The learning of laparoscopic skills presents unique challenges not seen in open surgery, such as a small working space, limited instrument movement, decreased tactile sensation, and counterintuitive manipulation of instruments in a 2-dimensional visual field. To help facilitate the development of laparoscopic skills in postgraduate urologists, the University of California, Irvine has established a 5-day M-R program.
The M-R curriculum was designed to facilitate the acquisition of laparoscopic skills by postgraduate urologists. Faculty members in the Department of Urology give didactic lectures, and hold question and answer sessions with the attendees, on subjects that pertain to the laparoscopic learning curve. These subjects include laparoscopic techniques, such as suturing and knot-tying, and management of complications. Mini-residents practice on a pelvic trainer or a computer-based laparoscopic surgery simulator for 30 minutes twice a day. They initially perform suturing and knot-tying on foam pads with hexagonal markings (), and also skills train on virtual reality simulators. Once proficient suturing is demonstrated on the rudimentary models, the trainees then practice on silicone models that simulate laparoscopic and robot-assisted closure of the collecting system, urethrovesical anastamosis, and pyeloplasty. Finally, near the end of the 5 days, the animal laboratories allow the mini-residents to further apply skills they have learned to laparoscopic or robot-assisted partial nephrectomy, pyeloplasty, and urethrovesical anastamosis, including complex suturing and knot-tying. Practice occurs in a 1:1 or 1:2 instructor to M-R ratio. The fellows in minimally-invasive surgery education and endourology and laparoscopy are the laboratory instructors for the M-R program. Throughout the 5-day M-R, cognitive and technical learning is enhanced by observation of operative cases. Acquisition of laparoscopic skills is assessed by testing mini-residents at the beginning and at the end of the M-R. Robotic and laparoscopic ST scores on ring transfer, suture threading, cutting and suturing improved significantly. This improvement may be a consequence of the focused and intensive M-R curriculum.
Interestingly, the participants enrolled in the robotic module demonstrated no significant improvement in their preand postrobotic skill task scores except in the cutting skill task category. This may reflect the ease by which the surgeons acquire these basic robotic-assisted surgical skills, making them very good performers almost immediately. Alternatively, there may be a much longer learning curve for these skills, and the M-R did not permit sufficient training time to realize improvement. The former seems more likely given the reported ease of surgeons acquiring robotic-assisted surgical procedures versus the laparoscopic counterpart.4
Conversely, the laparoscopic training modules allowed improvement in the pre- and postlaparoscopic skill task scores, suggesting in this more challenging surgical interface the learning curve effect is still being completed even at the conclusion of the educational program. It is anticipated that most in these training groups will require additional skills practice after their initial learning in the training program.
The purpose of this study was to assess whether those taking the course could develop basic laparoscopic and robotic skills, such as general coordination of instruments (ie, ring transfer and suture threading), and surgically oriented skills, such as cutting, and suturing. The results show that laparoscopic and robotic ST scores significantly improved over the 5-day course, while open ST scores did not. It would be expected that open ST scores would not improve following the M-R course, because these types of skills are not formally addressed during the course. The observation that robotic ST scores are significantly higher than the laparoscopic ST scores at both the beginning and the end of the course reflects the greater degree of complexity associated with performing pure laparoscopic skills. As other investigators have demonstrated, basic robotic skills are more easily acquired than are laparoscopic skills.4
The robot facilitates the skill performance by providing an intuitive working format with more precise instrument movement, 3-dimensional visualization, and increased surgeon comfort at the master console. The counterintuitive, 2-dimensional working environment, long instruments fulcrumed at the abdominal wall, and magnification of the surgeon's natural tremor all compound to make laparoscopy a challenging surgical technique.
Some correlation appears to exist between ST scores and age, particularly the robot-assisted ST scores. Urologists older than 54 years of age had significantly poorer scores on suture threading on both days 1 and 5 and ring transfer on day 1. Although robot-assisted suturing was no different between the groups on day 1, urologists older than 54 years had significantly lower scores on day 5 for ring transfer and suture threading. These data suggest that surgeons older than 54 years of age may have poorer fine motor coordination when using the robot and may have more difficulty learning robot-assisted suturing. These surgeons may require a longer training program to reach the same proficiency level as their younger counterparts, although this study did not assess that. Conversely, age does not appear to influence laparoscopic ST scores, including suturing. This may reflect the fact that all surgeons require more training and practice time learning laparoscopic skills than was provided during this 5-day education program. Time since graduation appears to have a less significant impact on ST scores than does age. Only robot suture threading (day 1), open suture threading (day 5), and laparoscopic cutting (day 5) varied significantly with time since graduation.
The M-R program at the University of California, Irvine improves basic laparoscopic and robotic skills, such as fine instrument coordination, cutting, and suturing. The degree of improvement is up to 10% from baseline. The question that remains is whether this degree of improvement translates into improved performance of laparoscopic surgery in the clinical realm. One of the first groups to study the impact of laparoscopy courses on urologists' practice patterns was the Department of Urology at the University of Iowa.1,2
These courses were held over a 2-day period and focused on teaching laparoscopic varicocelectomy and pelvic lymph node dissection. They consisted of 8 hours of didactic lectures, 4.5 hours on pelvic trainers, 4.5 hours on animal models, and observation of 2 live surgery video broadcasts. A questionnaire assessing laparoscopic practice patterns was sent at 1 and 5 years after course completion. Of the 322 urologists that participated in these courses, 166 (51%) responded. The initial results were encouraging with 84% of participants performing some form of laparoscopic surgery at 1-year follow-up.1
However, at 5-year follow-up, only 54% of course participants were performing laparoscopic surgery. The indicated reasons for this decrease in performing laparoscopic procedures included lack of indications for laparoscopic surgery, increased cost, decreased patient interest, higher complication rates, decreased institutional support, and increased operative time.2
A questionnaire on laparoscopic practice patterns was sent to the initial 32 participants in the laparoscopic ablative or reconstructive renal surgery M-R, 1 to 15 months (mean 8 months) after completion of the course.5
The response rate to the questionnaire was 100%. Most (72%) of the participants had prior laparoscopic training during their urology residency. Twenty-six participants (81%) were performing some form of laparoscopic surgery after their M-R. More of the participants were performing laparoscopic radical nephrectomy, nephroureterectomy, and pyeloplasty. Similarly, a questionnaire was sent to the initial 21 participants in the robot-assisted laparoscopic prostatectomy M-R 1 to 14 months (mean, 7.2) later.6
The response rate to this questionnaire was also 100%. Most (80%) of the participants had prior laparoscopic training in their urology residency, and 25% were performing robot-assisted laparoscopic prostatectomy before their M-R. After their M-R, 95% of the participants were performing robot-assisted laparoscopic prostatectomy. These data support the use of a focused, intensive 5-day M-R in assisting postgraduate urologists with the acquisition of laparoscopic and robot-assisted laparoscopic skills that are applicable to their clinical practice. Additional follow-up will reveal the durability of such skills acquisition and elucidate those factors responsible for skills maintenance.
Another method for postgraduate urologists to train in laparoscopic skills is through a mentor-trainee relationship. Shalhav et al7
developed a “mini-fellowship” model that consisted of 3 phases: 1) a 2- to 3-day hands-on course on pelvic trainers and animal laboratories; 2) observing the clinical mentor perform 6 or more major renal laparoscopic procedures; and 3) the trainee performing 6 or more major renal procedures under mentor guidance on the trainee's patients at the mentor's or trainee's hospital. In the initial report, 2 community urologists underwent this course in 2000. One trainee performed 30 laparoscopic procedures, including 17 radical nephrectomies, 4 simple nephrectomies, 4 nephroureterectomies, 4 renal cyst ablations, and 1 renal biopsy within the first 8 months after completing the training program. The second trainee performed 10 laparoscopic procedures within the first 3 months after training. Subsequent update of this course included 5 community urologists (personal communication with Dr. A. Shalhav). From this experience, 3 trainees have gone on to perform numerous laparoscopic surgeries following training. Two additional trainees who practice in a smaller group setting have had limited performance of laparoscopic procedures to date. This program was extremely time intensive for both the trainee and the mentor and was a significant financial burden to the trainee (ie, the mentor would bill as the primary surgeon). However, it enabled 3 of 5 (60%) trainees to gradually become more skilled and confident in laparoscopic surgery. The M-R program at the University of California, Irvine has attempted to foster the mentoring concept while providing a potential proctoring opportunity. It is interesting that only 14 of the 101 (14%) M-R registrants have participated in the proctoring/preceptoring opportunity of this program. It is unclear why so few M-R participants have taken advantage of this unique aspect of the program.
Similarly, Rane and colleagues8
proctored 6 postgraduate urologists and recommend that each trainee perform 12 to 15 cases under the supervision of the expert before independently performing laparoscopic procedures. These educators recommended that the proctors have a minimum experience of 50 laparoscopic cases. Thus far, 5 of the 6 trainees have successfully completed the program within 4 months of commencing the training.8
The overall 85% success or “take” rate of the University of California, Irvine M-R program compares favorably to the 83% take rate of this time-intensive laparoscopic proctoring training program.5,6
Of course, further long-term follow-up of both courses is necessary to determine the durability of these learned skills.