An exploratory project to develop an effective educational system to teach mastery of assistant laparoscopic gynecologic surgery skills

In laparoscopic surgery, the cooperation of the first assistant surgeon is essential for the creation and maintenance of an appropriate and safe surgical field. The aim of this study is a validation of the impact of our educational system for first assistant laparoscopic surgeon residency in a single university‐affiliated teaching hospital.


| INTRODUCTION
The outcomes of surgeries significantly depend on the skills of the primary surgeon but are also strongly influenced by the competencies of the entire surgical team. Effective coordination among the members of the collective operative team, including surgeons, anesthesiologists, and nurses, can contribute to a smooth operative procedure and better outcomes. [1][2][3][4][5][6][7][8][9] The first assistant surgeon plays a critical role in the operative procedure by creating the appropriate surgical field, providing good traction, and ensuring an optimal view of the dissection plane. Mastering the assistance skills to become the exquisite operator needed for laparoscopic surgery is also necessary for controlling the safety of the surgery. However, to our knowledge, an educational system for producing first assistant surgeons for laparoscopic surgery has yet to be reported.
In Japan, medical care is largely decentralized, unlike overseas, where it is often done at high-volume specialty centers. Hospital case volumes can positively influence the purely objective outcomes of surgery, such as operative time, blood loss, and risk for conversion to laparotomy. [10][11][12] Because of the decentralization in Japan, the number of specialized experiences per doctor is often small, so the proper surgical education in a lowvolume center is a critical issue, as it must balance the effective training of its residents against surgical safety.
Instructor feedback is an essential component of all surgical education. Although feedback increases the efficiency and reduces the time needed to reach a certain proficiency level, [13][14][15] inefficient feedback requires an excessive amount of time. It is thus important for educational clinicians to create a laparoscopic educational system that combines with an appropriate feedback system. This study evaluated the efficacy of our innovative educational system, equipped with a more effective feedback system, to improve the ability of new surgical residents to master their assistant skills in laparoscopic gynecological surgery.

| Participants
Five residents receiving their training at Osaka University between April 2016 and March 2017 were recruited into this study. According to the number of previous cases of gynecologic laparoscopic surgery they had already experienced, the five residents were divided into two groups: Group 1 (n = 3) was the less experienced group (the number of previous cases experienced was <40), and Group 2 (n = 2) the number of previous cases experienced was more than or equal to 40.

| An educational tool used to teach laparoscopic operative procedures
In laparoscopic gynecologic surgery for benign conditions, properly identifying the ureter is one of the most important operative procedures for safely accomplishing the surgery, so we stylized our operative procedure for identifying the ureter. First, we open the pelvic sidewall triangle and identify the ureter and the para-rectal space. We play up these procedures to accomplish total laparoscopic hysterectomies safely. Total laparoscopic hysterectomy and laparoscopic salpingo-oophorectomy involving these procedures were included in this study. All laparoscopic surgeries and evaluations were performed at our Osaka University Hospital.
We broke down the various operative procedures and created a Microsoft PowerPoint slide presentation with animations, videos, and illustrations describing the anatomical schema in each segmented step to master the surgical procedure ( Figure 1A). Residents postoperatively self-reviewed their operative procedures while referring to the educational tool checklist.

| Assessment procedure
Residents participated in surgery as first assistants who held a forceps in their right hand and a camera in their left hand. Immediately after the surgery, two experienced attending doctors evaluated the resident's procedure at the three stages of the residency experience: "0" was the stage at which the residents could do nothing, "1" was the stage at which residents can do supervised tasks, and "2" was the "unsupervised stage". Figure 1B shows a sample scene of the review. The residents self-evaluated their procedure.

| Educational system
Residents were responsible for reviewing their operative procedures in response to the attending doctor's assessment of each segmented operative procedure. In particular, the attending doctors encouraged the residents to review any operative procedure in which there was a gap between the resident's self-assessment and that of the attending doctor. Just before the next surgery, we urged residents to review the attending doctor's assessment of the previous surgery.

| Primary outcome
The primary outcome of this study was the objective evaluation of the transition of new resident's evaluation scores from before to after training in each experience group.

| After completion of the educational system
Using a visual analog scale (VAS) scale, the residents were asked to express their subjective level of satisfaction with our novel educational system.

| Statistical analysis
Analysis of the subject's baseline characteristics was performed using the Mann-Whitney U test. Differences between the transition of scores in both groups were tested using Pearson's Chi-squared test. We created a scatterplot of the concordance rates between the resident's self-assessment scores and the attending doctor's assessment scores using analysis of variance. Statistical analyses were performed using JMP-14 software (SAS Institute Inc., Cary, NC, USA), and P < .05 was considered to indicate a nominal statistical significance. Table 1 lists the background characteristics of the residents. The residents of Group 2 had experienced on average more cases before our specialized training than did the residents in Group 1 (45 ± 5 vs 20 ± 15, respectively, P = .127). For that reason, for their first assessed surgery at the start of their training, the more experienced residents of Group 2 had a higher evaluation score than Group 1 (48.7 ± 3.9 vs 29.1 ± 3.1, P = .010). During the training course, there was no difference in the number of cases experienced between the two groups (12 ± 4 vs 7 ± 2, P = .20).   Figure 2B shows the progression of scores for each individual resident during the study. The trainees all achieved higher scores as they experienced more surgeries. Figure 3 indicates the changes of concordance between the resident's self-assessment and the attending doctor's assessment of the resident's actions. In the beginning, the concordance rate between the two assessments was only 51%, but as the resident experienced more surgeries, the concordance significantly increased (P < .001).

| DISCUSSION
This study clearly demonstrates the efficacy of our advanced educational system for first assistant laparoscopic surgeons in residency, the importance of which is unquestioned. 16 However, there have as yet been no reports regarding similar educational systems to be used for training first assistant surgeons and their operative procedures.
It is well established that intraoperative feedback appears to be associated with an improvement in surgical performance; 17 however, the distractions of constantly interrupting the operative procedure to provide and receive live feedback make performing a smooth operation difficult. Our video-recorded surgical feedback system needs only a few minutes to set up and does not interrupt the operation in any way. Immediate postoperative feedback of segmented operative procedures increases the amount of information provided in a permanent record form. By using our educational system, novice residents quickly caught up to the more experienced residents and all participants expressed a high level of satisfaction with the training.
Finnesgard et al. found that having a more experienced certified surgical assistant led to significantly shorter operative times for laparoscopic pancreatoduodenoectomies. 9 Kim et al. found that having a novice first assistant resulted in longer operative times during laparoscopic sigmoidectomies, but this difference was canceled out after an initial learning curve of 10 cases. 18 As mentioned above, there are several reports regarding the importance of the first assistant surgeon, but as yet no articles on educational programs for them. In this study, we have developed an educational system that quickly, in just 1 year, brings less experienced residents up to the same level as more experienced operators. In addition, as case experiences accumulated, there was a higher concordance achieved between the resident's selfassessment and the attending doctor's assessment. Having the same perspective for operative success as the attending doctor is very important for a first assistant surgeon.
In Japan, medical care is decentralized and the number of specialized experiences per resident surgeon is unusually small, thus complete mastery of the required highly technical operative skills is fairly difficult. This novel post-operative educational system will help to overcome this particular disadvantage.
The results of this study should be interpreted in the context of its limitations. First, this was a pilot study and thus had only a small sample size of five residents. If the sample size had been larger, different results might have been derived. However, encouragingly, following this modified training, the inexperienced Group 1 accomplished a higher evaluation score than did Group 2, strongly suggesting that this educational system was effective. It would be interesting to see, in a much larger sample size, if this learning advantage for inexperienced surgeons holds up, as it would vindicate that old saying, "You can't teach an old dog new tricks"-that is, that once trained, the more experienced residents stuck with doing things the way they first learned them.
Second, this study was confined to a single university teaching center's experience, which limits both the study's ability to establish causative relationships and also limits the generalizability of its results. It will be necessary to further investigate whether the effects of this educational system are extendable to multiple institutions. Nevertheless, this study shows that residents entering at various experience levels at the beginning of this educational system could reach the same level of competency in a relatively short period with only a small number of cases for experience, regardless of the total number of prior cases under their belt.
Our immediate post-operational video-review educational system for first assistant surgeon training is highly appropriate and effective. Further efforts toward better quality and expansion of operative procedures are obviously necessary.