We conducted a 2-day pediatric endosurgery workshop for young pediatric surgeons in Russia in collaboration with Russian expert pediatric surgeons using a self-assessment questionnaire survey and objective skill validation system. The major findings of this study were as follows: (1) Pre-workshop assessment questionnaires revealed that young Russian pediatric surgeon strongly felt the need to acquire knowledge and training in endoscopic surgical skills and had low confidence in their endoscopic surgical skills, such as suturing. (2) Regarding the endoscopic surgery skill evaluation task using the A-Lap Mini, the completion rate of the suturing task and the number of full thickness sutures were significantly improved after the workshop. (3) The post-workshop assessment questionnaires revealed that they valued the contents of the workshop, such as basic principles in endoscopic surgery, fundamental endoscopic skills with demonstration, and the advanced technique and disease-specific simulator experience with video lectures. On the other hand, they felt more difficulty for performing the disease specific simulators. (4) young Russian pediatric surgeon had the confidence in endoscopic surgery skills significantly improved after workshop regarding forceps manipulation ability and suturing performance. They also evaluated the usefulness of the workshop for clinical surgery.
Although endoscopic surgery has the advantage of being less invasive than open surgery, it involves highly difficult techniques, which must be performed from a limited direction under a monitor using only limited instruments. With the widespread use of endoscopic surgery, many complications have been reported [4, 5]; however, many of these are due to the absence of an appropriate training program, which would facilitate the acquisition of skills needed to perform endoscopic surgery safely . To acquire skills in endoscopic surgery, reading textbooks and watching videos of clinical cases are not sufficient; hands-on training is absolutely essential. Under these circumstances, the Japan Society for Endoscopic Surgery established the world's first ESSQS [7, 8]. Certification examinations started in 2003 for obstetrics and gynecology, in 2004 for gastroenterology and general surgery, urology, orthopedics, and in 2008 for pediatric surgery. The accredited doctor system certifies that the acquirer "has the surgical skills to safely and properly perform endoscopic procedures and has the ability to provide direction and guidance." Japanese surgeons have endeavored to improve their endoscopic surgical skills and to train young surgeons through various activities, such as the establishment of the ESSQS, the provision of educational seminars, and the development of the Practice Guidelines on Endoscopic Surgery ,.
Based on this knowledge and sufficient experience in the development of educational systems that facilitate the acquisition of endoscopic surgery techniques in Japan, we held a hands-on seminar for young Russian pediatric surgeons this time. The content of this seminar was designed to not only provide knowledge in relation to endoscopic surgery through the lectures of experts, but also to use the disease-specific simulators brought from Japan to improve endoscopic surgery skills. The A-Lap Mini was developed to provide an objective assessment of the performance of the suture ligature method in intestinal anastomosis . This system can automatically indicate not only the examinee’s skills and weak points but also expert skill levels. Using this system, novice surgeons can recognize their skill levels and the differences of expert surgeons. They can also establish skill endpoints.
In this study, by evaluating the participants themselves before and after the workshop, we provided not only specific feedback on suturing techniques, but also the strong and weak points of each trainee. In fact, the two-day workshop was able to significantly improve the completion rate of the suturing task and number of full-thickness sutures. Furthermore, the area of wound-opening, suture tension and the maximum air leakage pressure tended to be improved, although these differences were not statistically significant. This means that loosening of the ligature disappeared due to improvement in the suturing technique. However, the training delivered in the 2-day workshop did not lead to a significant improvement in laparoscopic forceps skills, such as the performance time. Short-term training contributes to the improvement of skill acquisition, but does not improve skill quality [11, 12]. Continuous training is most important for performing safe, secure and high-quality endoscopic surgery.
Differences in surgical skill between expert surgeons and novice surgeons appear in the difference in their forceps handling during endoscopic surgery , it seems that considerable time and experience are required to improve a surgeon’s forceps handling. In a study examining the relationship between quick forceps handling and surgical performance , rough and quick handling of the forceps is associated with creating more organ damage, but not faster performance. In short, slow manipulation of the forceps (“zero” speed of acceleration) results in the performance of safe and secure endoscopic surgery in comparison to rough and quick manipulation of the forceps. This is a very important factor and a matter to be kept in mind, especially in pediatric endosurgery performed in small working spaces.
In addition, we also brought in a disease specific model of pediatric endosurgery from Japan for training. Since Satava et al.  pointed out the usefulness of simulators for endoscopic surgical training in 1993, many different types of simulators have been developed and their clinical application has been reported . Recently, three-dimensional models of organs produced by 3D printing have become more popular . In the pediatric endosurgery field, there is evidence that simulator training is a highly effective educational modality [18, 19]. However, there are very few simulators dedicated to pediatric endosurgery, and it is difficult to say whether sufficient training can be gained due to the lower number of cases. In this study, using a simulator developed by a Japanese company for pediatric surgery, we were able to give the trainees a taste of the difficulties of operating in the small working space unique to children. The objective evaluation of the suturing technique, which allowed the participants to understand their own weaknesses and to experience a disease simulator for pediatric endosurgery, is believed to have contributed to the satisfaction of the participants in this workshop.
The present study was associated with some limitations. We did not investigate whether the results of this workshop were correlated with subsequent clinical outcomes. This requires an objective evaluation by a similar simulator six months or several years later. The objective assessment of surgical performance and the provision of feedback are important processes for conducting effective training . These can give trainees a sense of improvement in their own surgical skills and may give them confidence. Successful surgery requires the smooth integration of different skills and this requires further training and assessment. We need to strive to hold these workshops on a regular basis.