ties to disclose.


  1. 1.
    Hutter MM, Kellogg KC, Ferguson CM, Abbott WM, Warshaw AL (2006) The impact of the 80-h resident workweek on surgical residents and attending surgeons. Ann Surg 243:864–871CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Palter VN, Grantcharov TP (2014) Individualized deliberate practice on a virtual reality simulator improves technical performance of surgical novices in the operating room: a randomized controlled trial. Ann Surg 259:443–448CrossRefPubMedGoogle Scholar
  3. 3.
    Peters JH, Fried GM, Swanstrom LL, Soper NJ, Sillin LF, Schirmer B, Hoffman K, SAGES FLS Committee (2004) Development and validation of a comprehensive program of education and assessment of the basic fundamentals of laparoscopic surgery. Surgery 135: 21–27CrossRefPubMedGoogle Scholar
  4. 4.
    Zendejas B, Ruparel RK, Cook DA (2016) Validity evidence for the fundamentals of laparoscopic surgery (FLS) program as an assessment tool: a systematic review. Surg Endosc 30:512–520CrossRefPubMedGoogle Scholar
  5. 5.
    Soper NJ, Fried GM (2008) The fundamentals of laparoscopic surgery: its time has come. Bull Am Coll Surg 93:30–32PubMedGoogle Scholar
  6. 6.
    Giannotti D, Casella G, Patrizi G, Di Rocco G, Castagneto-Gissey L, Metere A, Bernieri MG, Vestri AR, Redler A (2015) Spider surgical system versus multiport laparoscopic surgery: performance comparison on a surgical simulator. BMC Surg 15:54CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Bedada AG, Hsiao M, Bakanisi B, Motsumi M, Azzie G (2015) Establishing a contextually appropriate laparoscopic program in resource-restricted environments experience in Botswana. Ann Surg 261:807–811CrossRefPubMedGoogle Scholar
  8. 8.
    Okrainec A, Smith L, Azzie G (2009) Surgical simulation in Africa: the feasibility and impact of a 3-day fundamentals of laparoscopic surgery course. Surg Endosc 23:2493–2498CrossRefPubMedGoogle Scholar
  9. 9.
    Laubert T, Esnaashari H, Auerswald P, Höfer A, Thomaschewski M, Bruch HP, Keck T, Benecke C (2017) Conception of the Lübeck toolbox curriculum for basic minimally invasive surgery skills. Langenbecks Arch Surg. PubMedGoogle Scholar
  10. 10.
    Esposito C, Escolino M, Saxena A, Montupet P, Chiarenza F, De Agustin J, Draghici IM, Cerulo M, Sagaon MM, Di Benedetto V, Gamba P, Settimi A, Najmaldin A (2015) European Society of Pediatric Endoscopic Surgeons (ESPES) guidelines for training program in pediatric minimally invasive surgery. Pediatr Surg Int 31(4):367–373CrossRefPubMedGoogle Scholar
  11. 11.
    Goldin SB, Horn GT, Schnaus MJ, Grichanik M, Ducey AJ, Nofsinger C, Hernandez DJ, Shames ML, Singh RP, Brannick MT (2014) FLS skill acquisition: a comparison of blocked vs interleaved practice. Surg Educ 71:506–512CrossRefGoogle Scholar
  12. 12.
    Cassera MA, Zheng B, Swanström LL (2012) Data-based self-study guidelines for the fundamentals of laparoscopic surgery examination. Surg Endosc 26:3426–3429CrossRefPubMedGoogle Scholar
  13. 13.
    Orzech N, Palter VN, Reznick RK, Aggarwal R, Grantcharov TP (2012) A comparison of 2 ex vivo training curricula for advanced laparoscopic skills: a randomized controlled trial. Ann Surg 255:833–839CrossRefPubMedGoogle Scholar
  14. 14.
    Bonrath EM, Dedy NJ, Gordon LE, Grantcharov TP (2015) Comprehensive surgical coaching enhances surgical skill in the operating room: a randomized controlled trial. Ann Surg 262:205–212CrossRefPubMedGoogle Scholar
  15. 15.
    Mutabdzic D, Mylopoulos M, Murnaghan ML, Patel P, Zilbert N, Seemann N, Regehr G, Moulton CA (2015) Coaching surgeons: is culture limiting our ability to improve? Ann Surg 262:213–216CrossRefPubMedGoogle Scholar
  16. 16.
    Greenberg CC, Klingensmith ME (2015) The continuum of coaching: opportunities for surgical improvement at all levels. Ann Surg 262:217–219CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Singh P, Aggarwal R, Tahir M, Pucher PH, Darzi A (2015) A randomized controlled study to evaluate the role of video-based coaching in training laparoscopic skills. Ann Surg 261:862–869CrossRefPubMedGoogle Scholar
  18. 18.
    Placek SB, Franklin BR, Haviland SM, Wagner MD, O’Donnell MT, Cryer CT, Trinca KD, Silverman E, Matthew Ritter E (2017) Outcomes of fundamentals of laparoscopic surgery (FLS) mastery training standards applied to an ergonomically different, lower cost platform. Surg Endosc 31:2616–2622CrossRefPubMedGoogle Scholar
  19. 19.
    Franklin BR, Placek SB, Wagner MD, Haviland SM, O’Donnell MT, Ritter EM (2017) Cost comparison of fundamentals of laparoscopic surgery training completed with standard fundamentals of laparoscopic surgery equipment versus low-cost equipment. J Surg Educ 74:459–465Google Scholar
  20. 20.
    Boyd T, Jung I, Van Sickle K, Schwesinger W, Michalek J, Bingener J (2008) Music experience influences laparoscopic skills performance. JSLS 12:292–294PubMedPubMedCentralGoogle Scholar
  21. 21.
    Madan AK, Frantzides CT, Park WC, Tebbit CL, Kumari NV, O’Leary PJ (2005) Predicting baseline laparoscopic surgery skills. Surg Endosc 19:101–104CrossRefPubMedGoogle Scholar
  22. 22.
    Kolozsvari NO, Kaneva P, Brace C, Chartrand G, Vaillancourt M, Cao J, Banaszek D, Demyttenaere S, Vassiliou MC, Fried GM, Feldman LS (2011) Mastery versus the standard proficiency target for basic laparoscopic skill training: effect on skill transfer and retention. Surg Endosc 25:2063–2070CrossRefPubMedGoogle Scholar
  23. 23.
    Gallagher AG, Satava RM (2015) Surgical simulation: seeing the bigger picture and asking the right questions. Ann Surg 262:e50–e51CrossRefPubMedGoogle Scholar
  24. 24.
    Kowalewski TM, White LW, Lendvay TS, Jiang IS, Sweet R, Wright A, Hannaford B, Sinanan MN (2014) Beyond task time: automated measurement augments fundamentals of laparoscopic skills methodology. J Surg Res 192:329–338CrossRefPubMedGoogle Scholar
  25. 25.
    Cavallo F, Pietrabissa A, Megali G, Troia E, Sinigaglia S, Dario P, Mosca F, Cuschieri A (2012) Proficiency assessment of gesture analysis in laparoscopy by means of the surgeon’s musculo-skeleton model. Ann Surg 255:394–398CrossRefPubMedGoogle Scholar
  26. 26.
    Stefanidis D, Yonce TC, Korndorffer JR (2013) Does the incorporation of motion metrics into the existing FLS metrics lead to improved skill acquisition on simulators? A single blinded, randomized controlled trial. Ann Surg 258:46–52CrossRefPubMedGoogle Scholar
  27. 27.
    Aggarwal R, Grantcharov T, Moorthy K, Hance J, Darzi A (2006) A competency-based virtual reality training curriculum for the acquisition of laparoscopic psychomotor skill. Am J Surg 191:128–133CrossRefPubMedGoogle Scholar
  28. 28.
    Brunner WC, Korndorffer JR, Sierra R, Massarweh NN, Dunne JB, Yau CL, Scott DJ (2004) Laparoscopic virtual reality training: are 30 repetitions enough? J Surg Res 122:150–156CrossRefPubMedGoogle Scholar
  29. 29.
    Gallagher AG, Ritter EM, Champion H, Higgins G, Fried MP, Moses G, Smith CD, Satava RM (2005) Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training. Ann Surg 241:364–372CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Brinkman WM, Buzink SN, Alevizos L, de Hingh IH, Jakimowicz JJ (2012) Criterion-based laparoscopic training reduces total training time. Surg Endosc 26:1095–1101CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Surgical ClinicUniversity of BresciaBresciaItaly
  2. 2.Department of Medical, Oral and Biotechnological ScienceUniversity G. d’AnnunzioChietiItaly
  3. 3.General, Emergency and Trauma SurgeryPapa Giovanni XXIII HospitalBergamoItaly

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