Laparoscopic suturing skill is probably the most difficult skill to master in the minimally invasive environment.1,12
Despite the difficulty, studies reveal that these skills can be acquired with extensive training outside the operating room.2,5,7,8,13
However, the baseline skills required by the subject to learn laparoscopic suturing skills have not been defined, though many studies have found that previous laparoscopic exposure is not required for the acquisition of laparoscopic skills.
The method to assess acquisition of laparoscopic suturing skill varies among studies and has not been uniform. They vary from assessment of single intracorporeal knotting to 100 consecutive knots.3,14
No previous study has assessed the laparoscopic suturing skills of surgical trainees in the performance of bowel anastomosis on a porcine model in an almost real scenario. This is possibly the first study where laparoscopic suturing skills acquisition has been assessed by operation time, anastomotic leak, and size of the anastomosis, suture placement, mucosal approximation, and difficulty level.
Operation time is a significant parameter to assess the laparoscopic skills of a surgeon. It has been used as an objective measure of the acquisition of laparoscopic skills by many studies such as those done by Rosser et al.15
Vossen et al.16
Chung et al.17
Risucci et al.18
and Dubrowski et al.6
These studies reveal that as the surgeon becomes more skillful, operation time decreases and reaches a minimum level that is similar to that of the experts.19–21
In the present study, training resulted in significant improvement in mean operation time for all the participants. It was the first and the most significant parameter to improve after training. The difference in the operation time between the laparoscopy-exposed and laparoscopy-naïve surgeons also decreased significantly after the training course, signifying that training definitely shortens the learning curve for laparoscopic suturing skills for both the laparoscopy-exposed and laparoscopy-naïve surgeons and that the laparoscopy-naïve surgeons manage to catch up with the laparoscopy-exposed surgeons after training.
However, the trainees in our program could not reach the level of experts possibly because laparoscopic suturing is a very difficult task to master, and although they showed significant improvement in operative time, they still need more practice to reach the level of experts. The trainees showed a significant improvement in the overall anastomotic score from the baseline to the postcourse evaluation, which signifies that training helped them in acquiring the skills of laparoscopic suturing. The laparoscopy-naïve surgeons also had a significant improvement in the anastomotic score.
Similar improvement in laparoscopic suturing skills with training was also observed by Kanumuri et al.13
who found that third-year medical students improved task completion rate and time with training. Botden et al.22
observed statistically significant improvement in 18 novice medical students from the second knot to the top of the performance. Vossen et al.16
observed 100 consecutive intracorporeal suturings after a training and found that the quality of the knots increased when the first 10 were compared to the last 10 knots.
Few studies have shown that experience in laparoscopic procedures is not a prerequisite for trainees to learn laparoscopic suturing techniques and that novice surgeons can acquire complex skills of laparoscopic suturing in a shorter and similar time as compared to the trained surgeons. Aggarwal et al.4
who compared the performance of 9 senior operative residents (PGY 4 and 5; course A) with 14 junior operative resident (PGY 2 and 3) at an identical 2-d laparoscopic suturing course, had similar observations. In a study done by Stefanidis et al.23
novices demonstrated a 22-fold increase in performance after uniformly achieving proficiency in a reasonable (5.6 h) amount of time. Risucci et al.18
found significant and similar improvement in both the resident and attending surgeons from suturing trials 1 to 3 and trials 8 to 15.
The observations in our study are similar to the above-mentioned studies. Laparoscopy-naïve surgeons, despite the limitation of their minimal previous laparoscopic surgery experience and even exposure to open bowel anastomosis, were capable of learning basic laparoscopic skills as effectively and efficiently as the trained surgeons. It was seen that though the laparoscopy-exposed surgeons were faster than the laparoscopy-naïve surgeons in the beginning of the study, this difference in mean operation time between the 2 groups decreased significantly after training.
Many studies have shown variable effect of age and experience on acquisition of laparoscopic suturing skills. Rissuci et al.18
and Kroeze et al.3
demonstrated a positive relationship between laparoscopic suturing skill and experience. Our study also suggests that as age increases mean operation time decreases and as experience increases the mean operation time decreases and the mucosal approximation improves. Thus, with age, experience increases and both lead to better acquisition of laparoscopic suturing skills. However, Vossen et al.16
and Aggarwal et al.4
had observed that performance was not related to experience or age, respectively. The application and transfer of these skills in the operating theater directly on patients has not been studied and the sustainability and transfer of the skills acquired was not assessed due to logistical problems of retesting the individuals.
Though the relation of experience to acquisition of laparoscopic suturing skills is controversial, there may be some benefit to having previous experience in laparoscopic or open surgical procedures. One explanation is that laparoscopy-naïve surgeons had to first overcome the basic skills of laparoscopy, such as bimanual dexterity, depth perception, absence of haptic feedback, and other such things, accounting for their initially prolonged operative time. However, once they overcame this, they made significant improvement in the operative time and also the overall anastomotic score. Laparoscopy-exposed surgeons were able to achieve significant improvements in anastomotic leak rate and size of the anastomosis apart from the mean operation time. The overall anastomotic score was greater than that of the laparoscopy-naïve surgeons; however, the difference was not statistically significant. Our observations suggest that this group of participants acquired knowledge of the methods for laparoscopic suturing and were able to apply this knowledge without difficulty. Further, their experience in performing a secure anastomosis in open surgical procedures may have benefitted them. On the other hand, laparoscopy-naïve surgeons had to acquire knowledge of basic laparoscopic skills, laparoscopic suturing, bowel anastomosis, and dexterity during the 3-d course and hence could not achieve further improvement in mean operative time and other parameters. Since laparoscopic suturing is a complex skill involving several tasks, the mental workload threshold of participants, along with the short duration of training, probably prevented the laparoscopy-exposed surgeons from improving on their performance. Hence, it can be deduced from our study that training leads to improvement in skills in all the residents irrespective of their previous exposure to laparoscopic surgery. Laparoscopy-naïve surgeons can acquire skills comparable to that of the trained surgeons.
The findings of this study need to be tested on a larger scale with a greater number of trainees, and if the findings are proven and the skills are identical between the 2 groups, then it can have important implications in the training requirements of laparoscopy-naïve residents whereby it may become mandatory for laparoscopy-naïve as well as practicing surgeons to undergo training before they are exposed to the operating theater environment.