Author:

Keywords:

1114 Paediatrics and Reproductive Medicine, Obstetrics & Reproductive Medicine, 3215 Reproductive medicine, 4204 Midwifery

Abstract:

Objectives: Laparoscopy may reduce the morbidity of sacrocolpopexy by open surgery but requires advanced operative laparoscopic skills. The aim of this study is to analyse the learning process for performing laparoscopic sacrocolpopexy (LS) by a surgeon familiar with advance laparoscopy but not with LS (trainee) with operation time as a first outcome measure. Materials and methods: Prior to the study the trainee primed his suturing skills by 15 h of practicing endoscopic suturing on an endotrainer. LS was empirically divided in three parts: (1) dissection of the promontory, (2) of the paracolic gutter and vagina and (3) fixation of the implant to the vault and sacrum. The operation time, peri-operative complication rate and performance (on a Visual Analogous Scale :0–10) for each step were registered, analysed and compared to those of the surgeon experienced in performing LS (>200 LS) referred to as teacher. In the first 30 procedures the trainee only performed step 1 and 2. The trainee performed suturing and stapling (step 3) in the next 20; the study is ongoing. Results: Between November 2003 and March 2006 50 patients were included. The dissection of the promontory by the trainee took 14.8±8.6 min which was no different from that of the teacher (12.4±9.7 min; ns). The mean time to dissect the vaginal vault was 42.4±16.7 min, significantly longer than that by the teacher (25±18.4 min, p<0.05). When procedures were analysed in blocks of 10, a decrease in operation time to dissect the vault, by 10 min between cases 1–10 and 21–30 could be demonstrated (48± 23.4→39.1±8.2; p<0.05). After 30 procedures the mean operation time of the trainee remained 15 min longer than that of the teacher (39.1±8.2; p<0.05) suggesting that—if operation time is representative—the learning process was not completed yet. The mean time it took the trainee to suture the mesh to the vaginal vault was 55.9±15.5 min vs 40.4±15.5 for the teacher (p<0.05). When the first ten procedures were compared to the last procedure 10, a decrease in suturing time of 15 min could be demonstrated (63.8±15.9 vs 48.1±11.9; p<0.05; −26%). Although this decrease was dramatical, it was still 8 min longer than of the teacher (p<0.05). The performance score remained equal over the three studied steps of the operations. There were no intraoperative complications and one patient presented with a mesh erosion after 15 weeks. At the time of revision this was located at a place where the mesh was folded by a suture. Conclusion: It takes a long time to achieve comparable operation times by a trainee experienced with operative laparoscopy. This applies to the total operation time, dissection of the vault and the suturing. Even after 30 procedures there is still improvement, despite priming the surgeon for suturing.