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Preliminaries Evaluation of the Impact on clinical practice of MAS skills training at Nairobi Surgical Skills Centre (NSSC).
In the current era of evidence based medicine, enthusiasm for minimal access surgery (MAS) is rapidly gaining momentum. There is an immense amount of literature showing advantages of MAS and acceptance by the public. However the introduction of MAS led to many unnecessary complications thus challenging conventional system for surgical training and establishment of competency. Drawing from the successful paradigm of flight simulation, this led to the development of skills laboratories involving use of box trainers with either inanimate or animal tissues, but this lacks objective assessment of skill acquisition.
The Nairobi Surgical Skills Centre (NSSC), domiciled in the Department of Human Anatomy of the University of Nairobi and supported by Johnson & Johnson(J&J) is currently , the only structured facility offering MAS skills for practitioners(surgeons & gynaecologists) in Kenya and the region. Established in 2013, it has to its credit the training of 35 trainees (surgeons and gynaecologists) in basic laparoscopy skills and 11 trainees in intermediate skills from a total of 6 countries.
Evaluation and monitoring of the impact of training in a systematic scientific manner will benefit the centre, its faculty and the trainees on the areas of potential improvement and ensure that, the patient welfare is not compromised. At this early stage of the centre's existence, an attempt is being made to establish whether the skills training have had any change on the practice of the trainee in a clinical situation.
The database of the trainees was obtained from NSSC containing their names, county of origin and their contacts. A systematic sampling of the trainees was done in terms of training group, country of origin and the course-surgery or gynaecology. The sampled trainees were called on their cell-phones and the following areas were assessed:
a)The type of institution the trainee practices in; public/private
b)Availability of laparoscopy equipments-tower and hand instruments in the institution.
c)The pre-training exposure.
- Assisting in laparoscopy cases
- Operating laparoscopy cases.
d) Post-training exposure
- Further training.
The sample included:
Dr.Mavura (Tanzania) , Dr.Hungu (KNH) ,Dr.Gome (MSA) ,Dr.Koech A (AKUH),Dr.Makobore Patson(Uganda) ,Dr.Chrysostome (Rwanda) ,Dr.kuladasenge (MRTH) ,Dr.Ndegwa (Avenue),Dr.Riogi (AKUH), Dr.Chikoyo(Zambia), Dr.A Kaseko(Uganda).
The trainees were from public and private institutions. Trainees from private institutions tended to have unlimited access to laparoscopy equipments compared to those from public institution, where functional equipments are erratic or incomplete. All of the trainees sampled had assisted in laparoscopy prior to the training but only one had actually performed an operation under supervision. However this does not reflect on the total population because during training, there have been numerous reports of non-exposure at- all, to laparoscopy operations by many trainees.
All of the sampled trainees have increased the number of laparoscopy cases assisted and actually expressed more confidence in laparoscopy operations. This is reflected by the large number of laparoscopy operations performed after the training exposure. Most surgeons have been able to perform diagnostic laparoscopy and lap. Appendectomies with only two who have performed lap. cholecystectomy.Gynaecologists have performed cystectomies, ectopic pregnancies and tubal ligation/clipping. The number of post-training surgeries in both categories is significantly higher compared to pre-training periods.
Availability of functional laparoscopy equipments directly correlates with the ability of the trainee to practice. Those with unlimited availability of equipments have performed more operations compared to those with limited availability. The ones who have not operated do not have direct access to equipments and their experience is limited to assisting in centers other than their own.
All trainees expressed the need for further training and were enthusiastic of the introduction of the intermediate level skills training course. All of them expressed their interest in the course. Most of the trainees reported the need for extended preceptorship/mentorship in their institutions after the skills training course.
Comments & Recommendations
From this basic audit of the impact of laparoscopy skills training at NSSC to the practice of the trainees the following issues are evident.
1) Availability of laparoscopy equipments greatly contributes to the transfer of the skill learnt by the surgeons to the patients. There is the need to interest the public and policy- makers of the health institutions to the known benefits of MAS. The demand of MAS by the patients themselves has been a major driving force where this practice is well established.
2) The laparoscopy training course has had a great improvement in the practice of the training in MAS procedures both in assisting and actual execution. This clearly demonstrates that the training has directly translated to the transfer to the patients, the well known benefits of MAS.
3) There is need for repeated or escalated training after the initial exposure i.e.; basic then intermediate and ultimately advanced laparoscopy skills courses for maximal benefit of the trainees and the patients.
4) The demand for preceptorship at the trainees institutions need to be addressed. lf possible, a group of trainees from one region can have a number of surgical operations performed by a faculty preceptor at regular intervals after the training to enhance their confidence in their working environment.
5) For purpose of audit it is important to have a questionnaire on baseline knowledge and practice of laparoscopy before any training and to introduce a structured on-line log-book for the "graduates" to report back to NSSC on their performance after training.
DR B.M .NDUNG'U
Laparoscopy skills in GS