Position Paper -- Integrating Advanced Laparoscopy into Surgical Residency Training
Position Papers/Statements published on: 10/2003
by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)
INTEGRATING ADVANCED LAPAROSCOPY INTO SURGICAL RESIDENCY TRAINING
A SAGES POSITION PAPER
INTRODUCTION
Laparoscopic procedures are often integral to the operative management in the essential content areas of general surgery. The Society of American Gastrointestinal Endoscopic Surgeons is dedicated to the advancement of training in minimal access surgery to assure the safe performance of such operations. The purpose of this document is to further the integration of advanced laparoscopic surgical training into the curriculum of the general surgery residency. Opportunities to perform laparoscopic operations currently vary widely between surgical training programs. The proposals presented in this document are intended as current measures to improve educational opportunities in a dynamic environment. As utilization of minimal access procedures increases, residents will more readily learn the skills necessary to safely accomplish these operations. In that setting, the proposals below may no longer be necessary.
CURRICULUM GUIDELINES IN ADVANCED LAPAROSCOPIC SURGERY
Basic laparoscopic operations include laparoscopic cholecystectomy, laparoscopic appendectomy and diagnostic laparoscopy. All other laparoscopic operations are defined as advanced. Prior to learning or performing advanced laparoscopic operations, the resident must be familiar with and experienced in basic laparoscopy.
Laparoscopic operations, as with all operations, are appropriately learned in the broad context of surgical science and practice. Critical educational components include pathophysiology of disease, diagnosis, operative indications and contraindications, familiarity with alternative treatments, comprehensive principles of pre-and post- operative care and understanding of the prevention, diagnosis and treatment of complications. In addition, the relative advantages and disadvantages of both open and minimal access approaches must be known.
SAGES "Curriculum Guideline for Resident Education in GI Surgical Endoscopy, Laparoscopy, and Thoracoscopy" contains an outline of knowledge and skills to be mastered in basic and advanced laparoscopy.
SKILLS ACQUISITION FOR ADVANCED LAPAROSCOPIC OPERATIONS
Mastering advanced laparoscopic operations begins with acquisition of skills in basic laparoscopy. There is a core group of technical skills common to all advanced laparoscopic operations. Such skills are best acquiredthrough skills laboratories involving surgical trainers, animal models, virtual reality trainers, or other simulated operating conditions before the trainee enters the operating room with the intent of treating patients. Examples of such skills include two-handed dissection, intracorporeal suturing and intra- and extracorporeal knot tying. Mastery of these advanced laparoscopic skills by the resident is encouraged prior to initiating an experience performing advanced laparoscopic operations. Experience in the performance of a specific operation via celiotomy will also facilitate mastery of the equivalent laparoscopic.
Since many advanced laparoscopic skills are common to all advanced laparoscopic operations, experience in a specific operation enhances the acquisition of skills necessary to perform others. Therefore it is the combined experience in advanced procedures that should be emphasized during training, rather than the mastery of any one individual procedure.
METHODS TO INTEGRATE ADVANCED LAPAROSCOPY TRAINING INTO GENERAL SURGERY RESIDENCY
SAGES long-term goal is to facilitate complete integration of advanced laparoscopic training within each surgical program. Residents should ultimately learn these procedures in the operating room under the direction of skilled faculty instructors. Until such time as complete integration is possible, SAGES believes the following measures can help accomplish this goal:
- Train Faculty
- Train Residents
- Provide guidelines for post-residency training for prospective faculty
I. BASIC LAPAROSCOPIC SURGERY
Most programs provide adequate experience in basic laparoscopic surgery. To assure ongoing availability of basic training resources, the following is recommended:
Basic Laparoscopy Courses For Residents
SAGES plans to continue to offer courses in basic laparoscopic surgery. These two-day courses offered to residents throughout the year focus on the basic principles and skills of endoscopic and laparoscopic surgery. In the past, approximately 120 residents were enrolled yearly, which represented approximately 12% of the annual number of graduating residents. Increasing this percentage is a SAGES goal.
Basic Laparoscopy Courses for Faculty
When laparoscopy for general surgery was introduced, SAGES organized a series of ”Training the Trainers” courses which provided on-site faculty training at 17 institutions. This intensive training provided a mechanism to train more than 250 surgical faculty. The need for training in basic laparoscopy has diminished. However, if a need for faculty training in basic laparoscopy still exists, SAGES will endeavor to provide similar courses.
II. ADVANCED LAPAROSCOPIC SURGERY
A. 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. See Section B1.
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..
3) Fellowships: Post-graduate 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 surgical residents in training where they co-exist. SAGES maintains that the main goal of such fellowships should be to train future faculty.
B. RESIDENT TRAINING
1) Courses: Courses in advanced laparoscopic procedures are one method of introducing skills. SAGES offers ongoing courses for residents, and when necessary an accompanying faculty member, for a laboratory experience in advanced laparoscopic surgery.
Appropriate candidates for such courses are:
- Residents who plan a career in General Surgery
- Residents who have already achieved a mastery of basic laparoscopic surgery skills
- Residents who are unlikely, based on their program's current practice patterns, to obtain a significant experience in advanced laparoscopic surgical techniques.
- Faculty from programs who do not have faculty to teach the procedure in question, may elect to send a faculty member to the course.
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 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 current case loads are insufficient to produce such an experience. SAGES suggests that the appropriate leadership organizations consider reexamining the flexibility of the General Surgery residency training in order 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 Post-Graduate 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, and guidelines for credentialing, training and standards of practice. A separate candidate membership category exists for residents and fellows.
SUMMARY
SAGES was founded to further the professional advancement of surgeons performing gastrointestinal endoscopy. In part due to the society's previous efforts, an educational experience in flexible endoscopy is now recognized as a mandatory component of training in General Surgery. SAGES has more recently promoted the safe practice of laparoscopic surgery, which has evolved to become a standard component of the practice of most general surgeons. Consistent with the goal of continuing to provide the public with surgeons competent in performing all laparoscopic operations, SAGES joins other major surgical organizations in addressing the concern that, while basic laparoscopic procedures are mastered during residency training in General Surgery, advanced procedures and the skills required to safely initiate an experience in them often are not.
Incorporation of advanced laparoscopic surgical skills into surgical residency and the safe incorporation and performance of advanced laparoscopic operations into surgical practice are dynamic processes. With the above proposals, SAGES will facilitate both processes. We have, herein, set forth suggested curriculum guidelines for resident education in laparoscopic surgery. We have outlined measures through which resident and faculty training in advanced laparoscopic surgical skills may be realized. Focusing on adequately training the trainers is essential in order to facilitate resident education in the future. As practice patterns evolve, and the frequency of laparoscopic operations increases, the opportunities for residents to learn required skills will increase. In that setting, the proposed special efforts outlined above may no longer be necessary.
REFERENCES
1 Society of American Gastrointestinal Endoscopic Surgeons (SAGES): Framework for Post-Residency Surgical Education and Training--A SAGES Guideline. Surg Endosc 8:1137-1142, 1994.
This document was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), March 1997. It was prepared by an adhoc task force on Residency Integration and revised in 2003. The Board of Governors approved this document in October 2003.