The ACS/SAGES Fundamentals of Laparoscopic Surgery® Expands Internationally

| April 1, 2015

Bariatric Times. 2015;12(4):12–13.

An Interview with:
Steven Schwaitzberg, MD
Professor of Surgery, Harvard Medical School, Chief of Surgery, Cambridge Health Alliance, Cambridge, Massachusetts; SDS Chair, FLS Committee, AO Vice Chair FLS Committee-International Affairs.

Allan Okrainec, MD, MHPE, FRCSC, FACS
Head, Division of General Surgery, UHN, Peter A. Crossgrove Chair
in General Surgery, Director, Temerty/Chang Telesimulation Centre, Associate Professor, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

Bariatric Times interviewed Drs. Schwaitzberg and Okrainec to learn more about the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)/ American College of Surgeons (ACS) Fundamentals of Laparoscopic Surgery® (FLS) program. Since launching in 2004, FLS has opened more than 80 test centers throughout the United States and Canada. The FLS program expanded with test centers in Singapore (Khoo Teck Puat Hospital) and Israel (Bnai-Zion Medical Center). SAGES recently announced the opening of two additional international FLS test centers at IHU-Strasbourg, Strasbourg Institute of Image-Guided Surgery, in Strasbourg, France, and King Fahad Medical City (KFMC) in Riyadh, Saudi Arabia.

Please provide a brief background on the SAGES/ACS Fundamentals of Laparoscopic Surgery® program.

Drs. Schwaitzberg and Okrainec: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) began working on the concept of the Fundamentals of Laparoscopic Surgery (FLS) program as early as 1997, in response to the absence of any consistent training pathway for most surgeons practicing laparoscopy. At that time, there were no standardized training programs covering both cognitive information and psychomotor skills in the field.

Dedicated SAGES leaders made the decision to fill this gap and developed the didactic and psychomotor curriculum and assessments that were subsequently scientifically validated through extensive beta testing.

In 2004, FLS was launched as an educational program that included a high stakes validated examination. The results of this training program were so dramatic that four years later, the American Board of Surgery (ABS) made completion of this program a requirement in order to be qualified to sit for the ABS written examination.
The FLS program undergoes continuous refinement, updating, and reassessment.
Since its inception, more than 10,000 surgeons have successfully completed the FLS program.

Could you further explain how the components of the FLS program (web-based study guides, hands-on manual skills practice and training via the FLS Laparoscopic Trainer Box, and an assessment tool that measures your cognitive and technical skills) come together in training?

Drs. Schwaitzberg and Okrainec: FLS is a fully integrated program with three interconnected components. The web-based education module provides up-to-date didactic information that covers all aspects of minimally invasive surgery and serves as study material for successful completion of the cognitive portion of the FLS exam. It undergoes continuous updating and re-validation, both in the content and in the nature of the assessment questions.

These online didactics are complemented by a series of validated hands-on skills taught via a trainer box. These skills have been thoroughly researched and have been demonstrated to show improvement in the clinical setting. They are designed to teach the basic laparoscopic skills that every practicing general surgeon should know.
The assessment tool, known as the “FLS exam,” contains a cognitive written test and a skills test. Candidates must successfully complete both portions of the FLS exam in order to become an FLS certificate holder.

Please provide more details/examples on the process and tools used. Is there any research that supports learning in this way?

Drs. Schwaitzberg and Okrainec: If you were to search “FLS surgery skills” in PubMed, more than 100 manuscripts would appear. The earliest three that really got the ball rolling were as follows:
1.    Fried GM. Lessons from the surgical experience with simulators: incorporation into training and utilization in determining competency. Gastrointest Endosc Clin N Am. 2006; 16(3):425–434. Review.
2.    Swanstrom LL, Fried GM, Hoffman KI, Soper NJ. Beta test results of a new system assessing competence in laparoscopic surgery. J Am Coll Surg. 2006; 202(1):62–69.
3.    Fried GM, Feldman LS, Vassiliou MC, et al. Proving the value of simulation in laparoscopic surgery. Ann Surg. 2004; 240(3):518–525; discussion 525–528.

How does this compare to other methods of training in laparoscopic surgery?

Drs. Schwaitzberg and Okrainec: There is no other training program in the world that has been subjected to such a high scientific rigor; this is really the hallmark of the FLS program. It is a reliable and valid process for training and testing of competence in basic laparoscopy; SAGES also provides guidance to other specialties that wish to create similar training programs of their own.

Do you track outcomes?

Drs. Schwaitzberg and Okrainec: Tracking clinical outcomes and tying them to a specific training program is a complex task. We are only at the early stages of this process but we have a recent publication with a large retrospective trial that did demonstrate some impact.

Tracking outcomes will also help us understand how the FLS program is having a profound impact on a generation of surgeons and on patient safety.

Was it always a goal to expand the program beyond the United States?

Drs. Schwaitzberg and Okrainec: SAGES is a global organization with a long history of reaching out around the world. You can learn more about SAGES Go Global: Global Affairs and Humanitarian Efforts at http://www.sages.org/projects/go-global/. Amazing work by this team speaks for itself. Extending FLS training around the world is a natural extension of the work we have done for the last 30 years.

Are there similar programs/methods of training in other countries? How was the decision to expand decided? Did you collaborate with other programs?

Drs. Schwaitzberg and Okrainec: There is fine work around the world in this arena; a lot of it is in silos. FLS brings a standardized approach to the world stage and a wide audience.

FLS is administered jointly by SAGES and the American College of Surgeons (ACS); however, SAGES has responsibility for all program decisions which are subsequently ratified through a joint committee.

How did you select the four international FLS Center sites (Singapore, Israel, France, and Saudi Arabia)? Did they apply on their own first?

Drs. Schwaitzberg and Okrainec: Because SAGES is truly an international society, the collegial relationships that we develop worldwide form the basis of discussions from those sites most interested to be among the first to submit applications. Another important criterion, besides having a member of SAGES involved on the local level, is the need for a significant number of physicians in the geographic area able to take the exam in English.

With this growth, is SAGES FLS becoming the main program/standard for basic cognitive and technical skills used in performing laparoscopic procedures?

Drs. Schwaitzberg and Okrainec: Yes, FLS is transforming laparoscopic education around the world, always keeping in mind our goal to ensure competency in the fundamentals of laparoscopy and increase patient safety for all patients undergoing laparoscopic surgery.

What is next for the SAGES FLS program? Do you foresee opening more test centers internationally?

Drs. Schwaitzberg and Okrainec: It is premature to envision a world with easy access to FLS training and assessment. The opening of these four test centers is certainly the first step to provide a global and standardized platform for all patients who receive minimally invasive surgery.

Photos of FLS Training

Components of the FLS Program

FUNDING: No funding was provided.

DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.

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