Ontwikkeling en implementatie van een gestructureerde preklinische training in minimaal invasieve chirurgie.

For years, surgical residency programs used the operation room as a vehicle to teach both basic and advanced surgical skills. Open surgical training has traditionally been based on apprenticeships. For many operations, laparoscopy has replaced the open surgical approach. The surgical competencies required to perform laparoscopic surgery are challenging and make trainees go through an intensive learning period. Medico-legal regulations, increasing patient expectations and time constraints, imposed by the European Working Time Directive make it very difficult for trainees to learn these complex procedures on patients in theatre.Therefore, the concept of simulation training outside the operation room was developed.In many surgical training curricula including ours residents are offered a few simulation-training days were they train on animal models, laparoscopic box trainers or even virtual reality trainers.The main goal of this research work was to optimize the current laparoscopic simulation training.One of the important and difficult skills that is learned in the simulation lab is laparoscopic suturing.First we wanted to determine, for a fixed amount of training, the optimal distribution of sessions to acquire and retain laparoscopic suturing skills.During this first study we found that the optimal training schedule to obtain laparoscopic suturing skills is 1.5 hours a day. Longer training sessions result in worse performance during evaluation. At the long term, weekly sessions with deliberate practice in between or short daily sessions have a similar outcome.Based on this study we decided to use 1.5 hours a day as maximum training duration. As a next step we developed a training model for laparoscopic psychomotor skills training which we named the Laparoscopic skills testing and training model (LASTT). We proved the construct validity of this model by measuring the different learning curves in experts and novices. A profiency level for these exercises was set. By measuring the LASTT skills in residents, gynaecologist and expert laparoscopic surgeons during different international congresses we showed that the LASTT model has the potential to work as a skills testing model. To optimize skill acquisition during simulation training, structured training until proficiency, distributed training and deliberate practice are important components of an evidence based simulation program.However, integrating such a program into the busy residency schedule proved to be difficult. We studied if it was feasible to organise such a training program for last year medical students applying for a surgical career. The program (Centre Surgical Technologies, Preclinical Training Program: CST PTP)) was divided over 3 different training blocks: laparoscopic psychomotor skills with LASTT, laparoscopic suturing and knot tying, and last but not least haemostasis and dissection skills. For all this components students had to train until proficiency to obtain a training certificate. We showed that such a training program is feasible, that all the students were very enthusiast and furthermore, that 6 months later, at the beginning of their residency, their skills were still better then those of first year residents who didn’t follow this course. As a next step we compared the skills of residents who followed the CST PTP program as a last year medical student with the skills of residents who got the regular simulation training session and a control group of first year residents who didn’t get any simulation training at all. We found that CST PTP trained students, when assessed in the training lab after six months of residency, had better laparoscopic suturing skills and scored better on a pulsatile organ perfusion cholecystectomy model. The ultimate goal of a simulation program is to show transferability to a real clinical situation. A way to measure this is to study the difference in learning curve of a real human laparoscopic procedure.The first five laparoscopic cholecystectomies for the residents of our three different training groups were assessed.We found that the CST PTP trained residents caused fewer complications and that less staff takeovers were necessary. We also showed that their learning curve always started at a better level and that after 5 cholecystectomies they were still better than the residents from the other groups. With this work we proved that preclinical structured proficiency based training had a clear impact on the surgical learning curve as a first year trainee. As a last step we conducted a survey to evaluate the current laparoscopic simulation situation in Belgium.We found that most residents don’t feel prepared to perform laparoscopy at the end of their training curriculum and that most simulation programs don’t follow the current evidence about structured proficiency based training.It became clear that there are still many ways to improve the current Belgian training situation. We hope that our research work will be a step forward.status: publishe