The complexity of acquiring minimally invasive surgical (MIS) skills, combined with smaller case volumes for residents have pushed the development of skills training facilities on simulators outside the operating room (OR). Medico-legal and financial constraints have stimulated this development even more. However, the implementation of simulator training into a residency curriculum is shown to be troublesome. MIS skills training is organized in a uniform and easily applicable way in the Dutch obstetrics and gynecology residency curriculum. Every resident is obliged to attend the same basic surgical skills course, named Cobra-alpha course, intentionally during postgraduate year (PGY) 1 or 2. Furthermore, surgical skills are trained, evaluated and expanded on simulators in teaching hospitals. Additional to the Cobra-alpha course, residents may attend advanced training courses and congresses focusing on laparoscopy and hysteroscopy. This organization guarantees a uniform introduction to MIS skills training for every resident. However, preconditions for continuous training and evaluation after this introduction have to be optimized

A Darzi

A Hyltander

A Kingston

A Park

AG Gallagher

B Navez

BA Goff

BF Shay

CA Moulton

DJ Anastakis

DJ Scott

EG Verdaasdonk

Ellen Hiemstra

FH Loh

Frank Willem Jansen

FW Jansen

GM Lentz

HA Brolmann

JA Cadeddu

LS Feldman

MH Blanchard

MS Nussbaum

NE Seymour

R Reznick

W Kolkman

Wendela Kolkman

Y Munz

English

PubMed

Crossref

Skills training in minimally invasive surgery in Dutch obstetrics and gynecology residency curriculum

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TECHNIQUES AND INSTRUMENTATION
Skills training in minimally invasive surgery in Dutch
obstetrics and gynecology residency curriculum
Ellen Hiemstra & Wendela Kolkman &
Frank Willem Jansen
Received: 15 February 2008 /Accepted: 15 April 2008 /Published online: 29 May 2008
# The Author(s) 2008
Abstract The complexity of acquiring minimally invasive
surgical (MIS) skills, combined with smaller case volumes
for residents have pushed the development of skills training
facilities on simulators outside the operating room (OR).
Medico-legal and financial constraints have stimulated this
development even more. However, the implementation of
simulator training into a residency curriculum is shown to
be troublesome. MIS skills training is organized in a
uniform and easily applicable way in the Dutch obstetrics
and gynecology residency curriculum. Every resident is
obliged to attend the same basic surgical skills course,
named Cobra-alpha course, intentionally during postgradu-
ate year (PGY) 1 or 2. Furthermore, surgical skills are
trained, evaluated and expanded on simulators in teaching
hospitals. Additional to the Cobra-alpha course, residents
may attend advanced training courses and congresses
focusing on laparoscopy and hysteroscopy. This organiza-
tion guarantees a uniform introduction to MIS skills
training for every resident. However, preconditions for
continuous training and evaluation after this introduction
have to be optimized.
Keywords Surgical skills . Training . Simulation .
Implementation . Residency curriculum
Introduction
Minimally invasive surgery (MIS) has evolved into a major
surgical approach to treat a variety of gynecological
disorders. This approach has considerable benefits for
patients, such as a reduced morbidity, a shorter hospitali-
zation, better cosmetic results, and an earlier return to
normal activity [1].
However, acquiring MIS skills is more challenging than
acquiring the skills necessary to perform conventional open
surgical procedures. MIS poses specific demands on the
surgeon. During MIS, the three-dimensional operating field
has to be interpreted from a two-dimensional monitor
display in which depth perception is altered. In addition, a
surgeon has to manipulate long surgical instruments with
diminished tactile feedback and fewer degrees of freedom,
while adapting to the fulcrum effect [2, 3].
Apart from the complexity of acquiring MIS skills, a
residency curriculum has to deal with smaller case volumes
in the operating room (OR). This is due to a decrease in
resident working hours and a declining trend in major
gynecological surgical procedures in general [4, 5]. The
smaller case volumes, combined with issues such as quality
control, patient safety, efficiency and cost-effectiveness
have led to an increasing interest in simulator training
facilities outside the OR [3, 6]. Simulator training aims at
progression along the learning curve by repetitive training
of surgical skills with a lack a potential burden to patients
in a pressure free environment. [3]
With regard to MIS training the implementation into
residency programs is shown to be troublesome [7–9]. Even
though basic laparoscopic procedures have well been
incorporated in residency, more advanced procedures are
not [5, 10]. Lack of adequate training during residency
influences the subsequent use of a specific technique and
Gynecol Surg (2008) 5:321–325
DOI 10.1007/s10397-008-0402-1
E. Hiemstra :W. Kolkman : F. W. Jansen (*)
Department of Gynecology,
Leiden University Medical Centre (LUMC),
P.O. Box 9600, 2300 RC,
Leiden, The Netherlands
e-mail: F.W.Jansen@lumc.nl
ultimately may restrict the implementation of MIS in daily
practice after completion of residency training [11, 12].
In this report, we present the organization of MIS skills
training in the Dutch obstetrics and gynecology residency
curriculum which has continuously been evaluated and
improved over the past 15 years.
Surgical skills in the Dutch residency curriculum
The obstetrics and gynecology residency program lasts
6 years in the Netherlands. A basic surgical skill course,
named Cobra-alpha course, was incorporated in the
curriculum in 1992. It has been evaluated and improved
ever since. In 1997, this course was made compulsory for
every resident. Attendance to this course is mandatory for
obstetrics and gynecology residents during postgraduate
year (PGY) 1 or 2. One third of this two-day course is spent
on theory, while the complementary two thirds are spent on
hands-on training. The first day focuses on basic technical
skills, like instrument handling and knot tying, for
conventional surgery, while the second day concerns the
basic skills required for MIS which is subdivided into
laparoscopy and hysteroscopy. Two handbooks, focusing
on the basics of surgery and laparoscopy, are used for study
purposes and have been written for this course [13, 14].
The goal of the hands-on training in MIS during the
Cobra-alpha course is to provide an introduction to
simulator training for laparoscopic and hysteroscopic skills.
Additionally, residents need to expand the acquired skills
on simulators and have these skills evaluated by a mentor
or MIS expert in their own clinic. Necessarily, time for
training and evaluation has to be scheduled into the busy
clinical practice of the residency program.
A range of simulators is available for the hands-on
training. Inanimate box trainers are used to practice basic
laparoscopic skills like hand–eye coordination, adaptation
to the lack of depth perception and camera holding. The
construct validity is established for five of the available
exercises in the box trainers [15]. These five exercises are
placing a pipe cleaner through four small circles, stretching
a rubber band around 16 nails, placing 13 beads in a letter
‘B’, cutting a marked circle from a rubber glove and intra-
corporeal knot tying. The laparoscopic box trainer exercises
are presented in Fig. 1. With regard to hysteroscopic
simulators, vegetable models are available like pumpkins
and red peppers [16]. Furthermore, chicken meat simulates
an endometrium in a water-filled box and a porcine bladder
simulates a uterus. A selection of hysteroscopic exercises is
presented in Fig. 2. Basic hysteroscopic skills such as
camera holding, instrument handling, safe use of energy
sources and distention medium are trained. Besides, some
procedures like diagnostic hysteroscopy, endometrium
resection and resection of polyps or myomas are simulated.
Prior to the start of hands-on training, the exercises are
introduced and explained with the aid of audiovisual
demonstration. Afterwards, the participants go through a
rotation of simulators. The surgical performance is assessed
by calculating a score that rewards precision and speed. In
the validated exercises, the calculated individual scores are
1. Pipe cleaner 2. Rubber band 3. Beads
4. Cutting circle 5. Intra-corporeal knot tying
Fig. 1 Laparoscopic training exercises
322 Gynecol Surg (2008) 5:321–325
compared to a previously established performance standard
[15]. Training on the laparoscopic and hysteroscopic
simulators is intensively supervised by experts in MIS.
Regarding the number of participants attending the course,
which varies from 32 to 36, each simulator is used by two
or three residents and is supervised by one supervising
expert.
In addition to the mandatory Cobra-alpha course which
is mainly focused on basic skills, residents can apply to two
advanced courses in MIS, a laparoscopy course and a
hysteroscopy course. These courses can be attended on a
voluntary basis. The advanced courses are more procedure
orientated than the Cobra-alpha course. In spite of using
simulators, life surgery is used for teaching purposes.
Procedure-specific courses can further enhance skills and
knowledge, like a sacrocolpopexy course and a course
regarding laparoscopic adnex surgery. Besides, a variety of
(inter)national congresses focuses on MIS are organized.
The mandatory Cobra-alpha course, advanced MIS
courses and congresses form the training structure in the
Dutch residency curriculum, combined with simulator
training in the teaching hospitals during clinical rotation.
Discussion
The Dutch obstetrics and gynecology residency curriculum
has a clear structure regarding the training of MIS skills. A
mandatory basic surgical skills course is established for
residency training which is nationwide accepted and has a
broad Dutch faculty. Intentionally, the course has to be
attended during PGY 1 or PGY 2. Additionally, residents
may attend advanced courses and congresses focusing on
laparoscopy and hysteroscopy. This structure enhances the
implementation of basic MIS skills training into the
residency curriculum.
Basic MIS skills can be trained on simulators. Simu-
lators have shown great potential for training and objec-
tively assessing laparoscopic skills [17, 18]. The skills
acquired are transferable to real operative procedures [19–
21] and skills training is shown to decrease patient
complications [22]. For every resident, there is a learning
curve to achieve proficiency in performing MIS. Presum-
ably, acquiring basic MIS skills by simulator training leads
to progression along the first part of this learning curve
resulting in better prepared residents for the actual surgery.
After achievement of the basic skills, more attention can be
paid to the specific procedure during surgery on real
patients. With the growing evidence of valuable aspects of
1. Red pepper 2. Chicken meat in a water filled box 3. Porcine bladder
Fig. 2 Hysteroscopic training exercises
Table 2 Target numbers of MIS procedures required for certification
Procedure Target
number
(total)
Target number
performed on
competence level 4
Laparoscopic surgery
Diagnostic laparoscopy/
sterilization
50 10
Minor adhesiolysis 10 not applicable
Salpingectomy/
salpingotomy (inclusive EP)
20 5
Cystectomy 10 not applicable
Hysteroscopy
Diagnostic hysteroscopy 40 10
Resection polyps 10 5
Resection myomas type 0–I 10 not applicable
Resection myomas type II 10 not applicable
EP Ectopic pregnancy, level 4 able to perform without supervision,
target numbers according to NVOG–HOOG, 2005
Table 1 Global rating scale for level of competence
Level Definition
1 Has theoretical knowledge
2 Is able to perform under strict supervision
3 Is able to perform under limited supervision
4 Is able to perform without supervision
5 Is able to supervise and educate others
Levels according to NVOG–HOOG, 2005
Gynecol Surg (2008) 5:321–325 323
MIS simulator training, we feel there is no excuse for
depriving residents of this training.
The nationwide basic surgical skills course provides an
introduction in simulator training for acquiring MIS skills.
However, distributed practice is superior above massed
practice, which is provided during a two-day course, for
actually achieving these skills [23, 24]. Consequently, MIS
skills can only be acquired if residents continue simulator
training and evaluation in their own clinic. A first
precondition for this continuance of training is the presence
of simulator facilities in every cluster of teaching hospitals.
A second precondition is that residents really do use these
facilities. The first precondition is partially met. All 46
Dutch teaching hospitals are grouped in eight clusters and
simulator training is offered in at least one teaching hospital
of each cluster. However, the equipment varies widely
among these hospitals. The advantage of training on the
simulators used during the Cobra-alpha course is that these
are easily fabricated and inexpensive. Besides, the exercises
for the laparoscopic box trainer have been validated and a
performance standard has been established. Regarding the
second precondition, unfortunately, only one third of
residents actually train on a simulator if training is offered
on a voluntary basis [10]. The fact that most residents do
not voluntarily train is in contradiction with the residents’
opinion that simulator training is an important addition to
their residency program [10]. Hence, formal mandatory
MIS training is urgently needed in every training hospital,
which has to be scheduled in the busy practice of the
residency program.
In spite of structured training, proper evaluation of skills
contributes to the learning effect [25]. However, the
majority of residents’ surgical skills are evaluated infor-
mally and in a non-standardized fashion. There is a growing
need for objective assessment tools. An example of such a
tool is the Objective Structures Assessment of Technical
Skills (OSATS). This evaluation method consists of a
global rating scale and has proven high reliability and
construct validity for simulators [25, 26].
Regarding surgical competence, the requirements essen-
tial for certification in obstetrics and gynecology are clearly
defined in the Netherlands. These requirements are set on a
total number of each procedure a resident minimally has to
perform. Additionally, the number performed on compe-
tence level 4 is established. Level 4 is defined “able to
perform without supervision” on a 1 to 5 global rating scale
(see Table 1) [27]. The target numbers for the laparoscopic
and hysteroscopic procedures are expressed in Table 2 [27].
Although numbers of procedures are easily quantifiable,
total numbers do not represent the actual competence of a
resident due to individual difference in learning curves [6,
28]. Assessing a residents surgical skills and comparing
these skills to an established performance standard would
be more suitable than counting the number of procedures.
In this way, the individual training demands can be met.
This emphasizes, on one hand, the importance of objective
assessment tools for evaluation of surgical skills and to set a
performance standard. On the other hand, simulator training
can fulfill the individual training demands, as a source of
unlimited training while the training possibilities on real
patients in the OR are scarcer. Ultimately, every resident
should be able to achieve the predetermined level of skills
at the end of residency.
Although some adaptations have to be made to incorpo-
rate continued training and evaluation in daily practice, a
uniform introduction to MIS training on simulators is
guaranteed for every resident in the Netherlands by a
mandatory basic skills course, while advanced courses and
congresses provide possibilities for enhanced education.
Hopefully, this will facilitate and accelerate the implemen-
tation of MIS techniques in the gynecological surgical
palette.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
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An ergonomic analysis of the fulcrum effect in the acquisition of endoscopic skills.

Assessment of technical skills transfer from the bench training model to the human model.

Averch TD

Basics of Surgery, tools, techniques, attitude and expertise.

Darzi A

Declining trend in major gynaecological surgery in The Netherlands during

Gynecological laparoscopy in residency training program: Dutch perspectives. Surg Endosc 19:1498–1502 324 Gynecol Surg

Hysteroscopic training: the butternut pumpkin model.

Impact of work hour restrictions on resident case experience in an obstetrics and gynecology residency program.

Is there an impact on surgical skills and innovative ability?

Laparoscopic simulator: construct validity and performance standard. Gynecol Surg;

Laparoscopic training: results of a Belgian survey in trainees. Belgian Group for Endoscopic Surgery (BGES).

Laparoscopy, the basics. Laurier,

Ongoing deficits in resident training for minimally invasive surgery.

Recent advances in minimal access surgery.

Rege RV,

Surgical endoscopy training is integral to general surgery residency and should be integrated into residency and fellowships abandoned. Semin Laparosc Surg 9:212–215

Surgical skills assessment: a blinded examination of obstetrics and gynecology residents.

Teaching surgical skills: what kind of practice makes perfect?: a randomized, controlled trial. Ann Surg 244:400–

Testing surgical skills of obstetric and gynecologic residents in a bench laboratory setting: validity and reliability.

Testing technical skill via an innovative “bench station” examination.

The impact of minimal access surgery on gynaecological surgery in a university gynaecological unit over a 10-year period from 1991 to 2000. Singap Med

The influence of different training schedules on the learning of psychomotorskillsfor endoscopicsurgery.Surg Endosc21:214–219

The transfer of basic skills learned in a laparoscopic simulator to the operating room. Surg Endosc 16:1324–1328

Urology practice patterns after residency training in laparoscopy.

Using simulators to assess laparoscopic competence: ready for widespread use?

Virtual reality training improves operating room performance: results of a randomized, double-blinded study.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3133645

Skills training in minimally invasive surgery in Dutch obstetrics and gynecology residency curriculum

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