57been set to a nationalized and validated standard. The curriculum is proficiency-
based, whereby trainees are oriented to the materials and self-practice until expert-
derived performance levels are reached.
The following provides a description of each of the FLS manual skills tasks,
including the recommended proficiency requirements for each task.
Recommended proficiency requirements for each task:
The peg transfer exercise requires the trainee to lift six objects (shown in Fig. 5.2)
with a grasper first in his or her nondominant (i.e., left) hand and to transfer the
object midair to the dominant hand. Each object is then placed on a peg on the right
side of a peg board. There is no importance placed on the color of the objects or the
order in which they are placed. Once all six pegs have been transferred, the process
is reversed. Each peg is lifted using the dominant (i.e., right) hand from the right
side of the pegboard, transferred midair to the left hand and placed on the pegs on
the left side of the board. The required proficiency score is 48 s with no pegs dropped
out of the field of view. Proficiency scores must be achieved on 2 consecutive repeti-
tions and on 10 additional (nonconsecutive is acceptable) repetitions.
This exercise requires trainees to cut out a circle from a square piece of gauze
suspended between alligator clips, as shown in Fig. 5.3. The required proficiency
score is 98 s with all cuts within 2 mm of the line (either side) Proficiency scores
must be achieved on 2 consecutive repetitions only.
In this task trainees are required to place a pre-tied ligating loop or endoloop
around a tubular foam appendage on a provided mark as seen in Fig. 5.4. Once they
have positioned the endoloop properly, they must break off the end of the plastic
pusher at the scored mark on the outside of the box and secure the knot on the mark
near the base of the foam appendage by sliding the pusher rod down. A penalty is
assessed if the knot is not secure and for any distance that the tie misses the mark.
The required proficiency score is 53 s with up to 1 mm accuracy error; no knot
security errors (slippage) are allowed. Proficiency scores must be achieved on two
consecutive repetitions only.
Fig. 5.2 Task 1: Peg
transfer (Fundamentals of
Laparoscopic Surgery®
(FLS) Program is owned
by Society of American
Gastrointestinal and
Endoscopic Surgeons and
American College of
Surgeons. Images used
with permission)
5 Performance Assessment in Minimally Invasive Surgery