The Feasibility of Practical Training in Minimally Invasive Surgery at Medical School-A Prospective Study on the Pelvitrainer.

Background and Objectives: The acquisition of practical skills at medical school is an important part of the multidimensional education program of future physicians. However, medical schools throughout the world have been slow in incorporating practical skills in their curriculum. Therefore, the aims of the present prospective study were (a) to demonstrate the feasibility of such surgical training, (b) to objectify its benefit in medical education, and (c) to investigate the impact of such training on subsequent career choices. Material and Methods: We introduced a two-day laparoscopy course on the pelvitrainer as part of the curriculum of the gynecological internship of fifth year medical students from 2019 to 2020. The results of the students' training were matched to those of surgeons who completed the same curriculum in a professional postgraduate laparoscopy course from 2017 to 2020 in a comparative study design. Additionally, we performed a questionnaire-based evaluation of the impact of the course on medical education and subsequent career choices directly before and after completing the course. Results: A total of 261 medical students and 206 physicians completed the training program. At baseline, the students performed significantly more poorly than physicians in a median of three of four exercises (p < 0.001). However, this evened out in the final runs, during which students performed more poorly than physicians only in one exercise and even better than physicians in one. The general integration of surgical training in medical school curricula was rated very low (12.4% on the VAS, IQR 3-16%) despite the high demand for such training. In the survey, the course was deemed very beneficial for medical education (median VAS 80.7%, IQR 73-98%), but did not appear to influence the students' subsequent career preferences. Conclusions: The acquisition of practical surgical skills during medical school is significantly under-represented in many medical faculties. The benefits of such training, as demonstrated in our study, would improve the education of future physicians.

Factors influencing surgical performance and learning progress in minimally invasive surgery - results of an interdisciplinary multicenter study.

BACKGROUND: Advancing surgical techniques require a high level of adaptation and learning skills on the part of surgeons. The authors need selection procedures and decision support systems for the recruitment of medical students and young surgeons. The authors aimed to investigate factors influencing the surgical performance and learning abilities of surgeons and medical students. MATERIALS AND METHODS: The training scores of persons attending 16 standardized training courses (at three training centers) of the German Working Group for Gynecological Endoscopy (AGE e.V.) from 2017 to 2020, individual characteristics, and the results of psychomotor tests of three-dimensional imagination and hand-eye coordination were correlated. Similar analyses were performed for medical students in their final clinical year from 2019 to 2020. The training concept was evaluated in a prospective, multicenter, interdisciplinary, multinational setting. RESULTS: In all, 180 of 206 physicians (response rate 87.4%) and 261 medical students (response rate 100%) completed the multistage training concept successfully. Of personal characteristics, the strongest correlation was noted for good surgical performance and learning success, and the absolute number of performed laparoscopic surgeries ( r =0.28-0.45, P <0.001/ r =0.1-0.28, P <0.05). A high score on the spatial visualization ability test was also correlated with good surgical performance ( r =0.18-0.27, P <0.01). Among medical students with no surgical experience, however, age was negatively correlated with surgical performance, that is the higher the age, the lower the surgical performance ( r =0.13/ r =0.22, P <0.05/ P <0.001). CONCLUSION: Individual factors (e.g. surgical experience, self-assessment, spatial visualization ability, eye-hand coordination, age) influence surgical performance and learning. Further research will be needed to create better decision support systems and selection procedures for prospective physicians. The possibilities of surgical training should be improved, promoted, and made accessible to a maximum number of surgical trainees because individual learning curves can be overcome even by less talented surgeons. Training options should be institutionalized for those attending medical school.

From thigh to pelvis: female genital prolapse repair with an autologous semitendinosus tendon transplant : Data of the German multicenter trial.

INTRODUCTION AND HYPOTHESIS: The use of synthetic mesh for prolapse and incontinence surgery is discussed controversially and in several countries is either no longer used or permissible. Previous approaches with autologous tissue did not show from a patient´s perspective convincing long-term results. As there have been repeatedly significant complications with synthetic mesh, a new approach is urgently needed. During orthopedics and trauma surgeries, tendons from the thigh have been used for decades to replace cruciate ligament. The procedure of tendon removal from the thigh is fast, easy to learn and morbidity is low. In addition, a long-term durability of the transplant ought to be expected. The objective of this investigation was to show our experience with a semitendinosus tendon instead of a mesh for genital prolapse repair. METHOD: After the first successful attempts using such tendons in cervicosacropexy and pectopexy in patients with genital prolapse, we initiated a national multicenter study in 2020. Five German hospitals participated in order to determine the feasibility of cervicosacropexy with tendon tissue instead of mesh. RESULT: Up until now, we have operated and observed 113 patients for at least 6 months and have seen stable results in terms of fixation of the apical compartment. The expected low morbidity at the donor site was also confirmed through subjective assessment of the patients (Knee and Osteoarthritis Outcome Score). Improvement of quality of life was confirmed after the procedure with the Short Form Health Survey 12, Version 2.0. The results of this multicenter study showed that the desired elevation of the apical compartment with tendon tissue can be achieved with low morbidity and without a synthetic mesh. CONCLUSION: Women with uterine prolapse can be treated minimally invasively and with very low morbidity by using the semitendinosus tendon. The involvement of multiple (five) medical centers confirms that the technique is easy to learn and be transferred to other clinical centers.

The pelvitrainer for training in laparoscopic surgery - A prospective, multicenter, interdisciplinary study: Experimental research.

BACKGROUND: Minimally invasive surgical procedures have a flat learning curve, especially in the initial period of a surgeon's training. Pelvitrainers enable the prospective surgeon to drill the surgical technique, including camera navigation, instrument manipulation, and the individual steps of the operation, on a model rather than a patient. Integrating the pelvitrainer into standardized surgical training programs is challenging, but would be essential to achieve optimum effects of long duration in surgical education. MATERIAL AND METHODS: The pelvitrainer Realsimulator 2.0 (Endodevelop) was evaluated in 16 standardized training courses (at three training centers) of the German Working Group for Gynecological Endoscopy (AGE e.V.) from 2017 to 2020, The training concept was implemented and evaluated in a prospective, multicenter, interdisciplinary, multinational setting. RESULTS: One hundred and eighty of 206 physicians (response rate 87.4%) completed the multi-stage training concept successfully. A significant (p < 0.001) objective improvement (positive learning curve) was observed for all exercises on the pelvitrainer. The trainer's subjective evaluation revealed positive ratings for design (median 82%, IQR 71-91%), camera navigation (87%, IQR 76-95%), and instrument manipulation (median 87%, IQR 77-94%). A follow-up survey performed six months after the course confirmed its sustainable and high benefits in clinical routine (median 82%, IQR 70-97%). CONCLUSION: The present investigation proved the high educational value of pelvitrainers, which can be enhanced by using a structured training concept. The benefit of training courses for health care justifies their incorporation into a standardized training curriculum. The completion of such training courses should be regarded as a prerequisite for a doctor to qualify as an independent surgeon.

Results of a German wide survey towards current surgical approach in early stage cervical cancer NOGGO MONITOR 11.

Minimally invasive surgery (MIS) has become the standard approach in early stage cervical cancer (ECC). However, the recently published "LACC" trial and even others could show inferior PFS and OS of MIS compared to open radical hysterectomy. The results led to a widespread debate about the best surgical approach in ECC. The present survey aimed to get first insights after publication. NOGGO and AGE conducted a nationwide digital survey among 186 Gynecological Cancer Centers. Descriptive statistics and t-tests were performed using SPSS. A majority of the centers were of high expertise and/or experience in treatment of ECC and were highly aware of the LACC trial results. Trial quality and scientific value were rated as very good/good. However, still 40% would not change the standard of care to open surgery. Centers with higher volume and participating in clinical trials were more likely to change. This survey represents insights after the surprising results of recently published trials towards the surgical approach of ECC. There still seems to be a high need of future trials and possible explanations for the unexpected worse outcomes in the MIS group.

Didactic Benefits of Surgery on Body Donors during Live Surgery Events in Minimally Invasive Surgery.

BACKGROUND: Live surgery events serve as a valuable tool for surgical education, but also raise ethical concerns about patient safety and professional performance. In the present study, we evaluate the technical feasibility and didactic benefits of live surgery on body donors compared to real patients. METHODS: A live surgery session performed on a body donor's cadaver embalmed in ethanol-glycerol-lysoformin was integrated into the live surgery program presented at a major gynecological convention of minimally invasive surgery. Surgical procedures carried out in real patients were paralleled in the body donor, including the dissection and illustration of surgically relevant anatomical landmarks. A standardized questionnaire was filled by the participants (n = 208) to evaluate the appropriateness, effectiveness, and benefits of this novel concept. RESULTS: The live surgery event was appreciated as a useful educational tool. With regard to the use of body donors, authenticity was rated high (85.5%), and the overall value of body donors for surgical education and training was rated very high (95.0%). The didactic benefit of simultaneous operations performed on body donors and real patients was considered particularly useful (95.5%), whereas complete replacement of real patients by body donors was not favored (14.5%). CONCLUSIONS: The study demonstrated both the technical feasibility and didactic benefits of performing minimally invasive surgery in body donors as part of live surgery events. This novel concept has the potential to enhance anatomical knowledge, providing insights into complex surgical procedures, and may serve to overcome yet unresolved ethical concerns related to live surgery events.

Assessing practical laparoscopic training in certified Training Centers of the Gynecological Endoscopy Working Group (AGE) of the German Society of Gynecology and Obstetrics (DGGG).

PURPOSE: This study was performed to assess the practical laparoscopic training in Gynecological Endoscopy Working Group (AGE) certified Training Centers (TC) and evaluate the possible implementation for a manual dexterity skills-training within the Minimal Invasive Surgery (MIC) certification process. MATERIAL AND METHODS: An online questionnaire was developed and the link provided for the heads of the AGE TC. The questionnaire comprised topics on TC organization, practical training performance and perspectives for future training and demographic data. RESULTS: Response rate was 78.9% (15/19) of AGE TC. Grasping for the basic and suturing exercises for the advanced curricula, respectively, are thought to be of highest value (each 1.0 ± 0, on a scale from 1 = very valuable to 6 = not at all valuable). Most valuable parameter in assessing training was thought to be pressure/tension with 1.80 ± 1.08 The most valuable training capacity was considered for box training under supervision (1.27 ± 0.59) and feed-back box training with direct evaluation of various surgical skills (1.40 ± 0.63). Supervised box training was also thought to have the most positive influence on surgical performance (1.33 ± 0.49). The majority of respondents (86.7%) were qualified with the highest MIC certification and additional 66.7% were sub-specialized Gynecological Oncologists. CONCLUSION: The AGE certified TC offer a structured curriculum with emphasis on practical training. The results of this questionnaire and the additional respondents comments on value and future perspectives/changes of practical training support the concept and the implementation of a skills-training to the AGE MIC concept.

Updated Opinion of the Uterus Commission of the Gynecological Oncology Working Group (AGO) and the Gynecological Endoscopy Working Group (AGE) of the German Society of Gynecology and Obstetrics (DGGG) on the Randomized Study Comparing Minimally Invasive with Abdominal Radical Hysterectomy for Early-stage Cervical Cancer (LACC).

In this opinion on the randomized study comparing minimally invasive with abdominal radical hysterectomy for early-stage cervical cancer (LACC), the Uterus Commission of the Gynecological Oncology Working Group (AGO) and the Gynecological Endoscopy Working Group (AGE) of the Germany Society of Gynecology and Obstetrics (DGGG) state that, based on their examination of the published data, patients with FIGO stage IA1 (with LVSI), IA2 or IB1 cervical cancer must be informed about the results of this LACC study prior to making a decision on the route for radical hysterectomy.

Congress report of the 23rd AGE annual meeting from 26th - 28th April 2018 in Hamburg

The Study Group of Gynecological Endoscopy (AGE) has a growing number of members each year. This is an acknowledgment as well as a challenge for the study group. The challenges were faced in the form of exemplary cooperative work by the core members of AGE, the Velen Study Group for Ambulant Surgery (VAAO), the Foundation of Endometriosis Research (SEF), the Study Group of Urogynecology and Plastic Pelvic Floor Reconstruction (AGUB), the Study Group for Robotic-assisted Surgery in Gynecology (ARCGyn), and the Study Group of Gynecological Oncology (AGO). More than 1500 AGE members have been able to create significant effects preemptively by designing a Congress program that was prepared interactively. The program of live surgery was designed in the course of two days on the basis of an online inquiry. The first transmission of laparoscopy on a body donor and anatomic demonstrations on formalin-fixed specimens were especially significant in this context. Sessions of general gynecology, including myoma therapy, endometriosis and infertility treatment, and gynecologic oncology and urogynecology covered the entire spectrum of minimally invasive surgical techniques. Individual topics were addressed in specific courses. The Congress was preceded by an optional certified basic course (MIC I) of the AGE. Far more than 500 congress attendees from all German-speaking countries were spirited away to a paramedical steep face, which was ascended together with a renowned German extreme climber. The keynote lecture was especially impressive and held by the pioneer and founder of the neuropelveology. The world's leading expert in this field described the responsibilities of our specialty in a visionary manner and motivated all of the listeners strongly in regard of their actions and efforts.

Laparoscopic hysterectomy and prolapse: a multiprocedural concept.

BACKGROUND AND OBJECTIVES: Today, laparoscopic intrafascial hysterectomy and laparoscopic supracervical hysterectomy are well-accepted techniques. With our multimodal concept of laparoscopic hysterectomy for benign indications, preservation of the pelvic floor as well as reconstruction of pelvic floor structures and pre-existing prolapse situations can be achieved. METHODS: The multimodal concept consists of 3 steps: 1. Intrafascial hysterectomy with preservation of existing structures. A. Technique 1: Primary uterine artery ligation. B. Technique 2: Classic intrafascial hysterectomy. 2. A technique for the stable fixation of the vaginal or cervical stump. 3. A new method of pectopexy to correct a pre-existing descensus situation. RESULTS AND CONCLUSTION: This well-balanced concept can be used by advanced endoscopic gynecologic surgeons as well as by novices in our field.

Laparoscopic temporary clipping of uterine artery during laparoscopic myomectomy.

PURPOSE: Our aim is to study the feasibility and effect of bilateral laparoscopic temporary occlusion of uterine arteries by special vascular clamps on blood loss during laparoscopic myomectomy. METHODS: Of 166 women with symptomatic uterine myomas necessitating surgical intervention who wished to retain their uteri, 80 underwent laparoscopic uterine artery clipping and myomectomy (experimental group) and 86 received laparoscopic myomectomy only (control group). Main outcome measures were operating time, number and weight of leiomyomas, blood loss, Doppler examination of the uterine arteries and complications of procedure. RESULTS: In the experimental group the median hemoglobin drop measured on day 3 postoperatively was 1.2 g/dl. In the control group the mean hemoglobin drop measured on day 3 postoperatively was 1.45 g/dl. The time needed to put the clips in place (the time from the opening of the retroperitoneum and the positioning of the clips) varied between 6 and 40 min. No patient required blood transfusion. There were no conspicuous complications. CONCLUSION: The use of the clips has proved to be statistically effective in reducing hemoglobin loss during laparoscopic myomectomy.