Facts, Views & Vision
in ObGyn

In experienced hands…: the current challenges of laparoscopic education

Minimal surgical invasiveness should translate into minimal peri-operative morbidity. Based on this assumption and encouraged by the report of the first total laparoscopic hysterectomy in 1990 (Reich, 2007), endoscopic surgery has undergone a remarkable development. Laparoscopy has demonstrated its technical ability to perform gynaecological and abdominal surgery for most benign and malignant conditions (Canis et al., 2001; Walsh et al., 2009). Advances in image quality, surgical instruments and energy generation have allowed to perform more complex procedures in the fields of pelvic floor repair, deep endometriosis and oncology. In this context, adequate radicality is reported while reduced post-operative pain, intra-operative blood loss and hospital stay are noted (Galaal et al., 2012).
After a fourth of a century of an exciting surgical journey, one must admit that laparoscopy has come to a paradoxical status. While the limits of the endoscopic approach are pushed further everyday by some experts practicing in specialized surgical centres (Ferron et al., 2012), the proportion of patients treated by laparoscopy for even standard procedures has remained steadily low over the last decades. In France, where many of the laparoscopic operations have been pioneered, only 8000 of the 60000 patients (13%) undergoing a hysterectomy in 2013 were treated with a total laparoscopic approach (MPIS, 2013). Without a significant reappraisal, the situation will persist and the potential benefits of what was a surgical revolution will remain limited to a small subset of patients. Or worse, insufficiently trained surgeons might try to replicate complex surgeries with an increased risk of severe complications (Barber et al., 2014).
It is time to get back to basics and to acknowledge that each step in the field of surgery imposes a dedicated and detailed training program taking into consideration all particularities of the new surgical approach. It is about an in depth understanding of the morphological and the functional pelvi-abdominal anatomy, the surgical materials and the energies that we use. It is also about the ergonomic surgical set-up and the acquisition of specific movement skills. Finally it is about lab sessions and live surgical training, accompanied by experts to rehearse the procedures with a strict step by step approach and a clear codification of the security check points.
In this issue of Facts, Views and Vision in ObGyn, Campo et al. (2014) report on the Gynaecological Endoscopic Surgical Education and Assessment program (GESEA), a structured, educational training route trying to provide an answer to the current challenges of laparoscopic education. Endorsed by the European Society of Gynaecological Endoscopy (ESGE) and the European Academy of Gynaecological Surgery (+he Academy), the GESEA is a unique initiative that gives access to all trainees or senior gynaecologists to a multilevel training and certification program including successively a Bachelor (level 1), a Minimally Invasive Surgery (level 2) and a Master in Hysteroscopy and Laparoscopic Pelvic Surgery (level 3). This initiative must be recognized as a highly elaborate multidisciplinary teaching platform that takes all issues of laparoscopic surgical training into consideration, from the theoretical knowledge to the ultimate surgical competence.
Excellence needs training is evidence but excellence in laparoscopy remained an unmet goal as long as an optimal tool for teaching and certification was not available to the gynaecological surgical community. GESEA offers a unique opportunity to ensure that in a not too distant future, most of our patients will end up in experienced hands and benefit from modern and mastered surgical procedures.
Everything is doable not everything is indicated and inappropriate indication may also lead to catastrophes even in the most expert technical hands.

«It is not because things are difficult that we do not dare, it is because we do not dare that things remain difficult»
Sénèque

F. Kridelka
CHU of Liège, Department of Obstetrics and Gynaecology, Liège, Belgium

References

Barber EL, Neubauer NL, Gossett DR. Risk of Venous Thromboembolism in Abdominal Versus Minimally Invasive Hysterectomy for Benign Conditions. Am J Obstet Gynecol. 2014 Dec 12. [Epub ahead of print].
Campo R, Puga M, Meier Furst R et al. Excellence needs training “Certified programme in endoscopicsurgery”. Facts Views Vis Obgyn. 2014; 235-9.
Canis M, Mage G, Botchorishvili R et al. Laparoscopy and gynecologic cancer: is it still necessary to debate or only convince the incredulous? Gynecol Obstet Fertil. 2001;29: 913-8.
Ferron G, Pomel C, Martinez A et al. Pelvic exenteration: current state and perspectives. [Article in French]. Gynecol Obstet Fertil. 2012;40:43-7.
Galaal K, Bryant A, Fisher AD et al. Laparoscopy versus laparotomy for the management of early stage endometrial cancer. Cochrane Database Syst Rev. 2012;9:CD006655.
MPIS. Programme de médicalisation des systèmes d’information, 2013.
Reich H. Total laparoscopic hysterectomy: indications, techniques and outcomes. Curr Opin Obstet Gynecol. 2007; 19:337-44. Walsh CA, Walsh SR, Tang TY et al. Total abdominal hysterectomy versus total laparoscopic hysterectomy for benign disease: a meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2009;144:3-7.