ASCRS/SAGES Guidelines for Laparoscopic Colectomy Course

This statement was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) on Nov 2005.

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)

  1. Introduction
  2. A Focus Group on Laparoscopic Colectomy Education was convened and has developed a guideline for educating trained surgeons in the use of laparoscopic colectomy for colorectal disease. This guideline has been developed to address the increased interest in laparoscopic colectomy for cancer. The group has made recommendations regarding the content, faculty, and training model for hands on courses in laparoscopic colorectal surgery. This guideline is intended to assist societies, course directors, teaching institutions, and national organizations in developing training programs for their members and accrediting courses, which are provided by the members on a local levelThis recommendation for training was developed by a focus group of surgeons and industry representatives with extensive experience in training fellows in ACGME-approved training programs, teaching in a laparoscopic training program sponsored by the Association of Program Directors in Colon and Rectal Surgery, and training general surgeons in industry and institutional-sponsored training programs. The group was convened at Washington University in St. Louis in July 2004 and again at the annual meeting of the American College of Surgeons in New Orleans in October 2004.
  3. Basic Module
    1. General Objectives: To provide the practicing surgeon (general and colorectal) as well as the residents/fellows with exposure to basic skills in laparoscopic techniques which form the basis for laparoscopic colectomy and to provide the basic information regarding indications, complications, and special considerations for laparoscopic colectomy.
    2. Curriculum
      1. Didactic (8 hours)
        1. Instrumentation
        2. Operating Room set up (right, left, total, rectal)
        3. Insufflation
        4. Anatomy
        5. Tissue handling
        6. Complications – general laparoscopic/laparoscopic colorectal
        7. Indications/Contraindications
      2. Porcine Lab (8 hours)
        1. Basic Skills
          1. Safe trocar insertion and pneumoperitoneum
          2. Tissue handling/dissection/retraction
          3. Camera control
          4. Energy sources
          5. Vascular control
          6. Bowel division and anastomosis
          7. Use of gravity for retraction
          8. Eye-video-hand coordination and surgeon positioning
        2. Procedures Lab
          1. Simulated appendectomy with uterine horns-bilateral
          2. Tack and drain of bladder
          3. Mobilize rectum along aorta and into pelvis
          4. Divide rectum and perform EEA at multiple levels
          5. Small bowel resection and intracorporeal anastomosis
          6. Dissect cecum from terminal ileum and spiral colon
          7. Cecectomy
          8. End colostomy and colostomy closure
          9. Splenectomy (to simulate vascular control)
          10. Small bowel suturing
    3. Faculty
      1. Course Director: A surgeon who is certified by the American Board of Surgery (or equivalent) and has performed at least 50 laparoscopic colectomies and who is willing to proctor and/or precept trainees.
      2. Instructor: A surgeon who is certified by or eligible for certification by the American Board of Surgery (or equivalent) and has performed at least 50 laparoscopic colectomies.
      3. Faculty to Student Ratio: A minimum of one faculty member to three tables with three surgeons at each table (1:9). A lower faculty to surgeon ratio (1:6) is strongly encouraged.
    4. Facility: An animal laboratory equipped with at least two tables, all of which move to Trendelenberg position and tilt right or left, is required. Each table should have one video tower with insufflator, light source, and camera. Each animal should be monitored and a veterinary tech should be available to manage the anesthesia for the group of animals. The animal facility must meet FDA, AALAC, or IACUC guidelines.
    5. Participant Qualification: Senior Residents/ Fellows in training, colorectal surgeons with no/limited laparoscopic experience (<20 cases), general surgeons with no/limited laparoscopic colorectal experience (<20 cases) and with significant potential for colorectal cases.
    6. Certificate of Participation: The basic course will not provide adequate training for laparoscopic colectomy. The certificate of participation will state that the participant has completed this course in preparation for attending a subsequent advanced course
  4. Advanced Module
    1. General Objective: To provide the practicing general or colorectal surgeons and residents/fellows with the technical skills, video anatomic recognition, methods of retraction, exposure, and vascular ligation which will allow the right, left, transverse, and sigmoid colon and rectum to be safely removed.
    2. Curriculum
      1. Didactic (2 hours – generally 1 hour for right and transverse colon, 1 hour [at lunch] for left colon and rectum)
        1. Operating room set up and instrumentation
        2. Review of complications
        3. Video review of right, left, transverse, and sigmoid colectomy and rectal resection
        4. Hand-assisted approach
      2. Cadaver Lab (6 hours)
        1. Universal precautions
        2. Positioning, surgeon alignment
        3. Right colectomy – medial, lateral, posterior approaches
        4. Sigmoid colectomy – medial, lateral approaches
        5. Transverse colectomy – laparoscopic and hand-assisted approach
        6. Rectal resection – laparoscopic and hand-assisted approach
        7. Ureter identification, nerve preservation, splenic flexure mobilization, hepatic flexure mobilization, duodenal protection, small bowel retraction, omental preservation, omentectomy
    3. Faculty
      1. Course Director: A surgeon who is certified by the American Board of Surgery (or equivalent) and recognized as an expert in laparoscopic colectomy, having performed at least 50 laparoscopic colectomies and taught laparoscopic colectomy to residents/fellows or other practicing surgeons.
      2. Instructor: A surgeon who is certified by or eligible for certification by the American Board of Surgery (or equivalent) and has performed at least 50 laparoscopic colectomies.
      3. Faculty to Student Ratio: Each cadaver should be accompanied by one instructor. Each cadaver may have two to three students (one to drive the camera, two operating – rotating with each segment).
    4. Facility: A laboratory with the capacity for four to ten stations is optimal. The thawed fresh frozen cadaver should be prepared (wrapped) to prevent spillage of fluid. Tables must be able to provide Trendelenberg position and tilt to the right and left. Each table should be equipped with a video tower with insufflator and camera/light source. Although a veterinary tech is not needed, an adequate number of technical personnel should be available. The lab facility should conform with accepted guidelines (nationally or locally) for cadaver-based courses.
    5. Participant Qualification: The use of a cadaver to train surgeons to perform laparoscopic colectomy should be limited to the following groups:
      1. General or colorectal surgeons performing >25 colectomies per year with:
        1. advanced laparoscopic experience or
        2. experience in a basic laparoscopic colectomy course and experienced laparoscopic surgeons as partners who will mentor
      2. Advanced laparoscopic surgeons and/or senior surgical residents or fellows with the potential for >25 colectomies per yearA prerequisite for participation in an advanced course is demonstration of the availability of a mentor or preceptor who has a significant experience with laparoscopic colectomies or other advanced laparoscopic procedures . All of the 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/preceptor. A preceptor should be available for the trainee’s first case, as a minimum.
    6. Certificate of Participation: The advanced course will provide a certificate of participation that will attest to the participant’s completion of a cadaver course covering all aspects of laparoscopic colectomy. The certificate is not a measure of competence. However, the course director must be willing to withhold issuance of a certificate to those individuals who have not demonstrated, to the satisfaction of the director, the ability to safely and satisfactorily complete a laparoscopic colectomy. Such an individual may apply for participation in subsequent courses. The certificate of participation may be presented by the participant to hospital credentialing committees as evidence that the practitioner can perform laparoscopic colectomy. It is suggest that the course director developed a score sheet for each participant to be completed by each instructor for all participants at the cadaver table (Appendix 1). These records should be maintained on file for each practitioner.
  5. Continuing Medical Education (CME)CME credit should be available for all courses provided on a national level sponsored by societies or national organizations. Local/institutional courses should have the option to provide CME.
  6. SyllabusEach course should be accompanied by a syllabus consisting of a current bibliography, articles that provide technical points, diagrams of OR set-up, positioning and instrument placement, anatomic drawings of important land marks for each approach (medial, lateral, posterior) to colectomy. Objectives, goals, and a course curriculum should be provided with the syllabus. A step-wise approach to colectomy should be provided. The syllabus should be updated yearly.
  7. Data CollectionA pre- and post-course as well as a one-year adoption of technique survey should be performed by the course director (Appendix 2). Course participants should agree to participate in a registry, which collects not only case numbers, but also outcomes of their technique. Once such example is the web-based SAGES surgical registry.

/Appendix 1/

Appendix 2

 

This document was prepared and revised by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)

This statement was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) on Nov 2005.

For more information please contact:

SOCIETY OF AMERICAN GASTROINTESTINAL ENDOSCOPIC SURGEONS (SAGES)
11300 West Olympic Blvd., Suite 600
Los Angeles, CA 90064
Tel:
(310) 437-0544
Fax:
(310) 437-0585
Email:
publications@sages.org

Guidelines for clinical practice are intended to indicate preferable approaches to medical problems as established by experts in the field. These recommendations will be based on existing data or a consensus of expert opinion when little or no data are available. Guidelines are applicable to all physicians who address the clinical problem(s) without regard to specialty training or interests, and are intended to indicate the preferable, but not necessarily the only acceptable approaches due to the complexity of the healthcare environment. Guidelines are intended to be flexible. Given the wide range of specifics in any health care problem, the surgeon must always choose the course best suited to the individual patient and the variables in existence at the moment of decision.

Guidelines are developed under the auspices of the Society of American Gastrointestinal and Endoscopic Surgeons and its various committees, and approved by the Board of Governors. Each clinical practice guideline has been systematically researched, reviewed and revised by the guidelines committee, and reviewed by an appropriate multidisciplinary team. The recommendations are therefore considered valid at the time of its production based on the data available. Each guideline is scheduled for periodic review to allow incorporation of pertinent new developments in medical research knowledge, and practice.