The design of the LSS-program is based on key elements and factors, the model curriculum discussed in this chapter, as well as the elements and factors, essential for delivery and successful implementation of the curriculum.

The LSS-program is developed for surgeons in training, surgical fellows and practising surgeons wanting to start their laparoscopic surgery practice. The program is constructed around two grades and different levels to attend the divergent needs of surgeons of different levels of training or surgical expertise. In addition, eligible candidates are offered an option to enrol either to the LSS-assessment solely, or for LSS accredited course in which the LSS-assessment is embedded. The basic laparoscopic skills and the basic laparoscopic procedures are embedded in level I, while the advanced laparoscopic procedures are covered by the level II of Grade I. Grade II consists of a curriculum and assessment, focused on speciality surgery. Each level within the LSS-program addresses specific index procedures. An overview of LSS-grades and levels is presented in Table 2.1. The focus of the program is quality of performance of laparoscopic procedures and not just abstract tasks.

LSS offers a standard for comprehensive performance assessment for training and education in laparoscopic surgery. To obtain the LSS-diploma participating surgeons need to pass several types of assessment to assure that they have reached the appropriate level of performance (Fig. 2.2). Within this series of assessments the proficiency of surgeons in cognitive skills, surgical technical skills, judgment and decision-making is evaluated.

Adequate knowledge of the theory of basic laparoscopic and procedure-specific topics (e.g., techniques, instrumentation, energised instruments and ergonomics) corresponding to the LSS-level entered is tested using a web-based knowledge test. To prepare for this test all participants who enrol for LSS are provided online with a set of course documents describing theory and knowledge on the relevant index procedures. This applies for trainees, certified surgeons, both those who enrol only in the assessment process, as well as those who enrol for the accredited course. This is to ensure that the potential local preferences to which surgeons can be habituated will not impede performance during the assessment. The course documents are, as far as possible, based on a general international consensus on the indicator procedures and the training of laparoscopic skills. Since the available general consensus on theory is still limited, international renowned experts on laparoscopic surgery were consulted to establish the content by means of modified Delphi surveys. Passing the knowledge test is an admission requirement for the course and the scenario-based assessment and simulation assessment.

The aim of the simulator assessment is to certify that a sufficient level of psychomotor and technical surgical skills has been achieved to start performing the specific index procedures on patients under supervision of the mentor/trainer. The focus of all LSS-assessments is primarily on procedural knowledge and skills; however possession of basic laparoscopic skills is essential before mastering any procedural skills. For this reason simulator assessments of LSS-level also comprise some tasks to evaluate basic skills. Participants need to reliably demonstrate adequate performance of a selection of basic and procedural tasks on the assessment simulators to pass the simulator assessment successfully. The simulator assessment is an admission requirement for the clinical performance assessment.

Performance of a laparoscopic cholecystectomy on a porcine liver is assessed using the CAT forms. The same applies to the procedural simulation, while the performance on the VR procedural simulator is by metrics of the system and also using the CAT-forms. Self-assessment and assessment by the tutor takes place in both settings and is used for the formative and summative assessment.

To facilitate criterion-based training benchmarks have been established throughout the program. Pass/fail benchmarks are re-established in the scores of the participants, who performed the LSS-simulator assessment within the first LSS-year. We purposely chose the use of performance scores of the target group and not the scores of experts. This logically follows from the objectives of the assessment and is also based on our previous experience with performance of both surgical trainees and laparoscopic experts on surgical VR-simulator.

The hands-on training in LSS courses is criterion-based. The training benchmarks in LSS accredited courses are set as a challenging, yet realistically achievable level to keep all participants motivated. The performance parameters provided by the simulators throughout the training provide the participants and trainers direct feedback on milestone achievements. Participants, who succeed in achieving the training benchmarks within the course, can expect to pass the simulator assessment easily.

Having passed the scenario-based examination and simulation assessment a trainee has proven that a sufficient level of knowledge, psychometric and technical skills have been achieved to start performing specific index procedures under supervision of a mentor at their respective hospital. The workplace assessment takes place under supervision of a mentor/experienced laparoscopic surgeon at the hospital where the trainee works. For the purpose of assessment and feedback GAS forms are used.

Having collected a sufficient number of points participants of the program have to provide two non-edited videos of index procedures for assessment by two independent LSS assessors. At this point the trainee receives a diploma that indicates he/she fulfilled the requirements of the respective level of LSS program. In case of Grade I-level I the trainee is up to a standard that should enable them to perform index procedures, while the decision to allow the trainee to perform these procedures independently is the responsibility of the local training program director/mentor. Preliminary experience with LSS curriculum grade 1, level 1, has been recently published [70, 71].