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



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.


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.


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).


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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Correspondence to Rana M. Higgins.

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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).

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