EMIGS: A new standard of care

Moawad is professor and chief of the Division of Minimally Invasive Gynecologic Surgery (MIGS) at the University of Florida College of Medicine in Gainesville and chair of the American Association of Gynecologic Laparoscopists (AAGL) Steering Committee of EMIGS.

Moawad also detailed how the program began, its many benefits, and how it differs from the previously used Fundamentals of Laparoscopic Surgery (FLS) test. Read the Q&A below to find out more about the EMIGS program and how it is shaping the future of MIGS.

Editor’s note: This transcript has been edited for clarity and space.

What is the EMIGS program? What are its key components?

Nash Moawad, MD, MS, FACOG, FACS EMIGS is a standardized program that has 3 components. One is a didactic component that concentrates on minimally invasive gynecologic surgery, such as laparoscopic, robotic, and hysteroscopic surgery, as well as concepts and principles of electrosurgery, anatomy, positioning, complications, instrumentation, strategies, and everything to do with the essentials of MIGS.

The second and third components are tests. One of them is a cognitive exam, which is a multiple-choice exam that is validated and scored according to standards we set for our residents. The third is a manual assessment of laparoscopic skills that covers suturing, eye-hand coordination, precision, vaginal cuff closure, and the essential principles of laparoscopic surgery for our residents and trainees.

Are there any significant benefits or, if there are any, detriments when using the EMIGS program?

Moawad There are definitely a lot of benefits to using the EMIGS program. It is a standardized program developed by experts in the field over several years. The AAGL spent 9 years developing this, and we surveyed 300 gynecologists to find out what they thought would be the essential components to include in the EMIGS program. Then we developed the didactic questions for the cognitive exam, as well as the skills to be included in the manual exam. For trainees or junior faculty to go through such a standardized program that has been very well developed and validated, it is good for them to practice the same skills repeatedly, time themselves, try to do better every time to try to beat their scores. And with that, they develop those basic skills, and they can transfer those to the operating room with improved efficiency and safety for our patients.

Why create the EMIGS program?

Moawad There has never been a standardized program for gynecologic surgery training. It is more the old paradigm where you see 1, do 1, and teach 1, which is obviously not the best for our patients. This was the concept behind the all the efforts and resources that were devoted toward developing this program. It has been a very ambitious goal, and we have achieved it. You want to see what the residents are doing and what they need improvements on before they’re doing this in surgery in the operating room.

The American Board of Obstetrics and Gynecology (ABOG) recently decided to use this test as an alternative to the FLS test. What are some of the key differences between the 2?

Moawad There are so many differences. EMIGS is essentially made by gynecologic surgeons for gynecologic surgical trainees. Everything about it has to do with gynecology. There’s nothing that’s extraneous and not a good use of their time. Our residents’ time is very valuable, the duty hours are limited, and you have to learn so much in only 4 years. It is important to focus your time and attention on what’s pertinent to your field.

Some of the key differences are that the didactics are all gynecology related. There’s nothing there that is not the bread and butter of what we do every day. The didactics are all video narrated, making it easy to follow on a busy day between cases in the evening when you’re on call, or if you have a few minutes to catch here and there on a trip. Also, it is available on mobile devices, so it is easy for the residents to watch all the videos and learn on the go. You can watch them repeatedly, focus on certain areas, rewind, and go back to the area
of interest.

The cognitive exam contains all gynecology-related questions, and it is focused on improving efficiency and safety; it is frequently updated. The EMIGS steering committee meets, and psychometricians are heavily involved in the design and teaching the faculty how to write questions, going over the questions multiple times to make sure they are pertinent, making sure they’re evidence based and up-to-date.

From the manual skills standpoint, a few advances were added to EMIGS over FLS. One of them is how we operate in the pelvis. All our operating is in the pelvic cavity, and we don’t operate on a flat surface. We developed a proprietary platform several years ago called the
LaparoBowl, a pelvis-shaped platform with sidewalls, a front, and a back, just like the anterior and posterior cul-de-sacs. This way, when gynecologic surgeons are operating there, they feel as though they’re operating in the pelvic cavity. Also, the AAGL will send a free LaparoBowl to every residency program in the United States to help kick-start the EMIGS program, and additional ones can be ordered as needed for
larger programs.

Other advances in the manual skills include removing the ENDOLOOP task because we don’t use that very often in gynecologic surgery; we have replaced that
with vaginal cuff closure. Simple hysterectomy, laparoscopic hysterectomy, and robotic hysterectomy are essential for all gynecologic surgery trainees to learn and perfect before they finish residency. These are important skills to practice even as junior attendings, to go back and try to perfect it and do better in terms of precision, time, and efficiency.

The standards for the manual skills have been set to fit the gynecology resident in their late second year and early third year. As the faculty and steering committee went over different standards, what to score, what not to score, what weights to put on each skill, every decision was made with the gynecology resident in mind. This is important because we’re not working with general surgery residents or urology residents, we’re working with gynecology residents, and the questions and skills are developed by gynecology faculty.

What kind of reaction did you see across the health care community when the program was implemented?

Moawad We’ve seen overwhelming excitement and anticipation for the program. Everybody is asking, “When can we start? What do we need to do?” And we’re working hard in the background to get everything ready for them. We’ve been getting the equipment ready; shipping the LaparoBowls; communicating with the programs, residents, ABOG, and the Council on Resident Education in Obstetrics and Gynecology; involving all the stakeholders; working with psychometricians to update our questions; and working with a proctoring company, to make sure everything’s ready to go.

The manual skills and the cognitive exam will be virtually proctored. There’s no need to travel anywhere; they can take it at their hospital, or in their call room, if needed. There will be 2 cameras in the room, 1 monitoring the room environment and the other showing the lap trainer view. Everything’s recorded and uploaded to the cloud for the AAGL to grade and send the results.

It has been very exciting, and we can’t wait to start. We plan to start January 1, 2023, but the LaparoBowls should be available to the programs in October 2022 so residents can start practicing and getting ready to take the exam.