LapPass - The Laparoscopic Passport

 

Launching at the ALSGBI ASM in Southport in the Arthrex Mobile Training Lab

Laparoscopic surgery is technically demanding and the skills required for proficiency are difficult to acquire. It is not for everyone. However, perhaps more than for any other branch of surgery, simulator training lends itself for practicing and perfecting laparoscopic technical skills and from Autumn 2015 the ALSGBI will recognise those trainees who are able to demonstrate proficiency in a defined set of five laparoscopic tasks. These are not easy skills to perfect and the possession of the passport will be a badge of proficiency which will be recognised nationwide and will mark out those who are serious laparoscopic surgeons. In turn, it would be anticipated that trainers will recognise that those in possession of the LapPass will be suitable for accelerated operative training. The five skills include camera holding (which will be assessed intra-operatively) and four technical skill tasks which will be demonstrated and assessed in training jigs.

ASSESSORS and ASSESSMENT

We hope you will enjoy acquiring the LapPass. The tasks set are challenging but the skills required are very much clinically relevant and for most people not intuitive. They will require practice, probably over many hours at home or in the lab. They do not intend in any way to avoid the need for courses but much like the Driving Test: lessons will help speedy acquisition of the required proficiency and promote good habits but on the day you still have to pass the Test itself with or without formal lessons.

 

We expect to run assessments at the Annual Scientific Meetings again and to continue to do so at each of our Annual meetings. It will be perhaps the best opportunity for trainees to get access to assessment sessions with a proven faculty and in due course it may be possible to roll out these assessment sessions locally as was originally intended; but for the time being Council feel that concentrating assessment at the Annual Scientific Meeting will be the preferred option but we will complement these free assessment sessions with Council funded regional training days in order to deliver local ALSGBI training. Please watch the website and newsletter for further information. The tasks are designed to be able to be conducted on low fidelity jigs and we would encourage practice in this way.

ASSESSMENT FORMS

Once completed, please email these forms to Jenny Treglohan jtreglohan@alsgbi.org at the ALSGBI office


Click here to download practical skills assessment form
Click here to download camera holding assessment form

TASK 1

Basic grasping and manipulation of polo mints

EQUIPMENT
3 posts
3 polo mints
1 piece of string/cord 15cm in length
2 Johannes forceps

TASK
Transfer 3 polo mints from post to post from a start and finish position in the floor of the simulator with the polo writing face up.
From base to post 1: Using left hand only
From post 1 to post 2: Use right hand only remove from post one and place on post two upside down
From post 2 to post 3: Remove from post two with one hand, transfer in mid air to grasper in other hand then place on post 3
From post 3 to finish: Remove from post three and in mid air pass over the cord such that the polo mint does not touch the floor of the simulator. The mint is then placed back at the starting position.

ESSENTIAL ELEMENTS
Grasping and manipulation
Spatial awareness
Pronation and supination
Tactile feedback from graspers
Smooth performance.

CLOCK STARTS: As soon as the first polo mint is touched
CLOCK STOPS: As soon as the third polo mint is placed back at the starting point.
TARGET TIME: 4 minutes

COMMENTS
If a polo mint is dropped it is placed back at the starting position and the cycle is repeated for that individual polo mint.


 

TASK 2

TYING EXTRACORPOREAL ROEDER KNOTS AND PLACING THEM TO SIMULATE APPENDICECTOMY

EQUIPMENT
Partially inflated glove with 4 lines at 1cm intervals along one digit.
Long length of braided suture material
Johannes or knot pusher
Laparoscopic scissors

TASK
Create and place three Roeder knots, 2 proximally in zone 1, one distally in zone three and divide in zone two. Glove must not deflate

ESSENTIAL ELEMENTS
Demonstration of accurate and effective Roeder knot.
Precision placement of endoloop
Precision cutting

CLOCK STARTS: As soon as first endoloop is passed into the simulator
CLOCK STOPS: When tip of glove is separated from main glove and the last endoloop has been cut
TARGET TIME: 8 mins

COMMENTS
The first endoloop may be constructed outside the simulator before the exercise begins and is done in front of the assessor to confirm that the knot is being accurately constructed. There is no time limit on this stage. The technique of Roeder knot formation is available on the ALS website courtesy of the Royal College of Surgeons.
Inaccurate loops must be repeated. Inaccurate division of the tip of the glove or immediate (< 1 minute) deflation of the body of the glove disqualifies the exercise which must then be repeated in its entirety.




 

TASK 3

CUTTING A SHAPE

EQUIPMENT
Solid circular line on glove or chamois leather with inner and external parallel dotted lines 0.5 cm away. Diameter of circle must be at least 5 cm in minimum diameter.
Laparoscopic scissors and graspers.
Target circle

TASK
To precisely cut a circular shape without deviation from the line on excision and without damaging underlying tissue

ESSENTIAL ELEMENTS
Precision cutting
Grasping and manipulation
Placing the tissue under tension to facilitate the exercise

CLOCK STARTS: As the first instrument is placed into the simulator
CLOCK STOPS: As the shape is confirmed to be fully excised
TARGET TIME: 3 mins

COMMENTS
Touching or breaching either dotted line disqualifies the exercise. Scissors may be used in either hand and may be used interchangeably


 

TASK 4

SUTURING

EQUIPMENT
Flexible pad with two pairs of dots drawn in
Braided suture
Needle driver
Johannes/ second needle holder
LLaparoscopic scissors.

TASK
To place two accurate sutures and tie them securely to draw tissue under tension

ESSENTIAL ELEMENTS
Loading of needle drivers. Accurate suturing. Precise and secure knot tying with appropriate tension. The two target spots must be touching (outer dotted lines) on completion of the excercise.

CLOCK STARTS: As soon as suture material is inserted into simulator
CLOCK STOPS: With division of the suture material after second suture
TARGET TIME: 6 minutes

COMMENTS
Acceptable knot types: Szabo knot (secure reef knot with additional throw), may be tied using two hand technique (“C” and “D” loops) or (for advanced practitioners) tied single handedly, Surgeon’s knot. Precision and tension mandatory


 

CAMERA HOLDING SKILLS

Minimum of 6 cases each at least 30 mins long
Sole camera holder
Forewarn operator that this is an assessable task
At least 3 cases using 30 degree laparoscope

SKILLS TO BE DEMONSTRATED
Camera precision: Target to be maintained within the centre of the image for the majority of the time and to the satisfaction of the operator
An appropriate distance from the target tissue to be maintained and to demonstrate proactive dynamism with “zooming in” for precise tasks and “zooming out” for general views and instrument exchanges
An understanding of the principles of the 30 degree laparoscope with demonstration of orientation whilst maintaining the horizon
Appropriate teamworking skills