Minimally invasive surgery has become the gold standard for many surgical procedures. It’s easy to see why when patients recover faster, have less postoperative pain and reduced hospital length of stay. Laparoscopy is a highly technical surgical skill to learn. It’s difficult to master and it’s even more difficult to teach. The question remains – how do we best prepare our junior surgical trainees for this complex surgical procedure?
I remember the first laparoscopic procedure I ever did. I was a keen first year gynaecology trainee. I had assisted in numerous laparoscopic procedures but this largely involved statically holding instruments and driving a laparoscopic camera. We learnt by operating and practicing on patients.
My first case was a ruptured ectopic pregnancy. The anatomy was simple and my supervising consultant deemed it as ‘the perfect teaching case’. Excitedly I started the procedure, hands shaking, trying to control and find my instruments. I remember thinking – watch the bowel, the blood vessels, the uterus and the bladder. Don’t damage anything! I very slowly proceeded to remove the fallopian tube that contained the ectopic pregnancy. What should have been a 5 minute procedure likely took me 10 times longer. Thankfully despite my lack of expertise the case went smoothly with no complications and the patient made a full recovery.
Surely there has to be a better way to learn laparoscopy rather than practicing on patients? There has to be a simulator for that…
Laparoscopic Simulation in Surgical Training
There are now a huge variety of laparoscopic simulators available. These range from simple box trainers to highly technical virtual reality trainers where trainees can perform complete procedures. There is an abundance of evidence that tells us that laparoscopic simulation is helpful for acquisition of surgical skills. Trainees who have utilized laparoscopic trainers are up to 50% faster at surgical procedures. They also have significantly less complications. This is what we would expect.
Most of these simulators sit unused, collecting dust.
We know that surgical trainees simply having access to fancy highly technical simulators is not sufficient for improvement. There appears to be a problem with engagement of trainees in laparoscopic simulation programs.
One potential solution is ‘take home’ laparoscopic simulators. Surprisingly even with take home trainers only 50% of trainees actually used the trainers.
What we’re left with is a simulator that evidence tells us is helpful in skill acquisition… but what we don’t know is how and when to best integrate laparoscopic simulation into surgical training, how to engage our trainees in this process and how to maximize learning from this tool.
The Role of Test Enhanced Learning
Test enhanced learning (TEL) is the process of using defined assessments throughout the training phase of learning. TEL has been demonstrated to be an effective strategy in both knowledge and procedural skill acquisition – combining elements of mastery learning and gamification. We wondered if TEL might be helpful in engagement and skill progression for laparoscopic simulation? What better motivator for a bunch of surgical trainees than making it a competition to see who is the fastest!
We recruited 40 medical students to be part of a laparoscopic simulation study, with a program of exercises to complete, timed targets to achieve and feedback to improve performance from surgical supervisors. The program ran for 10 weeks and used simple laparoscopic simulators and a VR trainer. Half of the cohort – 20 students – were timed and tested on the exercises to complete each week (TEL group), while the remainder of the cohort were timed only at the beginning and the end of the 10-week program.
What we observed was fascinating… TEL group students were far more engaged in the program. Instead of simply ‘playing’ on simulators they were focused, deliberately practicing to achieve specific goals, and motivated to improve. TEL students attended the sessions more frequently and appeared to achieve better technique and performance at the end of the project. Have we found the key to making laparoscopic simulation more engaging for our surgical trainees…? maybe…?
At the end of the 10 weeks one of our students from the testing group had achieved sufficient skills to attempt a laparoscopic salpingectomy on a VR trainer. The student competently and safely removed the ectopic pregnancy using the simulator in minutes. I couldn’t help but reflect – what if this was standard for our surgical trainees? How much better and safer would this have been for the patients I operated on as I learnt. Surely the first time this student operates on a patient they will do so with more efficiency and skill than I had for my first procedure.
Questions and reflections
- Should TEL be further incorporated into all our procedural skills training?
- Should be we utilizing TEL for non-procedural learning too?
- What is the role of intrinsic and extrinsic motivation for our learners? Do some just have more ‘grit’?
1. Larsen CR et al. The efficacy of virtual reality simulation training in laparoscopy: a systematic review of randomized trials. Acts Obstet Gynaecol Scand 2012;91: 1015-1028
2. Nicol, L et al. Incentivising practice with take-home laparoscopic simulators in two UK core surgical training programmes. BMJ Simulation & Technology Enhanced Learning; 2016: 2, 4; 112
3. Blackhall V et al. Barriers and facilitators to deliberate practice using take-home laparoscopic simulators. Surg Endosc. 2019 Sep; 33(9): 2951-2959