Top+Gun

The Top Gun Laparoscopic Skills and Suturing Program A MODEL FOR SURGICAL TRAINING

JAMES C. ROSSER, JR, MD, STEVEN M. YOUNG, MD

INTRODUCTION

As we stand at the dawn of a new century, it has been over 30 years since Kurt Semm initiated the era of operative laparoscopy. The entrance of general surgeons into the practice of minimal access surgery has accelerated the appearance of new applications and techniques. But as we bask in the glory of this achievement, a bittersweet residue hangs over what has been accomplished. At the 10th International Congress of the Society of Laparoendoscopic Surgeons in 2001, French gynecological surgeons reported that only 15% of their surgeons were routinely practicing advanced videoscopic procedures. General surgeons in this country have not fared better. This has to represent one of the most noted examples of underachievement in the history of surgery. Many reasons have been offered as an explanation to this stagnation. But, the key factor is that the majority of surgeons practicing today do not possess the skills necessary to execute advanced videoscopic procedures safely and efficiently.

As we search for answers, we can draw similarities from the plight of United States naval aviation during the early days of the Vietnam War. During this time, the Navy and Air Force began to show signs of years of de-emphasis on air combat maneuvering training and an increased reliance on technology and air-to-air missiles. As the result of this neglect, their kill ratio sank alarmingly from 12:1 during previous wars to 2:1. This refers to the number of aircraft lost for every one of the enemy that is shot down. Out of this dark and gloomy period of aviation history, a rededication was born to the credo, “We fought to fly, we fly to fight, and we fight to win,” and a command decision was made to go “back to basics.” The special school that served as the launching pad of this policy was called Top Gun.

Top Gun is a 6-week long boot camp for fighter pilots that pushed the aircrews and equipment beyond their previously believed envelope of performance and made them better. A stressing of the fundamentals of air combat maneuvering was “prosecuted with extreme prejudice.” These “best of the best” pilots were then redeployed to the fleet and the kill ratio for the Navy went back up to 12:1. Today in any sky on this planet, our pilots prowl with a “controlled arrogance” that is predicated on the philosophy “train as you fight and fight like you train.”

In a similar fashion, surgeons and industry at one time had the notion that technology would minimize the need to establish the unique skill set required for the videoscopic environment. As surgeons today face the daunting task of developing skills necessary for advanced minimally invasive procedures, there must be a willingness to recommit to training in basic and advanced skills including suturing. In the open surgical arena, most attending surgeons would not allow a resident to perform a procedure without being able to suture. That standard must not be abandoned today. The Top Gun Laparoscopic Skills and Suturing Program is meant to provide an effective and rapid development platform for skills acquisition and suturing excellence in the videoscopic environment. It proudly patterns itself after a similar training methodology that forms the core curriculum of the Navy’s Top Gun school for fighter pilots. This includes a breakdown of complex tasks to their most elemental level, preparatory drills to facilitate complex task execution, teamwork building, and the use of metrics to evaluate performance. In addition, each time a course is conducted, it honors the men and women who defend our country and make the extraordinary seem routine. Excellence is not built on just talent but also on superior tactics and techniques. Surgeons are not born to greatness but rather they are made by a willingness to be trained.

HISTORY

The first Top Gun Laparoscopic Skill and Suturing Program was held in 1992 on the island of Aruba, sponsored by the Academic Medical Center in Amsterdam, Holland. The 20 participants representing 8 countries could not tie an intracorporeal knot within 10 minutes at the beginning of the course, and all could perform the task in less than 2 minutes at the end of the course. With the positive feedback from this course, it was offered in the US with the support of Carlos Babini and the United States Surgical Corporation (USSC). In 1995, the program crossed over into cyberspace with production of a CD-ROM whose effective knowledge transfer capability as described by Rosser et al1 will be pivotal to the development of a distance education program. In 1996, under the visionary guidance of Charlie Johnson of USSC, a Top Gun Course kit was distributed to over 50 university and community programs in the US and abroad. Many of those programs still feature Top Gun training as an element of their minimally invasive training program.

In 1996, Top Gun the competition debuted at the annual clinical congress of the American College of Surgeons, serving as a fun, competitive venue to put videoscopic skills acquisition front and center. From the preliminary elimination match open to the general membership of the congress, the top 7 qualifiers received a chance to compete for the title of “Top Gun.” The final Top Gun competition is a hard-hitting multimedia extravaganza with the moderator continually attacking each contestant in an effort to simulate the pressures of the operating room. This competition has now been showcased at the SLS International Congress and SAGES for the last 4 years.

Some traditional academic educators think that the Top Gun shootout is an undignified demonstration that has a carnival atmosphere and fully breaks with surgical education tradition. For the over 1000 individuals who have participated, they would probably beg to differ. This number does not include the throngs of people who have witnessed the event, or the unknown number of surgeons who did not participate but have been inspired to work on their skills.

METHODOLOGY

The Top Gun training philosophy separates itself from other training methodologies by several distinguishing characteristics. In addition to ergonomic correctness as exemplified in its trocar placement strategy, the Top Gun methodology also stresses utilization of the nondominant hand in all maneuvers including suturing. In fact, Level II, the Masters Program, requires that the participant show proficiency in suturing with the nondominant hand. The operative circumstance rather than hand dominance should dictate the choice of suturing options. It also believes that preparatory drills can impact skill transference. As described by Rosser et al in 1997 [2] and 1998 [3], 3 validated preparatory drills, the “Cobra Rope Drill” (Figure 1), the “Pea Drop Drill” (Figure 2), and the “Terrible Triangle Drill” (Figure 3), prepare the student for execution of a standardized suturing algorithm. The suturing drill (Figure 4) requires the ability to incorporate the skills developed from the dexterity drills to place a suture videoscopically by throwing 3 square knots. All of this is done under the pressure of time and dynamic supervision meant to improve quality control. Verbal instruction and distraction simulate the pressure profile of the operating theater. All times required to perform drills are recorded, and a performance report with standardized percentiles is given to every student.

FUTURE

The possibility of mass distribution of the Top Gun program is now possible with the development of the Top Gun remote education program that features a CD-ROM tutorial, videoconference lectures, and skill development exercises. The feasibility of this program was demonstrated with Operation Validation where the Top Gun program was conducted in England while the course director was headquartered at the Yale University School of Medicine. The success of this project suggests the possibility of multiple programs being given simultaneously around the world. With the availability of the performance database representing 5000 surgeons, follow-up evaluation of a student’s progress can be done on an ongoing basis via the Internet.

In response to a critique by Smith et al [4] of the Top Gun training program’s reliance on speed as the primary evaluation tool, Rosser et al5 have introduced a training arena called the Gabriel-Rosser Inanimate Proctor. This appliance represents a “hybrid” training platform that retains the advantages of traditional tabletop trainers while evaluating the participant’s control of economy of motion and registers errors. When the participant exhibits poor instrument control, a light flashes, a buzzer sounds, and an error is recorded. This platform has now been used in almost 400 participants and feasibility and validation studies are pending.

At the Medicine Meets Virtual Reality Conference (MMVR) in January 2004, Rosser et al [6] presented data that showed that participants with past, current, and demonstrated video game experience performed better during the Top Gun Laparoscopic Skill and Suturing Program. In addition, preliminary data suggest that warming up with video games may contribute to increasing videoscopic task performance [7]. In light of these data, future Top Gun programs will feature video gaming as one of the preparatory exercises in the course curriculum. As an interesting spin-off, 2004 saw the appearance of the Top Gun for Kids program. This program is meant to be an “edutaining” component of an effort meant to attract more of our youth to cutting edge career choices in science, engineering, technology, and medicine. The children first demonstrate their video gaming prowess, and then they show their ability to perform in the videoscopic environment using the same drills that surgeons have to perform during Top Gun. The hope is that this can lead to local, regional, and finally a national competition with multiple corporate sponsors and scholarships for the children.

In 2004, a concerted effort was started to make the Navy aware of this training program with the hope that it could be adopted as a training component for Navy surgeons. This can also serve as a high profile public relations tool to bring added exposure for the Top Gun Laparoscopic Skills and Suturing Program. The first phase began with an official visit to the USS Harry Truman and Naval Air Station Oceana, in Norfolk, Virginia. This is the home of an F-14 Tomcat air wing, and the commodore was presented with a special honorary Top Gun Laparoscopic Skill and Suturing Program award and proclaimed an honorary Top Gun Cyber Surgeon (Figure 5). It is hoped that this will be followed up with an official Top Gun skills course in 2005 for Navy surgeons and resident staff. The future of Top Gun has never been brighter and hopefully these efforts can assist in placing skill and suturing as an achievable priority for surgeons. We are hopeful that this can lead to a day when 85% of surgeons routinely perform advanced minimally invasive procedures worldwide.

Figure 1. Cobra Rope Drill. One of 3 validated drills to prepare for the execution of a standardized suturing algorithm.

Figure 2. Pea Drop Drill. One of 3 validated drills to prepare for the execution of a standardized suturing algorithm.

Figure 3. Terrible Triangle Drill. One of 3 validated drills to prepare for the execution of a standardized suturing algorithm.

Figure 4. Suturing Drill. Requires placement of a suture videoscopically by throwing 3 square knots.

Figure 5. USS Harry Truman and Naval Air Station Oceana in Norfolk, Viginia. Dr. Rosser presents the commodore with an honorary Top Gun Laparoscopic Skill and Suturing Program Award.

Address reprint requests to: James “Butch” Rosser, Jr, MD, Beth Israel Medical Center, 350 East 17th St, 16BH, New York, NY 10003, USA. Telephone: 212 420 4337, Fax: 212 844 1039

James C. Rosser, Jr, MD, is the Chief of Minimally Invasive Surgery at Beth Israel Medical Center in New York and is also Director of Beth Israel Advanced Medical Technology Institute. Dr. Rosser travels the globe teaching his Rosser Top Gun Laparoscopic Skills and Suturing Program.

Steven M. Young, MD, is a laparoscopic fellow at the Beth Israel Medical Center. Since beginning his fellowship, Dr. Young has helped instruct numerous Top Gun Laparoscopic Suturing courses. At the SLS 13th International Congress he moderated the Top Gun competition.

References

1.   Rosser JC, Herman B, Risucci DA, Murayama M, Rosser LE, Merrell RC. Effectiveness of a CD-ROM multimedia tutorial in transferring cognitive knowledge essential for laparoscopic skill training. Am J Surg. 2000;179(4):320-324.

2.   Rosser JC, Rosser LE, Savalgi RS. Skill acquisition and assessment for laparoscopic surgery. Arch Surg. 1997;132(2):200-204.

3.   Rosser JC Jr, Rosser LE, Savalgi RS. Objective evaluation of a laparoscopic surgical skill program for residents and senior surgeons. Arch Surg. 1998;133(8):911-912.

4.   Smith CD, Farrell TM, McNatt SS, Metreveli RE. Assessing laparoscopic manipulative skills. Am J Surg. 2001;181(6):547-550.

5.   Rosser JC, Ryan M, Lynch P, Brief J, Young SM. Validation of the internal guidance capability of the Gabriel-Rosser inanimate proctor for acquisition of laparoscopic surgical skills. Presented at: 13th International Congress and Endo Expo 2004, SLS Annual Meeting; September 29-October 2, 2004; New York, NY.

6.   Rosser JC, Lynch P. Video Gaming in Laparoscopic Skills Training. Presented at: 12th Annual Medicine Meets Virtual Reality Conference; January 14-17, 2004; Newport Beach, CA.

7.   Rosser JC, Lynch P, Haskamp L, Brief J, Ryan M, Young SM. The Effects of video game play on time and errors during laparoscopic skill development. Presented at: 13th International Congress and Endo Expo 2004, SLS Annual Meeting; September 29-October 2, 2004; New York, NY.

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