- Email: [email protected]
Laparoscopic Colorectal Surgical Training: A Curricular Approach
Laparoscopic Colorectal Surgical Training: A Curricular Approach Rajesh Aggarwal, MA, MRCS,* and Teodor Grantcharov, PhD† Large, prospective, multi-centre randomized trials have confirmed the role of minimally invasive colorectal procedures in the armamentarium of the surgical specialist. However, the learning curve for this procedure has been stated to be of the order of 50 to 400 procedures for a variety of different resections. This is known to vary between surgeons, and can also be influenced by patient selection and operative complexity. The aim of this article is to develop a structured, proficiency-based training program, with the facets of curricular design taken from a previously published framework of technical skills training, known as STATS (Systematic Training and Assessment in Technical Skills). There is a heavy emphasis on the use of simulated tissues to teach skills required. In order to enable objective assessment of performance, a procedure-specific global rating scale has been developed for assessment of performance during a laparoscopic anterior resection. An important part of the training program is to deliver team-based training for laparoscopic colorectal surgery. A key aspect of the curriculum is to focus on training the trainers, and it is with this advancement that opportunities shall evolve for surgical residents to learn these novel techniques, leading to their safe delivery with direct benefit to patients. Semin Colon Rectal Surg 19:115-121 © 2008 Elsevier Inc. All rights reserved.
M
inimal access surgical techniques are now considered to be the gold standard for biliary, antireflux, and bariatric surgery.1 This is mainly due to improved patient recovery in terms of reduced pain, a shorter hospital stay, and a quicker return to normal daily activities. More recently, there has been a drive toward the application of laparoscopic techniques to large bowel surgery. Although oncological clearance margins and survival are the primary outcomes that determine success from colorectal cancer resections, it is important to consider the secondary outcomes such as a reduction in postoperative complications, time taken to recover from surgery, urinary continence, and sexual function as determinants of quality of life post resection. It is these latter factors that have been suggested to be improved by a laparoscopic approach. Since the first laparoscopic colon resection for malignancy in 1991,2 a number of initial series have been reported to*Department of Biosurgery and Surgical Technology, Imperial College London, London, United Kingdom, Toronto, Canada. †Division of General Surgery, St. Michael’s Hospital, University of Toronto, Toronto, Canada. Address reprint requests to R. Aggarwal, Specialist Registrar/Honorary Clinical Research Fellow, Department of Biosurgery and Surgical Technology, Imperial College London, 10th Floor, QEQM Building, St. Mary’s Hospital, Praed Street, London, W2 1NY, United Kingdom. E-mail: [email protected].
1043-1489/08/$-see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1053/j.scrs.2008.02.008
gether with comments regarding the technical delivery of the procedure, lengthy operative times, high conversion rates, and concern regarding iatrogenic tumor dissemination.2-5 The first randomized prospective trial comparing open and laparoscopic approaches to colorectal cancer resections was a small study of 29 patients performed by Stage and coworkers in Denmark in 1997.6 Their conclusions demonstrated the feasibility and oncologic safety of laparoscopic surgery but were difficult to accept due to the small sample size. Lacy and coworkers confirmed the initial reports from nonrandomized trials and revealed recurrence rates comparable to those of open surgery, and a low incidence of port-site metastases.7 These initial trials set the scene for large, prospective, multicenter randomized trials published within the last few years. In 2004, the Clinical Outcomes of Surgical Therapy Study Group of the Laparoscopic Colectomy Trial reported their findings of a multi-institution prospective randomized trial of 872 in the New England Journal of Medicine.8 Patients with adenocarcinoma of the colon underwent open or laparoscopically assisted colectomy performed by credentialed surgeons. The median follow-up was 4.4 years. The primary endpoint was the time to tumor recurrence. At 3 years, the rates of recurrence were similar in the two groups—16% among patients in the group that underwent laparoscopically assisted surgery and 18% among patients in the open-colectomy group (P ⫽ 0.32). 115
R. Aggarwal and T. Grantcharov
116 The overall survival rate at 3 years was also very similar in the two groups (86% in the laparoscopic surgery group and 85% in the open-colectomy group, P ⫽ 0.51). Perioperative recovery was faster in the laparoscopic-surgery group than in the open-colectomy group, as reflected by a shorter median hospital stay (5 days versus 6 days, P ⬍ 0.001) and briefer use of parenteral narcotics (3 days versus 4 days, P ⬍ 0.001) and oral analgesics (1 day versus 2 days, P ⫽ 0.02). The rates of intraoperative complications, 30-day postoperative mortality, complications at discharge and 60 days, hospital readmission, and reoperation were very similar between groups. The authors concluded that rates of recurrent cancer were similar after laparoscopically assisted colectomy and open colectomy, suggesting that the laparoscopic approach is an acceptable alternative to open surgery for colon cancer.
The Learning Curve for Laparoscopic Colectomy A particular comment with regard to the aforementioned trials is the nature of the learning curve to perform laparoscopic colorectal oncological procedures. This has been stated to be on the order of 50 to 400 procedures for a variety of different resections. This is known to vary between surgeons and can also be influenced by patient selection and operative complexity. Tekkis and coworkers published results of 900 patients undergoing laparoscopic colorectal resections from November 1991 through April 2003.9 The conversion rate for right-sided colonic resections was 8.1% compared with 15.3% for left-sided resections. A risk-adjusted cumulative sum analysis demonstrated a learning curve of 55 cases for right-sided colonic resections versus 62 cases for the left side. Possible strategies to surmount the learning curve were suggested to include formal training courses, close intraoperative supervision by expert practitioners, and assistance form other well-trained staff. In July 2005, The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in collaboration with The American Society of Colorectal Surgeons published clinical practice guidelines regarding the safety of utilizing a laparoscopic approach for malignant colorectal disease. The mainstay of the guidelines were to ensure appropriate preoperative staging, bowel preparation to enable ease of laparoscopic manipulation of the bowel, together with adherence to standard oncologic principles. The article also stated that “adequate training and experience are necessary to perform an appropriate oncological resection.”
The Components for Advanced Laparoscopic Training Curricula In 2005, Harinath and coworkers published their results of a postal questionnaire to 540 colorectal surgeons in the United Kingdom.10 From the 200 who responded, only 45 (23%) practiced laparoscopic colorectal work, the majority being for right hemicolectomy and stoma formation. Nearly 22% of
Table 1 Faculty Training 1. Courses: “Hands-on” courses are useful for conveying the techniques of laparoscopic operations to those who are proficient in the similar open operations. Faculty members interested in obtaining advanced laparoscopic training may benefit from advanced laparoscopic courses. SAGES will provide an opportunity for faculty members to participate in advanced laparoscopic surgical courses. 2. Faculty mentoring: SAGES believes that faculty who have already acquired the fundamental skills in advanced laparoscopic surgery and who desire to learn a new or modified laparoscopic operation will benefit from observing and interacting with a peer who is skilled and accomplished in that specific operation. SAGES will facilitate this process by developing a list of mentoring opportunities available for specific laparoscopic operations. 3. Fellowships: Postgraduate training in advanced laparoscopic surgery is another means by which faculty or faculty candidates may obtain experience. Such programs should not detract from the experience of the surgical residency training where they coexist. SAGES believes the main goal of such fellowships should be to train future faculty.
surgeons had not had any formal training, and only 50% trained their residents in the technique. In 1998, SAGES’ position paper was published, entitled “Integrating advanced laparoscopy into surgical residency training.”11 The aim was to train faculty, train residents, and provide guidelines for post residency training for prospective faculty. The training structure presented in Tables 1 (faculty training) and 2 (resident training). The intention was to suggest curriculum guidelines for resident training in advanced laparoscopic surgery. Lin and coworkers published the results of their training program for six senior surgical residents delivered over a 2- to 3-month period.12 The components of training consisted of animal laboratory sessions, tutorial sessions, and feedback. The animal laboratory sessions were oriented around six specific skills (suturing, adhesiolysis, stapling, vascular control, anastomosis, and the use of energy devices, eg, ultrasonic dissectors), while preoperative tutorials with a mentor went through preoperative planning, operative strategies with the use of videos, books, and diagrams. Postoperative briefings enabled video-based feedback to be provided to the residents. The efficacy of this approach was analyzed through comparison of outcomes of laparoscopic colectomy for residents over a 3-year period (n ⫽ 100) with retrospective data from faculty-led procedures (n ⫽ 20). Each resident performed an average of 17 cases (range 11 to 29), with no differences in operative time when compared with faculty data. The conversion rate for the residents dropped from 30 to 14% from years 1 to 3, compared with 19% for faculty-led procedures. These are encouraging results for the uptake of laparoscopic colorectal practice during the residency years.
Laparoscopic colorectal surgical training Table 2 Resident Training 1. Courses: Courses in advanced laparoscopic procedures are one method of introducing skills. SAGES plans to offer ongoing courses for residents and, when necessary, an accompanying faculty member, for a laboratory experience in advanced laparoscopic surgery. 2. Skills labs: The creation of inanimate and animal training facilities by individual programs is encouraged to provide supplemental teaching of advanced laparoscopic surgical skills. SAGES will facilitate the acquisition of or access to advanced laparoscopic equipment and skills lab facilities. 3. Needs assessment: SAGES will continue to assess the needs of residency programs both in terms of faculty training and in overall program needs. 4. Reexamination of residency training: Optimal training in a general surgery residency includes an adequate experience in both advanced open and laparoscopic procedures. Data suggest that case load is insufficient to produce such an experience. SAGES suggests that the appropriate leadership organizations consider reexamining the flexibility of the general surgery residency training to optimize the availability of such advanced cases for residents planning a career in general surgery. 5. Educational resources: SAGES will continue to offer other educational endeavors such as postgraduate courses, annual meetings, an extensive video library, a syllabus on topics in endoscopic and laparoscopic surgery for residents, a curriculum guideline for residency training in endoscopic and laparoscopic surgery, guidelines for credentialing, training, and standards of practice. A separate candidate membership category exists for residents and fellows.
A Laparoscopic Colorectal Surgery Training Curriculum The aim of this initiative is to develop a structured, proficiencybased training program, along the lines of work published by SAGES and the American Society of Colorectal Surgeons. This curriculum needs to be evidence-based and safety-orientated, with a heavy emphasis on the use of simulated tissues to teach skills required for commencement of independent practice in laparoscopic colorectal procedures. The facets of curricular design are taken from a previously published framework of technical skills training, known as Systematic Training and Assessment in Technical Skills.13 The mainstay of this framework is in five sections, illustrated in Figure 1.
117 c. d. e. f.
anatomic knowledge safety and limitations of specific instruments ergonomics postprocedure management
Within this mode of learning, it is crucial to teach likely errors that can occur during an operative procedure, enabling trainees to anticipate and avoid errors, or to identify when errors have been committed, along with strategies to manage them.14 The trainee must be proficient in these categories before technical skills training. This can be assessed via a paperbased examination (or viva voce), which must be passed according to a preset mark before progression onto the next step of the curriculum.
Task Deconstruction of the Procedure To develop a systematic approach to technical skills training, it is necessary to fragment a procedure into its constituent parts. The ideal manner in which to do this is through observation of a complete procedure. However, different strategies are regularly used by different operators, so it is necessary to observe procedures performed by a number of experienced clinicians. This can be achieved through video-based recording of the procedure, and then by dividing the procedure into steps and substeps. Ideally, the procedure is fragmented into
Knowledge-Based Learning Paper-based examination
Task Deconstruction of the Procedure Video recording of procedures Define key tasks Define tool for assessment
Training in a Laboratory Environment Develop training model Validate model
Transfer of Skills to the Real Environment
Knowledge-based Learning A systematic approach to learning begins with the acquisition of procedure-specific knowledge. These have been broadly (and arbitrarily) defined into the following categories: a. preprocedure assessment b. preprocedure preparation
Granting Privileges for Independent Practice Figure 1 Systematic training and assessment in technical skills (STATS). (Color version of figure is available online.)
118 Table 3 Task Decomposition for Laparoscopic Anterior Resection ● Access and port insertion ● Sigmoid dissection and identification of vascular pedicle ● Placement of graspers ● Traction-countertraction ● Exposure of mesosigmoid ● Identification of dissection plane ● Identification of structures ● Transection of vessels and bowel ● Total mesorectal dissection ● Plane for dissection ● Mode of dissection ● Completion of dissection ● Transection of rectum ● Recto-sigmoid anastomosis ● Placement of anvil ● Trans-anal placement of circular stapler ● Approximation of anvil and stapler ● Check anastomosis (anterior and posterior) ● Remove ports and close
6 to 10 tasks, with a suggested mode shown in Table 3 for laparoscopic anterior resection. This can lead to the identification of key tasks, eg, laparoscopic total mesorectal excision, which can be used to form the basis of an assessment process. By recording videos of inexperienced operators performing the same procedure, and comparing performance at each stage with that of expert surgeons, it is possible to define the most challenging parts of the procedure. These shall be the tasks with the greatest differences in task completion indices, such as time taken, economy of motion, errors committed, etc. A framework of key task definitions can also enable institutions and commercial companies involved in developing models for surgical skills training to direct efforts toward simulation of particular tasks, rather than procedure-based simulation models, which inevitably take longer to develop and tend to be more expensive. Additional research may be able to define common key tasks between different procedures and enable the trainee to learn the skills required to perform more than one procedure.
Training in a Laboratory Environment Once the key tasks of a real procedure have been identified, it is necessary to develop a suitable model for training. The ideal platform for training may be said to be the patient, although this can be problematic for learning new skills. Training on patients occurs through chance encounters, rather than along a structured and stepwise mode of progression. It is often difficult to predict the intraoperative complexity of a procedure, leading to “takeover” by the senior surgeon and the loss of a hands-on training opportunity. Patient safety is, of course, the most important factor when acquiring or honing skills in the operating room; the skills laboratory enables primacy of the trainees’ goals, regardless of complication or error. In addition, specific tasks can be repeated over and over again, with time available during the
R. Aggarwal and T. Grantcharov session to stop for discussion, feedback, or evaluation, until proficiency is achieved. Although training within the operating room is a necessary part of surgical education, the aim is to reduce the length of the learning curve so that surgical novices are not subjected to the acquisition of new skills through practice on patients. The development of technical skills laboratories and advancements in simulation technology can allow trainees to learn the skills required in a safe environment on standardized models, which can then transfer to improved performance in the real environment.15 With regard to laparoscopic colorectal procedures, training may occur on human cadaveric, animal-based, synthetic, and virtual reality models. There is a great deal of interest in the application of virtual reality devices for acquisition of skills to perform laparoscopic colorectal surgery, although at present there is only one simulator that has a commercial product for this procedure.16 The ProMIS simulator developed by Haptica (Dublin, Ireland) enables training in handassisted colorectal surgery, and, while the simulator provides a realistic anatomical interpretation of the procedure, the device is bulky and expensive. Another feature of simulator-based training is the ability to train on standardized tasks, enabling difficult levels to be modified according to experience level.17 This can lead to the delivery of a stepwise training curriculum, whereby a trainee has to pass level 2 before commencing on tasks in level 3. To characterize such a curriculum, it is necessary to validate and then define benchmark levels of skill to be achieved before completion of the task, level, or module. Validation of the simulated models involves not only the physical model used but also the assessment parameters used to differentiate between the three groups of practitioners. Assessment of technical skill must be objective, reliable, and easy to perform.18 Current systems for this type of assessment can be divided into dexterity-based and video-analysis systems. Dexterity-based systems record parameters such as time taken, path length, number of movements, and trajectories of the hand or instrument tip. Video analysis provides a qualitative method of assessment, but quantification of performance through definition of correct steps and errors, although labor intensive, is a powerful mode of both formative and summative assessment. In this vein, a procedure-specific global rating scale has been developed for assessment of performance during a laparoscopic anterior resection (Table 4). The scale epitomizes the task-based approach by defining criteria at each of 14 tasks, rated from a scale of 1 to 5. Thus, the total score possible is 70, with a suggested competency level of 3 at each task, ie, score 42.
Transfer of Skills to the Real Environment It is essential to confirm that skills improve when training on a particular task, but it is also necessary to ensure that achievement of expert performance on the one or two key tasks will lead to proficiency at performing the entire procedure on a real patient. In this case, the learning curve for achieving procedural proficiency on a patient should be pri-
Specific Skill I. Access Access and port insertion
1 Poorly positioned ports, dangerous insertion techniques employed.
II. Sigmoid dissection and identification of IMA Placement of graspers Graspers traumatize bowel, cause bleeding and often clashing.
Traction-countertraction
Exposure of the mesosigmoid
Assistant traction is poorly used, ie, placed too far from area to dissect, angle of traction is pulling rather than exposing at an angle. Graspers do not place mesocolon under tension, continual readjustments necessary, ie, stop-start.
Identification of the plane for dissection
Dissection leads to excessive bleeding, plane of dissection never identified. Excessive use of high-energy devices.
Identification of structures
Mesocolon divided without identification of IMA and its branches.
Transection of vessels and bowel
Bowel transection and vessel division is traumatic. Excessive bleeding and leak of bowel contents. Vessels transected too close to the bowel.
III. Total mesorectal dissection Plane for dissection Excessive use of high-energy devices; excessive bleeding; plane not identified.
Mode of dissection
Haphazard dissection of mesorectum; lack of appreciation for importance of traction and countertraction for exposure of area to be dissected; lack of respect for ureters and sacral nerves.
2
3
4
5
Slow and careful in deciding where to position ports, access is appropriate but hesitant in nature.
Optimal port positioning, efficient mode of access with respect for intra-abdominal contents.
Gentle handling of bowel; graspers provide adequate exposure, though sometimes unergonomic placement of retractors. Assistant traction inconsistently sufficient. Often need for correction and reposition.
Gentle handling of bowel; graspers work in complementary manner.
Adequate exposure to allow dissection, though sometimes suboptimal, necessitating occasional readjustments. Repeated attempts before identification of the right plane, associated with minor bleeding points, which are managed effectively. IMA and branches identified after extensive and sometimes traumatic dissection. Division of vessels and transaction of bowel are adequate, though repeated attempts necessary.
Plane identified after several attempts at dissection, associated with unnecessary damage and some bleeding. Adequate dissection, although unsystematic, especially laterally. Single episodes with poor exposure and visualization of the area being dissected.
Laparoscopic colorectal surgical training
Table 4 Global Rating Scale for Laparoscopic Anterior Resection
Assistant traction used to optimal standard, ie, triangulates areas of dissection, repositions as necessary, and ensures exposes at correct angle. Excellent exposure at all times, ie, mesocolon always under tension.
Dissection is through a bloodless plane, blunt predominantly rather than sharp or with high-energy devices.
IMA clearly identified, and dissection centered around this structure and its branches. Stepwise dissection of vessels and bowel. Vessels transected with optimal distance from the bowel. No bleeding or leak of bowel contents. Identifies bloodless plane posteriorly at first using blunt dissection techniques.
Posterior dissection extended laterally in a systematic manner; excellent traction, and countertraction to maintain exposure of area to be dissected at all times; defines ureters and sacral nerves.
119
R. Aggarwal and T. Grantcharov Clear and precise instructions to assistant; intra-abdominal traction and retraction to aid accurate placement of stapler. Instructs assistant to maneuver stapler for ease of insertion of anvil; rapid and accurate placement of anvil into stapler in one fluid movement.
Accurate purse-string suture; anvil placed securely.
At ease with use of stapler; direct positioning of rectum within jaws.
Mesorectal dissection is complete; rectum is freely mobile.
Approximation performed adequately, though necessitated more than one attempt and did not demonstrate fluidity of movements.
Purse-string placed adequately, though necessitates more than one attempt. Anvil is placed securely. Slow, hesitant, but correct placement of the stapler, with appropriate instructions to assistant.
Dissection performed incompletely, however, rectum sufficiently mobile for transection of tumor. Rectum transected appropriately, though with more than one attempt to align stapler.
Contradictory instructions to assistant; excessive force applied transanally.
No instructions to assistant; numerous failed attempts to position anvil. Approximation of anvil and circular stapler
Unaware of how stapler functions; continual readjustment within pelvis; insufficient distance to distal tumor margin. Transection of the rectum
Transanal placement of circular stapler
Rectum remains attached at multiple points; mesorectal dissection incomplete. Completion of dissection
IV. Recto-sigmoid anastomosis Extra-abdominal Purse-string placed with lack of respect for placement of the anvil bowel edges; anvil is loose.
1 Specific Skill
Table 4 Continued
2
3
4
5
120
marily a function of the knowledge required to integrate the technical skills learned from training in the laboratory environment. Transfer of skills from the laboratory environment to real scenarios has been demonstrated for laparoscopic cholecystectomy and gastrointestinal endoscopy, although one of the main obstacles has been which tools to use for assessment of real procedures.19,20 It is certainly possible that the same tool for assessment of skill during the simulated procedure could be used to assess real performance (Table 4). In this case, it is also necessary to ensure there is built-in stratification to grade the difficulty of the real procedure to ensure the assessment is of technical skill rather than patient or disease variability.
Granting Privileges for Independent Practice A structured training program using a curriculum approach can provide graded teaching sessions. These sessions are targeted toward a specific group of doctors and, with preset expert-based benchmark criteria to be achieved at every stage of the curriculum, can ensure that everyone in the group benefits from the program. This benefit increases the motivation of both trainees and faculty involved, providing a more personal approach to technical skills acquisition. The curriculum should provide formative feedback to trainees and can also provide a clear indication of those who are falling behind and require further attention from their trainer. Completion of the curriculum though is not the endpoint to be achieved. On the basis of performance criteria, trainees can begin to perform laparoscopic colorectal resections in the company of an experienced surgeon. Gradually, the experienced surgeon will be less hands-on during the cases, leading to the concept of independent practice. It is during this early phase of independent practice that the newly qualified surgeon must accurately and honestly audit their practice. Crude examples are on the basis of morbidity and mortality data, conversion rates, time taken to perform the procedure, etc. It is also thought possible to undertake video review of the procedures in a blinded manner, rated on the aforementioned scale (Table 4). The involvement of credentialing bodies to certify one’s practice to independently perform laparoscopic colorectal procedures occurs throughout the training curriculum, although it is at this final stage that the surgeon can achieve their passport to continue practice. Those physicians who fail to make the grade should repeat constituent parts of the curriculum, but there is a possibility that some shall continue to lack the skills to become, or remain, competent. The medical profession must deal with this issue head-on by ensuring that the scientific base developed from a competency-based training curriculum is openly available so judgments of this nature can be made.
Training of the Operating Room Team It is unfortunate that a number of training courses for advanced surgical procedures are aimed solely at the primary
Laparoscopic colorectal surgical training practitioner. When a surgeon learns a new technique, it is also necessary for the “scrub team” to be aware of any changes in the operating room setup, be able to handle and setup new instruments, and to know any particular nuances of the procedure to be performed.21 This is traditionally learned through an experiential mode, leading to lengthened operating times, communication difficulties, and increased stress during surgery. It is with this background that an additional, although nonetheless important, part of the training program is to deliver team-based training for laparoscopic colorectal surgery. Studies in the aviation industry have stressed the role of human factors in causing error and, in an attempt to reduce the occurrence of adverse events, led to the organization of simulation-based training scenarios. Similar strategies have recently been employed for the surgical team with the development of a simulated operating room project.22 This enables technical and nontechnical performance of the surgeon and circulating staff to be assessed by experts situated in an adjacent control room and provides an opportunity for constructive feedback.23 In this way, it would be possible for the entire surgical team to practice technical and non-technical skills such as communication, team-building, leadership, and decisionmaking in a safe and monitored scenario. Particular examples are setup of the laparoscopic equipment and ability to convert to an open procedure in the face of uncontrolled bleeding, ie, crisis scenarios. This enables the team to be tested to the edge of their capabilities before performing real cases in the operating room. Once again, performance can be assessed during these standardized scenarios, adding to the proficiency-based nature of the training program.
Conclusions Incorporation of advanced laparoscopic surgical skills, in the manner required for laparoscopic colorectal surgery, during residency, and the delivery of laparoscopic colonic resections to our patients, is a dynamic process. The curriculum suggested in this article is a generic structure that is not intended to be either comprehensive or exhaustive. The aim was to provide a stepwise, structured, and proficiency-based model for acquisition of advanced laparoscopic skills, for the safe introduction of laparoscopic techniques to colorectal practice. A key aspect of the curriculum is to focus on training the trainers, and it is with this advancement that opportunities shall evolve for surgical residents to learn these novel techniques. This shall lead to the safe delivery of such procedures, enabling patients to benefit from superior outcomes when compared with traditional open surgical approaches.
121
References 1. Aggarwal R, Moorthy K, Darzi A: Laparoscopic skills training and assessment. Br J Surg 91:1549-1558, 2004 2. Jacobs M, Verdeja JC, Goldstein HS: Minimally invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc 1:144-150, 1991 3. Falk PM, Beart RW Jr, Wexner SD, et al: Laparoscopic colectomy: a critical appraisal. Dis Colon Rectum 36:28-34, 1993 4. Guillou PJ, Darzi A, Monson JR: Experience with laparoscopic colorectal surgery for malignant disease. Surg Oncol 2:43-49, 1993 (suppl 1) 5. Milsom JW, Fazio VW: Concerns about laparoscopic colon cancer surgery. Dis Colon Rectum 37:625-626, 1994 6. Stage JG, Schulze S, Moller P, et al: Prospective randomized study of laparoscopic versus open colonic resection for adenocarcinoma. Br J Surg 84:391-396, 1997 7. Lacy AM, Delgado S, Garcia-Valdecasas JC, et al: Port site metastases and recurrence after laparoscopic colectomy. A randomized trial. Surg Endosc 12:1039-1042, 1998 8. Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 350:2050-2059, 2004 9. Tekkis PP, Senagore AJ, Delaney CP, et al: Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections. Ann Surg 242:83-91, 2005 10. Harinath G, Shah PR, Haray PN, et al: Laparoscopic colorectal surgery in Great Britain and Ireland—where are we now? Colorectal Dis 7:8689, 2005 11. Society of American Gastrointestinal Endoscopic Surgeons. Integrating advanced laparoscopy into surgical residency training. Society of American Gastrointestinal Endoscopic Surgeons (SAGES). Surg Endosc 12: 374-376, 1998 12. Lin E, Szomstein S, Addasi T, et al: Model for teaching laparoscopic colectomy to surgical residents. Am J Surg 186:45-48, 2003 13. Aggarwal R, Grantcharov TP, Darzi A: Framework for systematic training and assessment of technical skills. J Am Coll Surg 204:697-705, 2007 14. Rogers DA, Regehr G, MacDonald J: A role for error training in surgical technical skill instruction and evaluation. Am J Surg 183:242-245, 2002 15. Aggarwal R, Darzi A: Technical-skills training in the 21st century. N Engl J Med 355:2695-2696, 2006 16. Carter FJ, Schijven MP, Aggarwal R, et al: Consensus guidelines for validation of virtual reality surgical simulators. Surg Endosc 19:15231532, 2005 17. Aggarwal R, Grantcharov T, Moorthy K, et al: A competency-based virtual reality training curriculum for the acquisition of laparoscopic psychomotor skill. Am J Surg 191:128-133, 2006 18. Moorthy K, Munz Y, Sarker SK, et al: Objective assessment of technical skills in surgery. BMJ 327:1032-1037, 2003 19. Grantcharov TP, Kristiansen VB, Bendix J, et al: Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Br J Surg 91:146-150, 2004 20. Sedlack RE, Kolars JC: Computer simulator training enhances the competency of gastroenterology fellows at colonoscopy: results of a pilot study. Am J Gastroenterol 99:33-37, 2004 21. Yule S, Flin R, Paterson-Brown S, et al: Non-technical skills for surgeons in the operating room: a review of the literature. Surgery 139: 140-149, 2006 22. Aggarwal R, Undre S, Moorthy K, et al: The simulated operating theatre: comprehensive training for surgical teams. Qual Saf Health Care 13:i27-i32, 2004 (suppl 1) 23. Moorthy K, Munz Y, Adams S, et al: A human factors analysis of technical and team skills among surgical trainees during procedural simulations in a simulated operating theatre. Ann Surg 242:631-639, 2005
M
inimal access surgical techniques are now considered to be the gold standard for biliary, antireflux, and bariatric surgery.1 This is mainly due to improved patient recovery in terms of reduced pain, a shorter hospital stay, and a quicker return to normal daily activities. More recently, there has been a drive toward the application of laparoscopic techniques to large bowel surgery. Although oncological clearance margins and survival are the primary outcomes that determine success from colorectal cancer resections, it is important to consider the secondary outcomes such as a reduction in postoperative complications, time taken to recover from surgery, urinary continence, and sexual function as determinants of quality of life post resection. It is these latter factors that have been suggested to be improved by a laparoscopic approach. Since the first laparoscopic colon resection for malignancy in 1991,2 a number of initial series have been reported to*Department of Biosurgery and Surgical Technology, Imperial College London, London, United Kingdom, Toronto, Canada. †Division of General Surgery, St. Michael’s Hospital, University of Toronto, Toronto, Canada. Address reprint requests to R. Aggarwal, Specialist Registrar/Honorary Clinical Research Fellow, Department of Biosurgery and Surgical Technology, Imperial College London, 10th Floor, QEQM Building, St. Mary’s Hospital, Praed Street, London, W2 1NY, United Kingdom. E-mail: [email protected].
1043-1489/08/$-see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1053/j.scrs.2008.02.008
gether with comments regarding the technical delivery of the procedure, lengthy operative times, high conversion rates, and concern regarding iatrogenic tumor dissemination.2-5 The first randomized prospective trial comparing open and laparoscopic approaches to colorectal cancer resections was a small study of 29 patients performed by Stage and coworkers in Denmark in 1997.6 Their conclusions demonstrated the feasibility and oncologic safety of laparoscopic surgery but were difficult to accept due to the small sample size. Lacy and coworkers confirmed the initial reports from nonrandomized trials and revealed recurrence rates comparable to those of open surgery, and a low incidence of port-site metastases.7 These initial trials set the scene for large, prospective, multicenter randomized trials published within the last few years. In 2004, the Clinical Outcomes of Surgical Therapy Study Group of the Laparoscopic Colectomy Trial reported their findings of a multi-institution prospective randomized trial of 872 in the New England Journal of Medicine.8 Patients with adenocarcinoma of the colon underwent open or laparoscopically assisted colectomy performed by credentialed surgeons. The median follow-up was 4.4 years. The primary endpoint was the time to tumor recurrence. At 3 years, the rates of recurrence were similar in the two groups—16% among patients in the group that underwent laparoscopically assisted surgery and 18% among patients in the open-colectomy group (P ⫽ 0.32). 115
R. Aggarwal and T. Grantcharov
116 The overall survival rate at 3 years was also very similar in the two groups (86% in the laparoscopic surgery group and 85% in the open-colectomy group, P ⫽ 0.51). Perioperative recovery was faster in the laparoscopic-surgery group than in the open-colectomy group, as reflected by a shorter median hospital stay (5 days versus 6 days, P ⬍ 0.001) and briefer use of parenteral narcotics (3 days versus 4 days, P ⬍ 0.001) and oral analgesics (1 day versus 2 days, P ⫽ 0.02). The rates of intraoperative complications, 30-day postoperative mortality, complications at discharge and 60 days, hospital readmission, and reoperation were very similar between groups. The authors concluded that rates of recurrent cancer were similar after laparoscopically assisted colectomy and open colectomy, suggesting that the laparoscopic approach is an acceptable alternative to open surgery for colon cancer.
The Learning Curve for Laparoscopic Colectomy A particular comment with regard to the aforementioned trials is the nature of the learning curve to perform laparoscopic colorectal oncological procedures. This has been stated to be on the order of 50 to 400 procedures for a variety of different resections. This is known to vary between surgeons and can also be influenced by patient selection and operative complexity. Tekkis and coworkers published results of 900 patients undergoing laparoscopic colorectal resections from November 1991 through April 2003.9 The conversion rate for right-sided colonic resections was 8.1% compared with 15.3% for left-sided resections. A risk-adjusted cumulative sum analysis demonstrated a learning curve of 55 cases for right-sided colonic resections versus 62 cases for the left side. Possible strategies to surmount the learning curve were suggested to include formal training courses, close intraoperative supervision by expert practitioners, and assistance form other well-trained staff. In July 2005, The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in collaboration with The American Society of Colorectal Surgeons published clinical practice guidelines regarding the safety of utilizing a laparoscopic approach for malignant colorectal disease. The mainstay of the guidelines were to ensure appropriate preoperative staging, bowel preparation to enable ease of laparoscopic manipulation of the bowel, together with adherence to standard oncologic principles. The article also stated that “adequate training and experience are necessary to perform an appropriate oncological resection.”
The Components for Advanced Laparoscopic Training Curricula In 2005, Harinath and coworkers published their results of a postal questionnaire to 540 colorectal surgeons in the United Kingdom.10 From the 200 who responded, only 45 (23%) practiced laparoscopic colorectal work, the majority being for right hemicolectomy and stoma formation. Nearly 22% of
Table 1 Faculty Training 1. Courses: “Hands-on” courses are useful for conveying the techniques of laparoscopic operations to those who are proficient in the similar open operations. Faculty members interested in obtaining advanced laparoscopic training may benefit from advanced laparoscopic courses. SAGES will provide an opportunity for faculty members to participate in advanced laparoscopic surgical courses. 2. Faculty mentoring: SAGES believes that faculty who have already acquired the fundamental skills in advanced laparoscopic surgery and who desire to learn a new or modified laparoscopic operation will benefit from observing and interacting with a peer who is skilled and accomplished in that specific operation. SAGES will facilitate this process by developing a list of mentoring opportunities available for specific laparoscopic operations. 3. Fellowships: Postgraduate training in advanced laparoscopic surgery is another means by which faculty or faculty candidates may obtain experience. Such programs should not detract from the experience of the surgical residency training where they coexist. SAGES believes the main goal of such fellowships should be to train future faculty.
surgeons had not had any formal training, and only 50% trained their residents in the technique. In 1998, SAGES’ position paper was published, entitled “Integrating advanced laparoscopy into surgical residency training.”11 The aim was to train faculty, train residents, and provide guidelines for post residency training for prospective faculty. The training structure presented in Tables 1 (faculty training) and 2 (resident training). The intention was to suggest curriculum guidelines for resident training in advanced laparoscopic surgery. Lin and coworkers published the results of their training program for six senior surgical residents delivered over a 2- to 3-month period.12 The components of training consisted of animal laboratory sessions, tutorial sessions, and feedback. The animal laboratory sessions were oriented around six specific skills (suturing, adhesiolysis, stapling, vascular control, anastomosis, and the use of energy devices, eg, ultrasonic dissectors), while preoperative tutorials with a mentor went through preoperative planning, operative strategies with the use of videos, books, and diagrams. Postoperative briefings enabled video-based feedback to be provided to the residents. The efficacy of this approach was analyzed through comparison of outcomes of laparoscopic colectomy for residents over a 3-year period (n ⫽ 100) with retrospective data from faculty-led procedures (n ⫽ 20). Each resident performed an average of 17 cases (range 11 to 29), with no differences in operative time when compared with faculty data. The conversion rate for the residents dropped from 30 to 14% from years 1 to 3, compared with 19% for faculty-led procedures. These are encouraging results for the uptake of laparoscopic colorectal practice during the residency years.
Laparoscopic colorectal surgical training Table 2 Resident Training 1. Courses: Courses in advanced laparoscopic procedures are one method of introducing skills. SAGES plans to offer ongoing courses for residents and, when necessary, an accompanying faculty member, for a laboratory experience in advanced laparoscopic surgery. 2. Skills labs: The creation of inanimate and animal training facilities by individual programs is encouraged to provide supplemental teaching of advanced laparoscopic surgical skills. SAGES will facilitate the acquisition of or access to advanced laparoscopic equipment and skills lab facilities. 3. Needs assessment: SAGES will continue to assess the needs of residency programs both in terms of faculty training and in overall program needs. 4. Reexamination of residency training: Optimal training in a general surgery residency includes an adequate experience in both advanced open and laparoscopic procedures. Data suggest that case load is insufficient to produce such an experience. SAGES suggests that the appropriate leadership organizations consider reexamining the flexibility of the general surgery residency training to optimize the availability of such advanced cases for residents planning a career in general surgery. 5. Educational resources: SAGES will continue to offer other educational endeavors such as postgraduate courses, annual meetings, an extensive video library, a syllabus on topics in endoscopic and laparoscopic surgery for residents, a curriculum guideline for residency training in endoscopic and laparoscopic surgery, guidelines for credentialing, training, and standards of practice. A separate candidate membership category exists for residents and fellows.
A Laparoscopic Colorectal Surgery Training Curriculum The aim of this initiative is to develop a structured, proficiencybased training program, along the lines of work published by SAGES and the American Society of Colorectal Surgeons. This curriculum needs to be evidence-based and safety-orientated, with a heavy emphasis on the use of simulated tissues to teach skills required for commencement of independent practice in laparoscopic colorectal procedures. The facets of curricular design are taken from a previously published framework of technical skills training, known as Systematic Training and Assessment in Technical Skills.13 The mainstay of this framework is in five sections, illustrated in Figure 1.
117 c. d. e. f.
anatomic knowledge safety and limitations of specific instruments ergonomics postprocedure management
Within this mode of learning, it is crucial to teach likely errors that can occur during an operative procedure, enabling trainees to anticipate and avoid errors, or to identify when errors have been committed, along with strategies to manage them.14 The trainee must be proficient in these categories before technical skills training. This can be assessed via a paperbased examination (or viva voce), which must be passed according to a preset mark before progression onto the next step of the curriculum.
Task Deconstruction of the Procedure To develop a systematic approach to technical skills training, it is necessary to fragment a procedure into its constituent parts. The ideal manner in which to do this is through observation of a complete procedure. However, different strategies are regularly used by different operators, so it is necessary to observe procedures performed by a number of experienced clinicians. This can be achieved through video-based recording of the procedure, and then by dividing the procedure into steps and substeps. Ideally, the procedure is fragmented into
Knowledge-Based Learning Paper-based examination
Task Deconstruction of the Procedure Video recording of procedures Define key tasks Define tool for assessment
Training in a Laboratory Environment Develop training model Validate model
Transfer of Skills to the Real Environment
Knowledge-based Learning A systematic approach to learning begins with the acquisition of procedure-specific knowledge. These have been broadly (and arbitrarily) defined into the following categories: a. preprocedure assessment b. preprocedure preparation
Granting Privileges for Independent Practice Figure 1 Systematic training and assessment in technical skills (STATS). (Color version of figure is available online.)
118 Table 3 Task Decomposition for Laparoscopic Anterior Resection ● Access and port insertion ● Sigmoid dissection and identification of vascular pedicle ● Placement of graspers ● Traction-countertraction ● Exposure of mesosigmoid ● Identification of dissection plane ● Identification of structures ● Transection of vessels and bowel ● Total mesorectal dissection ● Plane for dissection ● Mode of dissection ● Completion of dissection ● Transection of rectum ● Recto-sigmoid anastomosis ● Placement of anvil ● Trans-anal placement of circular stapler ● Approximation of anvil and stapler ● Check anastomosis (anterior and posterior) ● Remove ports and close
6 to 10 tasks, with a suggested mode shown in Table 3 for laparoscopic anterior resection. This can lead to the identification of key tasks, eg, laparoscopic total mesorectal excision, which can be used to form the basis of an assessment process. By recording videos of inexperienced operators performing the same procedure, and comparing performance at each stage with that of expert surgeons, it is possible to define the most challenging parts of the procedure. These shall be the tasks with the greatest differences in task completion indices, such as time taken, economy of motion, errors committed, etc. A framework of key task definitions can also enable institutions and commercial companies involved in developing models for surgical skills training to direct efforts toward simulation of particular tasks, rather than procedure-based simulation models, which inevitably take longer to develop and tend to be more expensive. Additional research may be able to define common key tasks between different procedures and enable the trainee to learn the skills required to perform more than one procedure.
Training in a Laboratory Environment Once the key tasks of a real procedure have been identified, it is necessary to develop a suitable model for training. The ideal platform for training may be said to be the patient, although this can be problematic for learning new skills. Training on patients occurs through chance encounters, rather than along a structured and stepwise mode of progression. It is often difficult to predict the intraoperative complexity of a procedure, leading to “takeover” by the senior surgeon and the loss of a hands-on training opportunity. Patient safety is, of course, the most important factor when acquiring or honing skills in the operating room; the skills laboratory enables primacy of the trainees’ goals, regardless of complication or error. In addition, specific tasks can be repeated over and over again, with time available during the
R. Aggarwal and T. Grantcharov session to stop for discussion, feedback, or evaluation, until proficiency is achieved. Although training within the operating room is a necessary part of surgical education, the aim is to reduce the length of the learning curve so that surgical novices are not subjected to the acquisition of new skills through practice on patients. The development of technical skills laboratories and advancements in simulation technology can allow trainees to learn the skills required in a safe environment on standardized models, which can then transfer to improved performance in the real environment.15 With regard to laparoscopic colorectal procedures, training may occur on human cadaveric, animal-based, synthetic, and virtual reality models. There is a great deal of interest in the application of virtual reality devices for acquisition of skills to perform laparoscopic colorectal surgery, although at present there is only one simulator that has a commercial product for this procedure.16 The ProMIS simulator developed by Haptica (Dublin, Ireland) enables training in handassisted colorectal surgery, and, while the simulator provides a realistic anatomical interpretation of the procedure, the device is bulky and expensive. Another feature of simulator-based training is the ability to train on standardized tasks, enabling difficult levels to be modified according to experience level.17 This can lead to the delivery of a stepwise training curriculum, whereby a trainee has to pass level 2 before commencing on tasks in level 3. To characterize such a curriculum, it is necessary to validate and then define benchmark levels of skill to be achieved before completion of the task, level, or module. Validation of the simulated models involves not only the physical model used but also the assessment parameters used to differentiate between the three groups of practitioners. Assessment of technical skill must be objective, reliable, and easy to perform.18 Current systems for this type of assessment can be divided into dexterity-based and video-analysis systems. Dexterity-based systems record parameters such as time taken, path length, number of movements, and trajectories of the hand or instrument tip. Video analysis provides a qualitative method of assessment, but quantification of performance through definition of correct steps and errors, although labor intensive, is a powerful mode of both formative and summative assessment. In this vein, a procedure-specific global rating scale has been developed for assessment of performance during a laparoscopic anterior resection (Table 4). The scale epitomizes the task-based approach by defining criteria at each of 14 tasks, rated from a scale of 1 to 5. Thus, the total score possible is 70, with a suggested competency level of 3 at each task, ie, score 42.
Transfer of Skills to the Real Environment It is essential to confirm that skills improve when training on a particular task, but it is also necessary to ensure that achievement of expert performance on the one or two key tasks will lead to proficiency at performing the entire procedure on a real patient. In this case, the learning curve for achieving procedural proficiency on a patient should be pri-
Specific Skill I. Access Access and port insertion
1 Poorly positioned ports, dangerous insertion techniques employed.
II. Sigmoid dissection and identification of IMA Placement of graspers Graspers traumatize bowel, cause bleeding and often clashing.
Traction-countertraction
Exposure of the mesosigmoid
Assistant traction is poorly used, ie, placed too far from area to dissect, angle of traction is pulling rather than exposing at an angle. Graspers do not place mesocolon under tension, continual readjustments necessary, ie, stop-start.
Identification of the plane for dissection
Dissection leads to excessive bleeding, plane of dissection never identified. Excessive use of high-energy devices.
Identification of structures
Mesocolon divided without identification of IMA and its branches.
Transection of vessels and bowel
Bowel transection and vessel division is traumatic. Excessive bleeding and leak of bowel contents. Vessels transected too close to the bowel.
III. Total mesorectal dissection Plane for dissection Excessive use of high-energy devices; excessive bleeding; plane not identified.
Mode of dissection
Haphazard dissection of mesorectum; lack of appreciation for importance of traction and countertraction for exposure of area to be dissected; lack of respect for ureters and sacral nerves.
2
3
4
5
Slow and careful in deciding where to position ports, access is appropriate but hesitant in nature.
Optimal port positioning, efficient mode of access with respect for intra-abdominal contents.
Gentle handling of bowel; graspers provide adequate exposure, though sometimes unergonomic placement of retractors. Assistant traction inconsistently sufficient. Often need for correction and reposition.
Gentle handling of bowel; graspers work in complementary manner.
Adequate exposure to allow dissection, though sometimes suboptimal, necessitating occasional readjustments. Repeated attempts before identification of the right plane, associated with minor bleeding points, which are managed effectively. IMA and branches identified after extensive and sometimes traumatic dissection. Division of vessels and transaction of bowel are adequate, though repeated attempts necessary.
Plane identified after several attempts at dissection, associated with unnecessary damage and some bleeding. Adequate dissection, although unsystematic, especially laterally. Single episodes with poor exposure and visualization of the area being dissected.
Laparoscopic colorectal surgical training
Table 4 Global Rating Scale for Laparoscopic Anterior Resection
Assistant traction used to optimal standard, ie, triangulates areas of dissection, repositions as necessary, and ensures exposes at correct angle. Excellent exposure at all times, ie, mesocolon always under tension.
Dissection is through a bloodless plane, blunt predominantly rather than sharp or with high-energy devices.
IMA clearly identified, and dissection centered around this structure and its branches. Stepwise dissection of vessels and bowel. Vessels transected with optimal distance from the bowel. No bleeding or leak of bowel contents. Identifies bloodless plane posteriorly at first using blunt dissection techniques.
Posterior dissection extended laterally in a systematic manner; excellent traction, and countertraction to maintain exposure of area to be dissected at all times; defines ureters and sacral nerves.
119
R. Aggarwal and T. Grantcharov Clear and precise instructions to assistant; intra-abdominal traction and retraction to aid accurate placement of stapler. Instructs assistant to maneuver stapler for ease of insertion of anvil; rapid and accurate placement of anvil into stapler in one fluid movement.
Accurate purse-string suture; anvil placed securely.
At ease with use of stapler; direct positioning of rectum within jaws.
Mesorectal dissection is complete; rectum is freely mobile.
Approximation performed adequately, though necessitated more than one attempt and did not demonstrate fluidity of movements.
Purse-string placed adequately, though necessitates more than one attempt. Anvil is placed securely. Slow, hesitant, but correct placement of the stapler, with appropriate instructions to assistant.
Dissection performed incompletely, however, rectum sufficiently mobile for transection of tumor. Rectum transected appropriately, though with more than one attempt to align stapler.
Contradictory instructions to assistant; excessive force applied transanally.
No instructions to assistant; numerous failed attempts to position anvil. Approximation of anvil and circular stapler
Unaware of how stapler functions; continual readjustment within pelvis; insufficient distance to distal tumor margin. Transection of the rectum
Transanal placement of circular stapler
Rectum remains attached at multiple points; mesorectal dissection incomplete. Completion of dissection
IV. Recto-sigmoid anastomosis Extra-abdominal Purse-string placed with lack of respect for placement of the anvil bowel edges; anvil is loose.
1 Specific Skill
Table 4 Continued
2
3
4
5
120
marily a function of the knowledge required to integrate the technical skills learned from training in the laboratory environment. Transfer of skills from the laboratory environment to real scenarios has been demonstrated for laparoscopic cholecystectomy and gastrointestinal endoscopy, although one of the main obstacles has been which tools to use for assessment of real procedures.19,20 It is certainly possible that the same tool for assessment of skill during the simulated procedure could be used to assess real performance (Table 4). In this case, it is also necessary to ensure there is built-in stratification to grade the difficulty of the real procedure to ensure the assessment is of technical skill rather than patient or disease variability.
Granting Privileges for Independent Practice A structured training program using a curriculum approach can provide graded teaching sessions. These sessions are targeted toward a specific group of doctors and, with preset expert-based benchmark criteria to be achieved at every stage of the curriculum, can ensure that everyone in the group benefits from the program. This benefit increases the motivation of both trainees and faculty involved, providing a more personal approach to technical skills acquisition. The curriculum should provide formative feedback to trainees and can also provide a clear indication of those who are falling behind and require further attention from their trainer. Completion of the curriculum though is not the endpoint to be achieved. On the basis of performance criteria, trainees can begin to perform laparoscopic colorectal resections in the company of an experienced surgeon. Gradually, the experienced surgeon will be less hands-on during the cases, leading to the concept of independent practice. It is during this early phase of independent practice that the newly qualified surgeon must accurately and honestly audit their practice. Crude examples are on the basis of morbidity and mortality data, conversion rates, time taken to perform the procedure, etc. It is also thought possible to undertake video review of the procedures in a blinded manner, rated on the aforementioned scale (Table 4). The involvement of credentialing bodies to certify one’s practice to independently perform laparoscopic colorectal procedures occurs throughout the training curriculum, although it is at this final stage that the surgeon can achieve their passport to continue practice. Those physicians who fail to make the grade should repeat constituent parts of the curriculum, but there is a possibility that some shall continue to lack the skills to become, or remain, competent. The medical profession must deal with this issue head-on by ensuring that the scientific base developed from a competency-based training curriculum is openly available so judgments of this nature can be made.
Training of the Operating Room Team It is unfortunate that a number of training courses for advanced surgical procedures are aimed solely at the primary
Laparoscopic colorectal surgical training practitioner. When a surgeon learns a new technique, it is also necessary for the “scrub team” to be aware of any changes in the operating room setup, be able to handle and setup new instruments, and to know any particular nuances of the procedure to be performed.21 This is traditionally learned through an experiential mode, leading to lengthened operating times, communication difficulties, and increased stress during surgery. It is with this background that an additional, although nonetheless important, part of the training program is to deliver team-based training for laparoscopic colorectal surgery. Studies in the aviation industry have stressed the role of human factors in causing error and, in an attempt to reduce the occurrence of adverse events, led to the organization of simulation-based training scenarios. Similar strategies have recently been employed for the surgical team with the development of a simulated operating room project.22 This enables technical and nontechnical performance of the surgeon and circulating staff to be assessed by experts situated in an adjacent control room and provides an opportunity for constructive feedback.23 In this way, it would be possible for the entire surgical team to practice technical and non-technical skills such as communication, team-building, leadership, and decisionmaking in a safe and monitored scenario. Particular examples are setup of the laparoscopic equipment and ability to convert to an open procedure in the face of uncontrolled bleeding, ie, crisis scenarios. This enables the team to be tested to the edge of their capabilities before performing real cases in the operating room. Once again, performance can be assessed during these standardized scenarios, adding to the proficiency-based nature of the training program.
Conclusions Incorporation of advanced laparoscopic surgical skills, in the manner required for laparoscopic colorectal surgery, during residency, and the delivery of laparoscopic colonic resections to our patients, is a dynamic process. The curriculum suggested in this article is a generic structure that is not intended to be either comprehensive or exhaustive. The aim was to provide a stepwise, structured, and proficiency-based model for acquisition of advanced laparoscopic skills, for the safe introduction of laparoscopic techniques to colorectal practice. A key aspect of the curriculum is to focus on training the trainers, and it is with this advancement that opportunities shall evolve for surgical residents to learn these novel techniques. This shall lead to the safe delivery of such procedures, enabling patients to benefit from superior outcomes when compared with traditional open surgical approaches.
121
References 1. Aggarwal R, Moorthy K, Darzi A: Laparoscopic skills training and assessment. Br J Surg 91:1549-1558, 2004 2. Jacobs M, Verdeja JC, Goldstein HS: Minimally invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc 1:144-150, 1991 3. Falk PM, Beart RW Jr, Wexner SD, et al: Laparoscopic colectomy: a critical appraisal. Dis Colon Rectum 36:28-34, 1993 4. Guillou PJ, Darzi A, Monson JR: Experience with laparoscopic colorectal surgery for malignant disease. Surg Oncol 2:43-49, 1993 (suppl 1) 5. Milsom JW, Fazio VW: Concerns about laparoscopic colon cancer surgery. Dis Colon Rectum 37:625-626, 1994 6. Stage JG, Schulze S, Moller P, et al: Prospective randomized study of laparoscopic versus open colonic resection for adenocarcinoma. Br J Surg 84:391-396, 1997 7. Lacy AM, Delgado S, Garcia-Valdecasas JC, et al: Port site metastases and recurrence after laparoscopic colectomy. A randomized trial. Surg Endosc 12:1039-1042, 1998 8. Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 350:2050-2059, 2004 9. Tekkis PP, Senagore AJ, Delaney CP, et al: Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections. Ann Surg 242:83-91, 2005 10. Harinath G, Shah PR, Haray PN, et al: Laparoscopic colorectal surgery in Great Britain and Ireland—where are we now? Colorectal Dis 7:8689, 2005 11. Society of American Gastrointestinal Endoscopic Surgeons. Integrating advanced laparoscopy into surgical residency training. Society of American Gastrointestinal Endoscopic Surgeons (SAGES). Surg Endosc 12: 374-376, 1998 12. Lin E, Szomstein S, Addasi T, et al: Model for teaching laparoscopic colectomy to surgical residents. Am J Surg 186:45-48, 2003 13. Aggarwal R, Grantcharov TP, Darzi A: Framework for systematic training and assessment of technical skills. J Am Coll Surg 204:697-705, 2007 14. Rogers DA, Regehr G, MacDonald J: A role for error training in surgical technical skill instruction and evaluation. Am J Surg 183:242-245, 2002 15. Aggarwal R, Darzi A: Technical-skills training in the 21st century. N Engl J Med 355:2695-2696, 2006 16. Carter FJ, Schijven MP, Aggarwal R, et al: Consensus guidelines for validation of virtual reality surgical simulators. Surg Endosc 19:15231532, 2005 17. Aggarwal R, Grantcharov T, Moorthy K, et al: A competency-based virtual reality training curriculum for the acquisition of laparoscopic psychomotor skill. Am J Surg 191:128-133, 2006 18. Moorthy K, Munz Y, Sarker SK, et al: Objective assessment of technical skills in surgery. BMJ 327:1032-1037, 2003 19. Grantcharov TP, Kristiansen VB, Bendix J, et al: Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Br J Surg 91:146-150, 2004 20. Sedlack RE, Kolars JC: Computer simulator training enhances the competency of gastroenterology fellows at colonoscopy: results of a pilot study. Am J Gastroenterol 99:33-37, 2004 21. Yule S, Flin R, Paterson-Brown S, et al: Non-technical skills for surgeons in the operating room: a review of the literature. Surgery 139: 140-149, 2006 22. Aggarwal R, Undre S, Moorthy K, et al: The simulated operating theatre: comprehensive training for surgical teams. Qual Saf Health Care 13:i27-i32, 2004 (suppl 1) 23. Moorthy K, Munz Y, Adams S, et al: A human factors analysis of technical and team skills among surgical trainees during procedural simulations in a simulated operating theatre. Ann Surg 242:631-639, 2005