Wendela Kolkman

The influence of experience and camera holding on laparoscopic instrument movements measured with the TrEndo tracking system

BackgroundEye–hand coordination problems occur during laparoscopy. This study aimed to investigate the difference in instrument movements between the surgeon him- or herself holding the camera and an assistant holding the camera during performance of a laparoscopic task and to check whether experience of the surgeon plays a role in this issue.MethodsThe participants were divided into three groups: experts, residents, and novices. Each participant performed positioning tasks using the right (R) and left (L) hands. During these tasks, the camera was manipulated either by the participant (Cself) or by an assistant (Cassistant). Movements of instruments were recorded with the authors’ new TrEndo tracking system. The performance was analyzed using five kinematic parameters: time, path length, three-dimensional (3D) motion smoothness, 1D motion smoothness (along the axis), and depth perception.ResultsA total of 46 participants contributed. Three tests were performed: test 1-LCself, test 2-LCassistant, and test 3-RCassistant. In all the tests, the experts performed better than the residents and novices in terms of time, path length, and depth perception. The novices performed better in tests 1-LCself and 2-LCassistant than in test 3-RCassistant in terms of path length, 3D motion smoothness, and depth perception.ConclusionsLaparoscopic experience and the camera-holding factor influenced the performance of laparoscopic tasks on the simulator. Time, path length, and depth perception clearly discriminate between different levels of experience in laparoscopy, whereas 3D and 1D motion smoothness play a limited role. Novices experienced more difficulties when an assistant held the camera. Therefore, self-manipulation of the camera seems to improve novices’ eye–hand coordination.

Gynecological laparoscopy in residency training program : Dutch perspectives

BackgroundImplementation of laparoscopy into residency training is difficult. This study was conducted to assess the current state of implementation of laparoscopic surgery into gynecological residency program, to identify factors influencing laparoscopic skills training, and to find solutions toward better training and implementation.MethodsIn 2003 a questionnaire was sent to all 68 postgraduate year 5 and year 6 residents in obstetrics and gynecology in The Netherlands. The questionnaire addressed demographics, performance of laparoscopy, self-perceived competence, simulator training, and factors influencing laparoscopic training in residency.ResultsOf the 68 residents, 60 (88%) responded; 46 (37%) were men and 78 (63%) women. Men showed significant higher mean self-perceived competence in some laparoscopic procedures than women. Of the respondents, 20% had no advanced laparoscopic gynecologist present in their teaching hospital. Residents felt that simulator training is important in relation to their performance in the operating room. Of all gynecological teaching hospitals in the Netherlands, 55% did not have the opportunity of simulator training. Of the respondents who had the possibility of simulator training, 33% did not use the simulator voluntarily. Residents who trained on a simulator felt training was significantly more important (p = 0.02) than residents who never practiced on a simulator. Respondents’ laparoscopic skills were subjectively evaluated in the operating room (92%) or were evaluated based on the number of laparoscopic procedures performed as primary surgeon (49%). Of the respondents, 47% were satisfied with their current laparoscopic skills and 27% also felt prepared for the more advanced procedures. Not having been primary surgeon in nonacademic teaching hospitals and even more so in academic teaching hospitals (p < 0.05) was a limiting factor in acquiring laparoscopic skills.ConclusionsIncorporation of basic laparoscopic procedures into residency training has been successful; however, advanced procedures are not. Simulator training is still in its infancy in The Netherlands, is not frequently used voluntarily, and should be mandatory during residency. Acquired laparoscopic skills on a simulator and in the operating room should be objectively assessed, and above all, training of trainers is imperative.

Value of an objective assessment tool in the operating room

BACKGROUND Concerns about the achievement of surgical proficiency during residency are increasing. To objectify surgical skills, the Objective Structured Assessment of Technical Skills (OSATS) was developed and proven valid, feasible and reliable for use in laboratory settings. This study aimed to evaluate the value of this tool for intraoperative use. METHODS Residents were assessed with an OSATS after every procedure they performed as the primary surgeon during a 3-month clinical rotation in gynecological surgery. We mapped individual learning curves (OSATS scores plotted against experience) and established the average procedure-specific learning curve. We used linear mixed models to assess the relation between performance and experience. RESULTS Nine residents were recruited and 319 OSATS analyzed. Individual learning curves revealed progression beyond 24 of 30 OSATS points for 7 residents. Performance on the average procedure improved with experience, and the OSATS score increased by an average of 1.10 points per assessed procedure (p=0.008, 95% confidence interval 0.44-1.77). Median OSATS scores ranged from 18 to 30 among the 21 assessors. CONCLUSION Intraoperative implementation of OSATS seems to offer important advantages: structured feedback is facilitated, and learning curves enable insight into individual progression. However, doubts have been raised about the objectivity of the tool. Therefore, caution is warranted in using it for graduation and certification.

Preoperative predictors of postsurgical adhesion formation and the Prevention of Adhesions with Plasminogen Activator (PAPA-study): results of a clinical pilot study

OBJECTIVE To identify predictors of postsurgical adhesion formation in peritoneal fluid and plasma, and assess efficacy and safety of reteplase (recombinant plasminogen activator [r-PA]). DESIGN Prospective randomized study. SETTING University Medical Center. PATIENT(S) Twenty-six abdominal myomectomy patients with early second-look laparoscopy (ESL). INTERVENTION(S) Randomization to IP treatment with 1 mg reteplase in 300 mL Ringers lactate or 300 mL Ringers lactate only. Scoring of adhesions and collecting peritoneal fluid during both surgical procedures and collecting plasma samples at ten time points. MAIN OUTCOME MEASURE(S) Incidence, severity, and extent of adhesions at ESL. Concentrations of C-reactive protein (CRP), tissue-type plasminogen activator (tPA), plasminogen activator inhibitor 1 (PAI-1), and fibrin degradation products (FbDPs). RESULT(S) Significant correlation between the extent of uterine adhesion formation and preoperative plasma levels of CRP (r(s) = 0.558), PAI-1 (r(s) = 0.413), and the change in tPA concentration in peritoneal fluid from initial surgery to ESL (Delta+PA: r(s) = -0.636). No significant differences in adhesion scores between treatment and control groups. CONCLUSION(S) Our finding that preoperative plasma CRP and PAI-1-levels are significantly correlated with extent of adhesion formation points to a role of chronic inflammation in the disease process. Results are highly indicative for the paradigm that adhesions are caused by an insufficiency in peritoneal fibrinolytic capacity. For successful adhesion prevention therapy relatively high amounts of r-PA are required.

Implementation of advanced laparoscopic surgery in gynecology: national overview of trends.

STUDY OBJECTIVE To estimate the implementation of laparoscopic surgery in operative gynecology. DESIGN Observational multicenter study (Canadian Task Force classification II-2). SETTING All hospitals in the Netherlands. SAMPLE Nationwide annual statistics for 2002 and 2007. INTERVENTIONS A national survey of the number of performed laparoscopic and conventional procedures was performed. Laparoscopy was categorized for complexity in level 1, 2, and 3 procedures. Outcomes were compared with results from 2002 to evaluate trends. MEASUREMENTS AND MAIN RESULTS In 2002, 21 414 laparoscopic and 9325 conventional procedures were performed in 74 hospitals (response rate, 74%), and in 2007, 16 863 laparoscopic and 10 973 conventional procedures were performed in 80 hospitals (response rate, 80%). Compared with 2002, in 2007, level 1 procedures were performed significantly less often and level 2 and level 3 procedures were performed significantly more often. The mean number of performed laparoscopic procedures per hospital decreased from 289 to 211 procedures. Teaching hospitals performed more than twice as many therapeutic laparoscopic procedures as nonteaching hospitals do. Cystectomy, oophorectomy, and ectopic pregnancy surgery were preferably performed using the laparoscopic approach. Laparoscopic hysterectomy was performed significantly more often, accounting for 10% of all hysterectomies. Annually, 20% of hospitals in which laparoscopic hysterectomy was implemented performed 50% of all laparoscopic hysterectomies, and 50% of the hospitals performed 20% of laparoscopic hysterectomies. CONCLUSION This study describes increasing implementation of therapeutic laparoscopic gynecologic surgery. Clinics increasingly opt to perform laparoscopic surgery rather than conventional surgery. However, implementation of advanced procedures such as laparoscopic hysterectomy seems to be hampered.

Teach the teachers: an observational study on mentor traineeship in gynecological laparoscopic surgery.

Background: To evaluate the effect of a mentor traineeship in laparoscopic surgery in a teaching hospital. Method: This observational study was performed between January 1997 and December 2004 at Bronovo Hospital, The Hague, The Netherlands. Since January 2001, an advanced endoscopic gynecologist has mentored a trainee in laparoscopic surgery. Data on the trainee’s procedures preceding (1997–2000) and during the mentor traineeship (2001–2004) were compared. The number and type of procedures performed, complications and conversions were derived from a prospectively kept database supplemented by a retrospective chart review. Operating times for total laparoscopic hysterectomy (TLH) were registered to establish the trainee’s learning curve. Results: Since the presence of a mentor, the trainee has performed significantly more advanced laparoscopic procedures. Despite the significant increase in advanced cases, the trainee’s laparoscopic conversion rate to laparotomy remained stable between period 1 and period 2 (7.5 and 4.5%, respectively, p = 0.35, 95% CI –0.033 to 0.092); moreover, for level-3 procedures the conversion rate decreased (p < 0.001, 95% CI 0.30–0.71). Despite the increase in advanced cases, the total complication rate remained stable (3.2–4.5%, p = 0.62, 95% CI –0.07 to 0.04) including the number of level-3 complications (p = 0.63, 95% CI –0.4 to 0.3). A decreasing trend in operating time for TLH was found; however, this was not significant (Spearman correlation coefficient –0.421, p = 0.81). Conclusions: Mentor traineeship in gynecology enhanced the advanced laparoscopic caseload. With the increase in advanced procedures, no increase in conversion rate, complication rate or operating times for TLH was found. Due to the mentorship, patients were not exposed to increased complications and conversions, or to the disadvantages of a prolonged operating time. Predominantly, mentor traineeship facilitated the implementation of laparoscopic surgery into an established gynecological practice in a teaching hospital.

Implementation of laparoscopic hysterectomy: maintenance of skills after a mentorship program.

Background: To evaluate the implementation and maintenance of advanced laparoscopic skills after a structured mentorship program in laparoscopic hysterectomy (LH). Methods: Cohort retrospective analysis of 104 successive LHs performed by two gynecologists during and after a mentorship program. LHs were compared for indication, patient characteristics and intraoperative characteristics. As a frame of reference, 94 LHs performed by the mentor were analyzed. Results: With regard to indication, blood loss and adverse outcomes, both trainees performed LHs during their mentorship program comparable with the LHs performed by the mentor. The difference in mean operating time between trainees and mentor was not clinically significant. Both trainees progressed along a learning curve, while operating time remained statistically constant and comparable to that of the mentor. After completing the mentorship program, both gynecologists maintained their acquired skills as blood loss, adverse outcome rates and operating time were comparable with the results during their traineeship. Conclusion: A mentorship program is an effective and durable tool for implementing a new surgical procedure in a teaching hospital with respect to patient safety aspects, as indications, operating time and adverse outcome rates are comparable to those of the mentor in his own hospital during and after completing the mentorship program.

Implementation difficulties of advanced techniques in gynecological laparoscopy

Laparoscopic surgery has developed into an important part of the gynecological surgical pallet. Its implementation into daily practice has shown to be complex, especially the advanced procedures. The difficulties of implementation is multifactorial; however, the training of laparoscopy is one of the major issues of this subject. The adequate training of residents and gynecologists is essential for its optimal and safe implementation. Concerning the advanced procedures, the question raises as to who should be able to perform these procedures and how this is established. Causes, difficulties, and limitations of the implementation of advanced laparoscopy will be discussed in this paper.

Are minimally invasive procedures harder to acquire than conventional surgical procedures

Background: It is frequently suggested that minimally invasive surgery (MIS) is harder to acquire than conventional surgery. To test this hypothesis, residents’ learning curves of both surgical skills are compared. Methods: Residents had to be assessed using a general global rating scale of the OSATS (Objective Structured Assessment of Technical Skills) for every procedure they performed as primary surgeon during a 3-month clinical rotation in gynecological surgery. Results: Nine postgraduate-year-4 residents collected a total of 319 OSATS during the 2 years and 3 months investigation period. These assessments concerned 129 MIS (laparoscopic and hysteroscopic) and 190 conventional (open abdominal and vaginal) procedures. Learning curves (in this study defined as OSATS score plotted against procedure-specific caseload) for MIS and conventional surgery were compared using a linear mixed model. The MIS curve revealed to be steeper than the conventional curve (1.77 vs. 0.75 OSATS points per assessed procedure; 95% CI 1.19–2.35 vs. 0.15–1.35, p < 0.01). Conclusions: Basic MIS procedures do not seem harder to acquire during residency than conventional surgical procedures. This may have resulted from the incorporation of structured MIS training programs in residency. Hopefully, this will lead to a more successful implementation of the advanced MIS procedures.