The Laparoscopic Advanced Skill Training (LAST) score system: a simple and useful tool to evaluate urological laparoscopic skills during a live-animal training program
Laparoscopic surgery training systems, ranging from bench top box trainers to virtual-reality (VR) simulators (dry-lab), even more to live animal models (wet-lab), have played an important role on residents training. Many authors suggest that proficiency-based training is the best method for residents to approach in laparoscopic skills with laparoscopic simulators. Moreover, some authors have demonstrated that live animal models are the most important training methods for surgeons who want to master the advanced techniques, to develop new surgical techniques and to improve procedures used less frequently in daily practice. Ethical and costs considerations have markedly reduced the use of live animals for teaching. Independently from models, the important aspect for trainees is to ensure that they have acquired basic skills and advanced techniques following validated criteria, and could transfer them into real operative theatre. As reported by British Associations of Urological Surgeons (BAUS), to learn laparoscopic skills the important steps that a laparoscopic novice should complete are: dry-lab courses, animal-based courses, watch live procedures, attending in a high volume center, identify a mentor and start practicing laparoscopic nephrectomy under the supervision of a mentor. After the novice has completed these important steps, his laboratory experience could be transfer to live surgery. In this sense, it would be rational to assume that a high fidelity anesthetized animal, would be superior in terms of training outcomes to a synthetic model. We developed a new score system for a live-animal training procedure. Aim of this study was to introduce the Laparoscopic Advanced Skill Training score system and to evaluate the progression of urologic surgeons in basic and advanced laparoscopic skills during a live-animal training program.
Materials and Methods
The LAST system consists of two checklists (technique and quality) and the total score is 100 points. The technique checklist has 4 categories: needle grasping, suturing, knotting and cutting. Each category has 2 columns, basic skills and instruments controlling. Based on the number of errors (errors≥ 3 0 points errors= 2, 1 point , errors≤1 2 points), the technique score is assigned. The quality score checklist has 2 columns, which are knot and anastomosis quality. The score is based on the quality ratio of 2 columns. For example, in a stomas with 12 stitches, the trainee completed 3 perfect stitches, the other stitches have visible gaps, the ratio is ¼, and the score is 0. The quality score is given, so the total score is 100 points.This was a double-blinded, prospective, non-randomized study. This study was approved by the Chinese Peoples` Liberation Army (PLA) General Hospital Ethics Committee. Trainees were divided into three groups based on their previous laparoscopic experience: novice (had no experience), junior (completed a basic dry-lab training course, could finish suturing with a surgical knot within 5 minutes), senior (finished 2 rounds live-animal training and performed 2 laparoscopic procedures as main surgeon under the supervision of a mentor). The study protocols and the LAST system were explained to all the trainees and informed consents were obtained.All procedures were recorded by digital video and properly saved for future analysis. The anastomotic stomas were cut off after procedures were done, then labeled. Two investigators were therefore blinded to the trainee’s identity and assigned the LAST score.To objectively reflect the actual training level, the mean time taken and LAST score of the First Three Procedures (FTP) and Last Three Procedures (LTP) of 12 consecutive procedures in all groups were evaluated.
Between August and December 2013, 48 postgraduate students and fellows were enrolled in this 36 days course. 25% (12 of 48) entered in the novice group, 50% (24 of 48) in the junior group and 25% (12 of 48) in the senior group. In time taken to complete the ureteroureterostomy between the FTP and LTP the novice (p-value=0.001), junior (p-value<0.001) and senior (p-value=0.001) presented significantly differences. The total LAST score between the FTP and LTP was significant different in each group, for the novice (p<0.001), for the junior (p<0.001), for the senior (p=0.005), respectively. Mann-Whitney U test showed differences in time taken between groups. There was significant difference between LTP of novice and FTP of junior (p=0.026), but there was no significant difference between LTP of junior and FTP of senior in time taken (p=0.097). There was no significant difference between LTP of novice and FTP of junior in LAST score (p=0.499). Conversely, there was significant difference between LTP of junior and FTP of senior (p=0.023) (Fig 2). The learning curves were very steep in novice (Fig 3 A) and junior (Fig 3 B), but very stable in senior (Fig 3 C). The novice learning curve was very steep in technique checklist, but low in quality score. The junior presented a significative progression in all LAST categories along the 12 procedures. As shown, the learning curve was stable for senior group. The inter-rater reliability for the time taken and checklist score was excellent with Cronbach’s α=0.991, ICC =0.905, α=0.992, ICC=0.910, respectively. All trainees found the LAST score system simple and helpful to approach in the live animal course. According to the questionnaire survey, the novice and junior groups considered this training program very helpful to learn laparoscopic surgery. The senior group wanted to transfer his ability to the real surgery.
New criteria should be validated objectively, validly and reliably . The results of this study validated the face, content and construct validity of the newly designed LAST system for live-animal laparoscopic training. All the items of LAST system were based on real operation and designed for theoretical and manual techniques (face validity). We introduced the items correlated with training procedures (construct validity). The items of LAST were easy for trainees to assess the experience level by themselves in live-animal training (content validity). Residents who received concrete information related to a specific skill goal would be able to direct their practice and improve their performance. The evaluation of the errors occurred during the procedure and the quality of the stomas permitted the trainee a better analysis of the learning curve progression. Based on improvement of laparoscopic training, several validated training programs with standardized checklists were reported. In 2008, a pan-European study  assessed the relationship between the laparoscopic suturing task score and the year of resident training during a hands-on training course. Recently, a Program for Laparoscopic Urological Skills (PLUS) [13-14], was developed and validated by a panel of experts in laparoscopic procedures. In 2011, the PLUS was introduced as a pilot final-year urologic resident examination . Moreover, the European Basic Laparoscopic Urologic Skills (E-BLUS) examination consisted of five tasks: peg transfer, pattern cutting, knotting, clip and cut, and needle guidance. Aim of this program was to evaluate bimanual dexterity, hand-eye coordination, spatial cognition, suturing technique, clipping and cutting skills. The results of the E-BLUS showed that the majority of residents did not pass the tasks due to the strict criteria . The results of the questionnaire revealed that overall training experience was limited and that most participants had not trained prior to the examination. Also, final-year residents in urology appeared to have limited exposure to actual laparoscopic procedures. In brief, the authors recommended to improve laparoscopic training programs. In contrast with this two training program the LAST score system introduce several important aspects to learn laparoscopic skills.First, it was scored by the mean points of the FTP and LTP, which reflected the objective outcomes of the course, and better than a single performance. Second, it was based on the number of errors of the procedures and quality ratio of the stomas. In this way, the trainees could “touch with their hands” on the progression of their learning curve.
Our data demonstrated that live animal training is important for trainees who have gained the basic techniques to acquire advanced skill-based, rule-based, and knowledge-based behavior than the obvious benefits of simulator, live-animal training program represents the important step to acquire advanced skills for young urologists. We introduced a new score system to evaluate laparoscopic training skills. This study enriches urologic residents and young urologists that solid laparoscopic experiences are important for translating into real arena, even for robotic surgery. Our findings support the reliability and validity of LAST system.The LAST score simple is a simple and useful tool to evaluated the laparoscopic learning curve.
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