Curriculum Outline for Resident Education

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

The following outline has been compiled by the SAGES Resident Education Committee and is meant to serve as a guideline for objectives to be met for a thorough resident education in the areas of flexible gastrointestinal endoscopy and in laparoscopic and thoracoscopic surgery. The guideline may prove useful to program directors in planning an educational curriculum. It may prove equally useful to the resident in training who wishes to confirm that the major areas of didactic and hands-on experience which would be generally expected of a thorough training in these areas have indeed been mastered. This curriculum guideline is not meant to be a thoroughly comprehensive and encyclopedic guideline to resident training in these areas, since the dynamic nature of the field precludes such a possibility for any significant length of time. The guidelines have been written in such a way as to emphasize both the subject matter, which should be addressed, but also to reflect what is generally considered current, appropriate experience in procedures in these areas.

It is recognized that this area of instruction is a dynamic one, as are the procedures which are being considered “standard” as part of the residency experience. Training programs should strive to provide residents with the appropriate fund of knowledge in the surgical sciences and core operative skills in the areas of flexible endoscopy and video telescopic surgery such that the ability to master new or evolving procedures in these areas in the future is easily feasible.

CURRICULUM GUIDELINES IN FLEXIBLE ENDOSCOPY

The skills and knowledge necessary to perform flexible endoscopy are incorporated into every General Surgical training program. The surgical trainee must have an understanding of the indications for these procedures and the ability to undertake the appropriate therapeutic maneuvers. Each trainee should be adequately trained such that by the completion of residency he or she is competent to independently perform flexible esophagogastroduodenoscopy, sigmoidoscopy, colonoscopy, choledochoscopy, and bronchoscopy. Residents are now required to complete at least 35 upper endoscopies and 35 lower endoscopies by the end of their training. These numbers are to increase next year. Rigid proctosigmoidoscopy should be a similarly mastered procedure. Certain programs may also provide the trainee an experience with more advanced endoscopic procedures, but it is recognized these are usually learned only in post-residency experiences. However, the indications and therapeutic maneuvers of endoscopic retrograde cholangiopancreatography and other advanced endoscopic procedures should be fully discussed and understood by the resident. A similar approach should be applied to endoscopic ultrasound: trainees must have a full understanding of the procedure and the information obtainable, but complete familiarity with the technical aspects of it are beyond the scope of standard surgical training.

I. UPPER GASTROINTESTINAL ENDOSCOPY

ESOPHAGOGASTRODUODENOSCOPY

The surgical resident should be knowledgeable regarding the following:

• indications and contraindications
• equipment necessary and available for upper endoscopy
• the proper maintenance and preparation of equipment used for flexible endoscopy patient monitoring and the appropriate use of conscious sedation blind and visually directed passage of the endoscope
• recognition of the anatomic landmarks of the normal esophagus, stomach and duodenum.

Specific attention should be focused on understanding and learning about the following skills:

• technique and indications for hot and cold biopsies
• proper use of snare cautery
• retrieval of foreign bodies
• use of cytology brushes and needles
• appropriate use of cautery/heater probes
• management of esophageal strictures using balloon, Savary or Maloney dilators
• laser ablation of esophageal tumors and placement of esophageal stents
• indications for and placement of overtubes
• management of esophageal varices with sclerotherapy or rubber band ligation using the endoscope
• diagnosis and management of endoscopic complications

While actual performance of all the above therapeutic procedures is recommended, a minimum knowledge should include familiarity with all of them and some experience with this group of procedures.

The following disease processes should be familiar to the surgical trainee, and their appearance demonstrated when feasible during esophagogastroduodenoscopy. Their treatment and implications of their identification should be thoroughly discussed with the surgical trainee:

ESOPHAGUS

• esophageal diverticula
• Schatzki’s rings
• webs
• glycogenic acanthosis
• peptic esophagitis
• infectious esophagitis
• radiation changes
• changes due to lye or acid ingestion
• strictures
• esophageal carcinoma
• esophageal motility disorders
• esophageal foreign bodies
• esophageal perforations
• tracheoesophageal fistula
• gastroesophageal reflux disease
• esophagitis

STOMACH

• hiatal hernia
• postoperative changes
• gastritis
• infections
• ulcers, primary and postsurgical
• gastric carcinoma
• arteriovenous malformations
• stromal tumors
• gastric polyps

DUODENUM

• ulcers
• webs
• diverticula
• benign duodenal lesions
• inflammatory bowel disease
• malignant duodenal lesions: duodenal vs. ampullary

UPPER GASTROINTESTINAL BLEEDING

The surgical resident should be well informed regarding the management of upper gastrointestinal bleeding. This includes knowledge about endoscopic management as well as appropriate surgical treatment when other interventions have failed. The following aspects of the diagnosis and management of upper gastrointestinal bleeding should be discussed and appreciated by all surgical trainees:

• appropriate resuscitative and monitoring measures
• indications and preparation for upper endoscopy
• indications for gastric lavage
• identification of bleeding sites and treatment options available
• morbidity and mortality associated with endoscopy
• the impact of endoscopy on blood transfusion and surgical intervention
• management of bleeding ulcers in the era of H. pylori
• management of active bleeding vs. visible vessels vs. adherent clot
• use of electrocautery/heater probe in the management of bleeding
• use of sclerosants and their complications
• application of laser technology in the management of bleeding
• complete knowledge of the complications of all procedures
• therapeutic interventions and their management

The treatment options listed below for the management of the following disease processes should all be familiar to the surgical resident as should these processes and their identification:

ESOPHAGUS

• esophageal varices
  • sclerotherapy
  • ligation
  • balloon tamponade
  • pharmacologic intervention
  • radiologic intervention
  • surgical intervention
• esophagitis
  • behavioral modification
  • pharmacologic intervention
  • surgical intervention
• esophageal carcinoma
  • laser ablation
  • dilatation
  • stenting
• Mallory-Weiss lesions (of stomach also)

STOMACH

• gastric varices
• gastritis
• gastric ulcers
• postoperative bleeding
• vascular lesions
• watermelon stomach
• gastric carcinoma
• benign gastric lesions (leiomyoma, lipoma)

DUODENUM

• ulcers
• duodenitis
• duodenal tumors
• vascular lesions
• hemobilia

An experience by the surgical resident with endoscopic management of the patient with upper gastrointestinal bleeding is strongly encouraged.

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY

The teaching of ERCP has been relegated to advanced surgical and gastrointestinal training. It is still imperative that the surgical trainee has a full understanding of the procedure and the therapeutic interventions that may be undertaken by an experienced endoscopist. ERCP has increasingly been used in the perioperative management of biliary disease in an effort to prevent open exploration of the common bile duct. It is also an important diagnostic tool that furnishes a guide for appropriate surgical management. These procedures are not without complications and a well-trained surgeon must be able to identify these complications and manage them appropriately.

Surgical residents should be well versed in the following aspects of ERCP:

• indications and contraindications for ERCP in biliary and pancreatic disease
• patient preparation for ERCP
• monitoring and sedation
• equipment and instruction used for ERCP i.e., orientation of the side-viewing scope
• anatomy of the duodenum and the papilla
• biopsy techniques and cytology
• interpretation of cholangiograms and pancreatograms
• therapeutic interventions
• sphincterotomy vs. dilatation of the papilla
• endobiliary or nasobiliary stenting
• management of common bile duct stones:
• retrieval balloons, baskets, biliary stents, and lithotripters
• management of biliary fistulae or leaks
• management of biliary strictures with dilatation and stenting
• management of pancreatic disease
• limitations and failures of ERCP
• complications of ERCP and their management
• indications for radiologic or surgical intervention
• management of cholangitis and biliary obstruction

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY AND JEJUNOSTOMY

The surgical resident should be familiar with the following:

1. Indications for performing enteral access, including neurologic, nutritional, mechanical, and oncologic reasons.
2. Appropriate candidates for PEG and PEG/J based on medical condition, nutritional status, anatomic situation, chronicity of disability to eat.
3. Patient preparation, including informed consent, preoperative antibiotics, other tests as needed
4. Techniques of PEG placement including the “push” technique, the “pull” technique, percutaneous introducer (Seldinger) technique, and radiologic placement techniques
5. Techniques of percutaneous jejunostomy, including primary placement and conversion of a PEG to PEJ
6. The use and types of buttons available, their indications, maintenance, and technique of changing them
7. Complications possible from PEG or PEJ, their diagnosis and management (including aspiration, perforation, inadvertent early removal, gastric wall and body wall necrosis, and leakage at the site).

SMALL BOWEL ENDOSCOPY

The resident should be familiar with the indications and contraindications for performing this procedure, including unknown sources of GI bleeding, and evaluation of an abnormality seen on small bowel series. As with other endoscopic procedures, the technique, including performance in the operating room or in the endoscopy suite, should be familiar. Residents should be familiar with double balloon enteroscopy. Knowledge of and ability to management potential complications, which may arise from this procedure, should also be learned by the resident.

CHOLEDOCHOSCOPY

At the completion of training, the surgical resident should be able to independently perform choledochoscopy. While the resident may not have performed choledochoscopy with all types of instruments available to do so (i.e. both rigid and flexible choledoschoscopes), he or she should be facile with one approach and familiar with the others. The resident should be familiar with not only the different instrumentation but also the different approaches and techniques used in laparoscopic or open procedures, as well as postoperative use of choledochoscopy where anatomically feasible and indicated.

The trainee must be able to identify the major anatomic landmarks of the biliary tree. He or she must also have a knowledge of and experience with common techniques of stone extraction, including use of baskets and balloons. The trainee should be familiar with other energy-based forms of stone fragmentation available to assist in stone removal (mechanical, electrohydraulic, and laser). In addition, knowledge of and ability to manage potential complications arising from the performance of choledochoscopy is required.

II. LOWER GASTROINTESTINAL ENDOSCOPY

Upon completion of the surgical residency, the resident must be capable of independently performing rigid proctosigmoidoscopy as well as flexible lower gastrointestinal endoscopy including sigmoidoscopy and colonoscopy. It is highly desirable that the resident have enough experience with therapeutic lower endoscopic procedures to also independently perform procedures including biopsy, cytologic brushing, polypectomy, and dilatation of strictures. Residents now need Knowledge of other therapeutic techniques used in flexible lower GI endoscopy is required, and an experience with them desirable. The resident must be capable of independently performing anoscopy and diagnosing and treating common anorectal problems with standard anoscopic-based techniques.

Specific details of the curriculum content are as follows. The resident should have a working knowledge of all of the following:

A. Instrumentation and equipment

1. Scopes:
   1. anoscopes
   2. sigmoidoscopes (rigid and flexible)
   3. colonoscopes
2. Cleaning and disinfecting scopes
3. Accessories
   1. biopsy forceps (hot and cold)
   2. snares
   3. cautery (monopolar and bipolar)
   4. cytology brushes and needles
   5. lasers
   6. heater probes
   7. over tubes
   8. dilators

B. Methods

Preoperative preparation and selection of the patient for lower GI endoscopy should be mastered by the surgical resident through a working knowledge of the following:

1. indications and contraindications
2. preoperative laboratories and tests indicated
3. mechanical bowel preparation

Appropriate patient safety and comfort must be assured by the resident also being thoroughly practiced with the appropriate intra procedural measures of:

4. patient monitoring
5. conscious sedation
6. antibiotic prophylaxis (when indicated)

C. Diagnostic Endoscopic Techniques

The surgical resident must be capable of independently performing flexible and rigid sigmoidoscopic examinations for the assessment of pathology of the rectosigmoid. The resident must be familiar with the appropriate techniques for these two approaches. He or she must be knowledgeable of the limitations of such examinations and their role in screening for carcinoma. The resident must be capable of independently performing diagnostic anoscopy and proctoscopy. The resident should be capable of independently conducting the following techniques of colonoscopic scope advancement so as to obtain an appropriately thorough examination of the entire colon:

1. patient positioning
2. external compression
3. maneuvers to avoid or remove loops
4. withdrawal

D. Therapeutic Techniques

Biopsy and Brushing

The resident should be capable of performing colonoscopic biopsy and brushing. A working knowledge of appropriate specimen handling is expected.

Polypectomy

The trainee should have the experience to independently perform polypectomy upon completion of training. This includes special preparative measures for its performance, the technique itself, and awareness of and capacity to manage potential complications.

Treatment of Bleeding

It is desirable for the resident to have some experience in the performance of treating lower GI bleeding through the colonoscope. Familiarity with the methods, including injection and heater probe use, is expected, as is knowledge of the indications for their use and potential complications and their management.

Colonoscopic Decompression of Pseudo-Obstruction and Volvulus

The resident should be able to independently perform colonoscopic decompression of these conditions. Knowledge of the appropriate indications, techniques, and post-procedure management of patients with such conditions is expected.

Foreign Bodies

The resident should have a working knowledge of the means of using flexible or rigid lower endoscopy to diagnose and remove foreign bodies. Familiarity with the appropriate techniques to facilitate this is necessary.

Anorectal pathology

It is expected the resident will become independently capable of diagnosing and treating common anorectal pathology using rigid anoscopic or proctosigmoidoscopic approaches to these problems as needed. These conditions include the following:

a. hemorrhoids
b. fissures
c. fistula-in-ano
d. sexually transmitted lesions
e. pruritus ani
f. condylomata acuminata
g. inflammatory bowel disease
h. infectious ulcers/lesions
i. neoplasms of the anorectum

E. Normal Anatomic Recognition

The resident should be capable of independently recognizing all the following landmarks of normal lower GI anatomy:

a. Rectum
b. Sigmoid and descending
c. Splenic flexure
d. Transverse colon
e. Hepatic flexure
f. Cecum and ascending

The following variations in anatomy should be able to be readily appreciated:

a. Fixation
b. Angulation
c. Spasm
d. Prominent folds
e. Melanosis coli
f. Diverticulosis

F. Pathologic Conditions of the Lower GI Tract

The resident should have a knowledge of all the following pathologic conditions of the lower GI tract. Familiarity with treatment approaches, when listed, is expected.

1. Colonic polyps

A. False or suction polyps
B. Epithelial polyps

• Adenomatous polyps
  • Tubular
  • Tubulovillous
  • Villous
  • Adenoma-carcinoma sequence
• Hyperplastic
• Inflammatory
• Juvenile

C. The polyposis syndromes

• Familial adenomatous polyposis coli (FAPC)
• Gardner’s Syndrome
• Turcot’s Syndrome
• Juvenile Polyposis
• Peutz-Jegher’s Syndrome
• Cronkhite-Canada Syndrome
• Cowden’s Disease

D. Submucosal lesions

• Lipomas
• Leiomyomas
• Carcinoids
• Lymphoid hyperplasia

E. Endometrial implants

2. Colonic Malignancies

A. Adenocarcinoma

• Appearances
• Biopsy and cytology
• Synchronous adenomas and cancers
• Surveillance

B. Lymphoma
C. Direct extension

• Cervix
• Uterus
• Ovaries
• Prostate

D. Metastases

• Breast
• Lung
• Melanoma

E. AIDS

• Kaposi’s sarcoma
• Opportunistic infections

3. Inflammatory Disease

A. Ulcerative colitis

• Appearance and grading
• Cancer surveillance
• Dysplasia

B. Crohn’s disease

• Appearance
• Features distinguishing from U.C.
• Role of Biopsy
• Cancer risk/surveillanc

C. Viral

• Viral gastroenteritis
• CMV

D. Bacterial

• Salmonella
• Shigella
• Yersinia
• Campylobacter

E. Antibiotic associated

• Pseudomembranous colitis
• Clostridium difficile

F. Amoebic colitis
G. Ischemic colitis
H. Radiation colitis/proctitis
I. Rare lesions

• Tuberculosis
• Hemolytic uremic syndrome
• Behcet’s disease
• Schistosomiasis

J. Drug induced

4. Colonic Strictures

A. Etiologies

• Diverticular
• Malignant
• Inflammatory bowel disease
• Ischemic
• Radiation
• Post operative
  • Circular stapled anastamosis
  • Hand sewn anastamosis
  • Inflammatory after anastomotic leak
• Lymphogranuloma venereum

B. Dilation of strictures

• Indications
• Techniques and biopsies

5. Colonic Bleeding

A. Etiologies

• Neoplastic
  • Adenomas
  • Malignant strictures
  • Leiomyomas/sarcomas
• Inflammatory bowel disease
• Ischemic colitis
• Radiation colitis
• Diverticular disease
• Vascular
  • Angiodysplasia
  • Hemorrhoids
  • Colonic varices
  • Hereditary hemorrhagic telangiectasias
  • Cavernous hemangioma

B. Diagnosis

• Occult vs. gross vs. massive
• Radionuclide scanning
• Angiography
  • Therapeutic aspects
• Endoscopy
• Air contrast barium enema

C. Treatment

• Role of colonoscopy
• Electrocautery
  • Monopolar
  • Bipolar
• Heater probe
• Injection
• Argon beam
• Laser
• Vasopressin

CURRICULUM GUIDELINES IN LAPAROSCOPIC SURGERY

The teaching of advanced laparoscopic surgical procedures, as with the teaching of all surgical procedures to treat pathologic conditions, is appropriately taught only in a setting of an understanding by the surgical trainee of the general principles and practice of surgical science as well as the specific pathophysiology of the disease process being treated. Without such a scientific approach to surgical therapy, its practice becomes a technical exercise only. As such, all conditions treated using laparoscopic surgical techniques should be fully understood in terms of the spectrum of disease, and the role of surgical therapy in its treatment. The indications and contraindications to performing any given procedure must be understood, as well any appropriate alternative treatment procedures and approaches. In particular, where an advanced laparoscopic procedure may be done alternatively using a traditional celiotomy approach, the surgeon-in-training must understand the relative merits of both approaches, and specific instances where one approach should be favored over another. In addition, the surgical trainee should, whenever possible, have an adequate experience with and exposure to the alternative or traditional approach to the procedure that allows that approach to be a part of his or her treatment armamentarium, and allows for a safe intraoperative conversion from one approach to another should that be in the patient’s best interest.

The principles of appropriate preoperative and postoperative care for a given surgical procedure, whether traditional or laparoscopic, must be mastered by the surgical resident prior to the initiation of any significant operative experience with performing that procedure. Similarly, the appreciation of potential complications is necessary, as well as their treatment.

Prior to initiating an experience with advanced laparoscopic procedures, the resident should be familiar with and experienced in basic laparoscopy and basic laparoscopic procedures. These are defined as diagnostic laparoscopy, laparoscopic cholecystectomy, and laparoscopic appendectomy. Since basic principles incorporated in the safe performance of these procedures are inherent in the similar performance of advanced procedures, a brief list and description of important aspects of these basic procedures, which should be mastered during the surgical residency training, are given below. All residents should have exposure to the Fundamentals of Laparoscopic Surgery (FLS) during their training in order to demonstrate a familiarity with basic principles and skills of laparoscopic surgery. FLS will be required for American Board of Surgery certification beginning in 2009.

SECTION ONE: BASIC LAPAROSCOPY

1. PHYSIOLOGY OF LAPAROSCOPY
   1. Mechanical Effects of Abdominal Distention
      1. Decreased lung volume
      2. Higher airway pressure
      3. Abdominal compartment distention
   2. Pharmacologic Effects of CO2
      1. Local effects
         1. Decreased visceral blood flow
         2. Decreased portal venous flow
         3. Decreased venous return to heart
      2. Systemic effects
         1. Decreased cardiac index
         2. Respiratory and metabolic acidosis
         3. Increased SVR, decreased PVR
         4. exacerbation of cardiac arrhythmias
      3. Both effects are rapidly reversible and clinical significance unclear
   3. Immunologic Response to Laparoscopy
      1. May be different than open procedure
      2. Evaluation continues
   4. Preoperative Patient Evaluation
      1. Overall physiologic performance
      2. Cardio-respiratory parameters
      3. Coagulation parameters
      4. Abdominal factors (i.e. prior surgery)
      5. Gasless laparoscopy an alternative
2. EQUIPMENT REQUIREMENTS
   1. Insufflation
      1. CO2 preferred (NO2, He, Ar, N, others possible)
      2. High flow (10-15 liters/min), pressure valves, visible flow rates, patient pressure monitors
   2. Camera
      1. Single/triple chip
      2. 3 dimensional
      3. Printers and video recorders
   3. Video monitors
   4. Light sources
      1. Safety precautions to prevent thermal injury
   5. Laparoscopes
      1. Size 10 mm to 1.4 mm (needlescopes)
         1. smaller size = less light
      2. Angles (0, 24, 30, 45 degree)
3. INSTRUMENTATION
   1. Disposable vs. Reusable
      1. Cost, sterility, reliability, availability
   2. Trocars
      1. Hasson, shielded, versatility
   3. Graspers/Dissectors/Scissors
      1. Traumatic, atraumatic, specialty designed
      2. Electrocautery capable
   4. Retractors
      1. Size, application
   5. Tissue Approximation Devices
      1. Clip appliers
      2. Linear staplers
         1. staple size, applications
      3. Specialty devices
   6. Hemostatic Devices
      1. Monopolar cautery
      2. Bipolar cautery
      3. Ultrasonic dissection
      4. Lasers
      5. Vessel sealing technologies
   7. Suturing
      1. Devices
      2. Pre-tied sutures
      3. Needle types
      4. Needle holders
   8. Trocar Closure Devices
   9. Others
      1. Dissecting balloons
      2. Gasless abdominal wall retractors
      3. Specimen containment devices
4. DIAGNOSTIC LAPAROSCOPY
   1. The surgical resident should be knowledgeable regarding the following:
      1. indications and contraindications
      2. role in diagnosing liver disease, fever of unknown etiology, abdominal or pelvic pain of unknown etiology
      3. staging and assessing intraabdominal tumors
      4. evaluating ascites
      5. selective role in penetrating and blunt trauma
      6. evaluating intestinal viability or ischemia
      7. complications specific to laparoscopy including subcutaneous emphysema, air embolism, pneumothorax, cardiac arrhythmias, injury from Verses needle or trocar to abdominal viscera, trocar site bleeding or hematoma, trocal site incisional hernia
      8. methods of safe creation of a pneumoperitoneum using the Veress needle technique
      9. creating a pneumoperitoneum using an open technique with a Hasson trocar
      10. appropriate port placement principles with respect to telescope and working port relationships, including alignment of axis of telescope with monitor
      11. principles of safe organ handling using laparoscopic instruments
      12. safe techniques of enterolysis when previous surgical adhesions preclude visual assessment or access
      13. techniques of liver biopsy and other organ biopsy
5. LAPAROSCOPIC CHOLECYSTECTOMY
   1. The resident must gain a firm understanding of the following:
      1. indications for procedure
      2. contraindications to approach
      3. trocar placement
      4. appropriate exposure of infundibulum and triangle of Calot
      5. indications for intraoperative cholangiography and its safe conduct and appropriate interpretation
      6. indications for intraoperative ultrasound as an alternative or adjunctive procedure to cholangiography, and where possible its safe conduct and appropriate interpretation
      7. understanding potential anatomic anomalies and their potential contribution to procedural complications
      8. recognition of the cystic duct/gallbladder junction
      9. technique of division of cystic artery and duct
      10. technique of removal of gallbladder off liver bed
      11. removal of gallbladder from abdominal cavity
      12. role of first assistant in proper exposure
      13. special considerations in patients with pregnancy, severe obesity, previous upper abdominal surgery, and potential choledocholithiasis
      14. complications peculiar to laparoscopic cholecystectomy and their treatment
      15. indications for conversion to open procedure
6. LAPAROSCOPIC APPENDECTOMY
   1. The resident must master a firm understanding of the following:
      1. indications for appendectomy and laparoscopic versus open approaches
      2. contraindications to appendectomy or laparoscopic approach
      3. trocar placement
      4. exposure of appendix for dissection
      5. evaluation of other potential sources of right lower quadrant abdominal pain technique of laparoscopic appendectomy using endo-loops
      6. technique of lap. appendectomy using stapler
      7. removal of appendix from abdomen
      8. treatment of appendiceal abscess
      9. indications for conversion to open procedure
      10. complications of the procedure and the approach and their treatment

SECTION TWO: ADVANCED LAPAROSCOPIC PROCEDURES

PRINCIPLES/SKILLS

The initiation of an experience in advanced laparoscopic surgical procedures for the surgical trainee should only begin once the skills of basic laparoscopy have been mastered. While individual training programs will likely have a different mix of cases in which advanced laparoscopic approaches are used, there is a core group of technical skills that should be mastered through the performance of some variety of such procedures. Such skills can be appropriately introduced and taught through preliminary and if needed concurrent additional skills laboratories involving surgical trainers, animal models, or other simulated operating conditions. These skills include but are not limited to the following:

• two-handed surgical manipulations
• two-handed dissection
• intracorporeal suturing
• intra- and extracorporeal knot tying
• intracorporeal tissue approximation with sutures and staples
• achieving hemostasis from unexpected hemorrhage
• exposure of all intra abdominal and retroperitoneal organs

Mastery of these core advanced skills, coupled with an adequate experience in the performance of a procedure using a traditional approach (for example, open Nissen fundoplication) will likely allow the surgical trainee to master the particular advanced laparoscopic procedure (in this example laparoscopic Nissen fundoplication) in a setting requiring fewer supervised or assisted cases than if those skills were not yet completely mastered before embarking on an experience with the advanced procedure.

The greater the experience of the resident in all types of advanced laparoscopic procedures, the greater the likelihood that the ability to learn and perform additional advanced procedures will occur with safety and facility. Thus it is the combined experience in advanced procedures that should be emphasized, rather than necessarily the mastery of any one individual procedure. However, it is also expected that case mix and availability will on some occasions allow the resident a significant enough experience in one of the procedures below to serve as a basis for mastery of its performance.

LAPAROSCOPIC INGUINAL HERNIORRHAPHY

The resident should become familiar with the following concepts and aspects of this procedure:

• indications for performing a laparoscopic versus an open inguinal herniorrhaphy; relative advantages and disadvantages of each approach
• situations where these advantages are more likely (i.e. recurrent and bilateral hernias for the laparoscopic approach)
• methods currently used: transabdominal preperitoneal and total extraperitoneal; relative advantages and disadvantages of each approach
• trocar placement
• knowledge of inguinal anatomy from the laparoscopic view
• proper dissection techniques
• placement of prosthetic mesh and securing it appropriately in place
• coverage of mesh
• complications specific to laparoscopic herniorrhaphy and their prevention and treatment
• expected long-term results

LAPAROSCOPIC ANTIREFLUX PROCEDURES

The resident should be knowledgeable about the following aspects of these procedures:

• indications for performing antireflux surgery
• interpretation of preoperative tests for GERD
• understanding modifications of operations based on preoperative testing
• expected benefits and efficacy of antireflux surgery
• knowledge of anatomy of proximal gastric/distal esophageal area including
• ability to locate and easily identify major structures including both vagal trunks
• technical performance of the procedure, including:
  • trocar placement
  • division of short gastric vessels
  • crural and esophageal dissection
  • suturing diaphragmatic crura
  • positioning of wrap
  • suturing of wrap
• potential intraoperative and postoperative complications, their recognition and treatment

LAPAROSCOPIC GASTRIC SURGERY

The resident should be familiar with the following aspects of laparoscopic gastric surgery, with the recognition that the experience in such procedures will likely, based on current practice patterns, be limited:

• situations and diagnoses where a laparoscopic approach to gastric resection or vagotomy is appropriate
• relative benefits of a laparoscopic approach in performing vagotomy or resection
• knowledge of the anatomy of the vagus nerves and stomach recognition of these structures under laparoscopic conditions
• Roux-en-y gastric bypass for weight loss and gastric banding procedures
• trocar placement and exposure
• mobilization and division of gastric blood supply
• division of branches of vagus
• division of stomach
• anastomotic techniques: stapled, stapled and sewn, sewn
• potential complications, operative and postoperative, especially those peculiar to a laparoscopic approach, and their diagnosis and treatment
• indications, preoperative selection, appropriateness for a laparoscopic approach for selected patients undergoing bariatric surgical procedures, along with the expected operative results and potential complications
• techniques currently used to perform such procedures and differences from celiotomy approach

LAPAROSCOPIC COLON/INTESTINAL RESECTION

The resident should be familiar with the following and have a working knowledge and, if possible, a practical experience with the following:

• indications for performing a laparoscopic resection or procedure for pathologic conditions of the colon and small intestine
• appropriate indications for surgery based on individual disease or condition
• role of resection, bypass, diversion as treatment options
• appropriate trocar placement based on condition
• techniques of intestinal mobilization and exposure
• knowledge of elevant anatomy, including blood supply, retroperitoneal structures, etc. relevant to performing appropriate surgical intestinal resection
• dissection techniques for bowel
• mesenteric vascular division techniques
• intestinal division techniques
• anastomotic techniques: intracoroporeal vs. extracorporeal
• anastomotic techniques: stapled vs. sewn
• relevant concerns using laparoscopy for treatment of malignant conditions
• technique of laparoscopic creation of colostomy/ileostomy
• technique of laparoscopic enteroenterostomy/enterocolostomy using above anastomotic techniques
• indications for surgical treatment of rectal prolapse specific instances where laparoscopic rectopexy is preferred or appropriate treatment technique of laparoscopic rectopexy for rectal prolapse
• potential intraoperative and postoperative complications of laparoscopic intestinal surgery, their recognition and treatment

LAPAROSCOPIC HEPATOBILIARY SURGERY (OTHER THAN CHOLECYSTECTOMY)

The resident should be exposed to laparoscopic exploration of the common bile duct, should have a working knowledge of the following, and in most cases have some hands-on experience with laparoscopic common duct exploration:

• interpretation of cholangiography and ultrasonographic findings during laparoscopic cholecystectomy that indicate likely presence of choledocholithiasis or bile duct pathology
• thorough knowledge of portal hilar anatomy and its variations
• technique of dilating cystic duct for transcystic exploration of common bile duct
• technique of choledochoscopy and use of choledochoscopic instruments for stone clearance
• use of transcystic baskets and balloons for stone clearance
• technique of laparoscopic dissection of portal area, including exposure of common duct and choledochotomy
• laparoscopic placement of T-tube and closure of cholecochotomy
• laparoscopic biliary-enteric anastomosis, including cholecystojejunostomy via stapled or sewn technique
• laparoscopic treatment of hepatic cysts, including localization using intraoperative laparoscopic ultrasound, drainage, resection, and destruction of cyst wall or placement of omental pedicle in cyst
• technique of laparoscopic use of special hepatic dissecting instruments including: ultrasonic surgical aspirator and argon beam coagulator
• technique of hepatic wedge resection

LAPAROSCOPIC SPLENECTOMY AND ADRENALECTOMY

The resident should become familiar with the following aspects of these solid organ removal procedures:

• indications for performing adrenalectomy
• indications for using laparoscopic approach for adrenalectomy
• indications for performing splenectomy
• indications for using laparoscopic approach for splenectomy
• relevant anatomy of spleen, especially as viewed laparoscopically from anterior and lateral positions
• anatomy and surrounding structures of left adrenal and right adrenal glands, including blood supply
• techniques for exposing left and right adrenal glands
• techniques for removing left and right adrenal glands, including vein ligation and division
• techniques for performing laparoscopic splenectomy, including division of short gastric vessels and splenic hilar vessels
• techniques of removal of adrenal from abdominal cavity
• techniques of removal of spleen from abdominal cavity
• potential intraoperative and postoperative complications peculiar to this operation and operative approach and their recognition and treatment

LAPAROSCOPIC GASTROSTOMY AND JEJUNOSTOMY

The resident should be expected to have an experience with these procedures to some extent, and be fully knowledgeable regarding the following:

• indications for performing gastrostomy or jejunostomy, and the relevant differences and preferences for each type of access
• contraindications to placing feeding access tubes
• indications for preference of using a laparoscopic approach to placing enteral access tubes
• trocar placement for laparoscopic gastrostomy
• technique of laparoscopic gastrostomy
• trocar placement for laparoscopic jejunostomy
• technique of laparoscopic jejunostomy
• potential intraoperative and postoperative complications arising from these procedures and their management
• postoperative management of enteral access tubes

CURRICULUM GUIDELINES IN LAPAROSCOPIC ULTRASOUND

Residents should be familiar with ultrasound technology, and apply its use to laparoscopic procedures where it facilitates patient care. A sufficient background in the physics of ultrasound as well as the principles of the transducer probes, their use, common artifacts encountered, and a supervised and proctored experience in learning basic use of ultrasound technology should precede the actual initiation of an operative experience with the technology. Where necessary, radiologic consultation is indicated if the surgeon employing the technology is not sufficiently experienced in its use. SAGES has established guidelines for the recommended training for surgeons using ultrasonography.

The resident should be exposed to ultrasound as a tool to supplement the lack of tactile sensation dictated by minimal access surgery. An exposure to using ultrasonography in the following situations should be a part of advanced laparoscopic training:

1. imaging the biliary system during laparoscopic cholecystectomy to determine the presence of common duct stones. The resident should ideally have an experience in imaging the extrahepatic biliary tree.
2. imaging the liver to become facile in identification of the hepatic segmental anatomy and identification of abnormalities observed. The resident should have sufficient experience to clearly identify normal hepatic anatomy and be exposed to the appearance of typical abnormal lesions.
3. intraoperative imaging of the pancreas. The resident should have an exposure to the intraoperative imaging of the pancreas and its normal appearance relative to the surrounding vascular structures.
4. use of laparoscopic ultrasound in combination with laparoscopy to stage abdominal tumors

The resident should have an exposure to the use of these combined modalities as an important tool to staging tumors of the gastrointestinal tract, liver, and pancreas, and determining their resectability. This will incorporate some of the experience in items 2 and 3 above.

CURRICULUM GUIDELINES IN THORACOSCOPY AND VIDEO-ASSISTED THORACIC SURGERY

The resident should have an experience in video-assisted thoracic surgery (VATS), sufficient to perform basic procedures under supervision and sufficient to obtain the core knowledge necessary to understand the indications, contraindications, techniques, and potential complications of commonly performed VATS procedures. An exposure to sufficient numbers of such cases to enhance this basic core knowledge is also highly desirable.

As with laparoscopy, VATS is appropriately taught only in the setting of a thorough understanding by the trainee of the general principles and practice of thoracic surgery as well as the specific pathophysiology of the disease process in particular. Therefore, the preoperative and postoperative measures that must be followed to insure safe conduct of the operation must be understood as well as the technical aspects of performing the procedure itself.

Indications and Contraindications
The resident should be thoroughly familiar with the indications and contraindications for performing procedures using a VATS approach. In particular, the contraindications of pulmonary function limitation, inability to tolerate one lung ventilation, or other conditions that would likely compromise the safety of the procedure must be understood. The relative advantages of using a minimal access approach, and the degree to which they are established, should be known for each procedure for which VATS is used.

Preoperative Evaluation
Basic preoperative workup parameters, such as pertinent aspects of the history and physical, and interpretation of findings on the chest X-ray, CT scan, and laboratory tests such as pulmonary function tests and arterial blood gases should be well understood.

Intraoperative Monitoring/Anesthesia
Requirements of safe intraoperative conduct of the operation must be well understood. The use of general anesthesia, appropriate monitoring with arterial line, blood gases, pulse oximeter, end-tidal CO₂ monitoring, and use of local or regional anesthesia supplementation must also be part of the resident’s fund of knowledge.

Access and Approach
For each basic procedure, the positioning of the patient, placement of special monitoring if needed, and placement of the video equipment and trocar sites should be familiar to the resident.

Methods of thoracic surgical access, including trocars (both disposable and reusable), rigid vs. flexible scopes, and “trocarless” access should be known.

Imaging Equipment
The resident should be familiar with at least the basic aspects of the following equipment in terms of purpose, function, adjustment mechanisms, sterilization techniques, storage and maintenance requirements, and “trouble-shooting” to rectify common malfunctions, which may occur during the procedure. It is understood residents may not be exposed to all pieces of equipment on the list, but a strong working knowledge of the equipment used in their hospital is essential.

1. Telescopes
   1. Size: 5mm, 7mm, 10mm
   2. Angled: 0, 30, 45 degree
   3. Rigid/flexible
2. Cameras
   1. Single chip
   2. Three chip
   3. 2 dimensional
   4. 3 dimensional
3. Light source
4. Video monitor(s)
5. Still picture imaging
6. Mixing boards
7. Other – CO₂ insufflator

Operative Instrumentation
The resident in training should become familiar with the following items of equipment, which may be used in VATS procedures. The same working knowledge of this equipment is expected as for the imaging equipment.

1. Standard thoracic instruments – “trocarless”
2. Hand instruments
   1. scissors
   2. graspers
   3. suction/irrigation/cautery devices
   4. fan retractors
   5. specimen retrieval bags
   6. endoscopic knitters
   7. endoscopic suturing devices
3. Endoscopic staplers: 30, 45, and 60 mm
4. Lasers and cautery devices
   1. Nd:YAG laser (when available)
   2. Argon beam coagulator
   3. Monopolar cautery
   4. Bipolar cautery

PROCEDURES

The following list of procedures is meant as a guideline to a complete exposure to VATS. Those procedures marked with a * are considered basic procedures, to which the resident should have exposure and, ideally, some experience in performing under supervision. Those procedures marked with a # are more advanced, but are procedures with which the resident should be familiar based on actual participation if possible. Other procedures listed are those about which the resident should have basic knowledge, while not necessarily a significant exposure.

1. Pleural Disease
   1. Diagnosis idiopathic pleural effusions *
   2. Diagnosis idiopathic pleural masses *
   3. Evacuation clotted/retained hemothorax *
   4. Management of chylothorax #
   5. Drainage/decortication early empyema *
   6. Trauma – non-exsanguinating hemorrhage #
2. Parenchymal Lung Disease
   1. Diagnosis indeterminate solitary pulmonary nodule #
   2. Wedge resection for diagnosis diffuse lung disease #
   3. Recurrent/persistent pneumothorax #
   4. Limited resection lung cancer
   5. Lobectomy
   6. Bullectomy for emphysema #
   7. Therapeutic metastatectomy
3. Mediastinal
   1. Diagnosis mediastinal masses/adenopathy *
   2. Excision mediastinal cysts #
   3. Staging of lung cancer #
   4. Thymectomy
4. Esophageal
   1. Resection benign tumors #
   2. Resection duplication cysts
   3. Heller myotomy for achalasia
   4. Staging of esophageal cancer #
   5. Esophagectomy
5. Pericardial
   1. Pericardiectomy for benign effusive disease *
   2. Diagnosis of indeterminate effusions *
   3. Pericardiectomy for malignant effusions #
   4. Defibrillator pericardial patch placement
6. Cardiac
   1. Patent ductus arteriosus ligation
   2. Internal mammary artery harvest
   3. Single vessel mammary grafting
7. Neurogenic
   1. Excision posterior mediastinal masses
   2. Sympathectomy #
   3. Transthoracic vagotomy #
8. Spine
   1. Biopsy vertebrae #
   2. Herniated disc
   3. Spinal deformity
   4. Drain disc space abscesses
   5. Corpectomy for decompression
   6. Spinal fusion

Postoperative Care
The resident should have a command of knowledge of the major aspects of postoperative care particular to VATS surgery, including appropriate monitoring, attention to cardiovascular and respiratory status, volume status, fluid and electrolyte management, management of tube thoracostomy, application of appropriate respiratory therapy and pulmonary toilet, and management of postoperative analgesia and anesthesia including local, regional, and epidural anesthesia and analgesic administration via PCA pump, parenteral, or oral routes. Management of appropriate antibiotic medication, nutritional support, and pulmonary and cardiac medications is also considered fundamental.

Complications
A thorough knowledge of the potential complications which may occur after all VATS procedures, as well as those peculiar to each individual one is also part of the basic knowledge expected of the resident. Knowledge of their management in terms of initial recognition, diagnosis, and formulation of initial management plan and action is also expected.

REFERENCES

1. Scott-Conner, CEH(ed). The SAGES Manual: Fundamentals of Laparoscopy, Thoracoscopy and GI Endoscopy, 2nd Edition. New York: Springer; 2006.

This document was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) April 2009. It was prepared by the Resident Education Committee in 1998 and was revised by the Resident Education Committee in 2009.