A new standard of care

Moawad is Professor and Chief of the Division of Minimally Invasive Gynecological Surgery (MIGS) at the University of Florida School of Medicine in Gainesville and Chair of the American Association of Gynecological Laparoscopic (AAGL) EMIGS Steering Committee. .

Moawad also detailed how the program got started, its many benefits, and how it differs from the Fundamentals of Laparoscopic Surgery (FLS) test used previously. Read the Q&A below to learn more about the EMIGS program and how it is shaping the future of MIGS.

Editor’s Note: This transcript has been edited for clarity and space.

What is the EMIGS program? What are its key components?

Nash Moawad, MD, MS, FACOG, FACS EMIGS is a standardized program which has 3 components. One is a didactic component that focuses on minimally invasive gynecological surgery, such as laparoscopic, robotic, and hysteroscopic surgery, as well as the concepts and principles of electrosurgery, anatomy, positioning, complications, instrumentation, strategies and everything related to the essentials of MIGS.

The second and third components are tests. One of them is a cognitive exam, which is a multiple-choice exam that is validated and scored according to the standards we set for our residents. The third is a manual laparoscopic skills assessment that covers suturing, hand-eye coordination, accuracy, vaginal cuff closure, and the essentials of laparoscopic surgery for our residents and trainees.

Are there any significant advantages or, if any, disadvantages when using the EMIGS program?

Moawad There are certainly many advantages to using the EMIGS program. It is a standardized program developed by experts in the field for several years. AAGL spent 9 years developing this, and we surveyed 300 gynecologists to find out what they thought were the essential components to include in the EMIGS program. Next, we developed the didactic questions for the cognitive exam, as well as the skills to be included in the manual exam. For trainees or junior teachers to follow such a standardized program that has been very well developed and validated, it is good for them to practice the same skills over and over, to time themselves, to try to do better each time to try to beat their scores. And with that, they develop those basic skills, and they can transfer them to the operating room with improved efficiency and safety for our patients.

Why create the EMIGS program?

Moawad There has never been a standardized training program in gynecological surgery. It’s more the old paradigm where you see 1, do 1 and teach 1, which obviously isn’t the best for our patients. This was the concept behind all the effort and resources that went into developing this program. It was a very ambitious goal, and we achieved it. You want to see what the residents are doing and what they need improvement before doing that in surgery in the operating room.

The American Board of Obstetrics and Gynecology (ABOG) recently decided to use this test as an alternative to the FLS test. What are the main differences between the 2?

Moawad There are so many differences. The EMIGS is essentially performed by gynecological surgeons for trainees in gynecological surgery. Everything has to do with gynecology. There’s nothing foreign that isn’t a good use of their time. Our residents’ time is very valuable, hours of service are limited and so much has to be learned in just 4 years. It’s important to focus your time and attention on what’s relevant in your field.

Some of the main differences are that didactics is entirely related to gynecology. There’s nothing there that isn’t the bread and butter of what we do every day. The didactic is fully narrated by video, making it easy to follow through on a busy day between cases in the evening when you are on call or have a few minutes to spare here and there while travelling. Plus, it’s available on mobile devices, so it’s easy for residents to watch all the videos and learn on the go. You can watch them repeatedly, focus on certain areas, rewind and return to the area
of interest.

The cognitive exam contains all questions related to gynecology and is focused on improving efficiency and safety; it is frequently updated. The EMIGS Steering Committee meets and psychometricians are heavily involved in designing and teaching faculty how to write questions, reviewing questions multiple times to ensure they are relevant, ensuring that they are evidence-based and up-to-date.

From a manual skills perspective, a few advancements have been added to EMIGS on FLS. One of them is the way we operate in the basin. All of our operations are done in the pelvic cavity, and we do not operate on a flat surface. We developed a proprietary platform several years ago called
LaparoBowl, a basin-like platform with side walls, a front and a back, as well as front and back cul-de-sacs. Thus, when gynecological surgeons operate there, they have the impression of operating in the pelvic cavity. In addition, AAGL will send a free LaparoBowl to each residency program in the United States to help kick-start the EMIGS program, and additional copies can be ordered as needed to
larger programs.

Other advances in manual skills include the removal of the ENDOLOOP task as we don’t use it very often in gynecological surgery; we replaced it
with vaginal cuff closure. Simple hysterectomy, laparoscopic hysterectomy, and robotic hysterectomy are essential for all gynecologic surgical trainees to learn and develop before completing their residency. These are important skills to practice even as beginners, to go back and try to perfect them and do better in terms of accuracy, time and efficiency.

The standards for manual skills have been set to accommodate the gynecology resident at the end of their second year and beginning of their third year. As the faculty and steering committee considered different standards, what to score, what not to score, what weight to give each competency, every decision was made with the gynecology resident in mind. . This is important because we don’t work with general surgery or urology residents, we work with gynecology residents, and the questions and skills are developed by the gynecology faculty.

What kind of reaction did you see in the healthcare community when the program was implemented?

Moawad We have seen overwhelming enthusiasm and anticipation for the program. Everyone asks, “When can we start?” What should we do?” And we’re working hard behind the scenes to get everything ready for them. We’re getting the equipment ready; shipping the LaparoBowls; communicating with programs, residents, ABOG and the Council on Resident Education in Obstetrics and Gynecology; involving all stakeholders; working with psychometricians to update our questions; and working with a monitoring company to make sure everything is ready.

Manual skills and the cognitive exam will be virtually monitored. There is no need to travel anywhere; they can take it to their hospital or call room, if necessary. There will be 2 cameras in the room, 1 monitoring the surroundings of the room and the other showing the coach’s view of the towers. Everything is logged and uploaded to the cloud for AAGL to score and send the results.

It’s been very exciting and we can’t wait to get started. We plan to start January 1, 2023, but LaparoBowls should be available for programs in October 2022 so residents can start practicing and prepare to take the exam.

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