Webinars as a Teaching Tool in Gynaecological Laparoscopy: A Success Story

Introduction: The prevalence of laparoscopic surgery in the field of Gynaecology is rapidly expanding and simultaneously necessitates aptly coached trainees in this field. Basic skills of laparoscopic surgery that need to be mastered by any trainee through hands on practice include depth perception, bimanual dexterity and ergonomic movements. The need for distant teaching and learning methods were warranted by the global outbreak of COVID-19. Restrictions to traditional hands-on teaching were mandated by the essential precautionary measures that were implemented by the government to contain and control the outbreak. taking all these factors in to consideration as well to fill the void in teaching and training created by this situation, the professorial unit in Obstetrics and Gynaecology of University of Sri Jayewardenepura in conjunction with the Srilanka College Obstetricians conducted a series of webinars named “Gynaecological Laparoscopy in 20 days”. This series consisted of 20 sessions which covered almost all aspects of Gynaecological Laparoscopy.
Objective: The purpose of this study is to assess the effectiveness of webinars based on presentations with the use of recorded surgeries for the teaching of gynaecological laparoscopy.
Methodology: A cross sectional descriptive study was conducted amongst trainees and consultants who participated in the Web Based Learning Program. Webinars were conducted in 20 sessions under two broad leaning objectives. Firstly, to enhance the understanding the principals of gynaecological laparoscopy and subsequently to discuss in-depth various surgical procedures with the use of recordings from live surgery. Participant feedback was assessed through Google forms which evaluated the computer literacy, comprehension of the participant and the quality of the conducted webinars. Recommendations for improvement was also collected. The questionnaire consisted of a five-point Likert scale for the purpose of evaluation.
Results: Feedback gathered through the questionnaire depicts good satisfaction with the majority being in favour of the series of webinars conducted in terms of convenience, course functionality, content, relevance to training and comprehensibility of techniques in laparoscopic surgery.
Conclusion: The satisfactory participant response generated by this study demonstrates that web-based indoctrination of surgical skills could be considerably effective despite lack of hands- on practice in laparoscopic training. With some fine-tuning and improvisation, web-based seminars in laparoscopic skills and techniques can be used for the seamless continuation of crucial training programs especially in the backdrop of situations necessitating social distancing.
 

Laparoscopic surgery has rapidly gained popularity in the surgical community over the years owing to its minimally invasive nature. Complications posed by open surgery are conveniently averted with the additional benefits of lesser recovery time and cosmetic appeal [1]. As with general laparoscopic surgery, the general precept of seeing, doing and teaching can be applied to the study of laparoscopic Gynaecological surgery. While it’s prevalence across the field of Gynaecology expands, it necessitates a simultaneous increase in the need for reliable training and assessment tools [2]. Whilst theoretical aptitude in laparoscopic surgery can be gained through books and lectures, clinical proficiency can only be gained through hands-on real-time or simulated training. Nevertheless, educational reforms, curtailment of working hours and a reduction in case load have necessitated the need for alternatives contemporary approaches to traditional teaching [3]. Supervised training on patients has provided trainees with a learning environment with little room for error. In an era where patient safety is of prime importance, hands on training provide trainees with ample opportunities to learn new techniques and procedures. Familiarity with operating tools is also augmented by this traditional method of learning [4].
Laparoscopic Gynaecological surgery is rapidly evolving with the introduction of novel operating tools. As with other subjects of medical education, the prospect of fundamental laparoscopic training via web-based platforms is a topic for debate [5]. In surgical education, the use of technology has exponentially increased in recent times. International educational institutions and training establishments including the Royal College of Obstetricians and Gynaecology [RCOG]. have established e-learning and teaching for basic laparoscopic surgery with the intention of pioneering a hassle-free method of conveying the fundamentals of laparoscopic surgery to trainees [6]. The substitution of traditional books with technologically enhanced sources of education have influenced new generations to be more technologically oriented and seek information through electronic media [7,8]. Web based seminars, colloquially termed “webinars" offer teachers, trainers and curriculum developers the opportunity to share surgical knowledge across a web-based platform [9]. While this contemporary method of learning is inexpensive, versatile and does not constitute restraints in time and distance, the effectiveness of indoctrination of laparoscopic Gynaecological surgical skills in trainees is inconclusive [10]. Implication of such webinars in other fields has also shown inconclusive effectiveness [11].
Disadvantages of webinars include the high initial cost, need for programming, expertise, and the requirement of a high-speed Internet connection for the users [12]. The requirement for long distance teaching and training methods is still more pronounced against the backdrop of the COVID 19 pandemic with social distancing being mandated as a method of minimizing transmission of the viral vector. In Sri Lanka, evidence for the effectiveness of web based surgical skills programs are acutely limited. This is partly due to the stunted progress in expansion of technology in comparison to most developed countries. The prime draw drawback of web based laparoscopic training is the lack of hands-on experience, the importance of which has been emphasized herein. Laparoscopic skills are neither instinctive nor easily simulated mainly due to the lack of tactile feedback. Cognitive factors, innate dexterity and individuality of the operator are crucial in the acquisition of laparoscopic skills [13]. 
In Sri Lanka, due to lack of specialist trainers in laparoscopy, there are voids in systematic training for postgraduate trainees and specialists. This fact increases the value and acceptability of a web-based training. Furthermore, a dire requirement of more formal workshops and training in endoscopy and surgical anatomy exists at a global level [14]. The purpose of implementing this study is to convey the experiences amassed through a web based laparoscopic training program conducted by the professorial unit in Obstetrics and Gynaecology of University of Sri Jayewardenepura in conjunction with the Sri Lanka College Obstetricians and Gynaecologists during the COVID-19 outbreak. This study will assess the effectiveness of the program, especially in terms of developing basic laparoscopic skills and provide suggestions and recommendations to improve the outcome of similar web-based skills training programs in future.

Process of developing the series of Webinars
Following the pandemic of Covid-19 and implementation of social distancing, the training programs conducted by the Post Graduate Institute of Medicine of the University of Colombo and the Sri Lanka College of Obstetricians and Gynaecologists were halted. Distant teaching and learning methods became an essential requirement in the curriculum for the continuation of training. After lengthy discussions, the Sri Lanka College of Obstetricians and Gynaecologists concluded that webinars could be employed as a useful tool to continue post-graduate education during the pandemic. A series of webinars was formulated to be conducted using “Zoom” video conferencing software. The series consisted of 20 sessions which covers 22 topics related to gynaecological endoscopy. Out of the 22 topics, 6 were based on presentations with embedded small video clips on basic laparoscopic surgical principles. The next sixteen sessions targeted more on improving surgical skills with recorded videos on simple to more advanced laparoscopic gynaecological procedures (Table 1). All were conducted by a single resource person whilst expert opinions were shared on the forum by senior consultants where appropriate.

Table 1: Topics coveredwith number of participants and duration of each session.

Webinars commenced at the same time each night and lasted approximately 90-150 minutes. Timing of the webinars were decided after careful consideration of work hours in order to maximize participation. An e-mail was forwarded each morning mentioning the lecture topic, time of commencement and the relevant login details for the Zoom video conference. Attendance of each participant was recorded at all lectures in order to assess satisfactory completion of the program.

As this was a new learning experience for the consultants and post-graduate trainees, authors strived to gather their perspectives and experiences of distant learning activities by sending them a questionnaire. The questionnaire was developed on “Google forms” and consisted of the following 4 domains of assessment,

• General information
• Evaluation of participant ‘s computer literacy
• Evaluation of the web-based learning program
• Participant’s self-evaluation

The assessment was carried out in four stages. The first stage assessed the participants’ computer literacy while the second stage assessed the participant perception of the webinars oriented towards teaching basic laparoscopic principles (First six webinars). The third and fourth stages assessed the participants’ perception about the use of video recordings for teaching and evaluated their suggestions to improve gynaecological endoscopy in Sri Lanka.
The questionnaire consisted of a five-point Likert scale where both open-ended questions along with multiple choice questions were incorporated to obtain a better understanding of the feedback. A prospective cross-sectional descriptive study was conducted amongst trainees and consultants who participated in the web-based learning program. A total of 131 Trainees and consultants who responded were included in the analysis. This study was conducted as a web- based teaching program. Therefore, there was no defined study setting. The study was done in an open forum which covered the entire island. Statistical Package of Social Science (SPSS version 25.0) was used to analyse the data extracted. Demographic data, participants’ computer literacy, perception on effectiveness of webinars and participants challenges in engaging with webinars were analysed in terms of mean and SD values.

Figure 1: Distribution of study participants’ gender, designation and working environment.

A male predominance was noted among the study participants. Male to female ratio was 6:1, A total of 131 participants have responded and the majority were pre-MD trainees (51.1%). Twenty-eight consultants (21.4%) also participated in the program. Participants were mainly from hospitals located in urban areas which amounted to 69.5% whereas 12.2% and 18.3 percentage belonged to the periphery and sub-urban areas respectively.

Table 1.1: Participants’ skill and competence in IT & related activities.

The table above depicts that the participants’ computer literacy skills and knowledge in web-based platforms of communication was above average. The skills on using devices including the ability to access the internet, skills on internet browsing and usage of e-mail were comparable between the consultants and trainees.

Table 1.2:Participants’ perception on the importance of the program according to categories.

A vast majority of the sample audience was of the opinion that the series of webinars conducted was useful and appropriate and most participants have agreed that they would like to learn more using these methods.

Table 2: Participants’ view on the series of webinars.

The evaluation results demonstrate high levels of course functionality, effectiveness of content and acceptance amongst the sample population. A majority of the sample population agreed that they were able to achieve stipulated learning outcomes at the end of the series. There was very high satisfaction of the resource persons teaching performance as well as overall experience of the web-based learning as a whole.

Table 3: The effectiveness of webinars on Gynaecological laparoscopy in achieving the outcome.

The participants have substantially developed their knowledge on gynaecological laparoscopic surgery following the course. In contrast it was clear that the general agreement was that the contribution on developing skills is less compared to other domains.

Table 4: Participants attitudes and reactions towards series of webinars for learning laparoscopy based on their experience.

Most participants had a positive outlook towards this novel method of learning and agreed they would recommend it for future learning.

Table 5: Participants’ perception on the effectiveness of each webinar/content to improve basic laparoscopic principles.

A vast majority of participants perceive webinars as an effective method in the indoctrination of basic gynaecological laparoscopic skills.

Table 6: Participants’ experience of challenges in engaging webinars.

A substantial fraction of the participants faced internet related challenges and some faced inconveniences where the scheduling of lectures was concerned. Some of the participants had personal commitments which interfered with participation to sessions.

Among 131 attended, most were males and were pre-MD trainees (51.1%) while 21.4% were consultants. They were mainly from urban 69.5% hospitals whereas 30.5% were from suburban and peripheral hospitals. This distribution can be correlated with the accessibility of facilities to perform advanced laparoscopic surgery in the respective areas where facilities are more densely concentrated in hospitals in urban localities. Male to female ratio was 6:1 and it is a representation of the gender distribution of the study population consisting of consultants and trainees in the field of Obstetrics and Gynaecology in Sri Lanka. It is noteworthy that twenty-eight consultants (21.4%) also participated in the program despite their busy schedules. The computer literacy on ability to access the internet, skills on internet browsing and usage of e-mail were good and comparable between with the consultants and trainees. A majority of the sample audience was of the opinion that the series of webinars conducted was useful and appropriate and most participants have agreed that this program provided a stimulus to learn more about gynaecological laparoscopy. The participants have developed their knowledge substantially and skills to a lesser extent on gynaecological laparoscopic surgery following the course. The participants have substantially developed their knowledge on gynaecological laparoscopic surgery following the course. Factors that could have contributed to this improvement include simple yet highly informative power point presentations and video recordings used by the highly experienced resource person. Most participants had a positive outlook towards this novel method of learning and agreed that they would recommend it for future learning also, the participants perceive webinars as an effective method to acquire basic gynaecological laparoscopic skills. A substantial fraction of the participants faced challenges due to internet related technical issues as well as inconveniences with the time scheduling of lectures due to duty and personal commitments.

According to our knowledge, this is the first large series of webinars conducted   in Sri Lanka on a single area related to surgery. Study participants recruited for this study represented all the provinces of Sri Lanka and according to the study findings it was identified that it is possible to use the Webinars to conduct successful training sessions by utilizing a minimum time and minimum resources. Interactive participation from other consultants created a platform for sharing knowledge and experiences. This is the first such online forum conducted in gynaecological laparoscopy in Sri Lanka.
Generally, it is very rare to achieve active discussion in conventional educational forums, whereas this series stimulated healthy interactive discussion. These were realized through audio, video and live chats. There was minimum room to objectively evaluate the skills gained through this training program and it was identified as the predominant limiting factor experienced during this study. However, it is an inevitable limitation during distance learning programs.
Authors have not objectively evaluated the improvement of participants’ knowledge and skills using pre and post-tests in this study as we believed that such an exercise would result in poorer participation and will exercise undue pressure on the participants at the outset of a novel educational experience.

Studies on laparoscopic surgery suggest that the key factor responsible for complications is the ability of the operator. Although there is no substitution for hands on training and constant practice, modern audio-visual tools which can be used in webinars could help to facilitate achieving skills than didactic teaching methods [15,16]. All in all, practice remains the essential requirement to gain hands on surgical skills. Laparoscopic surgeries are delicate and time consuming, therefore the number of surgeries which could be demonstrated in a live session is limited. In the webinars, fast forwarding, skipping unnecessary parts and using the on-screen drawing provided a unique educational experience as opposed to real-time surgery. Moreover, opportunities were created for the participants to question and clarify the practical problems faced during surgery. As the surgeon was devoid of surgical responsibility at the time and the ability to pause and rewind the video, the resource person had more opportunity to focus on the questions from the audience and provide clearer explanations [17]. Apart from this, it was specifically identified that both consultants and post graduate trainees thought that this webinar will improve their practice.

The satisfactory participant response generated by this study demonstrates that web-based indoctrination of surgical skills could be considerably effective despite lack of hands-on practice in laparoscopic training. With some fine-tuning and improvisation, web-based seminars in laparoscopic skills and techniques can be used for the seamless continuation of crucial training programs especially in the backdrop of situations necessitating social distancing.