Skill Development and Assessment

The field of laparoscopic urologic surgery has experienced a period of rapid regrowth in the past four years (1). Despite the initial skepticism that should generally be expected by such technologically demanding surgical procedures, this resurgence of interest has made popular demands upon training courses at the national meetings, local academic centers, and at international courses. The urologist must initially have an interest in laparoscopic surgery. All the nuances associated with instrumentation are significant. If one is not exposed early to laparoscopic instrumentation, the breadth of information necessary can seem staggering. Once the instrumentation has been mastered, the physiologic consequences of operating on patients must next be addressed. Safe utilization of electronic, high-speed insufflators and specific problems associated with pneumoperitoneum must be always understood during these cases. In addition to all this background material, the surgeon must also become adept at utilizing complex instruments in the laparoscopic environment. The laparoscopic environment consists of limited, fixed portals of access, longer than normal surgical instruments, and angles of access that at times must cross over one another to work within a brightly illuminated but small focal area within a live patient. Also there is complete reliance on the electronic image. That is to say, the movements within the operative field are within the surgeon's control, but there are activities often occurring outside of the surgeon's

Serveral authors confirmed our observations that the closer the endoscope is to the targeted reconstruction site, the more magnified the field of view and the more difficult will be the performance of the suturing task.

Hanna et al. demonstrated that the right-handed surgeons performed fewer errors and exhibited better first-time accuracy than the left-handed individuals. In addition, accuracy definitely favored the dominant hand in both groups.

view, such as retraction. Finally, add to this a lack of "true" stereotactic, three-dimensional vision and little ability to utilize the sense of touch (in the laparoscopic environment, the surgeon cannot palpate an organ or feel for the pulsations of a nearby artery) and you have summed up the potential limitations of working laparoscopically. But there are advantages as well or dedicated laparoscopic urologic centers would not have evolved. The brightly illuminated, magnified surgical field is an enticing environment to perform surgery, rather akin to microsurgery. The precision capable in such an environment is unparalleled. In addition, following the greatest traditions in urology, the technology fostered by laparoscopic surgery is by itself attractive.

Research currently focuses upon methods of learning, measuring, teaching, and modifying the mental and motor abilities to accomplish complex laparoscopic surgery (53). This is one of the most exciting areas of research in all of surgery currently. How do surgeons learn? What makes one person recognize pathways to practical motor problems quickly whereas others need to be shown? Should we be able to pick those potential urologic residents who will be able to master complex laparoscopic procedures by testing certain aptitudes? Are all urologic surgeons capable of adapting to the laparoscopic environment and mastering the techniques necessary to safely apply these in their practice? What skills are essential and can they be modeled and practiced to increase proficiency? These are some of the basic questions and clinical research currently being investigated on psychomotor skills necessary to perform complex laparoscopic surgery.

Psychomotor Skills

Surgical education to date has relied upon the formal apprenticeship model exemplified by the doctrine, "see one, do one, teach one" (54). Laparoscopic surgery has been defined by degrees of difficulty, with increasingly complex procedures resulting in "steep learning curves." These curves are usually, but not always, exemplified by the amount of time taken to accomplish the laparoscopic procedure, often comparing this to the open surgical equivalent (55). In addition, there are relatively few centers where advanced techniques are being used with regularity. On top of this, hospitals and regulatory agencies (particularly in the United States) are struggling with credentialing issues that surround "surgical proficiency." It is no wonder that the number of laparoscopic, urologic, intracorporeal-sutured reconstructions have not proliferated to any great extent. But the envelope continually expands and small groups of investigators such as Clayman, Janeschtek, Kavoussi, Gill, Gilloneou, Rassweiler, and others push us into rethinking the possibilities of this technology.

Paralleling the growing amount of research on laparoscopic suturing are investigations in the acquisition and development of psychomotor skills and skill evaluation. Derossis et al. from the McGill University evaluated 42 subjects to better understand how structured, objectively measured tasks could be utilized to improve performance during laparoscopic surgery. They demonstrated that the ability to develop suturing skills correlated with overall improvement in a wide variety of laparoscopic activities (56). Hanna et al. at the University of Dundee have investigated the differing abilities of right- and left-handed individuals to develop psychomotor skills for complex endoscopic manipulations. Utilizing a complex in vitro system, 10 right-handed and 10 left-handed individuals were evaluated for psychomotor aptitude, using both the dominant and nondominant hands.

They demonstrated that the right-handed surgeons performed fewer errors and exhibited better first-time accuracy than the left-handed individuals. In addition, accuracy definitely favored the dominant hand in both groups (57).

This same center reported upon the improvement of skill performance by optical axis manipulation. They noted that even small decreases in the viewing angle were attended by significant degradation in performance (58). Others have demonstrated this same phenomenon, such as Holden's group from The Hadassah Hebrew University Medical Center. They demonstrated that changes in the either the camera's position or the surgeon's position profoundly disrupted the surgeon's performance (59).

However, when the surgeon and camera positions were altered together, these detrimental effects could be altered and skilled performance could be regained. More specific to our topic at hand, endoscopic skills have been extensively evaluated by our group and others. Hanna again from Dundee evaluated the influence of direction of view, target-to-endo-scope distance, and manipulation angles upon the efficiency of intracorporeal knot tying.

These authors confirmed our observations that the closer the endoscope is to the targeted reconstruction site, the more magnified the field of view and the more difficult will be the performance of the suturing task.

They specifically evaluated distances of 50, 75, 100, 125, and 150 mm from the targeted task. The 50-mm distance uniformly resulted in the longest times. In addition, the 60° manipulation angle had the shortest execution times compared to 30° and 90°. Finally, some recent investigations have sought how to minimize these problems utilizing a 90° laparoscope to achieve movement parallax. In this investigation, the authors report upon the theoretical advantages of manipulating the endoscopic image to the surgeon's advantage, essentially recapitulating all of the problems alluded to previously. By synchronizing a flexible laparoscope to the movement of a surgeon's head, movement parallax or compensated visual-enhanced movement is achieved (60). They note that a head-controlled flexible 90° laparoscope improves the surgeon's depth perception and hand-eye coordination. This has not been significantly reported for expensive three-dimensional imaging systems (61,62).

The primary problem with these types of investigations is that small study groups do not reflect the community of surgeons who will be attempting these procedures. In addition, the ability of a surgeon to perform a given task is a complex issue involving adaptive capacity, traits, and aptitudes that a person brings to any given situation. This is quite different from the skill of a surgeon. Skill is referred to when specific combinations of techniques are deftly employed to accomplish a given task (63). Numerous investigators have begun to focus the attention of their investigations on how surgical residents develop laparoscopic skills and on how best to foster this skill transfer? Reznick, at the University of Toronto, has written extensively regarding this issue. He summarizes the crucial nature of these research endeavors by stating that the teaching of technical skills is one of the most important tasks of surgical educators. He concludes by calling for adherence to simple principles: treat pupils as adult learners, set specific objectives, realize that operative skills are multidimensional, be there to observe, be patient, provide feedback, be positive, and seriously structure the assessment process (64). Many struggle with the notion that there are individuals who have an aptitude for performing innately difficult laparoscopic maneuvers deftly. This has found little documented validity and many cling to the notion that all interested surgeons who seek to be trained should avail themselves of advanced courses. In practice, however, there is increasing pressure on our specialty societies, hospitals, and governmental watchdogs that more scrutiny is warranted (65). Macmillan, also from the Dundee group, recently reported on a method of identifying individuals who appear to have an innate aptitude for performing complex dexterous laparoscopic tasks. They propose that if larger studies confirm these initial observations, selection of candidates for advanced laparo-scopic training might be possible (66).

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