Assessing practical laparoscopic training in certified Training Centers of the Gynecological Endoscopy Working Group (AGE) of the German Society of Gynecology and Obstetrics (DGGG)

Purpose This study was performed to assess the practical laparoscopic training in Gynecological Endoscopy Working Group (AGE) certified Training Centers (TC) and evaluate the possible implementation for a manual dexterity skills-training within the Minimal Invasive Surgery (MIC) certification process. Material and methods An online questionnaire was developed and the link provided for the heads of the AGE TC. The questionnaire comprised topics on TC organization, practical training performance and perspectives for future training and demographic data. Results Response rate was 78.9% (15/19) of AGE TC. Grasping for the basic and suturing exercises for the advanced curricula, respectively, are thought to be of highest value (each 1.0 ± 0, on a scale from 1 = very valuable to 6 = not at all valuable). Most valuable parameter in assessing training was thought to be pressure/tension with 1.80 ± 1.08 The most valuable training capacity was considered for box training under supervision (1.27 ± 0.59) and feed-back box training with direct evaluation of various surgical skills (1.40 ± 0.63). Supervised box training was also thought to have the most positive influence on surgical performance (1.33 ± 0.49). The majority of respondents (86.7%) were qualified with the highest MIC certification and additional 66.7% were sub-specialized Gynecological Oncologists. Conclusion The AGE certified TC offer a structured curriculum with emphasis on practical training. The results of this questionnaire and the additional respondents comments on value and future perspectives/changes of practical training support the concept and the implementation of a skills-training to the AGE MIC concept.


Introduction
The Gynecological Endoscopy Working Group (AGE) strives for clinical excellence with a structured training and education curriculum in gynecological hysteroscopy and laparoscopy [1]. The AGE, founded in 1993, is part of the German Society of Gynecology and Obstetrics (DGGG) and represents the largest Workgroup of the German Society for Gynecology and Obstetrics (DGGG) with over 1800 members in 2019.
To standardize training and education as well as promote theoretical and clinical expertise, a graded certification module, Minimal Invasive Surgeon (MIC), was developed by the AGE board, discussed and optimized by the AGE council and accepted by the members during a general assembly in 2005 [1,2]. Gynecological specialists and trainees as members of the AGE can apply for accreditation. During the last decade, there was a continuously increasing number of certified AGE members with 1144 certified members (MIC 1: 612, MIC II: 439, MIC III: 93) and 24 Training Centers in 2019. Requirements for application and certification are a defined number of completed hysteroscopic and laparoscopic procedures, conference and work-shop attendances and visits within other departments i.e. A full list of requirements for the different MIC certificates are listed in detail on the AGE homepage (www.ag-endos kopie .de). An overview of personal requirements for MIC and institutional requirements for Trainings Center certification are summarized in Tables 1 and 2.
To further develop and add objective transparency to the MIC certification, the AGE board and members decided in 2016 to incorporate a scientifically based manual dexterity training or skills training to the already established individual certification requirements.
To better define and standardize specific box trainer or box trainer tasks and educational criteria for the skills training, this study aims to assess how the current practical laparoscopy training within certified AGE TC is performed and how to enquire on further perspectives of endoscopy training and skills training within the AGE TC.

Material and methods
An online questionnaire with 29 questions in three parts was developed. The first part comprised nine questions on Training Center organization and their course volumes. The questionnaires second part assessed practical laparoscopic training parameters. Demographic data were collected within the last six questions of part three.
A google account was created for this study and the questionnaire was based on Google Drive platform. The questionnaire is attached in "Appendix 1".
The heads of the AGE MIC Training Centers were invited by email to participate in this online survey between September and November 2016, with closing date 30th November 2016. At the end of October 2016 a reminder email was sent out. The answers were automatically saved on Google Drive and imported and analyzed with PSPP for iOS. Descriptive analysis was performed.  Respondents see a focus on practical training compared to theoretical education as an important characteristic for the basic curricula (57.3% ± 17.9 vs. 40.7% ± 17.1) and the advanced curricula (58.7% ± 21.0 vs. 42.7% ± 19.8). For basic and advanced curricula, box training with different training models and Virtual Reality Simulators were more frequently used then box training with sensors to track instrument/target interactions (Table 3).
While grasping exercises were thought to be most valuable training tools for the basic curricula, needle movement and suture exercises were thought to be most valuable in advanced curricula (Table 4). Additionally, respondents valued suture training and techniques combined with standardization of suturing as highly appreciated tasks for the basic and the advanced curriculum (Table 4). For the Basic Curriculum suggested additional tasks were: 1.Use of 0° and 30° scopes and coordination (3×), 2. Suture techniques (3×), 3. Dissection techniques (1×) and for the Advanced Curriculum: 1. Dissection with demonstration of anatomical structures (1×), 2. Simulation of surgical procedures (2×), 3. Complication management (×2), 4. Standardized suture techniques (4×) and 5. Practical training with objective measurement of skills (1×).
The respondents thought, there is no parameter clearly superior for evaluating participants during box training, however, assessed pressure/tension for the evaluation of tissue handling was thought to be most valuable (Table 4). Additionally, 6/15 respondents suggested further parameter to be of value. These comprised measuring blood loss in virtual reality environment, repetition of tasks and skills, tissue dissection and tissue handling, strategy in solving tasks, following instructions. Most important characteristics and features of box trainer are thought to comprise easiness and flexibility for set up and allowing for individual trocar positioning. The training models and tasks should be train relevant procedures in a structured way and be cost-effective and reusable ( Table 4).
The most valuable training capacity (1 = very valuable, 6 = not at all valuable) was considered for box training under supervision (1.27 ± 0.59) and feedback box training with direct evaluation of various surgical skills (1.40 ± 0.63) ( Table 5). Supervised box training was also thought to have the best positive influence on surgical performance (1.33 ± 0.49) ( Table 5).
Further considerations on value of training for the AGE courses were given from 67% (10/15) of participants.
Ten respondents addressed answers to most important changes in laparoscopic surgical education, these were

Discussion
The institutionally performed endoscopic training within the certified Gynecological Endoscopy Working Group (AGE) Training Centers (TC) in Germany was assessed and evaluated in this study. With fifteen responding AGE The importance of practical training is supported by scientific results showing box training on models and Virtual Reality Training being able to distinguish between novices and experts and directly translate to improved theatre performance and patient outcome [3][4][5][6][7].
Additionally, valuable training tasks are thought to include mainly coordination training within the basic and suture training within the advanced endoscopy courses.
The AGE TC mostly use box training and virtual reality (VR) training for the practical education. They favor standardized, easy to assemble and flexible box trainer with cost effective and reusable models simulating relevant surgical procedures. The variety of examined and published box trainer tasks ranges from raw swaps for suturing to costly and complex installable pulsating organ perfusion (POP) models [8,9]. Furthermore, VR Trainer allow for standardized training in an abstract or near realistic environment [10]. Whereas assessment of skills during box training is mostly subjective by the supervisor or has limited validity, such as time measurement for task completion, more advanced box trainer and VR Trainer assess various parameter (i.e. distance of instrument movement, force/traction and errors).
The inclusion of VR into AGE TC and endoscopy courses is mainly a result of the AGE purchasing a VR Hysteroscopy Trainer in 2010, which can be requested by TC for educational courses. Therefore, experience with VR-trainers, the benefits of objective skills-assessment and direct feedback has gained an important role within the TC. Even though a recent meta-analysis found better laparoscopy performance and time scores in VR training compared to box-training, all other evaluated parameter, regardless of the student's level of experience or type of activity, were equivalent [11].
In our study, AGE TC favor box trainer with sensors to objectively measure instrument movement, tissue handling, errors and time for the ability to evaluate the trainee. Therefore it is likely that TC add more advanced box trainer with objective skill assessment to their curriculum. Additionally, TC estimated all examined parameters to have a valuable role in skills assessment with pressure/tension being the most valuable and errors being the least valuable parameter in this study.
Technically these advanced objective assessments can be done by sensor equipped box trainer, such as the ForceSense system (Medishield) or VR Trainer, such as the LapSim (Surgical Science) [12,13]. However, the AGE TC clearly favor the sensor equipped box trainer over VR trainer. The similar ability to objectively assess trainees and receive instant score results after practice as well at the systems price difference may be an important reason. More than that, VR Trainer are technically more susceptible and the maintenance is more complex compared to box trainer.
The AGE graded sub-certification and the MIC certificate is unique and has become an important qualification tool within the German speaking gynecological field. Other gynecological societies as the International Society for Gynecological Endoscopy (ISGE), the Australian Gynaecological Endoscopy Society (AGES), the British Society for Gynaecological Endoscopy (BSGE) or American Association of Gynecological Laparoscopy (AAGL), to name a few, organize sub-specialized endoscopy courses with main focus on practical training as well, but without a pre-defined curriculum or skills-assessments. Only the European Society of Gynecological Endoscopy (ESGE) promotes a complex educational concept, allowing for graded accreditation [14].
The group of respondents are highly experienced and specialized practitioners with 13 out of 15 being MIC III certified and 67% being sub-specialized in gynecologic oncology. The results of this questionnaire and the additional respondents comments on value and future perspectives/changes of practical training, mainly expecting more standardization and box training with objective assessment tools, are the reason for the AGE to further develop the concept and the implementation of a skills-training to the AGE MIC concept.