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Preparing for and passing the fundamentals of laparoscopic surgery (FLS) exam improves general surgery resident operative performance and autonomy

  • 2023 SAGES Oral
  • Published:
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Abstract

Background

The American Board of Surgery made the Fundamentals of Laparoscopic Surgery (FLS) exam a prerequisite for board certification in 2009. Some residency programs have questioned the need for a continued FLS testing mandate given limited evidence that supports the impact of FLS on intraoperative skills. The Society for Improving Medical Professional Learning (SIMPL) app is a tool to evaluate resident intraoperative performance. We hypothesized that general surgery resident operative performance would improve immediately after preparing for the FLS exam.

Methods

The national public FLS data registry was matched with SIMPL resident evaluations from 2015 to 2021 and de-identified. SIMPL evaluations are scored in three categories: supervision required (Zwisch scale 1–4, 1 = show and tell and 4 = supervision only), performance (scale 1–5, 1 = exceptional and 5 = unprepared), and case complexity (scale 1–3, 1 = easiest and 3 = hardest). Statistical analyses compared pre and post-FLS exam resident average operative evaluation scores.

Results

There were a total of 76 general surgery residents, and 573 resident SIMPL evaluations included in this study. Residents required more supervision in laparoscopic cases performed before compared to after the FLS exam (2.84 vs. 3.03, respectively, p = 0.007). Residents performance scores improved from cases before compared to after the FLS exam (2.70 vs. 2.43, respectively, p = 0.001). Case complexity did not differ before versus after the FLS exam (2.13 vs. 2.18, respectively, p = 0.202). PGY level significantly predicted evaluation scores with a moderate correlation. A sub analysis grouped by PGY level revealed a significant improvement after the FLS exam in supervision among PGY-2 residents (2.33 vs. 2.58, respectively, p = 0.04) and performance among PGY-4 residents (2.67 vs 2.04, respectively, p < 0.001).

Conclusions

Preparation for, and passing, the FLS exam improves resident intraoperative laparoscopic performance and independence. We recommend taking the exam in the first two years of residency to enhance the laparoscopic experience for the remainder of training.

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References

  1. Buia A, Stockhausen F, Hanisch E (2015) Laparoscopic surgery: a qualified systematic review. World J Methodol 5(4):238–254. https://doi.org/10.5662/wjm.v5.i4.238

    Article  PubMed  PubMed Central  Google Scholar 

  2. St John A, Caturegli I, Kubicki NS, Kavic SM (2020) The rise of minimally invasive surgery: 16 year analysis of the progressive replacement of open surgery with laparoscopy. JSLS 24(4):e2020.00076. https://doi.org/10.4293/JSLS.2020.00076

    Article  PubMed  PubMed Central  Google Scholar 

  3. 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(2):512–520. https://doi.org/10.1007/s00464-015-4233-7

    Article  PubMed  Google Scholar 

  4. Lerner V, DeStephano C, Ulrich A, Han ES, LeClaire E, Chen CCG (2021) A systematic review of validity evidence for the fundamentals of laparoscopic surgery examination in gynecology. J Minim Invasive Gynecol 28(7):1313–1324. https://doi.org/10.1016/j.jmig.2021.04.010

    Article  PubMed  Google Scholar 

  5. McCluney AL, Vassiliou MC, Kaneva PA et al (2007) FLS simulator performance predicts intraoperative laparoscopic skill. Surg Endosc 21(11):1991–1995. https://doi.org/10.1007/s00464-007-9451-1

    Article  CAS  PubMed  Google Scholar 

  6. Sroka G, Feldman LS, Vassiliou MC, Kaneva PA, Fayez R, Fried GM (2010) Fundamentals of laparoscopic surgery simulator training to proficiency improves laparoscopic performance in the operating room-a randomized controlled trial. Am J Surg 199(1):115–120. https://doi.org/10.1016/j.amjsurg.2009.07.035

    Article  PubMed  Google Scholar 

  7. Antosh DD, Auguste T, George EA et al (2013) Blinded assessment of operative performance after fundamentals of laparoscopic surgery in gynecology training. J Minim Invasive Gynecol 20(3):353–359. https://doi.org/10.1016/j.jmig.2012.12.004

    Article  PubMed  Google Scholar 

  8. Quillin RC 3rd, Cortez AR, Garcia MA et al (2019) Gas off, room lights on: shedding light on the surgical resident’s experience in open and laparoscopic surgery. Surgery 166(4):460–468. https://doi.org/10.1016/j.surg.2019.04.042

    Article  PubMed  Google Scholar 

  9. Dubina ED, Pham XD, de Virgilio C (2019) Debunking myths about the purpose and intentions of fundamentals of laparoscopic surgery testing-reply. JAMA Surg 154(5):468–469. https://doi.org/10.1001/jamasurg.2018.5590

    Article  PubMed  Google Scholar 

  10. George BC, Teitelbaum EN, Meyerson SL et al (2014) Reliability, validity, and feasibility of the Zwisch scale for the assessment of intraoperative performance. J Surg Educ 71(6):e90–e96. https://doi.org/10.1016/j.jsurg.2014.06.018

    Article  PubMed  Google Scholar 

  11. Bergquist CS, Pienta MJ, Sood V et al (2021) Smartphone-based app for evaluating cardiothoracic residents: feasibility and engagement. J Card Surg 36(12):4684–4687. https://doi.org/10.1111/jocs.16016

    Article  PubMed  Google Scholar 

  12. Bohnen JD, George BC, Williams RG et al (2016) The feasibility of real-time intraoperative performance assessment with SIMPL (System for improving and measuring procedural learning): early experience from a multi-institutional trial. J Surg Educ 73(6):e118–e130. https://doi.org/10.1016/j.jsurg.2016.08.010

    Article  PubMed  Google Scholar 

  13. Shekar R, George BC, Bohnen JD, Villa A (2018) A SIMPL application to assess oral medicine residents’ performance and level of autonomy. Oral Surg Oral Med Oral Pathol Oral Radiol 126(3):246–251. https://doi.org/10.1016/j.oooo.2018.05.017

    Article  PubMed  Google Scholar 

  14. Wang RS, Daignault-Newton S, Ambani SN, Hafez K, George BC, Kraft KH (2021) Simplifying urology residency operative assessments: a pilot study in urology training. J Urol 206(4):1009–1019. https://doi.org/10.1097/JU.0000000000001874

    Article  PubMed  Google Scholar 

  15. Zendejas B, Lillehei CW, George BC, Modi BP (2020) Assessment of operative autonomy and readiness for independent practice among pediatric surgery fellows. J Pediatr Surg 55(1):117–121. https://doi.org/10.1016/j.jpedsurg.2019.09.061

    Article  PubMed  Google Scholar 

  16. Miles S, Donnellan N (2021) Learning fundamentals of laparoscopic surgery manual skills: an institutional experience with remote coaching and assessment. Mil Med. https://doi.org/10.1093/milmed/usab170

    Article  Google Scholar 

  17. Karim AS, Sternbach JM, Bender EM, Zwischenberger JB, Meyerson SL (2017) Quality of operative performance feedback given to thoracic surgery residents using an app-based system. J Surg Educ 74(6):e81–e87

    Article  PubMed  Google Scholar 

  18. Alevi D, Baiocco PJ, Chokhavatia S et al (2010) Teaching the competencies: using observed structured clinical examinations for faculty development. Am J Gastroenterol 105(5):973–977

    Article  PubMed  Google Scholar 

  19. Naples R, French JC, Thomas JD, Khandelwal C, Rosen MJ, Lipman JM (2021) Utilization of a quality reporting system to increase faculty participation in resident operative assessment. Surgery 169(3):483–487

    Article  PubMed  Google Scholar 

  20. Abdou H, Kidd-Romero S, Brown RF, Kavic SM, Kubicki NS (2022) Keep it SIMPL: improved feedback after implementation of an app-based feedback tool. Am Surg 88(7):1475–1478. https://doi.org/10.1177/00031348221082279

    Article  PubMed  Google Scholar 

  21. Cullinan DR, Schill MR, DeClue A, Salles A, Wise PE, Awad MM (2017) Fundamentals of laparoscopic surgery: not only for senior residents. J Surg Educ 74(6):e51–e54. https://doi.org/10.1016/j.jsurg.2017.07.017

    Article  PubMed  PubMed Central  Google Scholar 

  22. Schmiederer IS, Kearse LE, Jensen RM et al (2022) The fundamentals of laparoscopic surgery in general surgery residency: fundamental for junior residents’ self-efficacy. Surg Endosc. https://doi.org/10.1007/s00464-022-09443-z

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Minimally Invasive and Gastrointestinal Surgery, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA

    Rana M. Higgins, Mia S. Turbati & Matthew I. Goldblatt

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  1. Rana M. Higgins
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  2. Mia S. Turbati
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  3. Matthew I. Goldblatt
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Correspondence to Rana M. Higgins.

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Disclosures

Dr. Rana Higgins is a speaker for WL Gore and Intuitive Surgical. Mia Turbati has no conflicts of interest or financial ties to disclose. Dr. Matthew Goldblatt has the following disclosures: speaker, consultant, and researcher for W.L. Gore; speaker, consultant, and researcher for Medtronic; and proctor for Intuitive.

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Higgins, R.M., Turbati, M.S. & Goldblatt, M.I. Preparing for and passing the fundamentals of laparoscopic surgery (FLS) exam improves general surgery resident operative performance and autonomy. Surg Endosc 37, 6438–6444 (2023). https://doi.org/10.1007/s00464-023-10124-8

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