- Email: [email protected]
Advanced laparoscopic surgery
Advanced Gregory
Laparoscopic V. Stiegmann,
MD, Denver, Colorado
even years ago “advanced laparoscopic surgery” meant removal of the gallbladder or appendix. General surgeons began to shed their skepticism about laparoscopic operations and scurried to learn laparoscopic cholecystectotny by whatever means available. Most had no experience with diagnostic laparoscopy or image-based procedures. Training consisted of a one- or two-day course at which an operation (that most had done hundreds of times on patients at laparotomy) was performed in a closed peritoneal cavity, using unfamiliar instruments, guided by televised images, on a pig. In spite of a transient rise in the incidence of bile duct injury, the rapid transition from conventional to laparoscopic cholecystectomy was accomplished with surprisingly few adverse outcomes. A new era in general surgery had begun. Laparoscopic cholecystectomy, appendectomy, and diagnostic laparoscopy now comprise “routine” laparoscopic surgery. Training for routine laparoscopic surgery is provided in most of today’s surgical residency programs. Adequate volumes of conventional appendectomy and cholecystectomy (the latter often a secondary operation) assure that residents acquire skills necessary to master both conventional and laparoscopic operations. Most surgical residents completing training in 1997 will be adequately tramed in “routine” laparoscopic surgery. Advanced laparoscopic surgery is well delineated in the preceding review. Most operations in the abdominal cavity can be performed with these methods. Which laparoscopic operations are better for patients than the same operation done at laparotomy is not yet completely defined. Laparostopic operations for gastroesophageal reflux, splenectomy, and adrenalectomy produce excellent results in appropriately selected cases. Repair of body wall hernias is controversial although most agree that laparoscopic repair of recurrent or bilateral hernias is acceptable. Laparoscopic colon/rectal operations for benign conditions benefit some patients; however, such operations to cure cancer have not been proven equal to those performed via laparotomy and should be done within a protocol.
S
THE CHALLENGE LAPAROSCOPIC
be fluent with conventional surgical methods in the event a laparoscopic approach is not feasible or results in problems that require rapid conversion to “open” operation. Access, exposure, conduct of the operation, instruments, and the methods by which laparoscopic and open operations are accomplished are very different. Those who teach experience this difference first hand when a resident who has performed only laparoscopic cholecystectomy is bewildered when he or she faces the same operation at laparotomy.
EDUCATIONAL
OF ADVANCED TRAINING
Surgeons who perform advanced laparoscopic operations must be articulate in both conventional and laparoscopic surgical skills. Competence in the laparoscopic arena is not equal to competence in the conventional surgical sphere. The converse is also true. The laparoscopic surgeon must Am J Surg. 1997;173:19-20. From the Department of Surgery, University of Colorado, Denver, Colorado. Requests for reprints should be addressed to Gregory V. Stiegmann, MD, Department of Surgery, University of Colorado, 4200 East 9th Avenue, Denver, Colorado 80262. I 0 1997 by Excerpta All rights reserved.
Medica,
Inc.
Surgery
OPTIONS
Courses in advanced laparoscopic operations, similar to those for laparoscopic cholecystectomy, contine to serve a useful purpose and have successfully trained many. “Hands on” courses are optimal for conveying the techniques of laparoscopic operations to those who are proficient in the equivalent “open” operation. They are ideal for teaching technical skills but are not the best method for educating residents. Little operative judgment or planning is involved and there are many dissimilarities between normal animal and pathological human anatomy. Residents are best taught in the operating room by direct interaction with a skilled surgeon. Currently, there are relatively few academically based advanced laparoscopic surgeons and case loads at many teaching centers are not robust. The second option, laparoscopic surgical fellowships, can provide in depth training for limited numbers of individuals. About 20 of these ad hoc postresidency programs now exist. Some are associated with university-based surgical residencies, others are not. None is governed by uniform guidelines. The more comprehensive programs provide opportunities for both clinical and basic investigation. Most receive 40 to 50 applications per year for each available position. Fellowship postresidency programs could meet long-term training needs if the number of these programs were increased exponentially. A rapid expansion of this magnitude is not feasible now, nor is it desirable. Numbers of cases available for resident training would decline and de facto creation of a new specialty would result in more franchising and division within general surgery. The third option is incorporation of advanced laparostopic surgical training into the general surgery residency curriculum. This is the logical solution since laparoscopic operations deal with a core area of general surgery. Can integration be accomplished, however, when there is hardly enough available case material to train senior level residents in conventional surgery?’ Two-thirds of residents who complete five years of general surgical training go on to practice general surgery. Onethird enter residencies or fellowships in other surgical specialties.’ Those who wish to pursue these options (eg, plastics, vascular, pediatric, cardiac, thoracic) could begin subspecialty training before their final year of general surgery. The resulting net gain in cases could provide most, if 0002-961 O/97/$1 PII SOOO2-9610(96)00339-X
7.00
19
r--COMMENTARYBTIEGMANN
I
not all, of the additional laparoscopic and conventional operative experience needed for those who intend to practice general surgery. The evolution, validation, and justification of advanced laparoscopic surgical methods seems inevitable. Most of the new operations will prove superior to their conventional counterparts when used in appropriate circumstances. Future general surgeons need experience in both conventional and laparoscopic options if they are to provide the best surgical care. Residents completing training in general surgery expect and deserve to be trained in these new skills. For the next few years, all of these educational alternatives will be needed if we are to expand the number of individuals trained in advanced laparoscopic techniques. The extent to
20
THE
AMERICAN
JOURNAL
OF SURGERY@
VOLUME
173
which any one of these options contributes to the training of an individual will vary among residency programs. Complete integration of advanced laparoscopic training into the residency curriculum should be the long-term goal. This will not occur quickly or easily and will challenge teaching institutions, faculty, and residents. It may even require alteration of the current residency structure. Now is the time to chart a rationale course aimed at meeting this goal of providing the best training for future general surgeons.
REFERENCES 1. Cameron JL. Is fellowship training m alimentary surgery necessary! Am J Surg. 1993;165:2-8. 2. Longitudinal Study of Surgical Kr\&nts 1992-1993. Chicago: American College of Surgeons, 1994:43.
JANUARY
1997
Laparoscopic V. Stiegmann,
MD, Denver, Colorado
even years ago “advanced laparoscopic surgery” meant removal of the gallbladder or appendix. General surgeons began to shed their skepticism about laparoscopic operations and scurried to learn laparoscopic cholecystectotny by whatever means available. Most had no experience with diagnostic laparoscopy or image-based procedures. Training consisted of a one- or two-day course at which an operation (that most had done hundreds of times on patients at laparotomy) was performed in a closed peritoneal cavity, using unfamiliar instruments, guided by televised images, on a pig. In spite of a transient rise in the incidence of bile duct injury, the rapid transition from conventional to laparoscopic cholecystectomy was accomplished with surprisingly few adverse outcomes. A new era in general surgery had begun. Laparoscopic cholecystectomy, appendectomy, and diagnostic laparoscopy now comprise “routine” laparoscopic surgery. Training for routine laparoscopic surgery is provided in most of today’s surgical residency programs. Adequate volumes of conventional appendectomy and cholecystectomy (the latter often a secondary operation) assure that residents acquire skills necessary to master both conventional and laparoscopic operations. Most surgical residents completing training in 1997 will be adequately tramed in “routine” laparoscopic surgery. Advanced laparoscopic surgery is well delineated in the preceding review. Most operations in the abdominal cavity can be performed with these methods. Which laparoscopic operations are better for patients than the same operation done at laparotomy is not yet completely defined. Laparostopic operations for gastroesophageal reflux, splenectomy, and adrenalectomy produce excellent results in appropriately selected cases. Repair of body wall hernias is controversial although most agree that laparoscopic repair of recurrent or bilateral hernias is acceptable. Laparoscopic colon/rectal operations for benign conditions benefit some patients; however, such operations to cure cancer have not been proven equal to those performed via laparotomy and should be done within a protocol.
S
THE CHALLENGE LAPAROSCOPIC
be fluent with conventional surgical methods in the event a laparoscopic approach is not feasible or results in problems that require rapid conversion to “open” operation. Access, exposure, conduct of the operation, instruments, and the methods by which laparoscopic and open operations are accomplished are very different. Those who teach experience this difference first hand when a resident who has performed only laparoscopic cholecystectomy is bewildered when he or she faces the same operation at laparotomy.
EDUCATIONAL
OF ADVANCED TRAINING
Surgeons who perform advanced laparoscopic operations must be articulate in both conventional and laparoscopic surgical skills. Competence in the laparoscopic arena is not equal to competence in the conventional surgical sphere. The converse is also true. The laparoscopic surgeon must Am J Surg. 1997;173:19-20. From the Department of Surgery, University of Colorado, Denver, Colorado. Requests for reprints should be addressed to Gregory V. Stiegmann, MD, Department of Surgery, University of Colorado, 4200 East 9th Avenue, Denver, Colorado 80262. I 0 1997 by Excerpta All rights reserved.
Medica,
Inc.
Surgery
OPTIONS
Courses in advanced laparoscopic operations, similar to those for laparoscopic cholecystectomy, contine to serve a useful purpose and have successfully trained many. “Hands on” courses are optimal for conveying the techniques of laparoscopic operations to those who are proficient in the equivalent “open” operation. They are ideal for teaching technical skills but are not the best method for educating residents. Little operative judgment or planning is involved and there are many dissimilarities between normal animal and pathological human anatomy. Residents are best taught in the operating room by direct interaction with a skilled surgeon. Currently, there are relatively few academically based advanced laparoscopic surgeons and case loads at many teaching centers are not robust. The second option, laparoscopic surgical fellowships, can provide in depth training for limited numbers of individuals. About 20 of these ad hoc postresidency programs now exist. Some are associated with university-based surgical residencies, others are not. None is governed by uniform guidelines. The more comprehensive programs provide opportunities for both clinical and basic investigation. Most receive 40 to 50 applications per year for each available position. Fellowship postresidency programs could meet long-term training needs if the number of these programs were increased exponentially. A rapid expansion of this magnitude is not feasible now, nor is it desirable. Numbers of cases available for resident training would decline and de facto creation of a new specialty would result in more franchising and division within general surgery. The third option is incorporation of advanced laparostopic surgical training into the general surgery residency curriculum. This is the logical solution since laparoscopic operations deal with a core area of general surgery. Can integration be accomplished, however, when there is hardly enough available case material to train senior level residents in conventional surgery?’ Two-thirds of residents who complete five years of general surgical training go on to practice general surgery. Onethird enter residencies or fellowships in other surgical specialties.’ Those who wish to pursue these options (eg, plastics, vascular, pediatric, cardiac, thoracic) could begin subspecialty training before their final year of general surgery. The resulting net gain in cases could provide most, if 0002-961 O/97/$1 PII SOOO2-9610(96)00339-X
7.00
19
r--COMMENTARYBTIEGMANN
I
not all, of the additional laparoscopic and conventional operative experience needed for those who intend to practice general surgery. The evolution, validation, and justification of advanced laparoscopic surgical methods seems inevitable. Most of the new operations will prove superior to their conventional counterparts when used in appropriate circumstances. Future general surgeons need experience in both conventional and laparoscopic options if they are to provide the best surgical care. Residents completing training in general surgery expect and deserve to be trained in these new skills. For the next few years, all of these educational alternatives will be needed if we are to expand the number of individuals trained in advanced laparoscopic techniques. The extent to
20
THE
AMERICAN
JOURNAL
OF SURGERY@
VOLUME
173
which any one of these options contributes to the training of an individual will vary among residency programs. Complete integration of advanced laparoscopic training into the residency curriculum should be the long-term goal. This will not occur quickly or easily and will challenge teaching institutions, faculty, and residents. It may even require alteration of the current residency structure. Now is the time to chart a rationale course aimed at meeting this goal of providing the best training for future general surgeons.
REFERENCES 1. Cameron JL. Is fellowship training m alimentary surgery necessary! Am J Surg. 1993;165:2-8. 2. Longitudinal Study of Surgical Kr\&nts 1992-1993. Chicago: American College of Surgeons, 1994:43.
JANUARY
1997