Mentoring a surgical team towards procedural competence in the early learning curve for selective fetoscopic laser photocoagulation

Abstract

Introduction: Selective fetoscopic laser photocoagulation (SFLP) for twin-to-twin transfusion syndrome (TTTS) is challenging for new surgeons at the start of their learning curve. We described an approach utilising telementoring and team-based training to facilitate rapid attainment of the skills required for safe and efficient practice with a limited caseload.

Methods: We conducted a prospective observational study of SFLP performed by the novice primary surgical team in three stages: under direct on-site supervision from an expert mentor (Group 1), with remote tele-guidance from that mentor (Group 2) and independently (Group 3), at an academic tertiary hospital in Singapore. The primary team undertook regular training on high-fidelity tissue models to accelerate skills acquisition and complement the surgical performance.

Results: 9 patients diagnosed with Stage 2 TTTS were assessed for procedural characteristics, surgical outcomes and perinatal survival following SFLP. There were no significant differences in operative duration, anastomoses ablated, gestational age or birth weight at delivery. The complications observed were: recurrent TTTS (22.2% of pregnancies), twin anaemia polycythaemia sequence (33.3%), preterm prelabour membrane rupture (22.2%) and delivery at < 32 weeks (44.4%). ≥ 1 twin was live-born in 88.9% of cases, while postnatal survival to six months of ≥ 1 twin occurred in 77.8% of cases.

Conclusion: Systematic mentoring and specialised skills training are useful in aiding new surgeons to negotiate the steep learning curve and achieve good outcomes at the start of a new practice, particularly in the setting of low patient numbers. This is best paired with dedicated model training to achieve and maintain surgical dexterity for this complex procedure.

Keywords: fetoscopic laser photocoagulation; fetoscopy training; learning curve; surgical mentoring; twin-twin transfusion syndrome.

Fig. 1

Procedural flowchart shows the diagnosis and staging of patients with twin-to-twin transfusion syndrome (TTTS) who underwent selective fetoscopic laser photocoagulation (SFLP). IUFD: intrauterine fetal death; MCDA: monochorionic diamniotic; sIUGR: selective intrauterine growth restriction; TAPS: twin anaemia polycythaemia sequence

Fig. 2

Photographs show on-site mentoring and telementoring during the first cases of selective fetoscopic laser photocoagulation (SFLP). (a) The primary surgical team was mentored in a hands-off manner, with a focus on team organisation and (b) completing SFLP efficiently and safely, especially in technically demanding situations (e.g. on large vessels). (c) Residents recorded the locations of arteriovenous anastomoses (black circles) within the recipient twin amniotic sac during the initial fetoscopic end-to-end examination of the vascular equator. (d) For telementoring, fetoscopic images were filmed directly from the screen using a mobile device and sent to the mentor via the internet through the course of the surgery. Good image quality was obtained, allowing the telementor and team to identify outlying anastomoses with the donor or recipient origins of vessels (arrows) and (e) carefully ‘shave’ larger vessels with photocoagulation to prevent rupture or bleeding.

Fig. 3

Photographs show the results of placental dye injections performed to determine the accuracy of selective fetoscopic laser photocoagulation, identifying (a) AVAs (yellow stars); (b) recannulated AVAs, which, in this case, were the cause of recurrent twin-to-twin transfusion syndrome (white star in a & b); and in optimally completed procedures, (c & d) individually ablated AVAs (yellow stars) followed by superficial ablation of residual anastomoses (broken line in d). AVA: ablated arteriovenous anastomosis