Advances in training for laparoscopic and robotic surgery

Laparoscopic surgery is rapidly becoming a standard in many surgical procedures. This surgical technique should be mastered, up to a certain level, by all surgeons. Several unique psychomotor skills are required from the surgeon in order to perform laparoscopic surgery safely. These skills can be learnt by using simulation based training. Moreover, the acquired skills on simulators have shown to be transferrable into the operating room, leading to improvement of patient safety. The first part of this thesis addresses issues concerning learning of conventional laparoscopy. A general introduction explores the history of laparoscopic surgery and the backgrounds of training surgical skills. The current state of laparoscopic skills training in the Netherlands is stated. Several studies on simulators were performed. A laparoscopic training course, to be used in any box trainer, was constructed. This course was found valid to train surgical residents. A curriculum to train more advanced skills was developed for the SIMENDO™ virtual reality simulator and face- and construct validity was estimated. The exercises provide increasing levels of difficulty and practice variety. For the LapSim™ virtual reality simulator face- and construct validity for the basic-skill exercises and the gynaecologic module were established. Both simulators were able to differentiate between subjects with varying laparoscopic experience. An international consensus based list of criteria to evaluate skills laboratories and skills curricula for laparoscopy was developed. The most important criteria for a skills laboratory were: the presence of a box trainer, a laparoscopic expert, the availability of financial resources and the presence of a structured skills curriculum. The most important criteria for a skills curriculum were: mandatory training supervised by laparoscopic experts, dedicated time for skills training, maintenance of skills and evaluation of the progress of the resident. A retrospective study in women with suspected early ovarian cancer demonstrates that there is a significant learning curve for complex laparoscopic procedures. The second part addresses aspects of learning robot assisted laparoscopic surgery. This relatively new type of surgery is undergoing an exponential growth worldwide. With this increase there is a concomitant rising demand for training methods.A systematic review evaluating aspects of training and learning of this type of surgery on the da Vinci® surgical system was performed. Robot surgical training consists of two parts: system training and procedural training. System training should be formally organized and competence based, rather than time based. Virtual reality simulation will soon play an import role in training robotic surgery. For procedural training a stepwise approach with an objective assessment is recommended. The use of structured training programs seem to make it possible to train future robotic surgeons without affecting patient outcomes. Training should be preferably organized in high volume centers. For the dV-Trainer™ virtual reality trainer for training of robot assisted surgery, face- and construct validity was established. Based on this study simulator is considered to be a useful training tool for robotic surgery. In the discussion, the conclusions of this thesis are placed in a broader perspective and recommendations for a successful training program are made.