CHALLENGES IN TRAINING AND ASSESSMENT

OF MINIMALLY INVASIVE SURGICAL SKILLS

Magdalena K. Chmarra

, Sharon P. Rodrigues

, Frank-Willem Jansen

1,2

and Jenny Dankelman

BioMechanical Engineering, Delft University of Technology, Mekelweg 2, Delft, The Netherlands

Department of Gynaecology, Leiden University Medical Center, Albinusdreef 2, Leiden, The Netherlands

Keywords: Training, Assessment, Standardization, Minimally invasive surgery.

Abstract: Training and objective assessment of surgical competence receives more and more attention from society

and medical communities, and is an ongoing research challenge. For obvious reasons of patient safety,

ethics, and cost-effectiveness, there is a need to shift the training and assessment from the operating theatre

to a simulated environment (e.g. skills lab). This paper presents the state of the art on training and

assessment of surgical skills in minimally invasive surgery, and discusses remaining challenges.

1 INTRODUCTION

Minimally invasive surgery (MIS, ‘keyhole

surgery’) has been introduced into surgery to the

benefit of the patients. In contrast to conventional

open surgery, MIS is performed through small

(around 0.5 to 1 cm) incisions in the patient’s body

(Cuschieri, 1992). Through these incisions, special

cannulas are inserted in order to allow the

introduction of long, rigid instruments (e.g. scissors)

into the patient’s body. Visual feedback of the

operating field is obtained by a small camera, which

provides a two-dimensional (2D) image on a

monitor. Figure 1 shows surgeons performing MIS.

Since MIS is performed through small incisions,

patients experience less trauma than after an

conventional open procedure. Moreover, MIS causes

less postoperative pain and scaring. Patient’

recovery time is faster, resulting in shorter

hospitalization, and reduced incidence of post-

surgical complications (e.g. adhesions, infections)

(Cuschieri, 1992). For these reasons, MIS becomes

progressively a common technique for major

surgical procedures (e.g. in urology, gynaecology).

The advantages of MIS, however, come with special

demands on the surgeon, who needs to develop

unique psychomotor skills that are different from

those needed in the open procedures. These skills

include a shift form a conventional 3D operating

field to a 2D monitor display, reduced tactile

feedback, distorted eye-hand coordination, alteration

to the fulcrum effect, fewer degrees of freedom,

judgment of distorted depth perception and spatial

relationships (Wentink, 2003; Breedveld, 2000; den

Boer 1999; Hanna, 1999; Hanna, 1998).

It is evident that proper education of future

surgeons is crucial for patient safety. However,

standardized training curricula and objective

assessment methods are lacking. This paper presents

the state of the art on training and assessment of

MIS skills, and discusses remaining challenges.

Figure 1: The view of the operating room during MIS

procedure. The patient is lying on the operating table in

the supine position. The surgeons lead the operation from

the left side of the patient. The camera operator stands

next to the surgeon. Both the surgeon and the camera

operator watch the operating area on a monitor (not

presented in this picture).

261

K. Chmarra M., P. Rodrigues S., Jansen F. and Dankelman J..

CHALLENGES IN TRAINING AND ASSESSMENT OF MINIMALLY INVASIVE SURGICAL SKILLS.

DOI: 10.5220/0003289502610268

In Proceedings of the 3rd International Conference on Computer Supported Education (CSEDU-2011), pages 261-268

ISBN: 978-989-8425-50-8

 2011 SCITEPRESS (Science and Technology Publications, Lda.)

2 TRAINING OF MIS SKILLS

Mastering MIS skills requires repeated practice.

Traditionally, residents learn MIS skills in a classic

apprenticeship format with hands-on training in the

operating room (OR). However, some MIS skills are

difficult to be learnt in the OR because of its

environment complexity. These skills include, e.g.,

psychomotor skills. Due to use of rigid instruments

in a limited operating space, training of basic

(psychomotor) skills can be done outside the OR.

Currently, training of MIS skills is being done in

a traditional way (in the OR) and in a simulated

environment (in the skills lab).

2.1 Traditional Training

Traditionally, surgical residents (trainees) learn their

surgical skills while operating on patients under the

supervision of an expert surgeon (Dankelman,

2005). First, they observe experienced surgeons

performing several operations. After that, they

participate in the operation more actively; they

perform various basic techniques that they observed

during the first phase of the training. Finally, they

are taking a more independent role of a primary

surgeon. Such way of learning is potentially unsafe

for the patient. Moreover, it is not standardized, and

results in very long learning curve (Moore, 2002).

Besides, this kind of training is costly (Babineau,

2004; Bridges, 1999; Villegas, 2003).

Training of MIS skills takes also place on animal

models and human cadavers (Giger, 2008; Nebot-

Cegarra, 2004; Cundiff, 2001). The advantage of

using human cadavers for training MIS skills is that

they offer accurate anatomy. However, they lack of

bleeding when vessels are damaged during training,

and it is difficult to conserve the tissue of human

cadavers. Animal models offer comparable

physiological and tissue characteristics to those of

humans (Waseda, 2005; Olinger, 1999; Crist, 1994;

Bohm, 1994; Wolfe, 1993; Bailey, 1991). However,

there are no animals whose anatomy is exact the

same as that of humans. Moreover, animal models

and human cadavers are costly and one-time usable.

Besides, in several countries training on animals is

prohibited.

2.2 Training in Skills Labs

Quality control and patient safety gained lately

attention of health authorities and the public

(Inspectie, 2007; Roberts, 2006; Ritchie, 2004;

Satava, 2006). Therefore, there is a tendency to shift

the training from the OR to a simulated

environment.

Aggarwal et al. showed that training outside the

OR – for example in skills labs – is efficient

(Aggarwal, 2007). Thus, diverse training facilities

are being developed (Kolkman, 2007; Halvorsen,

2005; Youngblood, 2005; Katz, 2005; Schijven,

2003). A box trainer and a virtual reality (VR)

simulator are the most often used training facilities

in the skills labs.

Typically, a box trainer (Fig. 2) mimics a part of

a patient’s body (e.g. abdomen) and the surrounding,

as they are during real MIS. Box trainers allow to

use conventional MIS instruments and equipment. In

such a way, the residents are provided with a natural

force feedback, which is equivalent to that obtained

in the OR. The box can contain a variety of different

synthetic inanimate models (e.g. simple physical

objects such as pegs), synthetically produced organs,

and animal parts (Waseda, 2005; Scott, 2000).

VR trainers (Fig. 3) allow a training based on the

interaction with a computer-simulated environment.

Currently, there are various VR trainers for MIS on

the market (Halvorsen, 2005; Schijven, 2003). These

trainers supply the user with objective feedback

about his/her performance. Such feedback is

motivating for the residents to learn (Aggarwal,

2004; Grantcharov, 2001). There are, however, only

few VR trainers that are equipped with force

feedback (Halvorsen, 2005; Schijven, 2003). This

force feedback, however, is expensive and it differs

from the one experienced in the OR.

In surgical trainers, and especially in VR

trainers, there is a tendency to imitate reality as

much as possible. It is, however, not known whether

training on the high-fidelity trainers is the most

effective one for learning basic MIS skills (e.g. eye-

hand coordination) (Dankelman, 2005). In contrast

to animal models and human cadavers, which allow

training of various surgical skills, box trainers and

VR trainers are mostly used to train psychomotor

MIS skills only.

Figure 2: A box trainer used to train basic MIS skills.

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262

Figure 3: Simendo – a virtual reality trainer developed by

DelltaTech. (Courtesy of DelltaTech).

3 ASSESSMENT OF MIS SKILLS

Since MIS requires a lifelong learning, surgeons and

surgical organizations (e.g. the Accreditation

Council for Graduate Medical Education (ACGME),

the Dutch Association for Endoscopic Surgery

(NVEC), and the Dutch Health Care Inspectorate

(IGZ)) are calling for assessment tools that can be

used to credential surgeons as competent in MIS

(Park, 2002; Roberts, 2006; Ritchie, 2004; Satava,

2006; Inspectie, 2007). Because MIS requires a large

range of skills (e.g. motor skills, surgical judgment,

team work, communication, fast acting, technical

skills, cognitive knowledge), various objective

assessment methods are needed to assess those

skills.

A considerable amount of research has been

conducted into assessment of MIS skills. Existing

work can roughly be divided into three directions: i)

Assessment based on performed operations; ii)

Assessment of psychomotor MIS skills; iii) Task-

specific checklists and global rating scores.

3.1 Performed Operations

One of the fundamental and most commonly used

objective measure of surgical competence is the

number of performed cases, which is easily

quantifiable , and which indicates experience of a

surgeon (Park, 2002). However, it does not represent

the actual competence of the surgeon, since it is

based on the measure of surgical experience only. It

is also expected that different residents require

different number of cases for gaining required

surgical competence (Feldman, 2004).

Another easily quantifiable measures are the

number of complications and the number of errors

made (Mehrabi, 2006; Passerotti, 2008; Tang, 2005).

Assessment of MIS competence based only on

mortality and morbidity data is biased by the fact

that each patient and case are always different and

cannot be easily compared. Moreover, the

identification of the causes and results of medical

errors is complicated; it is difficult to identify errors

and their effects from the progression of patients’

underlying diseases, since different levels of

sickness and fragility among patients.

3.2 Psychomotor MIS Skills

Psychomotor MIS skills are assessed by analyzing

MIS instruments motion (Fig. 4) and/or applied

forces to the tissue (Cotin, 2002; Moorthy, 2003;

Van Sickle, 2005; Acosta, 2005; Cavallo, 2005;

Chmarra, 2010; Cesanek, 2008; Allen, 2009;

Cristancho, 2009). An example of typical MIS

instrument motions is presented in Fig. 4. Variety of

measures (parameters based on time-dependent 3D

representation of the tip motions of the MIS

instrument together with the rotation of the

instrument around its axis) have been suggested. The

most often used parameters are: time, path length,

movement economy, depth perception, accuracy,

deviation from the path, rotational orientation, and

motion smoothness (Chmarra, 2010a).

Many academic hospitals are equipped with box

trainers and VR trainers for the assessment of

individual MIS skills (Feldman, 2006; Goff, 2000;

Reznick, 1997; Dosis, 2005; Eriksen, 2005;

Gallagher, 2001; Kundhal, 2009; Salgado, 2009).

Such assessment is objective, but, similarly to the

current assessment methods based on performed

operations, it focuses on one aspect of competence.

3.3 Task-specific Checklists and Global

Rating Scores

Evaluation methods based on task-specific checklists

and global rating scores gained a lot of attention

(McKinley, 2008; Moorthy, 2003). They include the

Global Operative Assessment of Laparoscopic Skills

(GOALS), and Objective Structured Assessment of

Technical Skills (OSATS) (Moorthy, 2003; Goff,

2000; Gumbs, 2007; Chang, 2007; Pellen, 2009;

Martin, 1997; Cuschieri, 1979; McKinley, 2008;

Wincckel, 1994; Cohen, 1990). These methods

assess more than one aspect of surgical competence,

but it is difficult to judge surgical skills based on

them, since there is no clear definition of the passing

score that determines when a surgeon is competent

at different moments of his/her career.

Task-specific checklists and global rating scores

have been validated in the training environments.

Their realization in the OR remains a challenge; it is

CHALLENGES IN TRAINING AND ASSESSMENT OF MINIMALLY INVASIVE SURGICAL SKILLS

263

Figure 4: Typical instrument trajectories of an expert surgeon (left) and a novice (right) performing a positioning task.

(Adapted from (Chmarra, 2010)).

not known how to assess the residents, because there

is no clear description on when the various scores

should be given. For example, two residents that

obtained the same score in OSATS might have very

different MIS skills. This is especially possible when

assessing the first-year residents and the fifth-year

residents; since the year of residency is often not

taken into account. Another disadvantage of these

methods is the fact that assessment of MIS skills is

often done by surgical educators, who might be

influenced by, for example, personal relationships.

4 CHALLENGES

Although various training and assessment methods

of MIS skills exist, standardized training curricula

and objective assessment methods are currently

lacking. For example, the Dutch surgical residency

program is very much regional; the residents follow

a series of regionally organized courses and

tutorials, which conclude with an assessment (Borel-

Rinkes, 2008). The lack of national standardization

of residency program results in confusion when

comparing expertise of residents from different

regions. Therefore, training and assessment methods

in surgery should be standardized and formalized.

4.1 Training of MIS Skills

For obvious reasons of patient safety, ethics, and

cost-effectiveness, training of MIS skills is being

shifted from the OR to a simulated environment. A

potential benefit of simulated environments is the

possibility of introducing more uniformity across

training programs at different medical centres. In a

simulated environment, the training conditions are

controlled exactly and objective assessment criteria

can be defined.

At this point, there is a sense of disappointment

about the results (e.g. efficiency, effectiveness) of

current training programs. Although there have been

few breakthrough attempts to improve the training of

particular MIS skills, development of a proper

curriculum to train competent surgeons remains a

challenge.

To establish a reliable and valid training

curriculum, it is necessary to find answers to four

essential questions: What should be trained; Where

should it be trained; How should it be trained; When

should it be trained?

Currently, it is still not know ‘what’, ‘where’,

‘how’, and ‘when’ exactly should be trained. An

attempt to identify essential abilities and skills that

characterize surgical competence had been made by

Satava et al. during a workshop, which was

conducted ‘to establish a consensus on a baseline set

of metrics from which future education, training,

evaluation, and research in the technical aspects of

surgical and procedural skills can be measured’

(Satava, 2003). The ability has been defined as ‘the

natural state or condition of being capable, aptitude’,

and the skill has been defined as ‘a developed

proficiency or dexterity in some art, craft, or the

like’ (Satava, 2003). Since the definitions provided

by Satava should be seen as a first approximation at

establishing a standard set of nomenclature, further

studies are needed to either validate or refute these

initial concepts. Furthermore, it is necessary to

identify all the abilities and skills that characterize

competent surgeons. After that, a redistribution of

the surgical skills into sublevels (e.g. basic,

intermediate, advance) should take place.

It is important to determine behavioural level at

which the training is to be achieved, because it has

been recognized that different behavioural

characteristics should be learnt using different

training methods (Wentink, 2003; Dankelman,

2007). Wentink proposed to devise surgeon’s

behaviour using Rasmussen’s model of human

behaviour, which distinguishes three levels: skill-

based, rule-based, and knowledge-based levels

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(Wentink, 2003; Rasmussen, 1983). Table 1 shows

current training methods that are attributed to these

three behavioural levels. Although currently

available training methods are being used to train

different behavioural characteristics, it is still

necessary to identify essential surgical skills that

characterize surgical competence.

Table 1: Levels of human behaviour in surgery.

Level of human

behaviour

Training method

Skilled-based Box trainer, VR trainer

Rule-based Courses, literature,

internet, VR trainer

Knowledge-based Training in OR

VR – virtual reality; OR – operating room

Adapted from Dankelman (Dankelman, 2007)

There is a trend to imitate reality as much as

possible in surgical trainers. To find out whether

such high-fidelity trainers are the most effective

ones when learning basic MIS skills, studies have

been done to investigate whether those skills can

also be acquired using a low-fidelity trainers, in

which residents focus only on specific basic tasks.

Fundamental knowledge on efficient and effective

methods and tasks to train MIS skills, however, is

still lacking.

It is not known at which stage of training which

skills are learnt most effectively. Few studies

investigated how long a separate training session

should take and how long time between these

sessions should be (Verdaasdonk, 2007; Duffy,

2005; Mackay, 2002). These studies showed that a

common saying that ‘practice makes perfect’ is not

the only determinant of motor MIS skills learning;

the time that elapsed between two training sessions

seems to have a significant influence as well. It has

also been demonstrated that distributed training is

superior to the massed training.

4.2 Assessment of MIS Skills

To establish a reliable assessment methods for MIS,

it is necessary to find answers to four essential

questions: What should be assessed; Where should it

be assessed; How should it be assessed; When

should it be assessed?

Any attempt to assess technical competence of a

surgeon is difficult, because operative skill is a

combination of a surgeon’s knowledge, judgment,

and technical ability (Dankelman, 2005). Moreover,

to be able to assess the operative skill, it is necessary

to first measure that skill. Currently, there is no

method that is able to objectively assess surgical

competence based on data that includes: motion

analysis, force measurements, errors, final result of

operation, global assessment of performance,

number of performed surgeries, complications,

knowledge of anatomy, operational protocol, and

knowledge of equipment. This is partly caused by

the fact that not all the data mentioned above can

easily be measured.

Since it is not known where various MIS skills

should be trained, it is also not known (yet) where

these skills should be assessed. It is, however,

desirable to develop assessment methods that can be

used independently of the training setup. Developing

such methods is challenging, because factors such as

patient safety and ergonomics in the OR play a

critical role in designing these systems.

Assessment of technical competence of MIS

surgeons is a largely ignored aspect in researches on

patient safety, education in surgery, and MIS itself.

Many researchers focus only on validation of new

tasks and simulators for learning MIS skills

(Vassiliou, 2006; van Sickle, 2005; Stefanidis,

2010), whereas only a few isolated studies have been

found in the literature that introduce computer-aided

methods to assess and classify the surgeons based on

their technical competence (Cotin, 2002; Fraser,

2003; Allen, 2009; Cristiancho, 2009; Rosen, 2001;

Chmarra, 2010). All these attempts focus only on

manual dexterity of the surgeon, not taking into

account other skills.

Another problem is how to determine a passing

score, which defines when the surgeon is ‘good

enough’. The research is usually limited to show that

there is a correlation between the experience of a

surgeon and the proposed assessment measure.

Moreover, the existing methods assess competence

mostly on one individual (isolated) MIS skill only.

Few studies proposed methods to assess several

skills (Goff, 2000; Gumbs, 2007; Martin, 1997;

Mackay, 2003), but they combined these in a rather

ad-hoc, subjective manner. Moreover, some of these

methods were validated using data of experienced

surgeons and novices only. It is not known whether

these methods are able to distinguish between

surgeons with a finer gradation in experience (e.g.

expert and intermediate). Furthermore, none of these

methods takes into account that certain skills (e.g.

knowledge of procedure steps) can be compensated

by other skills (e.g. good teamwork).

Assessment of technical competence of surgeons

can be done either subjectively or objectively

(Feldman, 2004). Most of the present training

curricula use assessment methods that heavily rely

on subjective assessment measures (Darzi, 1999;

Martin, 1997; Moorthy, 2003). This should be

CHALLENGES IN TRAINING AND ASSESSMENT OF MINIMALLY INVASIVE SURGICAL SKILLS

265

changed, and objective assessment methods that are

less likely to be biased by personal relationships,

should be developed. There are two main advantages

of introducing objective assessment methods: i) It is

possible to compare surgical competence of various

surgeons; ii) An objective assessment is more

reliable than the subjective one. By consequence,

residents will be more likely to accept objective

feedback on their skills and constructively

incorporate it in training.

It is difficult to say when assessment methods

should be used; no reliable training curricula have

been standardized nor widely used. It is, however,

desirable to develop assessment methods that can be

used at any time during training. Then it will be

possible to improve training methods without

necessity of developing new assessment methods. It

is important to recognize that development of

training curricula is closely associated with

development of assessment methods. Once the MIS

skills to be trained are known, it will become known

which MIS skills have to be assessed. The same

takes place the other way around; once the MIS

skills to be assessed are known, it will become

known which MIS skills have to be trained.

5 RECOMMENDATIONS

To develop reliable and correct training and

assessment methods, few recommendations should

be taken into account. First, it is necessary to ‘follow

the evidence of effectiveness’. Improved and/or new

methods are likely to be more enthusiastically

embraced and introduced when they are based on

evidence of their effectiveness. Also, the results that

indicate changes (e.g. improvement) in performance

of the methods need to be measurable.

Patient safety introduces new knowledge into

quality of performed surgery by way of disciplines

such as human factors, sociology, organizational

psychology, informatics. Therefore, development of

training and assessment methods should be done in a

multidisciplinary team.

After reliable and validated training curricula and

assessment methods have been developed and

implemented, hospitals can adapt their specialization

areas to the strengths (and weaknesses) of their staff.

Only then patients undergoing surgery will know

that they are in ‘good hands’.

6 CONCLUSIONS

Training and assessment of MIS skills is important

from the patient safety point of view. To improve

patient safety by better safeguarding the quality of

surgical performance, a number of training and

assessment methods have been developed and

introduced in MIS. Training of MIS skills is

currently done in the OR and in the skills labs, and

can roughly be divided into assessment based on

performed operations, assessment of psychomotor

skills, and task-specific checklists and global rating

scores. Establishment of reliable and valid training

curricula and assessment methods is difficult,

because fundamental questions of what, where, how,

and when should be trained and assessed have not

yet been answered. Studies should be conducted to

find the answers to these questions and to develop

appropriate training and assessment methods.

Implementation of these methods in surgical training

curricula should result in improvement of patient

safety.

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