How can I develop a learning curve in minimal invasive surgery (MIS)?

Developing a Learning Curve in Minimally Invasive Surgery

To develop a learning curve in minimally invasive surgery (MIS), you should follow a stepwise, structured approach that divides each learning phase into manageable components, starting with basic skills in conventional settings before progressing to more complex minimally invasive procedures. 1

Team-Based Approach

• A team approach is essential, as each member must learn their specific role in the procedure 1
• Team failure can result from poor patient selection, inadequate procedural volume, too rapid progression, inconsistent assistance, limited experience with imaging techniques, and inadequate institutional support 1
• Bring the entire team (surgeons, anesthesia, nursing staff) to visit and train with successful MIS programs, as watching experienced teams and having proctors oversee initial cases is indispensable 1

Stepwise Learning Pathway

Preclinical Training

• Begin with didactic education to understand the basic functional aspects of minimally invasive instruments and equipment 1
• Practice with single-shafted instruments, knot pushers, and suture crimping instruments during conventional open cases before transitioning to MIS 1
• Utilize simulation training with inanimate models, starting with simple plastic models before progressing to more complex models 1, 2
• Virtual reality (VR) simulators can help master the specific psychomotor skills and eye-hand coordination needed for MIS, with evidence showing skills transfer to real operations 2, 3
• Incorporate animate or cadaveric training when available, as these provide higher fidelity for complex procedural tasks 1
• Training should address different levels of behavior: skill-based, rule-based, and knowledge-based 4

Clinical Training

• Begin with procedure-specific familiarization through operative case observation 1
• Start with the simplest cases and gradually progress to more complex ones 1
• For cardiac procedures, gain proficiency with peripheral cannulation and perfusion techniques before attempting minimally invasive approaches 1
• Progress to performing procedures through increasingly smaller incisions to become comfortable with videoscopic exposure and endoscopic instruments 1
• Avoid concurrent procedures during the early learning curve; these should be added only after proficiency with simple cases is obtained 1

Volume and Tracking Progress

• Adequate case volume is essential for developing proficiency - guidelines suggest at least 20 cases annually for robotic-assisted procedures 1
• Document the time required for all steps of the operation to track your learning curve and pursue shorter operative times 1
• Establish a registry of cases, outcomes, and modifications to avoid complications 1
• Implement structured assessment methods using validated tools rather than subjective evaluation 5
• Expect increased operative times during the early learning curve with minimally invasive and robotic procedures 1

Common Pitfalls and How to Avoid Them

• Poor patient selection: Begin with carefully selected, less complex cases 1
• Inadequate training: Complete comprehensive simulation training before attempting clinical cases 1, 6
• Insufficient volume: Ensure adequate caseload to maintain and develop skills 1
• Lack of structured assessment: Implement objective evaluation methods to track progress 5
• Attempting complex cases too early: Follow a graduated progression from simple to complex procedures 1
• Skipping preclinical training: Studies show that even three preclinical sessions practicing basic robotic skills can improve operative times by up to 40% 1

Institutional Considerations

• Be prepared to monitor outcomes and understand institutional requirements for starting MIS programs, particularly for robotic surgery 1
• Critical evaluation of successes and failures is crucial for ensuring program growth and sustainability 1
• Institutional support is essential for providing access to training resources and equipment 1

By following this structured approach to developing your MIS skills, you can efficiently progress through the learning curve while maintaining patient safety and achieving optimal outcomes.