Sentinel lymph node procedure with the combined technique is highly accurate in predicting the inguinofemoral lymph node status in patients with early-stage vulvar cancer. Future trials should focus on the safe clinical implementation of the sentinel lymph node procedure in these patients. Step sectioning and immunohistochemistry slightly increase the sensitivity of detecting metastases in sentinel lymph nodes and should be included in these trials.

Background Robotic assisted laparoscopic surgery is growing rapidly and there is an increasing need for a structured approach to train future robotic surgeons.Objectives To review the literature on training and learning strategies for robotic assisted laparoscopic surgery.Search strategy A systematic search of MEDLINE, EMBASE, the Cochrane Library and the Journal of Robotic Surgery was performed.Selection criteria We included articles concerning training, learning, education and teaching of robotic assisted laparoscopic surgery in any specialism.Data collection and analysis Two authors independently selected articles to be included. We categorised the included articles into: training modalities, learning curve, training future surgeons, curriculum design and implementation.Main results We included 114 full text articles. Training modalities such as didactic training, skills training (dry lab, virtual reality, animal or cadaver models), case observation, bedside assisting, proctoring and the mentoring console can be used for training in robotic assisted laparoscopic surgery. Several training programmes in general and specific programmes designed for residents, fellows and surgeons are described in the literature. We provide guidelines for development of a structured training programme.Authors' conclusions Robotic surgical training consists of system training and procedural training. System training should be formally organised and should be competence based, instead of time based. Virtual reality training will play an import role in the near future. Procedural training should be organised in a stepwise approach with objective assessment of each step. This review aims to facilitate and improve the implementation of structured robotic surgical training programmes.

Over the past decade, there has been an exponential growth of robot-assisted procedures and of publications concerning roboticassisted laparoscopic surgery. From a review of the available literature, it becomes apparent that this technology is safe and allows more complex procedures in many fields of surgery, be it at relatively high costs. Although randomised controlled trials in gynaecology are lacking, available evidence suggests that particularly in gynaecology robotic surgery might not only reduce morbidity but also be cost effective if performed in high-volume centres. Training in robotic surgery and programs for safe and effective implementation are necessary.

Objective To obtain face and construct validity for a new training course to be used in any type of box/video trainer and to give a comprehensive overview of validated exercises for box/video training.Design Cross-sectional study.Setting University Medical Centre.Population Students, residents and consultants.Methods Participants (n = 42) were divided into three groups according to their laparoscopic experience: 'Novices' (n = 18), 'Intermediates' (n = 14) and 'Experts' (n = 10). A laparoscopic training course consisting of six exercises was constructed. To emphasise precision, a penalty score was added. Every participant performed two repetitions of the exercises; total score per exercise was calculated. To determine face validity, participants filled in a questionnaire after completion of the exercises. An evidence-based literature search for validated box/video trainer exercises was performed.Main outcome measures Face and construct validity.Results The mean score of the 'experts' was set as the training target. Total scores appeared to be positively correlated with individual's laparoscopic experience. The overall score and the score for each exercise were significantly higher in the intermediate and expert groups when compared with the novice group (P £ 0.001). All participants completed the questionnaire. The overall assessment of the exercises was considered to be good. The course was found to be most appropriate for training residents year 1-3.Conclusion Face and construct validity for an inexpensive course for box/video training was established. A comprehensive and practical overview of all validated and published exercises for box/ video trainers is provided to facilitate an inexpensive, but optimal and tailored selection for training purposes.Keywords Box training, education, laparoscopy, simulation, validated exercises, video training.Please cite this paper as: Schreuder H, van den Berg C, Hazebroek E, Verheijen R, Schijven M. Laparoscopic skills training using inexpensive box trainers: which exercises to choose when constructing a validated training course. BJOG 2011;118:1576-1584. IntroductionTo perform laparoscopic surgery safely, several unique psychomotor skills are required from the surgeon. These include adaptation to the conversion from three-dimensional to two-dimensional vision, bi-manual dexterity, handling long instruments with an amplified tremor, dealing with the fulcrum effect and reduced tactile feedback. Simulation can be used to master these skills. Training on simulation models leads to a faster pace of the learning curve of the individual surgeon in a safe environment, thereby decreasing the burden on operating time and costs and increasing patient safety.1,2 Different simulation models and scenarios have been introduced and incorporated into various laparoscopic training curricula. 3 In general, these models can be categorised as in vivo anaesthetised or ex vivo animal trainers, high-fidelity and low-fidelity virtual reality simulators and inanimate box or video trainers.

Our data demonstrate the importance of accredited training and the need for harmonisation of gynaecological oncology training within Europe.

Abstract. Mota F, Vergote I, Trimbos JB, Amant F, Siddiqui N, Del Rio A, Verheijen R, Zola P. Classification of radical hysterectomy adopted by the Gynecological Cancer

Objective To investigate the learning curve of robot-assisted laparoscopy in early-stage cervical cancer and quantify impact on oncological outcomes. Design Observational cohort study. Setting Tertiary referral centre with one surgical team. Population All women with early-stage cervical cancer treated consecutively with robot-assisted laparoscopy between 2007 and 2017. Methods With multivariate risk-adjusted cumulative sum analysis (RA-CUSUM), we assessed the learning curve of robot-assisted laparoscopy of a single surgical team based on cervical cancer recurrence. Subsequently, a survival analysis was conducted comparing oncological outcomes of women treated during different phases of the learning curve. Main outcome measures Surgical proficiency based on recurrence, survival rates in the different learning phases. Results One hundred and sixty-five women with cervical cancer underwent robot-assisted laparoscopy, with a median follow up of 57 months (range 3-132 months). The RA-CUSUM analysis demonstrated two phases of the learning curve: a learning phase of 61 procedures (group 1) and an experienced phase representing the 104 procedures thereafter (group 2). The 5-year disease-free survival was 80.2% in group 1 and 91.1% in group 2 (P = 0.040). Both the 5-year disease-specific survival and overall survival significantly increased after the learning phase. Conclusion The learning phase of robot-assisted laparoscopy in early-stage cervical cancer in this institutional cohort is at least 61 procedures, with higher survival rates in the women treated thereafter. The learning curve of robot-assisted laparoscopy affects oncological outcomes and warrants more attention in the design of future studies.

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