Laparoscopic Simulator Betters OR Performance


NEW ORLEANS — Surgical simulators offer important benefits over traditional educational approaches when it comes to gauging laparoscopic proficiency, according to a multicenter, randomized, controlled study of 56 ob.gyn. residents.

Simulators are likely to see more use and gain in importance, with the explosion in technology that has increased the number of modalities residents are expected to be comfortable using, Dr. Rajiv Gala said at the Society of Gynecologic Surgeons annual meeting. In addition, the restriction on residents' hours means many are having less actual operating room experience.

The current study was open to all ob.gyn. residents at seven medical centers. Dr. Gala, an ob.gyn. at Ochsner Medical Center in New Orleans, presented results on 56 program year 1 and PGY2 residents. The average number of laparoscopic cases at baseline was 5.2.

After residents performed one laparoscopic salpingectomy, they were randomized to training with a laparoscopic surgeon on a simulator station with five tasks or to no simulator training. Simulator training included five 30-minute sessions on five exercises: pattern cutting, Peg-Board transfer, endoloop suturing, and intracorporeal and extracorporeal knot tying.

Ten residents dropped out of the study, leaving 18 who received simulator training and 28 who received only traditional training. Then all residents were evaluated in the operating room while performing a laparoscopic salpingectomy. The faculty reviewer was blinded to the resident's training.

All the residents improved, but trained residents had significantly greater levels of improvement on all five tasks. With use of competency scores for laparoscopic skills established in 2003 (Surg. Endosc. 2003;17:964–7), which set a cutoff of 270, no residents were considered competent at the study's initiation. By the trial's conclusion, 94% of trained residents were judged competent with a mean score of 355, and 43% of nontrained residents were judged competent with a mean score of 235. Operating room performance was evaluated with the University of Toronto's Objective Structured Assessment of Technical Skills, which includes a series of checklists and a separate global rating score.

Limitations of the study included the number of dropouts and the fact that some residents had to complete the second procedure outside of the initial rotation. Strengths included the use of validated tasks for laparoscopic surgery and construct validity—all residents improved with training, said Dr. Gala.

“We believe that proficiency-based simulation does offer some significant benefit over traditional [gynecologic] education,” he said, adding that he hoped the study would push educators to “move from quantity performance to quality performance.”

Dr. Paul Tulikangas, ob.gyn. fellowship program director at Hartford (Conn.) Hospital, said Dr. Gala's paper was important, because “surgical simulation is going to be playing a bigger and bigger role for all surgeons.”

He praised the researchers for testing residents in the operating room after they had shown competency on the simulator. His daughter professes to be a golfer after playing with the Nintendo Wii simulator, but once she steps onto an actual course, she's not as competent, he said. This study “put the resident in the tee box.”

Some improvement, however, might have been due to the fact that the simulator-trained group spent more time with faculty, he said.

The project was funded by an educational grant from the Society of Gynecologic Surgeons.

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