Simulation-Based Training – Evaluation of the Course Concept “Laparoscopic Surgery Curriculum” by the Participants

Introduction The learning curve in minimally invasive surgery is much longer than in open surgery. This is thought to be due to the higher demands made on the surgeon’s skills. Therefore, the question raised at the outset of training in laparoscopic surgery is how such skills can be acquired by undergoing training outside the bounds of clinical activities to try to shorten the learning curve. Simulation-based training courses are one such model. Methods In 2011, the surgery societies of Germany adopted the “laparoscopic surgery curriculum” as a recommendation for the learning content of systematic training courses for laparoscopic surgery. The curricular structure provides for four 2-day training courses. These courses offer an interrelated content, with each course focusing additionally on specific topics of laparoscopic surgery based on live operations, lectures, and exercises carried out on bio simulators. Results Between 1st January, 2012 and 31st March, 2016, a total of 36 training courses were conducted at the Vivantes Endoscopic Training Center in accordance with the “laparoscopic surgery curriculum.” The training courses were attended by a total of 741 young surgeons and were evaluated as good to very good during continuous evaluation by the participants. Conclusion Training courses based on the “laparoscopic surgery curriculum” for acquiring skills in laparoscopy are taken up and positively evaluated by young surgeons.

The learning curve in laparoscopic surgery is much longer than in open surgery. In the literature, the learning curve for laparoscopic cholecystectomy is given as 30 procedures (2,3), for endoscopic inguinal hernia surgery as 60 procedures (4), for laparoscopic gastric bypass as 100 procedures (5), and for laparoscopic colorectal surgery as 88-152 procedures (6). This is thought to be due to the more exacting demands made on the surgeon's skills (7). Among the factors militating against rapid acquisition of skills in laparoscopic surgery are the low number of cases suitable for teaching operations, difficulties with the videoeye-hand coordination, altered perceptions of depth, and laparoscopic suturing (8). This means that, often, even after completion of specialist surgical training, some surgeons have shortcomings when it comes to laparoscopic suturing techniques, bimanual coordination, and mastery of challenging anatomic situations (9). Therefore, the question raised at the outset of training in laparoscopic surgery is how such skills, i.e., the skills and competencies to perform laparoscopic surgery, can be acquired by undergoing training outside the bounds of clinical activities to try to shorten the learning curve.
In a systematic review, Zendejas et al. (7) demonstrated that laparoscopic techniques can be learned more effectively in a simulation-based training course compared with when learning such techniques only during clinical training. Training on expensive virtual reality trainers is no better than when using the more favorably priced pelvic trainers and boxes with porcine organs models from abattoirs (7,10).
Likewise, a Cochrane review identified advantages for acquiring skills in laparoscopic surgery by first participating in simulation-based training courses on pelvic trainers (11). Simulation-based training helps to shorten the operating time and enhance the ability to implement surgical techniques. The skills learned in training courses can be immediately applied for the patient in the operating room (12)(13)(14)(15).
In a prospective randomized trial on learning the total extraperitoneal patch plasty (TEP) technique in endoscopic inguinal hernia surgery, Zendejas et al. (16) demonstrated that surgeons who had undergone such simulation-based training had significantly shorter operating times, better performance scores, and fewer intraoperative and postoperative complications than those surgeons who had not taken part in such a training course.
Based on evidence-based data, it is urgently recommended that young surgeons in training as general and visceral surgeons take part in such training courses. Below are now described the experiences gained in Germany with the introduction of a curricular concept for simulation-based training in minimally invasive surgery, which was offered in parallel to the normal specialist surgical training program. The curricular structure provides for four 2-day training courses with an interrelated content and with each course focusing additionally on specific topics of laparoscopic surgery. The following key courses are recommended:   The recommendation is that young surgeons attend the training courses in the following order: "laparoscopic cholecystectomy" course in year 1-2; "endoscopic hernia surgery (TEP, TAPP, lap. IPOM)" course in year 3-4; course; "laparoscopic suturing, knot-tying, clipping, stapling, laparoscopic hemostasis, laparoscopic appendectomy, adhesiolysis, stomach wedge resection and gastroenterostomy, and Roux-Y anastomosis" course in year 4-5; and the "Laparoscopic colorectal surgery" course in year 5-6. Currently, there is no evaluation of the participants through implementation of a score to get permission for the next course level.
The course content is imparted to participants based on live operations from two operating rooms at the Vivantes Hospital Berlin (Figure 1) and lectures (Figure 2). But, the key element is the training units carried out on bio simulators (Figure 3), which give course attendees the chance to thoroughly practice all manual skills using porcine organ models from an abattoir or chickens from the supermarket. To that effect, the same videoendoscopic equipment, as used in the operating room, is available (Figure 3). The course trainers are available to assist the attendees throughout. The bio simulators confront trainees with a situation that mimics that which they have to master in an actual surgical setting. This practical test serves to make each participant aware of his/her technical shortcomings in performing surgery, which must now be overcome. Since participation in all four training courses is mandatory for attainment of the "laparoscopic surgery curriculum" overall certificate, the progress made by individual trainees can be well monitored over the years. Since 12 fully equipped working places traineeships are available at the Vivantes Endoscopic Training Center, thanks to the support from the firms Storz and Medtronic, up to 24 colleagues can participate in each training course (Figure 4). Between 1st January, 2012 and 31st March, 2016, a total of 36 training courses were conducted at the Vivantes Endoscopic Training Center in accordance with the "laparoscopic surgery curriculum. " The training courses were attended by a total of 741 young surgeons, and each course was evaluated on completion.
Attendees were asked to evaluate the course in terms of its learning content, scope of theoretical presentations, didactic concept, duration of exercises, quality of the live operations, and overall assessment. Responses were graded as follows: 1 (very good), 2 (good), 3 (satisfactory), 4 (sufficient), 5 (deficient), and 6 (insufficient). In general, participants evaluated the courses as being very good to good ( Table 5). The fact that, in the meantime, 49 participants of the Professional Association of German Surgeons attained the overall certificate documenting attendance of all four courses demonstrates the high acceptance of the curricular concept for teaching minimally invasive surgery skills through the combination of live surgery, lectures, and practical training on a bio simulator.

disCussion
In 2011, the German surgery societies adopted the "laparoscopic surgery curriculum" concept for simulation-based training in laparoscopic surgery. The curricular structure provides for four 2-day training courses with an interrelated, tiered content. The courses are designed to be attended in parallel to the normal specialist surgical training program. The course content is imparted based on live operations, lectures, and exercises carried out on bio simulators. In collaboration with the Professional Association of German Surgeons, 36 courses have, in the meantime, been held at the Vivantes Endoscopic Training Center in Berlin with a total of 741 participants. The courses were evaluated by attendees as being very good and good, i.e., trainees believed they had benefited from the courses. The advantage of this course concept is its direct relevance to the clinical setting with regular facilities for transmission of live operations. This also provides for close supervision by experienced surgeons in minimally invasive surgery. The dedicated training center has a training capacity for 24 trainees. Exercises carried out on biological specimens from the abattoir or supermarket permit intensive training, as resources are not limited. In a systematic review Zendejas et al. (7) demonstrated that laparoscopic techniques can be learned more effectively in a simulation-based training course compared with when learning such techniques only during clinical training.
The skills learned in simulation-based training courses can be immediately applied for the patient in the operating room (12)(13)(14)(15). Hence, simulation-based training helps to master the learning curve in minimally invasive surgery and enhance conduct of minimally invasive surgical procedures during the learning curve. Therefore, it is urgently recommended that young surgeons in training participate in such simulation-based courses. Bio simulators, which are used for practicing surgical skills on organ models in the pelvic trainer with standard video-endoscopic equipment, are currently the most cost-effective option. As such, the satisfaction ratings Course Concept "Laparoscopic Surgery Curriculum" Frontiers in Surgery | www.frontiersin.org August 2016 | Volume 3 | Article 47