A multi-modal approach to training in laparoscopic colorectal surgery accelerates proficiency gain

How to efficiently train and transfer skills in laparoscopic colorectal surgery is unclear. Errors are rarely avoidable during learning but may incur patient morbidity. Multi-modality training with a modular operative approach provides proficiency-based structured task-specific training in a sequential manner, fragmenting complex laparoscopic colorectal procedures by difficulty allowing more than one trainee to gain experience irrespective of prior experience. This study assessed multi-modality training and its effect on proficiency gain in laparoscopic colorectal fellows.

A prospective study of 750 consecutive laparoscopic colon and rectal resection training cases assessing proficiency gain using a modified direct observation of procedural skills (DOPS) (behaviors-assessment) and weighted global modular attainment score (GMAS) (maneuvers-assessment) was carried out. Two mentors delivered training in a standardized format from 2008. Consequential intra-operative errors (requiring a corrective maneuver to permit further progression of the operation) were recorded. Eight Laparoscopic Fellows were assessed in six-month periods over 4 years. Primary outcome was proficiency gain measured by cumulative sum (CUSUM) analysis with boot-strapping comparing weighted GMAS and modified DOPS assessment. Morbidity (Clavien-Dindo classification), and consequential errors were submitted to similar analysis to assess significant variations during the training period.

Fellows were trained on over 100 laparoscopic colorectal resections in a six Fellowship month period. Proficiency gain was identifiable in the DOPS and GMAS with 32 (99 % CI 25-37) and 39 (99 % CI 32-44) cases, respectively. Two- versus single-mentor training improved proficiency gain 35 (99 % CI 30-43) versus 55 (99 % CI 50-60). Overall consequential error rate and major morbidity rate (CD III-IV) were stable over time at 25 and 8.7 %, respectively.

Multi-modality training with modular operative training and technique standardization shortens the time to proficiency gain with low morbidity accepting an intra-operative consequential error rate of 25 %.