Current status, challenges, and future directions of laparoscopic training in young surgeons: a nationwide survey in China

Abstract

Background

With the rapid advancement of technology, minimally invasive surgery, particularly laparoscopic surgery, has made significant progress in the field of surgery. Despite the advantages of laparoscopic surgery, a systematic training system for laparoscopic procedures is lacking in Chinese postgraduate medical education. Our study aims to explore the prevalence of laparoscopic training among resident and attending physicians in China and to assess the current state of training programs.

Methods

A 10-item questionnaire was distributed to 1,750 resident and attending physicians specializing in surgery across China, with 1,324 valid responses (75.7% response rate). The survey focused on demographics, training curriculum content, and feedback on training effectiveness. Data analysis was conducted using Microsoft Excel and IBM SPSS.

Results

Among the 1,324 respondents, 30.7% reported receiving laparoscopic training, primarily at the attending physician stage. Only 4% of resident physicians and 14% of attending physicians could independently perform complex laparoscopic surgeries. Most respondents (76.6%) could only assist in surgeries. The majority expressed a desire for more frequent and longer training sessions, with suture training being identified as the most beneficial.

Conclusions

This study underscores the critical need for comprehensive laparoscopic training in China. Early, frequent, and structured training programs are essential for developing proficient laparoscopic surgeons. Future initiatives should focus on expanding access to training at all levels of medical education, ensuring continuous skill development and improved surgical care quality.

Introduction

With the rapid development of technology, minimally invasive surgery, particularly laparoscopic surgery, has made remarkable strides in the field of surgery [1]. Laparoscopic surgery offers several advantages, including minimal trauma, rapid recovery, shorter hospital stays, and superior cosmetic outcomes [2,3,4]. Currently, China performs over 10 million laparoscopic surgeries annually. Certain operations, such as appendectomies, cholecystectomies, and hernia repairs, are typically performed laparoscopically. In China, while it is highly encouraged and beneficial for surgical residents to gain substantial experience in laparoscopic surgery during their residency, a doctor who wants to perform laparoscopic surgery is not required to attend mandatory laparoscopic training course and laparoscopic training course is not a strict requirement for board certification. As a result, some doctors, especially those in low-level hospitals who lack experience in laparoscopy, cannot perform standardized procedures. Additionally, proficiency in minimally invasive techniques is not a universal requirement for all surgeons, with only a few highly specialized surgeons performing these procedures.

Surgery training is essential as it significantly enhances surgeons’ technical skills, reduces surgical errors, and even improves patient outcomes and satisfaction [5,6,7,8]. Given the trend towards laparoscopic procedures [9], it has become essential for every qualified medical student to learn the fundamental theories and techniques associated with laparoscopic surgery [10, 11]. However, there is currently no systematic laparoscopic training system integrated into postgraduate education in China and most young surgeons are exposed to laparoscopic surgery primarily from their teachers through clinical practice. Our research employs a survey to explore the prevalence of laparoscopic training in China and the specifics of existing training programs. By combining feedback on training effectiveness, we aim to establish an optimal laparoscopic training system, highlighting the necessity of a structured and standardized approach.

Methods

Survey construction and distribution

The questionnaire was designed to assess the prevalence and effectiveness of laparoscopic training among resident and attending physicians in China. It included closed-ended questions and Likert scales to gather demographic information, training experiences, and satisfaction levels. A 10-item questionnaire was constructed and distributed to resident physicians and attending physicians specializing in surgery via social media in China by Beijing BoYiTimes Medical Technology (Table 1). When designing the questionnaire, we consulted with epidemiology experts from our hospital to ensure its relevance and accuracy. We also conducted a small-scale pilot study within our institution to refine the questionnaire, taking into consideration the current medical landscape in China and the common concerns among practitioners. The questionnaire followed a logical sequence, beginning with general questions and moving to specific training-related inquiries. Demographics, laparoscopic training curriculum content, and post-training feedbacks were the three primary areas of focus of the study. Questions were asked regarding the seniority of the respondents. Given China’s extensive residency training cycle, resident physicians were categorized by post-graduate year (PGY) levels. We inquired about their current experience with laparoscopy and whether they had received laparoscopic training. For those who had, we asked further about the frequency and duration of their training, as well as their expected training schedule. Finally, we evaluated the perceived effectiveness of different training components by asking which sections they found most useful and helpful. Microsoft Excel was used to assemble and analyze the response data, while IBM SPSS Software was utilized to conduct the chi-squared analysis. A p value < 0.05 was defined as statistical significance. Ethical considerations were strictly observed, with voluntary participation and the assurance of respondent anonymity and confidentiality.

Survey Targets

In China, the medical hierarchy for doctors includes several levels: Resident Physician: This entry-level position involves specialized training in a hospital setting. Resident physicians undergo a standardized three-year training program, including rotations in various surgical departments such as general surgery, orthopedics, urology, vascular surgery, and cardiothoracic surgery. In addition to the three-year residency, there are also 1–2 years of rotations as chief residents. Attending Physician: After completing residency, doctors become attending physicians with more independence in patient care. They often supervise residents and may specialize in specific areas of medicine. Associate Chief Physician: Senior physicians with several years of experience as attending physicians. They lead clinical teams, manage complex cases, and contribute to teaching and research. Chief Physician: The highest level in the medical hierarchy, recognized as experts in their field, holding leadership positions, overseeing clinical standards, and heavily involved in research and education. Since laparoscopic training primarily targets resident physicians and attending physicians, we did not send the questionnaire to senior chief physicians.

Definition of simple and complex surgeries

In the survey, surgeries are defined according to their complexity. Level 1 Surgery: Minor surgeries with minimal risk, often performed under local anesthesia, typically not requiring a hospital stay (e.g., small skin lesion excisions, simple biopsies). Level 2 Surgery: Intermediate surgeries with slightly complexity, usually requiring regional or general anesthesia and a short hospital stay (e.g., appendectomies, simple fracture repairs, gallbladder removals). Level 3 Surgery: Major surgeries with moderate complexity and higher risks, requiring general anesthesia and involving longer hospital stays and extensive postoperative care (e.g., laparoscopic colostomy, laparoscopic inguinal hernia repair, transurethral resection of the bladder tumor). Level 4 Surgery: Highly complex and high-risk surgeries involving multiple organ systems or significant reconstructive procedures, requiring extensive preoperative planning, advanced surgical techniques, and prolonged postoperative care (e.g., Whipple procedure, laparoscopic anterior resection of the rectum, laparoscopic nephrectomy, laparoscopic radical prostatectomy). We define Level 4 surgeries as complex procedures, while Level 3 and below are categorized as simple surgeries.

Hospital grading system in China

The hospital grading system in China classifies hospitals based on their size, capacity, level of medical technology, and quality of care:

Primary Hospitals: Community-level facilities providing basic medical services, such as general outpatient care, preventive care, and some inpatient services.

Secondary Hospital: Regional hospitals offering more comprehensive medical services with a greater range of specialties and better equipment. Secondary hospitals are divided into:

Grade A: High-quality secondary hospitals with better facilities and more specialized services.

Grade B: Standard secondary hospitals providing essential medical services with fewer specialized resources compared to Grade A.

Tertiary Hospitals: Top-tier hospitals providing the highest level of medical care, advanced technology, and specialized services. They serve as referral centers for complex cases and are divided into:

Grade A: The highest level within tertiary hospitals, featuring advanced medical technology, extensive research capabilities, and comprehensive care for complex and severe cases, often affiliated with medical universities.

Grade B: High-level tertiary hospitals providing excellent medical care and specialized services but with slightly less capacity and resources compared to Grade A tertiary hospitals.

Study design and philosophical position

This study employed a cross-sectional survey design, which is well-suited for examining the current state of laparoscopic training among resident and attending physicians in China at a specific point in time. A cross-sectional design was chosen because it allows for the collection of data from a large, diverse population across multiple locations simultaneously, providing a snapshot of the prevalence and effectiveness of laparoscopic training. The research is grounded in a pragmatic philosophical position, which emphasizes the practical application of the findings to real-world surgical education for young surgeons. The study aimed to gather actionable insights that could inform improvements in the design and implementation of laparoscopic training programs, ultimately enhancing surgical skills and patient outcomes.

Table 1 10 Item questionnaire sent out to surgical residents and attending physicians

Result

Survey response rate

All surgeons were invited to participate in this survey, as they all have the opportunity to perform laparoscopic surgery now or in the future. A total of 1,750 questionnaires were distributed, and 1,324 were completed and returned, resulting in a response rate of approximately 75.7%.

Demographic characteristics and laparoscopic training experience of respondents

Respondents’ population distribution is detailed in Fig. 1. As shown in Table 2, of the 1324 respondents from twenty provinces, 334 (25.2%) respondents were at PGY 1, 270 (20.1%) at PGY 2, 150 (11.3%) at PGY 3, 256 (19.3%) at PGY > 3, and 314 (23.7%) were attending physicians. For the respondents’ hospital level, the majority of respondents (70.54%) were from grade A tertiary hospital. With regard to their current experience with laparoscopy. 1014 (76.59%) could only be an assistant in laparoscopic surgery. 244 (18.43%) respondents could perform simple tertiary surgery, while only 44 (3.32%) were able to carry out complex operations. For resident doctors, only 40 (3.96%) are able to perform simple surgery, and 44 (14.01%) attending physicians are able to perform the complex laparoscopic surgery independently.

In total, 406 (30.7%) respondents received laparoscopic training. According to their seniority, the rate of training is as follows: Resident physician (PGY = 1) 4.43% (18/406); Resident physician (PGY = 2) 6.90% (28/406); Resident physician (PGY = 3) 9.85% (40/406); Resident physician (PGY > 3) 20.20% (82/406); Attending physician 58.62% (238/406).

Fig. 1

The population distribution map for all 1324 respondents

Table 2 Laparoscopic training survey results according to the seniority for all 1324 respondents

Laparoscopic training initiation, frequency, and preferences among respondents

As shown in Table 3, among 406 respondents, 108 (26.60%) started the laparoscopic training at resident physician (PGY 1), 80 (19.70%) at resident physician (PGY 2), 60 (14.78%) at resident physician (PGY 3), 74 (18.23%) at resident physician (PGY 3), and 84 (20.69%) at the attending physician stage. For their current training frequency, over 60% of respondents received laparoscopic training once every half a year with each training duration of 1–2 h, however, over 90% respondents were expected to receive more frequent training and over 70% wanted to have longer training hours. When asked which training section improves them the most, nearly 70% preferred to suture training.

Table 3 Laparoscopic training survey results according to the seniority for 406 respondents who have received training in laparoscopy

Correlation between early training, frequency, and surgical proficiency

For attending physician who are able to perform complex surgery, they all started laparoscopic training at PGY 1–3, and 50% of them started training in the first year of the residency (Table 4). Compared to others who can only assistant or perform simple surgery, they were trained more frequently (p < 0.05), keeping the training frequency for at least once a month. Similarly, for resident physician who are able to perform simple surgery, 65% started training at PGY1 and received training more frequently (p < 0.05) (Table 5). Also, for both attending physician and resident physician, those who are more skilled are more likely to be trained in suturing (p < 0.05).

Table 4 Laparoscopic training patterns and preferences among attending physician

Table 5 Laparoscopic training patterns and preferences among resident physicians

Reliability and validity of questionnaire

By calculating Cronbach’s Alpha, the internal consistency coefficient of the questionnaire was found to be 0.925, indicating that the questionnaire has high reliability. Additionally, the structural validity of the questionnaire was assessed through factor analysis. The factor analysis indicated that the first two factors of the questionnaire together explained approximately 100% of the total variance, with the first factor accounting for about 59.75% of the variance and the second factor accounting for about 40.25%. These results suggest that the questionnaire demonstrates good construct validity. Besides, content validity was ensured through expert review, which confirmed that the questionnaire comprehensively covers all relevant areas.

Discussion

This study provides a comprehensive overview of the current state of laparoscopic training among resident and attending physicians across twenty provinces in China. The findings reveal several critical insights into the distribution, experience, and training frequencies of respondents, highlighting significant areas for improvement and development in laparoscopic surgery education in China.

Well designed and structured training programs can help surgeons learn and perform laparoscopy properly [12]. Laparoscopic suturing is a task that can be acquired during short skills courses by trainees, regardless of their baseline laparoscopic experience [13]. Five different laparoscopic and open technical tasks were performed forty times each in a training curriculum by 65 preclinical medical students. Results showed that 77% students reached proficiency in all tasks [14]. However, laparoscopic training is not fully available in most area around the world. Only 30.7% respondents in our study received laparoscopic training. A 2006 survey in the USA of 253 general surgery program directors revealed that although a large majority consider laparoscopic training labs important, 45% of the programs do not have such facilities. Also, there is significant variability of training equipment and practices existed in currently available training labs [15], which fully demonstrates the importance of popularizing standardized laparoscopic training. In our study, among 1,324 respondents, only 406 (30.7%) received laparoscopic training. This discrepancy highlights a potential gap in the current surgical education and training programs, suggesting that a large number of practitioners may lack essential skills in laparoscopic surgery, which underscores the need for more widespread and accessible laparoscopic training.

The main finding of this survey reveals a concerningly low rate of laparoscopic training among PGY 1–2 residents, suggesting that the current training programs may not be adequately addressing the needs of early-stage surgeons. This could lead to a lack of foundational skills essential for the effective practice of minimally invasive surgery as they progress in their careers. The high number of attending physicians without proper laparoscopic training underscores that even those who have completed their residency and are practicing independently may not have received sufficient training in laparoscopic techniques, which are increasingly important in modern surgical practice. These issues highlight potential shortcomings in current surgical curricula and the need for systemic changes to enhance training accessibility, frequency, and focus on essential skills. Addressing these gaps is crucial for improving surgical care quality and ensuring surgeons are well-equipped for laparoscopic procedures.

Additionally, a substantial proportion of respondents (76.59%) can only assist in laparoscopic surgery, while only 3.32% can perform complex operations. This suggests a significant gap in practical surgical skills among trainees, which is particularly pronounced among resident doctors, where only 3.96% can perform simple surgeries, in contrast to 14.01% of attending physicians who can independently handle complex procedures. Our data also reveal that attending physicians, who are expected to be more experienced, still exhibit a high number of individuals without proper laparoscopic training. This points to issues in the training framework that fail to ensure comprehensive skill development even at a relatively advanced stage.

The laparoscopic learning curve describes the learning process experienced by novices in mastering the laparoscopic technique [16]. In the initial stage, doctors may need to learn basic laparoscopic operation techniques, such as lens insertion, controller manipulation, surgical instruments application, etc. With the accumulation of experience and continuous practice, doctors gradually become familiar with the complexity and characteristics of laparoscopic surgery [17]. Generally, most scholars believe that the first stage encountered by beginners in the endoscopic learning curve is the rapid rise period. Our study also found that both resident physicians and attending physicians whose surgical ability exceeded their peers often started laparoscopic training at early stage and trained more frequently, which demonstrated that early laparoscopic training will benefit doctors’ long-term surgical skills and ability.

Laparoscopic surgery is progressively replacing open surgery due to the many patient-related benefits, but the difficulty of laparoscopic suturing has prevented laparoscopic surgery from being widely adopted [18]. Our survey revealed that suture training could mostly help the physician on their laparoscopic surgical skills. A well designed randomized controlled trial by Athanasiadis et al. enrolled 39 medical students and also revealed that compared with basic laparoscopic surgery training alone, the advanced laparoscopic suturing training further enhanced their laparoscopic suturing skill [19]. Another trial that included both senior and junior operative trainees showed that laparoscopic suturing courses are particularly beneficial and effective for junior surgical residents [13]. Given that the longer the training duration, the more refined the suturing skills become, it is evident that suture training should be initiated as early as possible [20]. Moreover, the preference for suture training among nearly 70% of respondents indicates that basic yet crucial surgical skills are highly valued and perhaps under-emphasized in current curricula. This highlights the need for incorporating comprehensive suture training into early stages of surgical education to ensure the development of proficient laparoscopic surgeons.

A crucial debate arises from the finding that only 44 (3.32%) of participants are capable of performing complex surgeries. This raises the question of whether the survey sample is biased towards less experienced surgeons or if there are indeed very few surgeons in China capable of complex laparoscopic procedures. Due to the fact that laparoscopic training mainly targets young surgeons (resident physicians and attending physicians), this survey also selected this group as the survey target. Therefore, the results of this survey can only reflect the skill level of young surgeons, and may not be fully promoted or reflect the situation of the entire surgeon group in China. This bias may underestimate the need for advanced training programs or overlook the retraining needs of senior surgeons.

Our survey findings underscore a critical need for improvement in laparoscopic training among Chinese surgeons, particularly at the resident level. The data suggest that early and structured integration of laparoscopic training into surgical residency programs is crucial. This can be achieved by incorporating dedicated laparoscopic modules in the early stages of training, increasing the frequency of hands-on training sessions, and placing a stronger emphasis on essential skills such as suturing, which was identified as the most beneficial component by respondents. Furthermore, the variability in training quality across different regions and hospital levels highlights the necessity of establishing a standardized national curriculum for laparoscopic training. Such a curriculum would ensure consistent and comprehensive education, enabling all surgeons to acquire the necessary skills, regardless of their training location. By addressing these areas, the surgical education system in China can be significantly enhanced, leading to better-prepared surgeons, improved patient outcomes, and a higher overall standard of surgical care.

The application of visual-assistive technologies in laparoscopic training has demonstrated significant advantages [21,22,23]. By utilizing real-time image enhancement, 3D images reconstruction, virtual reality (VR), and augmented reality (AR), these technologies provide clearer surgical views and a multidimensional understanding of anatomical structures [24,25,26], enabling trainees to rapidly improve their operative skills. Additionally, these technologies offer a safe virtual environment where trainees can repeatedly practice complex procedures. However, despite the benefits of visual-assistive technologies in enhancing training outcomes, their high cost and steep learning curve may limit their adoption in resource-constrained training centers [26, 27]. To overcome these challenges, gradual implementation and interdisciplinary collaboration to reduce costs, along with systematic training courses to help trainees better master these emerging technologies, are essential.

This study is by far the largest number of included questionnaire surveys for laparoscopic training, focusing on the beginning training phase and separating respondents by seniority. This study highlights the need to seek continued reform in laparoscopic training curricula, particularly since the low prevalence and training frequency of training. However, the study’s limitations must be acknowledged. The relatively small number of survey questions, and the low participant rate compared to the estimated number of surgeons in China are significant concerns. Also, it is essential to emphasize that these findings are derived from Chinese data, and thus, the conclusions should primarily address the Chinese healthcare system. These factors may affect the generalizability of the findings. Additionally, the survey’s potential bias towards younger and less experienced surgeons further limits the ability to draw broad conclusions about the entire population of Chinese surgeons.

Conclusion

Our research offers an extensive overview of the present status of laparoscopic training among resident and attending physicians across twenty provinces in China, highlighting the critical role of early, frequent, and targeted laparoscopic training in developing surgical proficiency. Future initiatives should focus on expanding access to training across all levels of medical training, with particular emphasis on early exposure and continuous skill development.