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Establishing Standards in Minimally Invasive Gynecologic Surgery


Minimally invasive endoscopy, with and without robotics, has become a viable option for almost every operative gynecologic procedure.

Yet, despite a solid body of evidence demonstrating the benefits of minimally invasive approaches and despite tremendous progress in postgraduate education, many gynecologic surgeons are not incorporating endoscopic options into their practices – or even into their patient education. Others have adopted minimally invasive techniques, but sometimes without the essential or optimal knowledge and skills needed to perform minimally invasive gynecologic surgery with optimal outcomes and patient safety.

By Dr. Ceana Nezhat

New gynecologic surgeons, in the meantime, are leaving residency programs with variable levels of experience and proficiency. Some have adequate opportunity to gain the skills and experience they need to be comfortable and confident in the endoscopic arena, but many do not.

As Dr. Charles E. Miller, past president of the AAGL (formerly known as the American Association of Gynecologic Laparoscopists), said in his presidential address in 2008, data have shown that one in three residents graduate with a paucity of experience in minimally invasive gynecologic procedures.

At the root of these realities are the lack of a defined knowledge base and the lack of a specific, unified endoscopy curriculum. There have been no minimal standards set for gynecologic endoscopy, no quantifiable measures defined for proficiency in minimally invasive gynecologic surgery, and no validated tools developed for gynecologic surgeons to learn and then document their competency.

Change is underway, however. For the past 2 years, the AAGL has worked with hundreds of physicians and experts to determine the essential knowledge needed for performing minimally invasive gynecologic surgery – and to develop an appropriate assessment test for gynecologic surgeons.

Called Essentials in Minimally Invasive Gynecology (EMIG), the test is based upon professional testing standards and guidelines established by professional testing societies. The process used to develop the test has incorporated the important principles of validity, reliability, and defensibility.

The EMIG cognitive assessment is currently in the beta-test stage and is scheduled to be administered for the first time in November 2012 at the AAGL annual clinical meeting. After that, physicians will be able to take the test through any one of multiple proctored testing centers operated worldwide by the consulting firm that helped develop and validate Fundamentals of Laparoscopic Surgery (FLS), the educational program that is now a standard part of all general surgery residencies.

The EMIG cognitive test covers the areas of applied anatomy and physiology, endoscopic principles, patient selection, instrumentation, energy sources, operating room/equipment setup, laparoscopy, hysteroscopy, and complications. A skills testing portion of the EMIG is under development.

Most immediately, for practicing gynecologic surgeons, EMIG will give them the opportunity to demonstrate and validate their laparoscopic skills. Then, as training becomes more standardized, gynecologists will be able to acquire skills, or enhance their skills, through postgraduate courses that incorporate EMIG principles in a unified, standardized manner.

Continuous Progress

It was gynecology that pioneered use of the laparoscope and brought it to our general surgery colleagues. And over the years, gynecology has been cognizant of the need to develop a standardized assessment, curriculum, and training to meet the demands of the dynamic developments in endoscopy.

In the early 1990s, the American College of Obstetricians and Gynecologists issued basic guidelines for credentialing gynecologists to perform laparoscopy, and the Accreditation Council for Gynecologic Endoscopy (now the Council for Gynecologic Endoscopy and part of the AAGL) started a registry identifying gynecologists skilled at laparoscopy and hysteroscopy.

In 1998, Dr. Andrew Brill and Dr. Robert Rogers outlined a comprehensive program for resident training in the Journal of the American Association of Gynecologic Laparoscopists (J. Am. Assoc. Gynecol. Laparosc. 1998;5:223-8). Recently, the Fellowship in Minimally Invasive Gynecologic Surgery program issued guidelines as well for fellow and resident education, hands-on training, written examinations and skills testing, and supervised surgery.

In the world of general surgery, in the meantime, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) began developing the FLS in the late 1990s; the FLS is a comprehensive web-based education module designed to teach and assess basic cognitive, technical, and psychomotor skills required to perform laparoscopic surgery.

FLS has two parts: didactic testing, which is online multiple choice testing, and skills testing, which is hands-on. Endorsed by the American College of Surgeons (ACS), FLS was designed to give surgical residents, fellows, and practicing physicians an opportunity to learn the fundamentals of laparoscopic surgery in a consistent, scientific format.

The goal was not only to increase familiarity with and access to minimally invasive techniques, but to ensure good outcomes and patient safety.


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