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Focus Group on Laparoscopic Colectomy Education As Endorsed 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 Surgery, Washington University, St. Louis, Missouri 2 Department of Colorectal Surgery, 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 cancer. 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 Rectum 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 anastomosis 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 appendectomy 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-bowel resection 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 colostomy 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 transverse colon, 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
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