Establishing Standards in Minimally Invasive Gynecologic Surgery

Minimally invasive endoscopy, with and without robotics, has become a viable option for almost every operative gynecologic procedure.

Yet, despite a solid body of evidence demonstrating the benefits of minimally invasive approaches and despite tremendous progress in postgraduate education, many gynecologic surgeons are not incorporating endoscopic options into their practices – or even into their patient education. Others have adopted minimally invasive techniques, but sometimes without the essential or optimal knowledge and skills needed to perform minimally invasive gynecologic surgery with optimal outcomes and patient safety.

New gynecologic surgeons, in the meantime, are leaving residency programs with variable levels of experience and proficiency. Some have adequate opportunity to gain the skills and experience they need to be comfortable and confident in the endoscopic arena, but many do not.

As Dr. Charles E. Miller, past president of the AAGL (formerly known as the American Association of Gynecologic Laparoscopists), said in his presidential address in 2008, data have shown that one in three residents graduate with a paucity of experience in minimally invasive gynecologic procedures.

At the root of these realities are the lack of a defined knowledge base and the lack of a specific, unified endoscopy curriculum. There have been no minimal standards set for gynecologic endoscopy, no quantifiable measures defined for proficiency in minimally invasive gynecologic surgery, and no validated tools developed for gynecologic surgeons to learn and then document their competency.

Change is underway, however. For the past 2 years, the AAGL has worked with hundreds of physicians and experts to determine the essential knowledge needed for performing minimally invasive gynecologic surgery – and to develop an appropriate assessment test for gynecologic surgeons.

Called Essentials in Minimally Invasive Gynecology (EMIG), the test is based upon professional testing standards and guidelines established by professional testing societies. The process used to develop the test has incorporated the important principles of validity, reliability, and defensibility.

The EMIG cognitive assessment is currently in the beta-test stage and is scheduled to be administered for the first time in November 2012 at the AAGL annual clinical meeting. After that, physicians will be able to take the test through any one of multiple proctored testing centers operated worldwide by the consulting firm that helped develop and validate Fundamentals of Laparoscopic Surgery (FLS), the educational program that is now a standard part of all general surgery residencies.

The EMIG cognitive test covers the areas of applied anatomy and physiology, endoscopic principles, patient selection, instrumentation, energy sources, operating room/equipment setup, laparoscopy, hysteroscopy, and complications. A skills testing portion of the EMIG is under development.

Most immediately, for practicing gynecologic surgeons, EMIG will give them the opportunity to demonstrate and validate their laparoscopic skills. Then, as training becomes more standardized, gynecologists will be able to acquire skills, or enhance their skills, through postgraduate courses that incorporate EMIG principles in a unified, standardized manner.

Continuous Progress

It was gynecology that pioneered use of the laparoscope and brought it to our general surgery colleagues. And over the years, gynecology has been cognizant of the need to develop a standardized assessment, curriculum, and training to meet the demands of the dynamic developments in endoscopy.

In the early 1990s, the American College of Obstetricians and Gynecologists issued basic guidelines for credentialing gynecologists to perform laparoscopy, and the Accreditation Council for Gynecologic Endoscopy (now the Council for Gynecologic Endoscopy and part of the AAGL) started a registry identifying gynecologists skilled at laparoscopy and hysteroscopy.

In 1998, Dr. Andrew Brill and Dr. Robert Rogers outlined a comprehensive program for resident training in the Journal of the American Association of Gynecologic Laparoscopists (J. Am. Assoc. Gynecol. Laparosc. 1998;5:223-8). Recently, the Fellowship in Minimally Invasive Gynecologic Surgery program issued guidelines as well for fellow and resident education, hands-on training, written examinations and skills testing, and supervised surgery.

In the world of general surgery, in the meantime, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) began developing the FLS in the late 1990s; the FLS is a comprehensive web-based education module designed to teach and assess basic cognitive, technical, and psychomotor skills required to perform laparoscopic surgery.

FLS has two parts: didactic testing, which is online multiple choice testing, and skills testing, which is hands-on. Endorsed by the American College of Surgeons (ACS), FLS was designed to give surgical residents, fellows, and practicing physicians an opportunity to learn the fundamentals of laparoscopic surgery in a consistent, scientific format.

The goal was not only to increase familiarity with and access to minimally invasive techniques, but to ensure good outcomes and patient safety.

Since the FLS test became available in 2004, the number of physicians seeking FLS certification rose annually. A study of the first 5 years of FLS certification testing (2004-2009) shows an overall pass rate of 88% on the examination – close to the target pass rate of 90% established during the test-setting process. Almost 20% of the test participants over this time period were attending surgeons; the rest were senior residents or fellows (the largest participant group) and junior residents. A small number – 4% – were gynecologists (Surg. Endosc. 2011;25:1192-8).

In 2008, the ACS went one step further by requiring all general surgery residents, starting in 2009, to complete and pass the FLS course before achieving board certification. This mandate set minimum standards for basic cognitive and technical skills, and encouraged a uniform framework for laparoscopy training in general surgery residency programs.

Urology has similarly deliberated and addressed the idea that standard training and credentialing initiatives are critical to have and to update as surgical technology and techniques evolve. The American Urologic Association has developed and is validating a Basic Laparoscopic Urologic Surgery (BLUS) skills curriculum similar to FLS for laparoscopic cognitive and technical skills. The association also has created a Simulation Advisory Board that will vet current and future skills courses and provide guidance for matching learning objectives with effective simulation-based technologies. In addition, the AUA is expanding a preexisting urology-specific robotic skills curriculum and, along with AAGL, SAGES, and the Minimally Invasive Robotic Association, is developing a Fundamentals of Robotic Skills curriculum.

Essential Gynecologic Knowledge

As minimally invasive surgery becomes mainstream, it is important for gynecologic surgeons to be familiar with the fundamentals of laparoscopic gynecologic surgery and hysteroscopy, whether or not they are utilizing or planning to utilize robotic technology.

Development of the cognitive portion of EMIG is the first step of an AAGL-led effort that will ensure that gynecology meets the need for a standardized, demonstrable set of skills. As it takes shape and gains acceptance, the EMIG assessment should provide a standardized tool for physicians, patients, hospitals and payers to identify gynecologic surgeons who have demonstrated the knowledge and skills necessary to understand the intricacies of minimally invasive gynecology.

Unlike the FLS, the EMIG test is specifically focused on gynecology and includes hysteroscopy. Hundreds of physicians were involved in completing a survey, writing psychometrically correct items, and reviewing questions. A test development psychometrician directed the AAGL through test development and technical review and performed a psychometric edit.

As of May 2012, beta testers were scheduled to answer approximately 380 questions, over two sessions totaling 6-8 hours, in a proctored environment. From the results, two forms of the test, with approximately 125 questions each, will be created. A passing score will be determined, and the test will be made available in online test delivery software so it can be taken anywhere in the world – after its first run at the AAGL meeting this fall.

Concurrently, the AAGL has been developing an approach to testing psychomotor skills, which is needed, along with cognitive assessment, to ascertain the qualifications of a surgeon. The AAGL identified essential skills by asking more than 1,000 physicians to rank the importance and frequency of the skills. This information will be used to evaluate skills trainers and testing instruments.

Eventually, it is hoped, a standardized core curriculum – based on the EMIG knowledge base – will be developed and incorporated into residency programs, just as it has been for general surgery. Such a curriculum could also be implemented in the Fellowship in Minimally Invasive Gynecologic Surgery, cosponsored by the AAGL and the Society of Reproductive Surgeons (an affiliate society of the American Society for Reproductive Medicine), in which case it could be longer in duration.

A standardized core curriculum could be implemented as well in the growing number of postgraduate courses that are available to practicing gynecologic surgeons; in this case, the curriculum would be shorter in duration.

A proposal for a formal gynecologic endoscopy curriculum, published a few years ago in The Journal of Minimally Invasive Gynecology (J. Minim. Invasive Gynecol. 2009;16:416-21), envisions a quarterly system with an online examination given after quarters 1 and 2, a hands-on examination given after quarter 3, and a demonstration of leadership and teaching skills in the operating room after quarter 4.

As envisioned in the proposed curriculum, the first quarter would focus on knowledge of pelvic and abdominal anatomy that is specific to laparoscopy and gynecology, including the major branches of anterior and posterior division of the internal iliac artery and the major nerve supplies to the pelvis. Knowledge of the physiology and principles of creating and maintaining pneumoperitoneum and the principles and application of electrosurgery, ultrasonic energy, and various laser energy sources, for instance, also would be acquired.

The second quarter would encompass patient selection, preoperative planning and preparation, and patient counseling. Technical skills for performing safe diagnostic laparoscopy and hysteroscopy would be a focus, along with an understanding of potential complications and appropriate management. The third quarter would be dedicated to acquiring specific surgical skills – knowing the boundaries of pelvic spaces and using techniques such as hydrodissection and traction/countertraction, for instance, as well as performing laparoscopic suturing and using agents for adhesion prevention. By the end of the fourth quarter, the trainee would be able to independently implement appropriate surgical and medical plans as well as teach and assist other surgeons.

It is important to appreciate that robotic surgery is, in fact, a form of laparoscopy, and the best preparation for robotic surgery lies in basic laparoscopic training. There are physicians who are performing both laparoscopic and robotic-assisted laparoscopic surgery without having a basic knowledge of laparoscopy.

Looking back to the general surgery literature of the late 1980s and early 1990s, there were reports of complications relating to laparoscopy that were new to general surgeons but were well known to gynecologists, such as problems with abdominal entry, port-related injuries, and laser and electrosurgery injuries. Currently, a look at the robotic urology literature shows the same known laparoscopy-related complications being reported as robotic surgery complications.

Dr. Nezhat is the current secretary/treasurer of the AAGL; adjunct clinical associate professor of gynecology and obstetrics at Emory University, Atlanta; adjunct clinical associate professor of obstetrics and gynecology, Stanford (Calif.) University; and fellowship director, Center for Special Minimally Invasive Surgery & Reproductive Medicine, Atlanta. He is a pioneer in the field of laparoscopic surgery, specializing in infertility and endometriosis, as well as urologic and pelvic reconstruction. He has authored more than 100 publications including refereed journal articles, book chapters, and two books. Dr. Nezhat is a frequent lecturer and educator and regularly serves as a medical volunteer in underdeveloped countries. He had no disclosures to report.

Minimally invasive endoscopy, with and without robotics, has become a viable option for almost every operative gynecologic procedure.

Yet, despite a solid body of evidence demonstrating the benefits of minimally invasive approaches and despite tremendous progress in postgraduate education, many gynecologic surgeons are not incorporating endoscopic options into their practices – or even into their patient education. Others have adopted minimally invasive techniques, but sometimes without the essential or optimal knowledge and skills needed to perform minimally invasive gynecologic surgery with optimal outcomes and patient safety.

New gynecologic surgeons, in the meantime, are leaving residency programs with variable levels of experience and proficiency. Some have adequate opportunity to gain the skills and experience they need to be comfortable and confident in the endoscopic arena, but many do not.

As Dr. Charles E. Miller, past president of the AAGL (formerly known as the American Association of Gynecologic Laparoscopists), said in his presidential address in 2008, data have shown that one in three residents graduate with a paucity of experience in minimally invasive gynecologic procedures.

At the root of these realities are the lack of a defined knowledge base and the lack of a specific, unified endoscopy curriculum. There have been no minimal standards set for gynecologic endoscopy, no quantifiable measures defined for proficiency in minimally invasive gynecologic surgery, and no validated tools developed for gynecologic surgeons to learn and then document their competency.

Change is underway, however. For the past 2 years, the AAGL has worked with hundreds of physicians and experts to determine the essential knowledge needed for performing minimally invasive gynecologic surgery – and to develop an appropriate assessment test for gynecologic surgeons.

Called Essentials in Minimally Invasive Gynecology (EMIG), the test is based upon professional testing standards and guidelines established by professional testing societies. The process used to develop the test has incorporated the important principles of validity, reliability, and defensibility.

The EMIG cognitive assessment is currently in the beta-test stage and is scheduled to be administered for the first time in November 2012 at the AAGL annual clinical meeting. After that, physicians will be able to take the test through any one of multiple proctored testing centers operated worldwide by the consulting firm that helped develop and validate Fundamentals of Laparoscopic Surgery (FLS), the educational program that is now a standard part of all general surgery residencies.

The EMIG cognitive test covers the areas of applied anatomy and physiology, endoscopic principles, patient selection, instrumentation, energy sources, operating room/equipment setup, laparoscopy, hysteroscopy, and complications. A skills testing portion of the EMIG is under development.

Most immediately, for practicing gynecologic surgeons, EMIG will give them the opportunity to demonstrate and validate their laparoscopic skills. Then, as training becomes more standardized, gynecologists will be able to acquire skills, or enhance their skills, through postgraduate courses that incorporate EMIG principles in a unified, standardized manner.

Continuous Progress

It was gynecology that pioneered use of the laparoscope and brought it to our general surgery colleagues. And over the years, gynecology has been cognizant of the need to develop a standardized assessment, curriculum, and training to meet the demands of the dynamic developments in endoscopy.

In the early 1990s, the American College of Obstetricians and Gynecologists issued basic guidelines for credentialing gynecologists to perform laparoscopy, and the Accreditation Council for Gynecologic Endoscopy (now the Council for Gynecologic Endoscopy and part of the AAGL) started a registry identifying gynecologists skilled at laparoscopy and hysteroscopy.

In 1998, Dr. Andrew Brill and Dr. Robert Rogers outlined a comprehensive program for resident training in the Journal of the American Association of Gynecologic Laparoscopists (J. Am. Assoc. Gynecol. Laparosc. 1998;5:223-8). Recently, the Fellowship in Minimally Invasive Gynecologic Surgery program issued guidelines as well for fellow and resident education, hands-on training, written examinations and skills testing, and supervised surgery.

In the world of general surgery, in the meantime, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) began developing the FLS in the late 1990s; the FLS is a comprehensive web-based education module designed to teach and assess basic cognitive, technical, and psychomotor skills required to perform laparoscopic surgery.

FLS has two parts: didactic testing, which is online multiple choice testing, and skills testing, which is hands-on. Endorsed by the American College of Surgeons (ACS), FLS was designed to give surgical residents, fellows, and practicing physicians an opportunity to learn the fundamentals of laparoscopic surgery in a consistent, scientific format.

The goal was not only to increase familiarity with and access to minimally invasive techniques, but to ensure good outcomes and patient safety.

Since the FLS test became available in 2004, the number of physicians seeking FLS certification rose annually. A study of the first 5 years of FLS certification testing (2004-2009) shows an overall pass rate of 88% on the examination – close to the target pass rate of 90% established during the test-setting process. Almost 20% of the test participants over this time period were attending surgeons; the rest were senior residents or fellows (the largest participant group) and junior residents. A small number – 4% – were gynecologists (Surg. Endosc. 2011;25:1192-8).

In 2008, the ACS went one step further by requiring all general surgery residents, starting in 2009, to complete and pass the FLS course before achieving board certification. This mandate set minimum standards for basic cognitive and technical skills, and encouraged a uniform framework for laparoscopy training in general surgery residency programs.

Urology has similarly deliberated and addressed the idea that standard training and credentialing initiatives are critical to have and to update as surgical technology and techniques evolve. The American Urologic Association has developed and is validating a Basic Laparoscopic Urologic Surgery (BLUS) skills curriculum similar to FLS for laparoscopic cognitive and technical skills. The association also has created a Simulation Advisory Board that will vet current and future skills courses and provide guidance for matching learning objectives with effective simulation-based technologies. In addition, the AUA is expanding a preexisting urology-specific robotic skills curriculum and, along with AAGL, SAGES, and the Minimally Invasive Robotic Association, is developing a Fundamentals of Robotic Skills curriculum.

Essential Gynecologic Knowledge

As minimally invasive surgery becomes mainstream, it is important for gynecologic surgeons to be familiar with the fundamentals of laparoscopic gynecologic surgery and hysteroscopy, whether or not they are utilizing or planning to utilize robotic technology.

Development of the cognitive portion of EMIG is the first step of an AAGL-led effort that will ensure that gynecology meets the need for a standardized, demonstrable set of skills. As it takes shape and gains acceptance, the EMIG assessment should provide a standardized tool for physicians, patients, hospitals and payers to identify gynecologic surgeons who have demonstrated the knowledge and skills necessary to understand the intricacies of minimally invasive gynecology.

Unlike the FLS, the EMIG test is specifically focused on gynecology and includes hysteroscopy. Hundreds of physicians were involved in completing a survey, writing psychometrically correct items, and reviewing questions. A test development psychometrician directed the AAGL through test development and technical review and performed a psychometric edit.

As of May 2012, beta testers were scheduled to answer approximately 380 questions, over two sessions totaling 6-8 hours, in a proctored environment. From the results, two forms of the test, with approximately 125 questions each, will be created. A passing score will be determined, and the test will be made available in online test delivery software so it can be taken anywhere in the world – after its first run at the AAGL meeting this fall.

Concurrently, the AAGL has been developing an approach to testing psychomotor skills, which is needed, along with cognitive assessment, to ascertain the qualifications of a surgeon. The AAGL identified essential skills by asking more than 1,000 physicians to rank the importance and frequency of the skills. This information will be used to evaluate skills trainers and testing instruments.

Eventually, it is hoped, a standardized core curriculum – based on the EMIG knowledge base – will be developed and incorporated into residency programs, just as it has been for general surgery. Such a curriculum could also be implemented in the Fellowship in Minimally Invasive Gynecologic Surgery, cosponsored by the AAGL and the Society of Reproductive Surgeons (an affiliate society of the American Society for Reproductive Medicine), in which case it could be longer in duration.

A standardized core curriculum could be implemented as well in the growing number of postgraduate courses that are available to practicing gynecologic surgeons; in this case, the curriculum would be shorter in duration.

A proposal for a formal gynecologic endoscopy curriculum, published a few years ago in The Journal of Minimally Invasive Gynecology (J. Minim. Invasive Gynecol. 2009;16:416-21), envisions a quarterly system with an online examination given after quarters 1 and 2, a hands-on examination given after quarter 3, and a demonstration of leadership and teaching skills in the operating room after quarter 4.

As envisioned in the proposed curriculum, the first quarter would focus on knowledge of pelvic and abdominal anatomy that is specific to laparoscopy and gynecology, including the major branches of anterior and posterior division of the internal iliac artery and the major nerve supplies to the pelvis. Knowledge of the physiology and principles of creating and maintaining pneumoperitoneum and the principles and application of electrosurgery, ultrasonic energy, and various laser energy sources, for instance, also would be acquired.

The second quarter would encompass patient selection, preoperative planning and preparation, and patient counseling. Technical skills for performing safe diagnostic laparoscopy and hysteroscopy would be a focus, along with an understanding of potential complications and appropriate management. The third quarter would be dedicated to acquiring specific surgical skills – knowing the boundaries of pelvic spaces and using techniques such as hydrodissection and traction/countertraction, for instance, as well as performing laparoscopic suturing and using agents for adhesion prevention. By the end of the fourth quarter, the trainee would be able to independently implement appropriate surgical and medical plans as well as teach and assist other surgeons.

It is important to appreciate that robotic surgery is, in fact, a form of laparoscopy, and the best preparation for robotic surgery lies in basic laparoscopic training. There are physicians who are performing both laparoscopic and robotic-assisted laparoscopic surgery without having a basic knowledge of laparoscopy.

Looking back to the general surgery literature of the late 1980s and early 1990s, there were reports of complications relating to laparoscopy that were new to general surgeons but were well known to gynecologists, such as problems with abdominal entry, port-related injuries, and laser and electrosurgery injuries. Currently, a look at the robotic urology literature shows the same known laparoscopy-related complications being reported as robotic surgery complications.

Dr. Nezhat is the current secretary/treasurer of the AAGL; adjunct clinical associate professor of gynecology and obstetrics at Emory University, Atlanta; adjunct clinical associate professor of obstetrics and gynecology, Stanford (Calif.) University; and fellowship director, Center for Special Minimally Invasive Surgery & Reproductive Medicine, Atlanta. He is a pioneer in the field of laparoscopic surgery, specializing in infertility and endometriosis, as well as urologic and pelvic reconstruction. He has authored more than 100 publications including refereed journal articles, book chapters, and two books. Dr. Nezhat is a frequent lecturer and educator and regularly serves as a medical volunteer in underdeveloped countries. He had no disclosures to report.

Minimally invasive endoscopy, with and without robotics, has become a viable option for almost every operative gynecologic procedure.

Yet, despite a solid body of evidence demonstrating the benefits of minimally invasive approaches and despite tremendous progress in postgraduate education, many gynecologic surgeons are not incorporating endoscopic options into their practices – or even into their patient education. Others have adopted minimally invasive techniques, but sometimes without the essential or optimal knowledge and skills needed to perform minimally invasive gynecologic surgery with optimal outcomes and patient safety.

New gynecologic surgeons, in the meantime, are leaving residency programs with variable levels of experience and proficiency. Some have adequate opportunity to gain the skills and experience they need to be comfortable and confident in the endoscopic arena, but many do not.

As Dr. Charles E. Miller, past president of the AAGL (formerly known as the American Association of Gynecologic Laparoscopists), said in his presidential address in 2008, data have shown that one in three residents graduate with a paucity of experience in minimally invasive gynecologic procedures.

At the root of these realities are the lack of a defined knowledge base and the lack of a specific, unified endoscopy curriculum. There have been no minimal standards set for gynecologic endoscopy, no quantifiable measures defined for proficiency in minimally invasive gynecologic surgery, and no validated tools developed for gynecologic surgeons to learn and then document their competency.

Change is underway, however. For the past 2 years, the AAGL has worked with hundreds of physicians and experts to determine the essential knowledge needed for performing minimally invasive gynecologic surgery – and to develop an appropriate assessment test for gynecologic surgeons.

Called Essentials in Minimally Invasive Gynecology (EMIG), the test is based upon professional testing standards and guidelines established by professional testing societies. The process used to develop the test has incorporated the important principles of validity, reliability, and defensibility.

The EMIG cognitive assessment is currently in the beta-test stage and is scheduled to be administered for the first time in November 2012 at the AAGL annual clinical meeting. After that, physicians will be able to take the test through any one of multiple proctored testing centers operated worldwide by the consulting firm that helped develop and validate Fundamentals of Laparoscopic Surgery (FLS), the educational program that is now a standard part of all general surgery residencies.

The EMIG cognitive test covers the areas of applied anatomy and physiology, endoscopic principles, patient selection, instrumentation, energy sources, operating room/equipment setup, laparoscopy, hysteroscopy, and complications. A skills testing portion of the EMIG is under development.

Most immediately, for practicing gynecologic surgeons, EMIG will give them the opportunity to demonstrate and validate their laparoscopic skills. Then, as training becomes more standardized, gynecologists will be able to acquire skills, or enhance their skills, through postgraduate courses that incorporate EMIG principles in a unified, standardized manner.

Continuous Progress

It was gynecology that pioneered use of the laparoscope and brought it to our general surgery colleagues. And over the years, gynecology has been cognizant of the need to develop a standardized assessment, curriculum, and training to meet the demands of the dynamic developments in endoscopy.

In the early 1990s, the American College of Obstetricians and Gynecologists issued basic guidelines for credentialing gynecologists to perform laparoscopy, and the Accreditation Council for Gynecologic Endoscopy (now the Council for Gynecologic Endoscopy and part of the AAGL) started a registry identifying gynecologists skilled at laparoscopy and hysteroscopy.

In 1998, Dr. Andrew Brill and Dr. Robert Rogers outlined a comprehensive program for resident training in the Journal of the American Association of Gynecologic Laparoscopists (J. Am. Assoc. Gynecol. Laparosc. 1998;5:223-8). Recently, the Fellowship in Minimally Invasive Gynecologic Surgery program issued guidelines as well for fellow and resident education, hands-on training, written examinations and skills testing, and supervised surgery.

In the world of general surgery, in the meantime, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) began developing the FLS in the late 1990s; the FLS is a comprehensive web-based education module designed to teach and assess basic cognitive, technical, and psychomotor skills required to perform laparoscopic surgery.

FLS has two parts: didactic testing, which is online multiple choice testing, and skills testing, which is hands-on. Endorsed by the American College of Surgeons (ACS), FLS was designed to give surgical residents, fellows, and practicing physicians an opportunity to learn the fundamentals of laparoscopic surgery in a consistent, scientific format.

The goal was not only to increase familiarity with and access to minimally invasive techniques, but to ensure good outcomes and patient safety.

Since the FLS test became available in 2004, the number of physicians seeking FLS certification rose annually. A study of the first 5 years of FLS certification testing (2004-2009) shows an overall pass rate of 88% on the examination – close to the target pass rate of 90% established during the test-setting process. Almost 20% of the test participants over this time period were attending surgeons; the rest were senior residents or fellows (the largest participant group) and junior residents. A small number – 4% – were gynecologists (Surg. Endosc. 2011;25:1192-8).

In 2008, the ACS went one step further by requiring all general surgery residents, starting in 2009, to complete and pass the FLS course before achieving board certification. This mandate set minimum standards for basic cognitive and technical skills, and encouraged a uniform framework for laparoscopy training in general surgery residency programs.

Urology has similarly deliberated and addressed the idea that standard training and credentialing initiatives are critical to have and to update as surgical technology and techniques evolve. The American Urologic Association has developed and is validating a Basic Laparoscopic Urologic Surgery (BLUS) skills curriculum similar to FLS for laparoscopic cognitive and technical skills. The association also has created a Simulation Advisory Board that will vet current and future skills courses and provide guidance for matching learning objectives with effective simulation-based technologies. In addition, the AUA is expanding a preexisting urology-specific robotic skills curriculum and, along with AAGL, SAGES, and the Minimally Invasive Robotic Association, is developing a Fundamentals of Robotic Skills curriculum.

Essential Gynecologic Knowledge

As minimally invasive surgery becomes mainstream, it is important for gynecologic surgeons to be familiar with the fundamentals of laparoscopic gynecologic surgery and hysteroscopy, whether or not they are utilizing or planning to utilize robotic technology.

Development of the cognitive portion of EMIG is the first step of an AAGL-led effort that will ensure that gynecology meets the need for a standardized, demonstrable set of skills. As it takes shape and gains acceptance, the EMIG assessment should provide a standardized tool for physicians, patients, hospitals and payers to identify gynecologic surgeons who have demonstrated the knowledge and skills necessary to understand the intricacies of minimally invasive gynecology.

Unlike the FLS, the EMIG test is specifically focused on gynecology and includes hysteroscopy. Hundreds of physicians were involved in completing a survey, writing psychometrically correct items, and reviewing questions. A test development psychometrician directed the AAGL through test development and technical review and performed a psychometric edit.

As of May 2012, beta testers were scheduled to answer approximately 380 questions, over two sessions totaling 6-8 hours, in a proctored environment. From the results, two forms of the test, with approximately 125 questions each, will be created. A passing score will be determined, and the test will be made available in online test delivery software so it can be taken anywhere in the world – after its first run at the AAGL meeting this fall.

Concurrently, the AAGL has been developing an approach to testing psychomotor skills, which is needed, along with cognitive assessment, to ascertain the qualifications of a surgeon. The AAGL identified essential skills by asking more than 1,000 physicians to rank the importance and frequency of the skills. This information will be used to evaluate skills trainers and testing instruments.

Eventually, it is hoped, a standardized core curriculum – based on the EMIG knowledge base – will be developed and incorporated into residency programs, just as it has been for general surgery. Such a curriculum could also be implemented in the Fellowship in Minimally Invasive Gynecologic Surgery, cosponsored by the AAGL and the Society of Reproductive Surgeons (an affiliate society of the American Society for Reproductive Medicine), in which case it could be longer in duration.

A standardized core curriculum could be implemented as well in the growing number of postgraduate courses that are available to practicing gynecologic surgeons; in this case, the curriculum would be shorter in duration.

A proposal for a formal gynecologic endoscopy curriculum, published a few years ago in The Journal of Minimally Invasive Gynecology (J. Minim. Invasive Gynecol. 2009;16:416-21), envisions a quarterly system with an online examination given after quarters 1 and 2, a hands-on examination given after quarter 3, and a demonstration of leadership and teaching skills in the operating room after quarter 4.

As envisioned in the proposed curriculum, the first quarter would focus on knowledge of pelvic and abdominal anatomy that is specific to laparoscopy and gynecology, including the major branches of anterior and posterior division of the internal iliac artery and the major nerve supplies to the pelvis. Knowledge of the physiology and principles of creating and maintaining pneumoperitoneum and the principles and application of electrosurgery, ultrasonic energy, and various laser energy sources, for instance, also would be acquired.

The second quarter would encompass patient selection, preoperative planning and preparation, and patient counseling. Technical skills for performing safe diagnostic laparoscopy and hysteroscopy would be a focus, along with an understanding of potential complications and appropriate management. The third quarter would be dedicated to acquiring specific surgical skills – knowing the boundaries of pelvic spaces and using techniques such as hydrodissection and traction/countertraction, for instance, as well as performing laparoscopic suturing and using agents for adhesion prevention. By the end of the fourth quarter, the trainee would be able to independently implement appropriate surgical and medical plans as well as teach and assist other surgeons.

It is important to appreciate that robotic surgery is, in fact, a form of laparoscopy, and the best preparation for robotic surgery lies in basic laparoscopic training. There are physicians who are performing both laparoscopic and robotic-assisted laparoscopic surgery without having a basic knowledge of laparoscopy.

Looking back to the general surgery literature of the late 1980s and early 1990s, there were reports of complications relating to laparoscopy that were new to general surgeons but were well known to gynecologists, such as problems with abdominal entry, port-related injuries, and laser and electrosurgery injuries. Currently, a look at the robotic urology literature shows the same known laparoscopy-related complications being reported as robotic surgery complications.

Dr. Nezhat is the current secretary/treasurer of the AAGL; adjunct clinical associate professor of gynecology and obstetrics at Emory University, Atlanta; adjunct clinical associate professor of obstetrics and gynecology, Stanford (Calif.) University; and fellowship director, Center for Special Minimally Invasive Surgery & Reproductive Medicine, Atlanta. He is a pioneer in the field of laparoscopic surgery, specializing in infertility and endometriosis, as well as urologic and pelvic reconstruction. He has authored more than 100 publications including refereed journal articles, book chapters, and two books. Dr. Nezhat is a frequent lecturer and educator and regularly serves as a medical volunteer in underdeveloped countries. He had no disclosures to report.