Guidelines Focus Group on Laparoscopic Colectomy Education as Endorsed by The American Society of Colon and Rectal Surgeons (ASCRS) and The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) James Fleshman, M.D.,1 Peter Marcello, M.D.,2 Michael J. Stamos, M.D.,3 Steven D. Wexner, M.D.4 1 Department of Colorectal , Washington University, St. Louis, Missouri 2 Department of , Lahey Clinic, Burlington, Massachusetts 3 Department of Surgery, Division of Colon and Rectal Surgery, University of California, Irvine, Medical Center, Orange, California 4 Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida

INTRODUCTION developing training programs for their members and accrediting courses, which are provided by the mem- A Focus Group on Laparoscopic Colectomy Edu- bers on a local level. This recommendation for train- cation was convened and has developed a guideline ing was developed by a focus group of surgeons for educating trained surgeons in the use of lap- and industry representatives with extensive experi- aroscopic colectomy for colorectal disease. This ence in training fellows in ACGME (Accreditation guideline has been developed to address the increased Council For Graduate Medical Education) – approved interest in laparoscopic colectomy for . The training programs, teaching in a laparoscopic train- group has made recommendations regarding the ing program sponsored by the Association of Pro- content, faculty, and training model for hands-on gram Directors in Colon and Rectal Surgery, and courses in laparoscopic colorectal surgery. This guide- training general surgeons in industry and institution- line is intended to assist societies, course directors, al-sponsored training programs. The group was teaching institutions, and national organizations in convened at Washington University in St. Louis in July 2004 and again at the annual meeting of the This document was reviewed and approved by the SAGES American College of Surgeons in New Orleans in Board of Governors and the Continuing Education and Guidelines October 2004. Committee and the ASCRS Executive Council and Standards Committee. Correspondence to: Steven D. Wexner, M.D., Cleveland Clinic, Florida, 2950 Cleveland Clinic Blvd., Weston, Florida 33331-3609, BASIC MODULE e-mail: [email protected] Dis Colon 2006; 49: 945–949 General Objectives DOI: 10.1007/s10350-006-0559-5 * The American Society of Colon and Rectal Surgeons To provide the practicing surgeon (general and Published online: 2 May 2006 colorectal) as well as the residents/fellows with

945 946 FLESHMAN ET AL Dis Colon Rectum, July 2006 exposure to basic skills in laparoscopic techniques Instructor. A surgeon who is certified by or eligible that form the basis for laparoscopic colectomy and to for certification by the American Board of Surgery provide the basic information regarding indications, (or equivalent) and has performed at least 50 complications, and special considerations for lapa- laparoscopic colectomies. roscopic colectomy. Faculty to Student Ratio. A minimum of one faculty member to three tables with three surgeons at each Curriculum table (1:9). A lower faculty to surgeon ratio (1:6) is Didactic (8 hours) strongly encouraged. i. Instrumentation Facility. An animal laboratory equipped with at ii. Operating room setup (right, left, total, rectal) least two tables, all of which move to Trendelenberg iii. Insufflation position and tilt right or left, is required. Each table iv. Anatomy should have one video tower with insufflator, light v. Tissue handling source, and camera. Each animal should be mon- vi. Complications – general laparoscopic/laparo- itored and a veterinary technician should be available scopic colorectal to manage the anesthesia for the group of animals. vii. Indications/contraindications The animal facility must meet the Food and Drug Porcine Lab (8 hours) Administration, the Association for Assessment i. Basic Skills and Accreditation of Laboratory Animal Care 1. Safe trocar insertion and pneumoperitoneum International, or the Institutional Animal Care and 2. Tissue handling/dissection/retraction Use Committee guidelines. 3. Camera control Participant Qualification. Senior Residents/Fellows 4. Energy sources in training, colorectal surgeons with no/limited lap- 5. Vascular control aroscopic experience (<20 cases), general surgeons with 6. Bowel division and no/limited laparoscopic colorectal experience (<20 7. Use of gravity for retraction cases) and with significant potential for colorectal cases. 8. Eye-video-hand coordination and surgeon po- sitioning Certificate of Participation. The basic course will ii. Procedures Lab not provide adequate training for laparoscopic co- 1. Simulated with uterine horns- lectomy. The certificate of participation will state that bilateral the participant has completed this course in prepara- 2. Tack and drain of bladder tion for attending a subsequent advanced course. 3. Mobilize rectum along aorta and into pelvis 4. Divide rectum and perform EEA (end-to-end ADVANCED MODULE anastomosis) at multiple levels 5. Small- and intracorporeal General Objective anastomosis To provide the practicing general or colorectal 6. Dissect cecum from terminal ileum and spiral surgeons and residents/fellows with the technical colon skills, video anatomic recognition, methods of retrac- 7. Cecectomy tion, exposure, and vascular ligation that will allow 8. End and colostomy closure the right, left, transverse, and sigmoid colon and 9. Splenectomy (to simulate vascular control) rectum to be safely removed. 10. Small-bowel suturing Curriculum Faculty Didactic (2 hours – generally 1 hour for right and Course Director. A surgeon who is certified by the , 1 hour (at lunch) for left colon and American Board of Surgery (or equivalent) and has rectum) performed at least 50 laparoscopic colectomies and i. Operating room setup and instrumentation who is willing to proctor and/or precept trainees. ii. Review of complications Vol. 49, No. 7 GUIDELINES FOR LAPAROSCOPIC COLECTOMY COURSE 947 iii. Video review of right, left, transverse, and sig- Participant Qualification. The use of a cadaver to moid colectomy and rectal resection train surgeons to perform laparoscopic colectomy iv. Hand-assisted approach should be limited to the following groups: a. General or colorectal surgeons performing >25 Cadaver Lab (6 hours) colectomies per year with: i. Universal precautions i. advanced laparoscopic experience or ii. Positioning, surgeon alignment ii. experience in a basic laparoscopic colectomy iii. Right colectomy – medial, lateral, posterior course and experienced laparoscopic surgeons approaches as partners who will mentor iv. Sigmoid colectomy – medial, lateral approaches b. Advanced laparoscopic surgeons and/or senior v. Transverse colectomy – laparoscopic and hand- surgical residents or fellows with the potential for assisted approach >25 colectomies per year. vi. Rectal resection – laparoscopic and hand-assisted A prerequisite for participation in an advanced approach course is demonstration of the availability of a vii. Ureter identification, nerve preservation, splenic mentor or preceptor who has a significant expe- flexure mobilization, hepatic flexure mobilization, rience with laparoscopic colectomies or other duodenal protection, small-bowel retraction, advanced laparoscopic procedures. All of the omental preservation, omentectomy above must show evidence of the availability of a mentor or preceptor who will help the student/ trainee through the learning curve. Proof should be in the form of a letter from said mentor/ Faculty preceptor. A preceptor should be available for the trainee’s first case, as a minimum. Course Director. A surgeon who is certified by the American Board of Surgery (or equivalent) and Certificate of Participation. The advanced course recognized as an expert in laparoscopic colectomy, will provide a certificate of participation that will having performed at least 50 laparoscopic colectomies attest to the participant’s completion of a cadaver and taught laparoscopic colectomy to residents/ course covering all aspects of laparoscopic colectomy. fellows or other practicing surgeons. The certificate is not a measure of competence. However, the course director must be willing to Instructor. A surgeon who is certified by or eligible withhold issuance of a certificate to those individuals for certification by the American Board of Surgery who have not demonstrated, to the satisfaction of the (or equivalent) and has performed at least 50 lap- director, the ability to safely and satisfactorily aroscopic colectomies. complete a laparoscopic colectomy. Such an indi- Faculty to Student Ratio. Each cadaver should be vidual may apply for participation in subsequent accompanied by one instructor. Each cadaver may courses. The certificate of participation may be have two to three students (1 to drive the camera, presented by the participant to hospital credentialing 2 operating – rotating with each segment). committees as evidence that the practitioner can perform laparoscopic colectomy. It is suggested that Facility. A laboratory with the capacity for four to the course director develop a score sheet for each ten stations is optimal. The thawed, fresh-frozen participant to be completed by each instructor for cadaver should be prepared (wrapped) to prevent all participants at the cadaver table (Appendix 1). spillage of fluid. Tables must be able to provide These records should be maintained on file for each Trendelenberg position and tilt to the right and left. practitioner. Each table should be equipped with a video tower with insufflator and camera/light source. Although a veterinary technician is not needed, an adequate CONTINUING MEDICAL EDUCATION number of technical personnel should be avail- able. The lab facility should conform to accepted Continuing Medical Education (CME) credit should guidelines (nationally or locally) for cadaver-based be available for all courses provided on a national courses. level sponsored by societies or national organiza- 948 FLESHMAN ET AL Dis Colon Rectum, July 2006 tions. Local/institutional courses should have the Santa Margarita, CA; Gene Stewart, United States option to provide CME. Surgical, Norwalk, CT; William Timmerman, M.D., Richmond, VA; Wes Vega, Olympus America Inc., Ballwin, MO; Dan Vonder-Haar, Karl Storz, Chester- SYLLABUS field, MO; Mark Whiteford, Oregon Clinic, Portland, OR; John Wilson, United States Surgical, St. Louis, MO. Each course should be accompanied by a syllabus consisting of a current bibliography, articles that provide technical points, diagrams of operating room APPENDIX 1 setup, positioning and instrument placement, and anatomic drawings of important landmarks for each Laparoscopic Colectomy Cadaver Course approach (medial, lateral, posterior) to colectomy. Participant Evaluation Sheet Objectives, goals, and a course curriculum should be provided with the syllabus. A step-wise approach to Date Institution colectomy should be provided. The syllabus should be updated yearly. Participant Name: ______

YES NO DATA COLLECTION Video Review Right colectomy ______A precourse and postcourse as well as a one-year Left colectomy ______adoption of technique survey should be performed Rectal dissection ______by the course director (Appendix 2). Course partic- Technical AspectsCircle ff Appropriate answer ipants should agree to participate in a registry, which (1 = unsatisfactory collects not only case numbers, but also outcomes of to 5 = superior) Trocar placement 1 2345 their technique. One such example is the web-based Camera operation 1 2345 SAGES surgical registry. Works in line with 1 2345 pathology/camera Handles tissue carefully 1 2345 Understands vascular control 1 2345 ACKNOWLEDGMENTS Identifiesplanesfordissection12345 Identifies ureter 1 2345 The Focus Group: David Beck, M.D., Ochsner Understands traction/ 1 2345 Clinic, New Orleans, LA; Elisa Birnbaum, M.D., countertraction Understands approaches 1 2345 Washington University, St. Louis, MO; Brad Burklow, to colectomy Olympus America, Melville, NY; Jeffrey Cohen, M.D., Right medial 1 2345 Hartford Hospital, Hartford, CT; Paul Conrad, Ethi- Right lateral 1 2345 con Endosurgery Inc., Cincinnati, OH; Matt Fahy, Right posterior 1 2345 Left medial 1 2345 Olympus America Inc., Melville, NY; Peggy Frisella, Left lateral 1 2345 Washington University, St. Louis, MO; Tiffanie Heller, Rectal posterior 1 2345 Ethicon Endosurgery Inc., Cincinnati, OH; Gary Omentectomy 1 2345 Omental preservation 1 2345 Johnson, Applied Medical, Rancho Santa Margarita, Transverse colectomy 1 2345 CA; David Margolin, M.D., Ochsner Clinic, New Hand-assisted approaches 1 2345 Orleans, LA; Susan Martin, Ethicon Endosurgery to above Inc., Cincinnati, OH; Tim Miravalle, Olympus Amer- ______ica, Inc., St. Charles, MO; Molly Morales, Karl Storz, Participant Signature Culver City, CO; Matthew Mutch, Washington Uni- versity, St. Louis, MO; Deborah Nagle, M.D., Drexel, ______Date Philadelphia, PA; Melissa Pregel, Ethicon Endosur- gery Inc., Cincinnati, OH; Howard Ross, M.D., ______University of Pennsylvania, Philadelphia, PA; Clifford Instructor Signature Simmang, M.D., University of Texas Medical Center, ______Dallas, TX; Ted Stanley, Applied Medical, Rancho Date Vol. 49, No. 7 GUIDELINES FOR LAPAROSCOPIC COLECTOMY COURSE 949 APPENDIX 2 Ì Laparoscopic colectomy is an important tool in surgeon’s armamentarium Ì Patients are demanding laparoscopic colectomy Laparoscopic Colectomy Ì Gastrointestinal referrals are demanding laparoscopic colectomy Precourse Evaluation 8. Which of the following prompted you to select this 1. How many laparoscopic colectomies did you perform course? (check all that apply) Ì during: Course location Ì Faculty a. Residency, of these, ______Ì Cost # for cancer ______# for benign disease ___ Ì Hands-on lab b. Fellowship, of these, ______Ì Cadaver model # for cancer ______# for benign disease ___ Ì Student/instructor ratio c. Practice, of these, ______Ì Hand-assisted technique # for cancer ______# for benign disease ___ Ì Lecture topics 2. How many open or laparoscopic colectomies do you Ì Videos of procedures perform in an average month? 9. Have you attended any of the following? (check all that Ì 0 apply) Ì 1–5 Ì Basic Laparoscopic Techniques Course Ì 6–10 Date: ______Ì 11–20 Ì Hands-on Animal Course on Laparoscopic Colectomy Ì >21 Date: ______Ì <50 Ì Hands-on Cadaver Course on Laparoscopic Colectomy 3. Have you performed other laparoscopic procedures? Date: ______Ì Yes Ì Advanced Laparoscopic Techniques Course Ì No Date: ______If yes, #inpast12months. Basic : Ì ____ Ì Appendectomy ____ Postcourse Evaluation Ì Inguinal repair ____ Advanced laparoscopy: 1. Are you now ready to perform a laparoscopic colectomy Ì Ventral ____ for (check all that apply) Ì ____ Ì Right colon cancer Ì Gastric bypass or resection ____ Ì Left colon cancer Ì Gastric banding ____ Ì Rectal cancer Ì Nephrectomy ____ Ì Ì Adrenalectomy/splenectomy ____ Ì Colon polyps Ì Other advanced procedures ____ 2. How many laparoscopic colectomies for benign disease 4. Do you have partners who perform laparoscopic will you perform before attempting a laparoscopic colectomy? colectomy for cancer? Ì Yes Ì 0 Ì No Ì 1–5 5. Do you have partners who perform advanced laparo- Ì 6–10 scopic surgery? Ì 11–20 Ì Yes Ì >21 Ì No Ì <50 6. Does your hospital have an ‘‘internal’’ preceptor for you 3. Will you use hand-assisted techniques? to begin laparoscopic colectomy? Ì Yes Ì Yes Ì No Ì No 4. Will you attend another laparoscopic colectomy course 7. Why are you taking this course? (check all that apply) in the next year? Ì COST (Clinical Outcomes of Surgical Therapy) Study Ì Yes New England Journal of Medicine 2004 results Ì No Ì Losing patients to surgeons performing laparoscopic 5. Would you recommend this course to other interested colectomy surgeons? Ì Laparoscopic colectomy provides recovery benefits Ì Yes over open colectomy Ì No