Retention of laparoscopic psychomotor skills after a structured training program depends on the quality of the training and on the complexity of the task

The general aim of this study was to evaluate laparoscopic skills retention after a structured training program. The specific objectives were to assess whether skill retention varies according to the training program and the laparoscopic task complexity. To evaluate the former, we used four different training programs and hypothesized that the program assigned to G1 would determine better results, whereas the program assigned to G4 would determine poorer results. To evaluate the latter, we used basic and advanced tasks and hypothesized that hand-eye coordination with the DH would be the easier to retain, whereas intra-corporeal knot tying would be the more difficult to retain.

Our data demonstrate that after a 2-year resting period, and without practicing any laparoscopic surgery o skill training, participants retained to a large extent the skills registered at the end of the training programs and that although some skill decay was noticed, they remained significantly better than at baseline. The level of retention, however, varied according to the group and the task analyzed, confirming our hypothesis.

Indeed, G1 had the better improvement after training (T2 vs. T1) and was able to retain the skills of the three tasks at the same level than 2 years earlier (T3 vs. T2), indicating the relevance of a comprehensive training for skills acquisition and retention. G4, however, did not show any improvement after training (T2 vs. T1), maintaining the sub-optimal skills execution in this study (T3 vs. T2) for more difficult tasks. For easiest task, however, a slight but significant improvement was observed, indicating a learning effect after few repetitions. G2 and G3 were in between the previous groups and had a significant improvement after training (T2 vs. T1). This was observed for trained and non-trained tasks, suggesting that intra-corporeal knot tying training may compensate to some extent the lack of hand-eye coordination training. Interestingly, both G2 and G3 were able to retain the hand-eye coordination skills, but not the intra-corporeal knot tying skills, at the same level than 2 years earlier, suggesting that retention of most difficult tasks may require more training.

Our data are consistent with the reports of other studies, but we must be cautious for general conclusions because the studies evaluating skills retentions differ significantly in study populations, training and tests programs/models, resting period, scoring systems, coaching and feedback, etc., as discussed in detail below.

Akdemir et al. evaluated skills retention in 11 first-year gynecology residents (without experience in laparoscopy) 6 months after a training program [9]. Although a matched control group was included for skills acquisition evaluation, there was no control group for skills retention evaluation. The 5-week program consisted in lectures (week 1) and 1-h practice session per week on a box trainer (weeks 2–5). The tasks performed in this box were well described, but the number of repetitions and the level of proficiency acquired were not reported. The baseline, post-training, and retention tests were done in another model (salpingectomy on the LapSim), and time, economy (path lengths and angular path), and error (blood loss and ovarian damage) were measured. The study concluded that the skills suffered a slight (angular path) or significant (time and path length) deterioration although they remained significantly better than at baseline [9].

Bonrath et al. evaluated skills retention in 36 medical students (without experience in laparoscopy) 6 or 11 weeks after a training program [10]. The 5-day program consisted in tutorials (day 1), baseline test (day 2), training (days 3–4), and post-training test (day 5). Participants, working in fixed pairs and accompanied by an expert for individual coaching, performed 4 cycles of nine tasks (navigation, grasping, transfer, positioning, cutting, loop tie, extra-corporal and intra-corporal knot tying and clipping) in a box trainer. The skills retention was evaluated after different time points (6 and 11 weeks) but unfortunately in two different groups. For testing purposes, time and errors of the same tasks performed during training were scored. The study concluded that skills are retained for at least 6 weeks and that deterioration, especially of the difficult tasks, started around 11 weeks [10].

Magaard et al. evaluated skills retention in a cohort of novices (n = 9) and experts (n = 10) 6 and 18 months after a training program [11]. The program (salpingectomy on the LapSim) consisted in 10 sessions (sessions 1–3: familiarization with the simulator, session 4: baseline test, sessions 5–9: training, session 10: after training test). The retention skills tests were done in the same model and time; economy and error (“bleeding”) were measured. The novices were tested after 6 and 18 months, and the experts only after 6 months. The study reported different performance for novices and experts. For novices, the skills were retained after 6 months, but they return back to the pre-training level after 18 months [11]. For experts, it seemed that the training program had no effect at all since they showed a constant performance from the baseline test up to the retention test at 6 months.

Hiemstra et al. evaluated skills retention in seven novices 1 year after a training program [12]. The seven-session program consisted in a baseline test (session 1), once a week training (sessions 2–6), and a final test (session 7). Participants performed five tasks on a box trainer (pipe cleaner, placing rubber band, placing beads, cutting circle, and intra-corporeal knot tying). Scores for speed and precision were measured. The retention test was performed in the same model. The study concluded that most basic skills acquired during a short training program sustain over time and that although some showed deterioration after 1 year, all skills remained better than before training [12].

De Win et al. evaluated skills retention in 145 medical students 1 and 6 months after different training programs [13]. Participants were randomly allocated to different groups according to training frequency (three sessions daily, two sessions daily, one session daily, one session on alternative days, one session per week, one session per week with optional additional practice in between sessions). All groups underwent six training sessions of 1.5 h each, consisting in three basic tasks (thumbnail, paperclip, needle rotation) to learn intra-corporeal suturing (session 1), needle positioning and penetration (session 2), and suturing (sessions 3–6). For the post-training and the retention tests, a 5-cm chicken-skin incision model was used and time was scored. The study concluded that once daily, 1.5-h session seems most beneficial for acquiring and for retaining intra-corporeal endoscopic suturing [13].

To a certain extent, our study counteract the limitations of these studies and extent their observations in several aspects. First, we enrolled a larger study population than most other studies. Second, our study comprises a longer resting period and ascertains that participants did not practice laparoscopic surgery or skill training during the 2-year resting period. Third, our study evaluates and discriminates between tasks of different levels of difficulties. Fourth, our study ascertains that during the skills acquisition phase, training was long enough to reach the plateau of the learning curve, in contrast with other studies in which participants were just briefly exposed to a task or allowed to practice it for a short period.

To be able to accomplish our objectives, the major challenge was to recruit the same participants of a study carried out 2-year earlier to evaluate skills acquisition. At that time, we recruited gynecologists with sufficient experience in open and vaginal surgery but without experience in laparoscopy. In order to avoid any confounding effect of additional training in laparoscopy, only those who did not performed any laparoscopic procedure during the resting period were included in the present study. This challenge was achieved because we were able to recruit 91.25 % of the participants of the previous study (90 % in G1, G3, and G4 and 95 % in G2), who were obviously 2 years older and some of them with other training status (many residents became specialists). Today, when gynecological laparoscopic surgery became a routine procedure in daily practice, this study population is no longer available worldwide. In our setting, however, this was still not the case; residents and specialists being exposed only to the tools and experience offered by the study design and hence being them a unique population for studying a variety of parameters that can affect training in laparoscopy. We are fully aware that this situation is difficult to reproduce and that might not be clinically realistic, because in most scenarios, an intensive 1-month training will not be followed by a 2-year period without exposure to laparoscopic surgery. On the contrary, one would be encouraged to apply one’s surgical training in the operating room to solidify hand memory and to advance one’s skills.

In conclusion, our study demonstrates that when using the European Academy of Gynecological Surgery inanimate box model, LASTT, laparoscopic skills retention depends on the quality of the previous training program and on the task complexity, suggesting that a comprehensive training is advisable to acquire and to retain laparoscopic skills. This indicates that laparoscopic psychomotor skills are comparable to swimming or cycling in the sense that they can be retained for longer periods of time once achieved proficiency. It remains unclear, however, the ideal method for a faster skills acquisition, which will require the evaluation of the characteristics of the learning curves of both basic and advanced laparoscopic skills, as well as the evaluation of other potential influencing factors, such as tutor feedback [14] and the additive effect of training others basic skills (e.g., camera navigation, bimanual coordination). And more importantly, it also remains to be demonstrated the predictive validity of these training models.