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The Impact of Systematic Laparoscopic Skills and Suture Training on Laparoscopic Hysterectomy Outcomes in a Brazilian Teaching Hospital

O impacto do treinamento laparoscópico sistematizado de habilidades e sutura nos resultados da histerectomia laparoscópica em hospital universitário brasileiro

Abstract

Objective

To evaluate the impact of systematic laparoscopic skills and suture training (SLSST) on the total laparoscopic hysterectomy intra- and postoperative outcomes in a Brazilian teaching hospital.

Methods

A cross-sectional observational study in which 244 charts of total laparoscopic hysterectomy (TLH) patients operated from 2008 to 2014 were reviewed. Patient-specific (age, parity, previous cesarean sections, abdominal surgeries and endometriosis) and surgery-related variables (hospital stay, operative time, uterine volume and operative complications) were analyzed in three different time-frame groups: 2008-09 (I-1) - TLHs performed by senior attending physicians; 2010-11 (I-2) - TLHs performed by residents before the implementation of the SLSST program; and 2012-14 (I-3) - TLHs performed by residents after the implementation of the SLSST program.

Results

A total of 244 TLH patients (mean age: 45.93 years) were included: 24 (I-1), 55 (I-2), and 165 (I-3). The main indication for TLH was uterine myoma (66.4%). Group I-3 presented a decrease in surgical time compared to group I-2 (p=0.010). Hospital stay longer than 2 days decreased in group I-3 compared to group I-2 (p=0.010). Although we observed decreased uterine volume (154.2 cm3) in group I-2 compared to group I-1 (217.8 cm3) (p=0.030), logistic regression did not find any association between uterine volume and surgical time (p=0.103).

Conclusion

The total operative time for laparoscopic hysterectomy was significantly shorter in the group of patients (I-3) operated after the systematic laparoscopic skills and suture training was introduced in our hospital.

Keywords:
hysterectomy; laparoscopic surgery; education; suture training

Resumo

Objetivo

Avaliar o impacto do treinamento laparoscópico sistematizado de habilidades e sutura (TLSHS) nos resultados intra e pós-operatórios da histerectomia laparoscópica em um hospital universitário brasileiro.

Métodos

Estudo observacional transversal de revisão de 244 prontuários de pacientes submetidas a histerectomia total laparoscópica (HTL) operadas entre 2008 e 2014. Os fatores específicos das pacientes (idade, paridade, cesariana prévia, cirurgias abdominais, e endometriose) e as variáveis relacionadas à cirurgia (tempo de hospitalização, tempo de cirurgia, volume uterino e complicações operatórias) foram analisados em três grupos temporais: 2008-09 (I-1) - HTLs realizadas por médicos experientes; 2010-11 (I-2) - HTLs realizadas por residentes sem TLSHS; 2012-2014 (I-3) - HTLs realizadas por residentes após a implementação do TLSHS.

Resultados

Um total de 244 pacientes submetidas a HTLs foram incluídas (média de idade de 45,93 anos): 24 operadas no período I1, 55 no I2, e 165 no I3. A principal indicação para HTL foi mioma uterino (66,4%). O grupo I-3 apresentou diminuição no tempo cirúrgico quando comparado ao grupo I-2 (p=0,010). Hospitalização superior a 2 dias diminuiu no grupo I-3 comparado ao grupo I-2 (p=0,010). Apesar de observarmos diminuição no volume uterino dos pacientes do grupo I-2 (154,2 cm3) em comparação com os do grupo I-1 (217,8 cm3) (p=0,030), a regressão logística não revelou associação entre volume uterino e tempo cirúrgico (p=0,103).

Conclusão

O tempo cirúrgico na HTL foi significativamente menor no grupo de pacientes submetidas à cirurgia após a implantação do TLSHS em nosso hospital.

Palavras-chave:
histerectomia; cirurgia laparoscópia; educação; treinamento de sutura

Introduction

Laparoscopy-assisted hysterectomy has evolved as an alternative to conventional open surgery since the end of the twentieth century.11 Arbogast JD, Welch RA, Riza ED, Ricaurte EL, Pieper DR. Laparoscopically assisted vaginal hysterectomy appears to be an alternative to total abdominal hysterectomy. J Laparoendosc Surg 1994;4(03):185-190 It uses cameras and specific instruments to remove the uterus, the fallopian tubes, and/or the ovaries through a minimally-invasive trans-vaginal access.22 Reich H. New techniques in advanced laparoscopic surgery. Baillieres Clin Obstet Gynaecol 1989;3(03):655-681 33 Ng CC, Chern BS. Total laparoscopic hysterectomy: a 5-year experience. Arch Gynecol Obstet 2007;276(06):613-618. Doi: 10.1007/s00404-007-0385-6
https://doi.org/10.1007/s00404-007-0385-...
The procedure is called total laparoscopic hysterectomy (TLH) when hemostatic clamping of the uterine vessels, resection of the uterosacral and cardinal ligaments, and colporrhaphy are all performed through a minimally-invasive video-assisted approach.33 Ng CC, Chern BS. Total laparoscopic hysterectomy: a 5-year experience. Arch Gynecol Obstet 2007;276(06):613-618. Doi: 10.1007/s00404-007-0385-6
https://doi.org/10.1007/s00404-007-0385-...
The benefits of TLH are diminished postoperative pain, lower use of opioid analgesics, shorter hospital stay, early rehabilitation and return to work, minimal blood loss, enhanced visualization of intra-abdominal structures, which minimizes the risk of iatrogenic lesion to bladder and ureters, and lower rate of short- and long-term complications.44 Chapron C, Laforest L, Ansquer Y, et al. Hysterectomy techniques used for benign pathologies: results of a Frenchmulticentre study. Hum Reprod 1999;14(10):2464-2470. Doi: 10.1093/humrep/ 14.10.2464
https://doi.org/10.1093/humrep/...
55 Chapron CM, Dubuisson JB, Ansquer Y. Is total laparoscopic hysterectomy a safe surgical procedure? Hum Reprod 1996;11 (11):2422-2424. Doi: 10.1093/oxfordjournals.humrep.a019128
https://doi.org/10.1093/oxfordjournals.h...
66 Hohl MK, Hauser N. Safe total intrafascial laparoscopic (TAIL) hysterectomy: a prospective cohort study. Gynecol Surg 2010;7 (03):231-239. Doi: 10.1007/s10397-010-0569-0
https://doi.org/10.1007/s10397-010-0569-...
Additonally, the intrafascial dissection technique preserves the vaginal apex support structures, maintaining vaginal length.66 Hohl MK, Hauser N. Safe total intrafascial laparoscopic (TAIL) hysterectomy: a prospective cohort study. Gynecol Surg 2010;7 (03):231-239. Doi: 10.1007/s10397-010-0569-0
https://doi.org/10.1007/s10397-010-0569-...
77 Chapron C, Dubuisson JB. Ureteral injuries after laparoscopic hysterectomy. HumReprod 2000;15(03):733-734. Doi: 10.1093/humrep/ 15.3.733
https://doi.org/10.1093/humrep/...
88 Shwayder JM. The learning curve for laparoscopically assisted vaginal hysterectomy/laparoscopic hysterectomy. JAm Assoc Gynecol Laparosc 1994;1(4, Part 2):S33 99 Cavalli N, Sória HL, Galletto D, Sória-Vieira S, Bandeira CP, Fagundes DJ. Histerectomia vaginal assistida por videolaparoscopia associada à técnica intrafascial (HVALi) em579 operações. Rev Bras Videocir 2003;1:128-134

However, TLH is not widespread in many countries.55 Chapron CM, Dubuisson JB, Ansquer Y. Is total laparoscopic hysterectomy a safe surgical procedure? Hum Reprod 1996;11 (11):2422-2424. Doi: 10.1093/oxfordjournals.humrep.a019128
https://doi.org/10.1093/oxfordjournals.h...
77 Chapron C, Dubuisson JB. Ureteral injuries after laparoscopic hysterectomy. HumReprod 2000;15(03):733-734. Doi: 10.1093/humrep/ 15.3.733
https://doi.org/10.1093/humrep/...
1010 Einarsson JI,MattesonKA, Schulkin J,ChavanNR, Sangi-Haghpeykar H. Minimally invasive hysterectomies-a survey on attitudes and barriers among practicing gynecologists. JMinim Invasive Gynecol 2010;17(02):167-175. Doi: 10.1016/j.jmig.2009.12.017
https://doi.org/10.1016/j.jmig.2009.12.0...
1111 Cosson M, Lambaudie E, Boukerrou M, Querleu D, Crépin G. Vaginal, laparoscopic, or abdominal hysterectomies for benign disorders: immediate and early postoperative complications. Eur J Obstet Gynecol Reprod Biol 2001;98(02):231-236 1212 Sória HLZ, Fagundes DJ, Sória-Vieira S, Cavalli N, Santos CRC. [Hysterectomy and benign gynecological diseases: what has been performed inMedical Residency in Brazil?] Rev Bras Ginecol Obstet 2007;29:67-73. Doi: 10.1590/S0100-72032007000200002
https://doi.org/10.1590/S0100-7203200700...
Data from the Brazilian Unified Healthcare System reveals only 2,947 laparoscopic procedures out of 932,382 hysterectomies performed from 2008 to 2017.1313 Ministério da Saúde. Procedimentos Hospitalares do SUS - Por Local de Internação - Brasil.2017http://tabnet.datasus.gov.br/cgi/ tabcgi.exe?sih/cnv/qiuf.def. Accessed April 29, 2017.
http://tabnet.datasus.gov.br/cgi/ tabcgi...
Developed countries like the United States and England estimate that 20% to 30% of hysterectomies are laparoscopic-assisted.1010 Einarsson JI,MattesonKA, Schulkin J,ChavanNR, Sangi-Haghpeykar H. Minimally invasive hysterectomies-a survey on attitudes and barriers among practicing gynecologists. JMinim Invasive Gynecol 2010;17(02):167-175. Doi: 10.1016/j.jmig.2009.12.017
https://doi.org/10.1016/j.jmig.2009.12.0...
1414 Sculpher M, Manca A, Abbott J, Fountain J, Mason S, Garry R. Cost effectiveness analysis of laparoscopic hysterectomy compared with standard hysterectomy: results from a randomised trial. BMJ 2004;328(7432):134. Doi: 10.1136/bmj.37942.601331.EE
https://doi.org/10.1136/bmj.37942.601331...
The major struggle regarding laparoscopic surgery expansion has been to train new surgeons. The long learning curve to achieve proficiency in two-dimension screen vision, camera navigation, hand-eye coordination, and psychomotor skills to handle laparoscopic tools with dexterity conflict with a limited number of procedures and professionals in teaching hospitals with scarce resources.77 Chapron C, Dubuisson JB. Ureteral injuries after laparoscopic hysterectomy. HumReprod 2000;15(03):733-734. Doi: 10.1093/humrep/ 15.3.733
https://doi.org/10.1093/humrep/...
1212 Sória HLZ, Fagundes DJ, Sória-Vieira S, Cavalli N, Santos CRC. [Hysterectomy and benign gynecological diseases: what has been performed inMedical Residency in Brazil?] Rev Bras Ginecol Obstet 2007;29:67-73. Doi: 10.1590/S0100-72032007000200002
https://doi.org/10.1590/S0100-7203200700...
1515 Campo R,Molinas CR, DeWilde RL, et al. Are you good enough for your patients? The European certification model in laparoscopic surgery. Facts Views Vis ObGyn 2012;4(02):95-101 1616 Takeda J, Kikuchi I, Kono A, Ozaki R, Kumakiri J, Takeda S. Efficacy of short-term training for acquisition of basic laparoscopic skills. Gynecol Minim Invasive Ther 2016;5:112-115. Doi: 10.1016/j. gmit.2015.06.001
https://doi.org/10.1016/j...
On the other hand, increased demand for laparoscopic procedures in private health systems pressure junior surgeons to take up complex cases they may not be proficient to deal with, resulting in lower surgical performances and increased morbidity and mortality.1515 Campo R,Molinas CR, DeWilde RL, et al. Are you good enough for your patients? The European certification model in laparoscopic surgery. Facts Views Vis ObGyn 2012;4(02):95-101 1717 Ahlberg G, Enochsson L, Gallagher AG, et al. Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies. Am J Surg 2007;193(06):797-804. Doi: 10.1016/j.amjsurg.2006.06.050
https://doi.org/10.1016/j.amjsurg.2006.0...

Laparoscopic psychomotor skills must be preliminarily acquired by practicing on specific validated training models outside the operating room.1515 Campo R,Molinas CR, DeWilde RL, et al. Are you good enough for your patients? The European certification model in laparoscopic surgery. Facts Views Vis ObGyn 2012;4(02):95-101 1616 Takeda J, Kikuchi I, Kono A, Ozaki R, Kumakiri J, Takeda S. Efficacy of short-term training for acquisition of basic laparoscopic skills. Gynecol Minim Invasive Ther 2016;5:112-115. Doi: 10.1016/j. gmit.2015.06.001
https://doi.org/10.1016/j...
1717 Ahlberg G, Enochsson L, Gallagher AG, et al. Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies. Am J Surg 2007;193(06):797-804. Doi: 10.1016/j.amjsurg.2006.06.050
https://doi.org/10.1016/j.amjsurg.2006.0...
Similar to a video game, training platforms enable the repetitive practice of standard laparoscopic tasks. They also evaluate performance objectively, and provide feedback to the trainees.1818 Sroka G, Feldman LS, Vassiliou MC, Kaneva PA, Fayez R, Fried GM. Fundamentals of laparoscopic surgery simulator training to proficiency improves laparoscopic performance in the operating room-a randomized controlled trial. Am J Surg 2010;199(01): 115-120. Doi: 10.1016/j.amjsurg.2009.07.035
https://doi.org/10.1016/j.amjsurg.2009.0...
Simulators were proven to shorten surgical time and improve perioperative morbidity in TLH procedures,1919 Clark NV, Gujral HS, Wright KN. Impact of a fellowship-trained minimally invasive gynecologic surgeon on patient outcomes. JSLS 2017;21(03):e2017.00037. Doi: 10.4293/JSLS.2017.00037
https://doi.org/10.4293/JSLS.2017.00037...
and they potentially reduce the learning curve compared to traditional surgical teaching methods.2020 Seymour NE, Gallagher AG, Roman SA, et al. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg 2002;236(04):458-463, discussion 463-464. Doi: 10.1097/00000658-200210000-00008
https://doi.org/10.1097/00000658-2002100...
Current surgical practice regulations demand a controlled, standardized and validated training program for new laparoscopic surgeons, such as the “Winners” program in Europe and the American College of Obstetricians and Gynecologists (ACOG) Fundamentals of Laparoscopic Surgery (FLS) program, in the US.1515 Campo R,Molinas CR, DeWilde RL, et al. Are you good enough for your patients? The European certification model in laparoscopic surgery. Facts Views Vis ObGyn 2012;4(02):95-101 In an effort to validate an implemented standardized laparoscopic training in Brazil, the present study evaluated the impact of the systematic laparoscopic skill and suture training (SLSST) on the outcomes of TLH performed in a teaching hospital (Santa Casa de Misericórdia de São Paulo, in the city of São Paulo, Brazil) from 2008 to 2014. We hypothesized that the SLSST would have a positive impact on the intra- and postoperative outcomes of TLH.

Methods

The present research was approved by the Ethics in Human Research Committee and Institutional Review Board of Santa Casa de Misericórdia de São Paulo (under number: 14945313.8.0000.5479)

We conducted a cross-sectional observational study in which 610 charts of patients submitted to hysterectomy at Santa Casa de Misericórdia de Sãoo Paulo from 2008 to 2014 were reviewed. All TLHs were included in the study, corresponding to 40% (244) of the procedures. The exclusion criteria were: subtotal or partial hysterectomy; hysterectomies associated with open rectosigmoidectomy and/or partial cystectomy due to endometriosis; and malignant diseases requiring total hysterectomy with open retroperitonial exploration.

Patient-specific (age, parity, previous cesarean sections, abdominal surgeries and endometriosis) and surgery-related (hospital stay, operative time, rate of conversion to open procedure, uterine volume, intra- and postoperative complications) variables were analyzed.

The postoperative complications were divided according to the Clavien-Dindo (C-D) classification (Table 1), which was created in 1992 (by Clavien PA, Dindo D and Demartines N at University Hospital of Zurich, Zurich, Switzerland) is widely used, and is based on the type of therapy needed to correct the complication.2121 Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 2009;250(02):187-196. Doi: 10.1097/SLA.0b013e3181b13ca2
https://doi.org/10.1097/SLA.0b013e3181b1...

Table 1
Clavien-Dindo classification

In our institution, we receive every year 4 first-year residents (PGY-4 OB/GYN) of the Gynecologic Endoscopy and Endometriosis Fellowship Program, and 2 second-year residents (PGY-5 OB/GYN) of the Gynecologic Endoscopy and Endometriosis Fellowship Program. The surgeries were divided into three different time-frame groups reflecting distinct benchmarks of the SLSST curriculum implemented for the Gynecology Endoscopy and Endometriosis Fellowship Program: 2008-09 (I-1) – TLH performed by senior attending physicians with more than 5 years of experience in laparoscopic surgery; 2010-11 (I-2) – TLH performed by the new first-year residents (PGY-4 OB/GYN) before the implementation of the SLSST, supervised by senior physicians; and 2012-14 (I-3) –TLH performed by the new first-year residents (PGY-4 OB/GYN) after the implementation of the SLSST. The surgeries performed during the first 14 weeks of the SLSST (dominant hand training period) were excluded from this group. The surgeries were assisted and supervised by a second-year (PGY-5 OB/GYN) resident who was also submitted to the same training program, but at the end of the previous year.

An average of 7 TLHs per PGY-4/year was observed in the I-2 group, and an average of 14 TLHs per PGY-4/year was observed in the I-3 group.

Standard Total Laparoscopic Hysterectomy

The intrafascial technique has been standardized to all TLHs performed by the Gynecologic Endoscopy and Endometriosis Group of Santa Casa de Misericórdia de São Paulo since 2008. The same standard steps are performed in the same order for every TLH.

  1. Position on the gynecological table with the legs on the gaiters, the buttocks 5 cm above the table, and arms on jambs along the body, asepsis/antisepsis, followed by late bladder catheterization using a no. 14 Foley catheter, hysterometry and uterine manipulator placement.

  2. Intra-umbilical incision (longitudinal or arch-shaped), abdominal puncture using a Veress needle followed by safety maneuvers (dual recoil test, saline infusion-suction test, and pendant drop test), peritoneum distention with CO2 (6 mmHg to 20 mmHg), assessment of abdominal distension symmetry, and loss of liver solidness to percussion sign.

  3. Introduction of the intra-umbilical trocar and cavity inventory to assess puncture accidents and adherences. Low pneumoperitoneum pressure to 14 mmHg, Trendelemburg position, and establishment of accessory portals using 5-mm trocars (Figure 1).

  4. Left round ligament styptic section, dissection of the anterior peritoneum from the broad ligament to the bladder reflex, and establishment of an avascular plane left uterus-ovarian ligament styptic section, followed by left salpingectomy. If left oophorectomy is required, identify the left ureter and perform the styptic section of the infundibulum (Figure 2).

  5. Dissect the posterior peritoneum from the broad ligament of the uterus to the sacrouterine ligament and perform the styptic section of the left uterine vessels (Figure 3A).

  6. The same sequence (4 and 5) is then repeated on the right side.

  7. Bladder retracted inferiorly (Figure 3B), colpotomy using a monopolar cautery (Figure 3C), and transvaginal removal of the uterus employing a vaginal liner.

  8. Place a vaginal tampon to hold the pneumoperitoneum, followed by trans-peritoneal colporrhaphy using no. 0 Vicryl (polyglactin 910 manufactured by Ethicon Inc., a subsidiary of Johson and Johnson) with x-shaped stitches at the angles of the vagina and continuous stitches in the center (Figure 3D).

  9. Review the hemostasis, remove the vaginal tampon, perform the suction of the pneumoperitoneum, return to horizontal decubitus, and perform the intra-umbilical aponeurosis suture and trocar incision closure.

Fig. 1
Locations of the portals.

Fig. 2
(A) Hemostatic section of the left round ligament; (B) dissection of the left broad ligament of the uterus; (C) left avascular window; (D) hemostatic section of the left uterus-ovarian ligament.

Fig. 3
(A) Section of the left uterine vessels; (B) lower retraction of the bladder; (C) colpotomy; (D) colporrhaphy.

Systematic laparoscopic skills and suture training (SLSST)

The training was implemented to the curriculum of the Gynecologic Endoscopy and Endometriosis Fellowship Program in 2012. Based on the Romeo Gladiator Rule seven-week activities2222 Liceaga A, Fernandes LF, Romeo A, Gagstatter F. Romeo's gladiator rule: knots, stitches and knot typing techniques: a tutorial based on a few simple rules; new concepts to teach suturing techniques in laparoscopic surgery. 2nd ed. Schramberg: Endo Press; 2015. (Table 2), the SLSST consisted of a 21-week (4 hours per week) hands-on training at the experimental laboratory. Each week, the residents had to practice the scheduled exercise for a minimum of 4 hours. The core exercises were performed with the dominant hand on the lateral trocar for the initial 7 weeks of the program, followed by the dominant hand on the central trocar from the 8th to the 14th weeks, and the non-dominant hand on the lateral trocar from the 15th to the 21st weeks.

Table 2
Systematic laparoscopic skills and suture training core program

Statistical Analysis

All data were recorded in Excel (Microsoft Corp., Redmond, WA, US), version 14.5.7, spreadsheets, and the statistical analyses were performed using in the Statistical Package for the Social Sciences (SPSS, IBM Corp., Armonk, NY, US) software, version 22. The calculation of the sample size was estimated based on a pilot group of 10 patients obtained from the first period of time (I-1). Using a standard deviation of 50 minutes and an estimated difference of 30 minutes, a sample of 34 patients was suggested to obtain a study power of 80% with a significance of 5%. The Kolmogorov-Smirnov test was performed for each independent variable to determine normal distribution. The Chi-squared test was used to compare parametric variables. The Student t-test was used to compare parametric continuous variables, and logistic regression was performed to determine the association between the variables. Data are shown as mean ± standard deviation (SD). Values of p< 0.05 were considered significant for the inferential analysis.

Results

We included 244 cases of TLH in the study: 24 operated in 2008-09 (I-1); 55 in 2010-11 (I-2); and 165 in 2012-14 (I-3). The increase in TLHs performed per year at our hospital between periods I-1 and I-2 was of 129%, and between I-2 and I-3, it was of 100%. The mean age of the patients was 45,93 ± 8,37 (SD) years. Patient-specific variables are reported on table 3. The procedures performed together with TLH, like salpingectomy, oophoroplasty/oophorectomy, and deep endometriosis are shown in table 3.

Table 3
Patient-specific variables and procedures performed

The clinical indications for TLH were mainly uterine myoma (66.4%) and endometriosis (16.4%). Only two cases were diagnosed with malignant disease, and they were referred to the gynecologic oncology service after surgery. Comparing the three groups studied, we observed a significant difference in the number of previous cesarean sections, previous abdominal surgeries, rate of conversion to open surgery, and hospital stay longer than 2 days (Table 4). Out of 244 TLHs, 3 were converted to open laparotomy due to high uterine volume, and 1 required an open vaginal route. The overall complication rate was of 5.7%: 2.0% intraoperative and 3.7% postoperative complications.

Table 4
Clinical indications and associated variables stratified by time period

We observed 6 intraoperative complications (1 internal iliac artery lesion, 1 acute respiratory failure, 2 sutured bladder lesions and 2 vaginal wall lacerations) and 11 postoperative complications (1 left iliac fossa seroma – C-D II; 1 umbilical hernia – C-D IIIb; 1 wall endometrioma – C-D IIIb; 2 vaginal dome granulomas – C-D IIIb; 1 buckling in the distal left ureter with loss renal function – C-D Iva; 1 intraperitoneal vesical fistula – C-D IIIa; 1 vaginal dome bleeding – C-D IIIb; 1 urinary retention – C-D II; 1 paralytic ileus – C-D II; and 1 postlumbar-puncture headache – C-D II).

We observed a decrease in uterine volume in group I-2 compared to group I-1: 217.8 cm3 and 154.2 cm3 respectively (p= 0.03). There was no difference in the uterine volume between groups I-2/I-3 and I-1/I-3. The operative time was longer in group I-2 when compared to group I-3 (p = 0.01); there was no difference between groups I-1/I-2 and I-1/I-3 (Table 5). The logistic regression showed an association between uterine volume and baseline uterus disease (p= 0.02), comorbidities (p= 0.03), and type of surgery performed (p< 0.001). The operative time showed association with baseline uterus disease (p= 0.001), hospital stay > 2 days (p= 0.002), endometriosis (p= 0.002), and intraoperative complications (p= 0.013). No significant association was found between uterine volume and operative time (p= 0.10) (Table 6).

Table 5
Uterine volume and operative time by group
Table 6
Logistic regression results

Discussion

The data confirmed our hypothesis that the SLSST would have a significant impact on TLH outcomes. The procedures performed by the SLSST-trained residents (group I-3) presented a reduction in operative time, length of hospital stay and conversion, reinforcing that a systematic training program can shorten the long learning curve, improve performance, and promote safe laparoscopic surgical practice in a teaching hospital.2323 Nácul MP, Cavazzola LT, de Melo MC. Current status of residency training in laparoscopic surgery inBrazil: a critical review. ArqBrasCir Dig 2015;28(01):81-85. Doi: 10.1590/S0102-67202015000100020
https://doi.org/10.1590/S0102-6720201500...
Technique standardization for TLH contributed to make the surgical outcomes comparable regardless of the surgeon who performed the procedure, and made the training process easier for the residents, who were no longer exposed to multiple technique variations.

We observed an increasing number of TLHs during the time-frames analyzed in the present study. The mean annual number of procedures more than tripled after the implementation of the training program. The complexity of the surgeries also increased, with bilateral salpingectomy becoming routine in 2013, but it did not increase the surgical time, hospital stay, or the complication rates. The bilateral salpingectomy became routine for all TLHs in order to decrease the risk of ovarian cancer.2424 Dilley SE, Straughn JM Jr, Leath CA III. The evolution of and evidence for opportunistic salpingectomy. Obstet Gynecol 2017; 130(04):814-824. Doi: 10.1097/AOG.0000000000002243
https://doi.org/10.1097/AOG.000000000000...
These findings may be related to an increased confidence and proficiency in performing more complex laparoscopic procedures after the training program. When analyzing the hospital stay for patients submitted to TLH, one should consider quantitative data or a qualitative approach. Considering that the majority of the patients were discharged between the first and second postoperative days, we preferred to use qualitative data and a cutoff of two days of hospitalization. The length of our hospital stay was consistent with the current literature, and the rate of complications was half of those reported in the literature.2525 Viganò P, Parazzini F, Somigliana E, Vercellini P. Endometriosis: epidemiology and aetiological factors. Best Pract Res Clin Obstet Gynaecol 2004;18(02):177-200.Doi: 10.1016/j.bpobgyn.2004.01.007
https://doi.org/10.1016/j.bpobgyn.2004.0...
We found higher prevalence rates of previous cesarean sections (48%) and endometriosis (18%) than those reported in the literature,2323 Nácul MP, Cavazzola LT, de Melo MC. Current status of residency training in laparoscopic surgery inBrazil: a critical review. ArqBrasCir Dig 2015;28(01):81-85. Doi: 10.1590/S0102-67202015000100020
https://doi.org/10.1590/S0102-6720201500...
2626 Nakamura-Pereira M, Esteves-Pereira AP, Gama SGN, Leal M. Elective repeat cesarean delivery in women eligible for trial of labor in Brazil. Int J Gynaecol Obstet 2018;143(03):351-359. Doi: 10.1002/ijgo.12660
https://doi.org/10.1002/ijgo.12660...
which may be related to the extraordinary number of cesarean sections performed in Brazil,2525 Viganò P, Parazzini F, Somigliana E, Vercellini P. Endometriosis: epidemiology and aetiological factors. Best Pract Res Clin Obstet Gynaecol 2004;18(02):177-200.Doi: 10.1016/j.bpobgyn.2004.01.007
https://doi.org/10.1016/j.bpobgyn.2004.0...
and to the fact that our hospital is a center of excellence for endometriosis care.

The present study did not find an association between uterine volume and operative time, neither between uterine volume and rate of complications. Our trained residents were able to significantly reduce TLH operative time in about 25 minutes, despite the fact that they resected a higher volume of uteri than the non-trained residents, suggesting that adequate training provided time-efficient abilities to young surgeons.

The traditional apprentice-tutor model is no longer valid to develop all skills necessary in gynecological surgery; the complexity of modern surgery has increased the demands and challenges to surgical education and the quality control.2727 Ferreira H, van Belle Y, Tanos V, et al. Simulation and training of gynaecological skills. Facts Views Vis ObGyn 2018;10(01):21-27 Simulators motivate residents through the journey of proficiency in laparoscopy.2828 Munz Y, Almoudaris AM, Moorthy K, Dosis A, Liddle AD, Darzi AW. Curriculum-based solo virtual reality training for laparoscopic intracorporeal knot tying: objective assessment of the transfer of skill from virtual reality to reality. Am J Surg 2007;193(06): 774-783. Doi: 10.1016/j.amjsurg.2007.01.022
https://doi.org/10.1016/j.amjsurg.2007.0...
The positive impact that simulator-acquired skills have on real surgeries was published in a recent systematic review.1919 Clark NV, Gujral HS, Wright KN. Impact of a fellowship-trained minimally invasive gynecologic surgeon on patient outcomes. JSLS 2017;21(03):e2017.00037. Doi: 10.4293/JSLS.2017.00037
https://doi.org/10.4293/JSLS.2017.00037...
A positive relationship between systematic training in simulators and reduced operative time and complications were also reported in cases of bariatric and urologic laparoscopic surgery.2929 Thuler FR, de Freitas WR Jr, Ilias EJ, Kassab P, Malheiros CA. Laparoscopic bariatric surgery training program model: gastric bypass. BMC Surg 2014;14:101. Doi: 10.1186/1471-2482-14-101
https://doi.org/10.1186/1471-2482-14-101...
3030 Mucksavage P, Lee J, Kerbl DC, Clayman RV, McDougall EM. Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon. J Endourol 2012;26(07):765-768. Doi: 10.1089/end.2011.0134
https://doi.org/10.1089/end.2011.0134...
In a Turkish study, Asoglu et al3131 Asoglu MR,AchjianT,AkbilgiçO, BorahayMA,KiliçGS.Theimpactofa simulation-basedtraining labonoutcomes ofhysterectomy. J TurkGer Gynecol Assoc 2016;17(02):60-64. Doi: 10.5152/jtgga.2016.16053
https://doi.org/10.5152/jtgga.2016.16053...
concluded that a simulator lab improves the outcomes of hysterectomy performed at a teaching institution, and may play an adjunct role in developing the resident's surgical skills; the results found by them are in line with the findings of our study.

In the present study, repetitive practice in simulators enabled the fellows to improve their psychomotor skills without the fear of making mistakes that could had been fatal in an actual surgery. The mistakes were analyzed by tutors who provided feedback and guided the residents to overcome obstacles. Tutorship in a stress-free environment translated into faster, safer and efficient surgical performance even for more experienced attending physicians.3232 Korndorffer JR Jr, Stefanidis D, Scott DJ. Laparoscopic skills laboratories: current assessment and a call for resident training standards. AmJ Surg2006;191(01):17-22.Doi:10.1016/j.amjsurg.2005.05.048
https://doi.org/10.1016/j.amjsurg.2005.0...
Many countries have established systematic training on simulators as requirements for laparoscopic surgeons.3333 Nickel F,KowalewskiKF,Müller-StichBP. [Riskawarenessandtraining for prevention of complications in minimally invasive surgery]. Chirurg 2015;86(12):1121-1127. Doi: 10.1007/s00104-015-0097-6
https://doi.org/10.1007/s00104-015-0097-...
The present study was the initial step to validate a laparoscopic training program in Brazil. Our model may stimulate other academic hospitals to expand their proficiency laparoscopic skills, serving a bridge to a safe and effective full practice of in vivo laparoscopy.

Our study had several limitations. The cross-sectional design did not enable us to establish a temporal relationship between the training and surgical outcomes, or to determine if the experience of the surgeon measured by the number of TLHs previously performed had any influence over the surgical outcomes. Moreover, the substantial difference in the number of TLHs among the groups, and the variable skill levels of the senior attending physicians whose surgeries were included in group I-1 may be possible biases. Further prospective studies may define the number of previous TLHs necessary to reduce complications. On the other hand, the present study was, to our knowledge, this first clinical study to apply and evaluate the interference of the Romeo Gladiator training method on the outcomes of a surgical procedure.

Conclusion

The operative time for TLH was significantly shorter in the group of patients operated after the SLSST was introduced in our hospital.

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Publication Dates

  • Publication in this collection
    03 Feb 2020
  • Date of issue
    Dec 2019

History

  • Received
    15 May 2019
  • Accepted
    16 Sept 2019
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