Integrating Advanced Laparoscopy into Surgical Residency Training — A SAGES Position Paper

This statement was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) on Apr 2009.

INTRODUCTION

Laparoscopic techniques have become an integral part of the operative management in virtually every realm of general surgery. The Society of American Gastrointestinal Endoscopic Surgeons (SAGES) is dedicated to the advancement of training in minimal access surgery to ensure the safe performance of such operations. The purpose of this document is to foster the integration of advanced laparoscopic surgical training into the curriculum of the general surgery residency. Opportunities to perform laparoscopic procedures currently vary widely among surgical training programs. The proposals presented in this document are intended as measures to improve educational opportunities in a dynamic educational environment. As the utilization of minimal access procedures increases, residents will more readily acquire the skills necessary to accomplish these operations safely.

CURRICULUM GUIDELINES IN ADVANCED LAPAROSCOPIC SURGERY

Basic laparoscopic procedures include laparoscopic cholecystectomy, laparoscopic appendectomy, and diagnostic laparoscopy. All other laparoscopic operations are defined as “advanced”. Prior to performing advanced laparoscopic procedures, the resident must be familiar with and experienced in basic laparoscopic skills.

Laparoscopic procedures, as with all operations, should be learned in the broad context of surgical science and practice. Critical educational components include the pathophysiology of disease, diagnosis, operative indications and contraindications, alternative treatments, comprehensive principles of pre-and post- operative care, and understanding the prevention, diagnosis and treatment of complications. In addition, surgical residents must be familiar with the advantages and disadvantages of both open and minimal access approaches.

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.

SAGES recommends that surgical training programs adopt a policy that assures acquisition of advanced laparoscopic skills during residency training. Surgeons-in-training who plan to practice the specialty of general surgery should be given ample opportunity to apply those skills during their residency training.

SKILLS ACQUISITION FOR ADVANCED LAPAROSCOPIC OPERATIONS

Acquisition and mastery of basic laparoscopic skills must precede the performance of advanced laparoscopic operations. There is a core group of fundamental skills common to all advanced laparoscopic operations. Such skills are best acquired in skills laboratories using surgical trainers, animal models, virtual reality trainers, or other simulated operating conditions before the trainee performs these procedures in the operating room on patients. Examples of such skills include two-handed instrument manipulation, dissection, intracorporeal suturing, and intra- and extracorporeal knot tying. Prior open experience with a specific operation via celiotomy will also promote mastery of the equivalent laparoscopic procedure.

Since many advanced laparoscopic skills are common to all advanced laparoscopic operations, experience in one operation is likely to enhance the acquisition of skills necessary to perform others.

METHODS TO INTEGRATE ADVANCED LAPAROSCOPY TRAINING INTO GENERAL SURGERY RESIDENCY

SAGES’ long-term goal is to continue to facilitate the complete integration of advanced laparoscopic training within each surgical program. Residents should ultimately master 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 surgical residency programs provide a fundamental experience in basic laparoscopic surgery. A number of resources are offered by SAGES to promote laparoscopic skill acquisition:

Basic Laparoscopic Courses For Residents

SAGES offers courses in gastrointestinal endoscopy and basic laparoscopy for residents at least twice a year. These two-day courses focus on the basic principles and skills of therapeutic flexible endoscopy and laparoscopic surgery. It includes hands-on laboratory experience in addition to didactic lectures. The faculty includes some of the most experienced and respected endoscopic surgeons in the world.

In the past, approximately 120 residents were enrolled yearly, which represented approximately 12% of the annual number of graduating residents. Increasing this percentage is an objective of SAGES. Residents and fellows participating in the SAGES laparoscopic and endoscopic courses are required to apply for candidate membership.

Basic Laparoscopic 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 in the United States has diminished. SAGES has initiated such courses on an international level to bring basic laparoscopic skills to developing countries.

II. ADVANCED LAPAROSCOPIC SURGERY

Advanced laparoscopic procedures include hernia repair (inguinal and ventral), antireflux surgery, Heller myotomy, splenectomy, adrenalectomy, nephrectomy, liver resection, small bowel resection, colon resection, Roux-en-Y gastric bypass, adjustable gastric banding and other similarly complex procedures.

A. FACULTY TRAINING

  1. Courses: “Hands-on” courses are useful for introducing the techniques of the laparoscopic approach to those who are proficient in the similar open operations. SAGES offers a number of hands-on advanced laparoscopic surgical courses during the annual meeting.
  2. Faculty Mentoring: SAGES believes that faculty who are proficient in advanced laparoscopic surgical skills and who wish 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 procedure. SAGES facilitates such interaction.
  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 training in the same institution. 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 for a laboratory experience in flexible endoscopy and advanced laparoscopic surgery. Appropriate candidates for such courses are:
    • Residents who will pursue a career in General Surgery
    • Residents who have already achieved a mastery of basic laparoscopic surgical skills
    • Residents who are unlikely to obtain a significant experience in advanced laparoscopic surgical techniques based on their program’s current practice patterns.
  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 requires a fundamental experience in both advanced open and laparoscopic procedures 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.
  6. Fundamentals of Laparoscopic Surgery (FLS). FLS is a program designed to teach the physiology, fundamental knowledge, and technical skills required in basic laparoscopic surgery. The FLS program is a joint educational offering of SAGES and the American College of Surgeons (ACS). FLS consists of two CD-ROM / Online study guides, hands-on manual skills practice and training via the FLS Laparoscopic Trainer Box; and an assessment tool that measures both cognitive and technical skills.

SUMMARY

SAGES was founded to further the professional advancement of surgeons performing gastrointestinal endoscopy. Largely 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 been active in promoting the safe practice of laparoscopic and endoscopic surgery, which has evolved to become a standard component of the practice of most general surgeons. Its goal is to promote surgeons’ competency in all laparoscopic operations. SAGES joins other major surgical organizations to address the concern that, while basic laparoscopic procedures are mastered during General Surgery residency training, advanced procedures are not performed consistently in all programs.

The integration of advanced laparoscopic surgical skills into surgical residency and the safe incorporation and performance of advanced laparoscopic operations into surgical practice are evolving. 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. Training both residents and faculty is essential in order to facilitate resident education in minimally invasive surgery in the future. As practice patterns evolve, and the frequency of laparoscopic operations increases, SAGES predicts that the opportunities for residents to learn such skills will increase.


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), in April 2009. It was prepared by an adhoc task force on Residency Integration in 2003 and revised by the Resident Education Committee in 2009.

This document was prepared and revised by an ad hoc task force on Residency Integration

This statement was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) on Apr 2009.

This is a revision of a SAGES publication printed Apr 2003, revised Apr 2009.

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.