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Surg Clin N Am 86 (2006) 987–1004

Advanced Laparoscopic Skills
Acquisition: The Case of Laparoscopic
Colorectal Surgery
Eric C. Poulin, MD, MSca,b,*, Jean Pierre Gagné, MDc,
Robin P. Boushey, MD, PhDa,d
a
Department of Surgery, University of Ottawa, 501 Smyth Road, Ottawa,
Ontario K1H 8L6, Canada
b
Department of Surgery, The Ottawa Hospital, 501 Smyth Road, Ottawa,
Ontario K1H 8L6, Canada
c
Centre Hospitalier Universitaire de Que´bec, Hôpital Saint-François d’Assise,
10 de l’Espinay, Que´bec G1L 3L5, Canada
d
Department of Clinical Epidemiology, The Ottawa Hospital, 501 Smyth Road,
Ottawa, Ontario K1H 8L6, Canada

‘‘The only constant is change’’
Heraclitus, Greek philosopher
2500 years ago

Historical context
It has been almost 20 years since the introduction of laparoscopic chole-
cystectomy by Eric Mühe [1] and Philippe Mouret [2] in the early 1990s, and
it changed the face of surgery forever. Since then, the development and val-
idation of advanced end-organ and intestinal minimally invasive procedures
have occupied an ever-increasing place in the surgical literature [3–8]. More-
over, multiple randomized trials have demonstrated the superiority of lapa-
roscopic colon resection over the open method for short-term outcomes
[9–13]. More recently, a well-publicized trial (Clinical Outcomes of Surgical
Therapy; COST) showed the noninferiority of laparoscopic colon resection
for colon cancer survival, whereas another even suggested better long-term

* Corresponding author. Department of Surgery, The Ottawa Hospital, 501 Smyth Road,
Ottawa, Ontario K1H 8L6, Canada.
E-mail address: epoulin@ottawahospital.on.ca (E.C. Poulin).

0039-6109/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.suc.2006.05.004 surgical.theclinics.com

June 1998 It has taken time for the surgical community to accept that the journey of modern surgery is defined by equal or better outcomes with less surgical trauma. Although solid data are difficult to obtain. Although much is based on evidence. and varies from 5% (United States) to 15% (France) [16]. and similar trials to evaluate laparoscopic mesorectal excision in rectal cancer are being set up. SAGES) that fellowship programs should ‘‘train teachers. it was estimated recently that the penetra- tion of laparoscopic colon resection is limited. This has created a sense of urgency for surgeons in training and surgeons in practice to acquire ad- vanced laparoscopic skills. unpublished data). Rome. This article reviews the basic principles of technical skills acquisition. Of interest is a population study that was performed by the College of Physicians of a Canadian province (Québec.988 POULIN et al survival for stage III disease [14. and the number of minimally invasive surgery (MIS) research projects [17]. despite the recommendation by respected societies (eg. a fact that correlates well with the insuffi- cient number of teachers. fellows. Studies also have demonstrated the poor exposure of North American surgery residents to advanced laparo- scopic procedures by the end of their training (!10 advanced cases during surgical training of 4 or 5 years). a significant portion also is based on the experience that has been gained in teaching advanced laparoscopic skills to residents. ‘‘The Capacity of American Surgery to Adequately Teach Advanced Min- imally Invasive Surgery is Simply Overwhelmed’’ Frederick Greene. The impact of hiring laparoscopic surgeons in academic health sciences centers is felt clinically by an increase in the num- ber of advanced cases. World Congress of Laparoscopic Surgery. a vision that has been endorsed more rapidly by patients. Furthermore. It studied 5707 appendectomies and found that a low rate of laparoscopic appendectomy (!20%) was found in 50% of teaching hospitals and 37% of nonteaching institutions (Gagné and colleagues. its acceptance also is discouraging. 7. and surgeons over the last 15 years. the transfer of this technology has faced many hurdles. more laparoscopic training sessions. despite the fact that multiple randomized trials and more systematic reviews than one would care to read have demonstrated its supe- riority. The results of more trials on various continents are expected soon. and a blueprint for integration of new skills into practice. Yet. Society of American Gastrointestinal Endoscopic Surgeons. which complicates the issue with political agendas even further.15].8 million population) dur- ing 1 year (April 2002–March 2003). Although the routine performance of laparo- scopic appendectomy is suggested by most experts as the best introduction to the performance of laparoscopic colon resection. . the various methods of skill transfer. MD.’’ some exceptional fellowship-trained laparoscopic surgeons have not been able to find work in teaching environments.

you can train a monkey to operate. Integration starts when the new knowledge is translated into the ap- propriate motor behavior. and sports. Although it is beyond the scope of this article to review all theories that govern skill acqui- sition and the development of expert performance. These theoriesdfar from being contradictoryd provide complementary insights into the learning of surgical technical skills. guided practice) is essential to learning skills. performance is irregular with each step of the task easily identifiable. and autonomous. and performance becomes smooth and automatic. A minimum exposure to error-prone alternatives also is essential for an efficient skill teaching program. Practice improves flow of movement to the point where routine execution no longer requires cognitive input. The first involves knowing what to do without necessarily being able to do it. The Kopta Theory of Skill Acquisition Three overlapping phases are described in the learning of any motor skill: cognitive. world class athletes. it has become evident that the difficulty of acquiring the technical skill aspect of surgery has been underestimated [18]. cognitive knowledge.’’ With the advent of advanced laparo- scopic procedures. art. During the early integrative phase. The first states that expert performance requires years of intensive training. Boxes 1 through 3 illustrate common strategies that are used to teach skills. Then the learner needs to intellec- tualize what one wants to do and plan the necessary steps to accomplish the task. the autonomous phase has been attained. chess. chess players) are seen many years after physical maturation and require approximately 10 years of intensive or ‘‘deliberate practice’’ [21]. ADVANCED LAPAROSCOPIC SKILLS IN COLORECTAL SURGERY 989 Basic principles of technical skill acquisition Unfortunately. and decision-making capabilityd ‘‘. Surgeons. integrative. always should be looking for ways to improve [19–21]. like any other expert performers. many teachers of surgery in the past have downplayed the technical aspect of surgery while trying to highlight the importance of sound surgical judgment. science. The issue with this theory is that automaticity implies satisfaction with the level of competence. An instructor must be able to break down a task into its components and communicate those to the learner. At this level. There is a world of difference between a junior resident spending 20 minutes working with a box trainer and Moe Norman (recognized as one of the world’s best golf ball strikers) who from . Practice with feedback (ie. Ericsson’s Model of Expert Skill Acquisition The theory is based on research on expert performers in the fields of music. The evidence supports that the highest levels of human performance (eg. a brief overview of a few is relevant to understand the challenges that are faced by surgical educators in the current environment. It has two main parts. ‘‘Deliberate practice’’ requires effort.

Instead. Instructional phases Introductory phase Needs assessment Introduction of objectives Explanation of rationale Familiarization with equipment Demonstration of sequential steps Practice phase Give specific instruction Guide the initial attempts Provide feedback Allow independent practice Certify competence Perfecting phase Provide for continued practice Evaluate performance under actual conditions .990 POULIN et al Box 1. He argues that experts de- velop complex cognitive networks that allow them to seem to bypass normal human limits. The change in ability is not so much physical as Box 2. experts have learned to find preexisting clues that allow them to predict what is likely to happen in a given situation. they do not have faster hands. He suggests that experts do not reach a level of automaticity. or Bobby Fisher. The second part of Ericsson’s model has not been studied as much. the famed chess player who was known to spend 5 to 10 hours a day practicing and studying games played by chess grandmasters [20]. Experts may appear to have faster reaction times. in fact misleading. Principles of teaching surgical technical skills Analogous to teaching competitive sport Accuracy Speed Economy of effort Adaptability Teaching motor skills is different than teaching verbal skills Represents a chain of responses Requires eye-hand coordination Requires organization of subroutines age 19 to 32 routinely hit 800 balls a day. Rather the ap- pearance of automaticity is. In fact.

imagery . cognitive. conditions within the learner (internal conditions) and conditions within the teaching environment (external conditions) were considered essential for effective learning (Box 4). According to this theory. For each ability. the best hockey player of all time. autonomous). This involves the combination of several basic surgical skills that are performed in an orderly series of steps whereby recall of part skills is one of the most important in elaborating learning hierarchies. he seemed to have the best overall premonition of where the next play would occur and could translate that into scoring opportunities faster than anybody. According to this approach. checking. It also argues against the strategy of isolating technical skill as a focus separate from the cognitive aspects of surgery. associative. The Ericsson Theory argues against the traditional model of skill acqui- sition. and attitudes [22]. Experts can generate a complex representation and awareness of the encountered situation. A good example in the world of sports is Wayne Gretzky. The steps to mastery by repetition Unconsciously incompetent Consciously incompetent Consciously competent Unconsciously competent To teach a technical skill. the teacher must revert to a consciously competent state of mind. Although not a great skater. which describes skill learning as occurring in phases that develop from cognitive to automatic (see Box 3). ADVANCED LAPAROSCOPIC SKILLS IN COLORECTAL SURGERY 991 Box 3. The Behaviorist School The behaviorists unified the results of many years of research in the field of education into a conceptual framework. cognitive strategies. practice is another key condition of learning motor skills. Neuropsychologic testing Neuropsychologic tests have been conducted on surgical residents to measure pure motor skills (speed and precision of movement). learning of a skill occurs through the integration of the executive routine along the previously described phases (cognitive. or stick handler. and classified human abilities into five categories: verbal information. This information is integrated with existing knowledge. intellectual skills. motor skills. and reasoning about alternative actions [20]. shooter. and allows selection of action as well as evaluation.

Educational strategies Advanced laparoscopic surgery is a highly intellectual activity that in- volves the processing of perceptual information that is received from propri- oceptive.24]. therefore. visual. of structures yet to be exposed. and stress tolerance without significant corre- lation with tests of pure motor abilities [23.992 POULIN et al Box 4. and. orga- nize. These images will be made up of the visible anatomy at various stages of procedures. and auditory sources. and visuospatial organization (ability to represent mentally a three-dimensional situation). Conditions of learning motor skills Internal conditions Recall of part skills Recall of executive routines (learning hierarchies) External conditions Provide verbal instructions Provide pictures Use demonstrations Give opportunity to practice Give feedback (internal representation of an object). tactile. Imagery Imagery as defined as the internal representation of an object has been found best suited for learning concrete information. and sys- tematic review of performance. The final score of high performance correlated significantly with complex visuospatial organiza- tion. The quality of this representation depends on the interpretation he makes of the visual information. This is especially important in advanced laparoscopic surgery where the tactile or visual clues are so different at first. . Ten percent to 12% of the population report being unable to create imagery. but perhaps more importantly. mental practice. Trainees will benefit from learning to make mental images as they observe or perform surgery. The importance of visuospatial perceptual ability also has been identified by other investigators [25]. somatosensory memory. and retain perceptual information: imagery. should be applicable to surgery. the surgeon uses the two-dimensional image from the monitor to construct a three-dimensional mental representation of the anatomy before him. DesCôteaux and colleagues [26] have suggested three strategies to help learners process. In laparoscopic surgery. olfactory.

This technique improves the performance of skills that involve a large mental component (anterior resection of the rectum) rather that a sin- gle pure motor skill (inserting a trocar). in every . MIS surgeon. The procedure is rehearsed in memory several times before the actual performance. one has to admit the necessity of the ‘‘apprenticeship’’ model (one-on-one) of the learning environment in the operating room or the animal laboratory. Systematic review of performance Providing feedback as close to the actual performance as possible is an essential component of the external conditions for learning motor skills (see. Netherlands Halifax.) This should permit study. the only profession that labors incessantly to destroy the reason for its existence. Mental practice Mental practice is to imagery what movies are to still photography. James Bryce. Japp Bonjër. who. it certainly depicts the philosophy of MIS surgeons. British historian (1838–1922) In the past 2 decades. the use of the least aggressive treatment that provides equivalent or better outcomes for the patient has been a clear direction of surgical therapy in all specialties. Observation allows concentration on the perception and processing of information to build mental images without the distraction of the many other stimuli that can reduce the concentration that is needed in building imagery. In advanced laparoscopic surgery. This process is well understood by high-performance athletes or musicians. Although this vision still may seem utopian for some. Box 4.’’ Dr. Without fluidity in mental practice there can be no fluidity in actual performance. a recent study suggest that a combination of the two is complementary [27]. This is successful only if the learner can internalize the comments by linking them to the sensory information assembled to adjust and correct the next performance. external conditions. because of the steep learning curves that are involved. Rotterdam. ADVANCED LAPAROSCOPIC SKILLS IN COLORECTAL SURGERY 993 ‘‘Advanced laparoscopic surgery is not a science of the hands. analysis. Nova Scotia Although there is constant debate as to how much time trainees should spend on observation and on actual practice. Integration of technical skills into practice The MIS mindset Medicine. it is a science of the eyes. and processing of the perceptual information that is received during the procedure.

The inability to use the nondominant hand represents one of the major weak- nesses of novice laparoscopists. because the appendix is lo- cated in the area of the abdomen where the distance between the abdominal wall and the spine is shortest. laparoscopy allows confirmation of diagnosis or alternatively defines another unsuspected pathology. and some cases of trauma is well accepted. Nurs- ing. try to use the least aggressive approach to reduce the overall trauma of surgery. In urgent situations. Third. The value of diagnostic or staging laparoscopy has been well established in cases of pan- creatic [28]. anesthe- sia protocols. Lost opportunities (laparoscopic appendectomy) A pessimist sees the difficulty in every opportunity. gastric [29]. Doing appendectomies laparoscopically during the day and the open technique at night sends the wrong message. It determines the feasibility of fully laparoscopic treatment or allows better po- sition of incisions with a view to reduce the clinical impact for the patient. this approach allows standardization of processes (eg. following the tried and true principle of ‘‘first do no harm. perforated diverticulitis [32. First. Sir Winston Churchill (1874–1965) Laparoscopic appendectomy certainly emerges as the ideal teaching and learning procedure to transfer advanced laparoscopic skills. aftercare issues) to permit provision of quality of MIS care 24 hours a day. but to a surgical philosophy. it forces the surgeon to learn working in a re- stricted environment. small bowel obstruction [34]. and Anesthesia. The first step. whether the surgery is urgent or elective. As the surgeon gains experience.994 POULIN et al case. patient positioning. one might wonder about the reason for its low use in academic health sciences centers (Gagné and colleagues. Although the topic is beyond the scope of this article. Second. MIS not only refers to several surgical techniques. Given its high volume and its technical requirements. is to begin many body cavity procedures by a laparoscopic exploration. Furthermore. With the confir- mation of its value [35]. more urgent abdominal conditions are dealt with entirely laparoscopically. for a retrocecal appendix the surgeon . unpublished data). fast-track postoperative care.’’ In that sense.33]. the procedure requires bimanual instruments handling. first trocar entry. The laparoscopic management of perforated duodenal ulcers [31]. laparoscopic appen- dectomy is regarded by those who teach laparoscopic surgery as the ideal introduction to advanced MIS procedures. the integration of any advanced technical skill into practice cannot occur without creating a team approach that includes Surgery. an essential skill to the performance of advanced MIS. instruments. and esophageal [30] cancers where 25% to 33% of patients are found to have incurable disease and more invasive surgery would be futile. in many cases. The truly MIS surgeon tries to introduce elements of surgical trauma reduction in the management of every patient. an optimist sees the op- portunity in every difficulty.

patient weight (!60 kg. It is a natural introduction to laparoscopic colon surgery. and acute cholecystitis. O90 kg). ADVANCED LAPAROSCOPIC SKILLS IN COLORECTAL SURGERY 995 learns to mobilize the line of Toldt. in bariatric surgery: steatohepatitis. completion of the procedure and peritoneal cleaning require safe small bowel handling. Multiple risk factors have been reported as predicting a higher risk for con- version in various conditions. anterior resec- tion of the rectum. Although patient characteristics generally are not contraindications as such. and the need for multiple resections [37]. however. previous abdominal surgery. the presence of an abscess or fistula. and surgeons only experienced with open surgery often are lost at first and are almost . and the diagnosis of cancer that correlates well with the likelihood of con- version to open surgery. they will serve as a predictor of the difficulty of the procedure. and the risk for conversion [36]. and cancer [40]. In Crohn’s disease: multiple bouts. and body mass index [38]. use of immu- nosuppressive drugs. Finally. once appropriate exposure is obtained. large waist size. 60–90 kg. and in colon surgery: left colon surgery. the anticipated need for experienced assis- tance. another essential skill for most advanced laparoscopic procedures. (2) proper assistance for advanced cases is different and much more demanding than in open cases. the first step to ileocecal resection. diabetes mellitus. it became evident that the contraindications were related more to the surgeon’s experience than to the patient’s status. Patient selection The evolution of laparoscopic surgery over the last 15 years has seen a constant decline in the number of absolute contraindications to the perfor- mance of MIS techniques. they initially serve to guide the selection of cases. Colorectal surgeons or any subspecialist not taking call in General Sur- gery and limiting themselves to subspecialty call are forfeiting many opportunities to improve their laparoscopic skills. Learning curves Several factors seem to impede the learning of advanced laparoscopic surgery and contribute to a steep learning curve: (1) learners usually fail to appreciate the value of sitting in the operating room to observe a few cases at first and come ill-prepared. obesity. Laparoscopy even facilitates surgery in obese patients. and obesity [39]. male sex. Therefore. Other than the inability to tolerate a general an- esthetic there remains few contraindications. Schlachta and colleagues [41] described a simple point system (0 to 4) based on surgical experience (less than or more than 50 cases). because it generally is advisable to start with easier cases. Classic contraindications to laparoscopic chole- cystectomy in the early 1990s consisted of pregnancy. diverticulitis. previous bile leaks. choledocholithiasis. Also. adhesions from various causes. wise selection of appropriate cases should guide the novice in advanced laparoscopic surgery. in gallbladder surgery: cholecystitis.

996 POULIN et al useless as assistants during an advanced case early on. Roux-en-Y gas- tric bypass. operative times. but merely as a rough indicator of what is needed to achieve technical competence. Nissen fundoplications. the number of cases that is attached to the learning curve of a spe- cific procedure should not be viewed as a definite benchmark. Reality has shown the subjectivity of measures to assess technical competence. Because many laparoscopic skills are common to all advanced lap- aroscopic operations. Most investigators consider the learning curve to be the number of cases that has to be performed to reach a plateau in outcomes. Skill sets more specific to advanced laparoscopic surgery Several problems need to be addressed for the adequate performance of advanced laparoscopic procedures. Based on results from the COST trial [14].45]. 100 cases [43]. at the same time. and Heller myotomies. Al- though some surgeons will be technically facile after a few cases. such as conversion rates.43]. 20 cases [48]. what these numbers say is that there is a peculiar challenge to MIS that is unseen in open surgery. The surgeon must be ready to invest time and patience to reach the desired level of competence. Fig- ures vary for other advanced procedures. This has been con- firmed in a joint statement by the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal Endoscopic Sur- geons. and patience is paramount. One cannot cut corners in laparoscopic surgery. and perioperative and postoperative complications [42. Some examples are inguinal hernia repair. others never will integrate MIS into their practice [49]. There is at least three ways that the principles of triangulation . and most advanced laparoscopists of the first generation often have learned the hard way. Also. and (3) teaching ad- vanced cases is far more challenging than is traditional surgery. Some skills that seem to define advanced laparoscopic surgery are re- viewed. This surgery is not for impatient surgeons. The margin of error from the teacher perspective is smaller and the ability to control all aspects of the procedure is more difficult. Triangulating/sectoring Triangulation is defined as ‘‘the location of an unknown point by the for- mation of a triangle having the unknown point and two known points as the vertices’’ [50]. they cited that performing 20 procedures is necessary to attain the level of expertise that is required to undertake laparoscopic resection of colon cancers on a curative basis. In essence. experience in a specific operation enhances the acquisition of skills that are necessary to perform others. The number of cases that is needed to reach proficiency varies from 30 to 70 for laparoscopic colon resections [44. 20 cases [47]. Laparoscopic surgery is based foremost on the prophylaxis of any errors. 50 cases [46].

and practice responsible cost containment. They should be reserved for specific indications. Ohio). and desiccation currents. This can be cumbersome and tiring for the surgeon and the assistant. ADVANCED LAPAROSCOPIC SKILLS IN COLORECTAL SURGERY 997 (also used in global positioning systems) are used in laparoscopic surgery. it is simply too costly to ‘‘dumb down’’ laparoscopic procedures with expensive alternate energy sources used routinely. the operative field. or SonoSurg (Olympus. Boulder. Second. Orangeburg. The classic arrangement for a laparo- scopic procedure is to set the camera between the two working trocars of the operating surgeon. Colorado). triangulation principles are used less frequently to ‘‘reset’’ the surgeon whose working instruments are off the operating field and the view of the monitor. First. In a busy unit. such as Harmonic Scalpel (Ethicon Endo-Surgery. Again. the surgeon is looking at his work from a lateral perspective. A quick look on the patient’s abdomen to check the direction where the laparoscope is point- ing facilitates ‘‘resetting’’ the working instruments to the operating field. Cincin- nati. unless a mechanical camera holder is used. the optimal working trocar place- ment follows triangulation principles. It is essential for all MIS surgeons to learn all aspects of safe electrosurgery for dissection and hemostasis. Mastering sectoring is es- sential before undertaking colon resections. too many surgeons have succumbed to the propaganda and have forgotten the basics. They can use the sides or surfaces of the instrument with all type of currents with a speed and precision that cannot be matched while reducing the cost of MIS procedures significantly. again using the principles of triangulation. the two working trocars are side by side and the laparoscope is located to the left or to the right of the surgeon. It is amazing that so few surgeons ignore the differences between cutting. and surgeons should be encouraged to master cheap and safe alternatives. the surgeon needs to locate the site of surgery by interpreting mental triangles that are made by drawing imaginary lines between one’s eyes. which is an awkward concept at first. Many ex- pert laparoscopists who have mastered the electrosurgery hook rarely use alternate energy sources. This creates a working scheme that is different from open surgery. Finally. fulguration. while maintaining good working angles of 45 to 75 in the process [51]. Ligasure (Valleylab. Mastery of monopolar cautery Although few will deny the monumental contribution of laparoscopic he- mostatic devices. The downside of this ergonomic design is that the hand that holds the camera head necessarily has to cross over one of the surgeon’s hand. New York) and others to the field of laparoscopic surgery. notions that were de- scribed initially by Cushing and Bovie almost a century ago [51a]. laparoscopic appendectomy is the ideal procedure with which to master sectoring because the trocars are configured this way: scope in the umbilicus and the two working trocars to the left. . and the monitor. One way to avoid this is to use the concept of sectoring.

Relegating the nondominant hand to retrac- tion is not sufficient. If an iatrogenic enterotomy occurs while . cutting. and use scissor dissection to avoid iat- rogenic sparking of hidden viscera. In an environment in which instruments are fixed and hinged in the abdominal wall and where working angles and camera angles vary. Intracorporeal knotting and suturing Tying of knots and intracorporeal suturing is considered an advanced skill in laparoscopy. Experienced mentors always put in a few stitches them- selves during procedures that require this skill. some trainers suggest that learners complete at least 50 sutures and knots before expecting decent intraoperative performance. usually in close proximity to the peritoneum. one has to get used to the magnification of the laparoscope (10–13) in the es- timation of bleeding severity. Empirically. the minimal use of the nondominant hand is a major obstacle in advanced MIS. is paramount to better vision throughout the case. dissection. noncritical roles. All MIS surgeons have faced the question of ‘‘Can this bleeding be controlled laparoscopically or does the operation need to be converted to an open case?’’. The use of energy sources should be lim- ited to areas of adhesions where vessels need control. Keeping the operative field blood-free. The environment of the skills laboratory is particularly well suited to learn laparoscopic suturing and knot tying to minimize painful intraoperative performance. Intraoperative mishaps and Disaster Tolerance Index Initially. Although adequate open surgery can be performed in this way. even though it is basic in all types of open surgery. The surgeon needs to be able to find the most avascular plane. For example. tissue manipulation. one of the most difficult skills to master in MIS surgery is the ability to gauge the gravity of intraoperative mishaps. the non- dominant hand has to be trained for critical tasks (eg. This is different than dissecting adhesions in open surgery where one can touch and feel the bowel. In- tracorporeal knot tying in laparoscopic surgery is time-consuming and dif- ficult to learn. suturing).998 POULIN et al Enhancing use of the nondominant hand Training MIS surgeons in a fellowship environment has revealed that many surgeons use their nondominant hand only for secondary. especially at the beginning of a procedure when adhesions usually are encountered. Intracorporeal lysis of adhesions Managing intra-abdominal adhesions is an important skill of advanced MIS. and many believe that this is one skill that tends to deteriorate if not used regularly.

demonstrations. this aspect of surgery is most unforgiving in advanced laparoscopic surgery. Short courses Short courses traditionally occur on weekends. Most often in laparoscopic fellowship training. Any small event that often could be taken care of easily in open surgery can be problematic in laparos- copy. and it adds significant time for a laparoscopic resolution or triggers a conversion. instrument manipulation. and are useful in introducing learners to laparoscopic equipment and teaching the basics of triangulation. Methods of skill transfer in laparoscopy Skills laboratory and simulators Skills and simulation laboratories have proliferated in the teaching envi- ronment of academic health sciences centers over the last few years. and likely will be more helpful for the learning of advanced laparoscopic surgery. . and offer a combination of lectures. there is some evidence that points to the limits of short courses alone in the overall education requirements for advanced MIS [53]. They serve as a good introduction to the topic of an advanced surgical domain. what the authors have termed an increase in the Disaster Tolerance Index. In the future. Most are well organized from a pedagogical perspective. With regards to laparoscopic skills they offer an introduction to basic MIS skills with a spectrum of tools that ranges from box trainers to virtual reality sim- ulators. In the authors’ estimation. should the case be converted or the bowel sutured laparoscopically? With experience and training there is an increase in the ability of the MIS surgeon to deal with intraoperative adverse events laparoscopically. and hands-on experience in laboratories. laparoscopic cholecystectomy). The case for the importance of practice in the acquisition of any technical skill has been made in the previous paragraphs. and defensive surgery whereby all adverse events are prevented. the first thing that has to be impressed on trainees is the need to slow themselves down and to learn ‘‘preventative’’ dissection in the appropriate plane. and knot tying. higher-fidelity simulators will increase the enthusi- asm for practice sessions. They have been shown to improve operating room performance in basic laparoscopic procedures (eg. deliberate. It is more crucial to develop a style of careful. this prepares learners for the operating room environment [52]. however. But presence in the skills labora- tory does little to teach the seamless flow of steps and the ability to recognize anatomic planes that are required to perform a bloodless advanced MIS procedure. ADVANCED LAPAROSCOPIC SKILLS IN COLORECTAL SURGERY 999 dissecting adhesions. Undoubt- edly. and requires a degree of concentration that is greater than what is needed in traditional surgery.

The trainees can leverage their experience by teaming up with other colleagues for surgery. Most would agree that successful preceptorships need to have one-on-one hands-on training. if any. Trainees are responsible for auditing their own data. MD. So far. There are few. there are many anecdotal reports whereby expert laparoscopic surgeons have spent significant time training surgeons in the community. The entire MIS team at the trainee’s hospital is required to be trained to support the development of the MIS program.1000 POULIN et al Preceptorships Preceptor is defined as a ‘‘specialist in a profession. A recent paper from a regional hospital illustrates the quality outcomes in a three-surgeon practice where these principles were followed for the introduction of laparoscopic colon surgery in a com- munity environment [55]. arranging for significant time for preceptorship has been elusive. personal communication. especially medicine. it remains that for the appropriate transfer of this technology to practicing surgeons. Mamazza. Preceptors travel if requested. who gives practical training to a student’’ [54]. They tend not to occur in academic health sciences center other than in the form of observerships because of competition from other trainees (residents and fellows). 333 MIS operations had been performed. In General Surgery. Because of the paucity of trainers for advanced MIS procedures. Several models exist. either by a series of single operative days or during a concentrated visit of 1 to 2 weeks (J. according to a 1997 report. No colorectal resections took place in this program [56]. It was scheduled to start in 2004. the Minimal Access Therapy Training Unit Scotland was set up in 1994. and it is recommended that the preceptorship involve two to four cases. 2005). 234 training sessions had occurred for 99 trainees who attended a median of two sessions each. Although it is beyond the scope of this article to evaluate the pedagogical value of these programs. In Scotland. funded programs need to . Compensation and clinical lia- bilities are addressed. Valuable preceptorships also are given by experi- enced laparoscopists in the community. structured training programs for established surgeons to take on laparoscopic colorectal surgery. Candidates for this program need to have watched at least 10 live laparoscopic colorectal resections first. Colleagues assisting each other until the learning curve is passed have been successful in the transfer of laparoscopic colorectal surgery skills in a community setting. Advanced cases can be performed with the surgeons designated for the apprenticeship with good results. During these sessions. comprehensive. Although there is little literature on this topic. It involved the National Health Service releasing funds for 4- hour operating sessions for training purposes in MIS. Another initiative between the Association of Laparoscopic Surgeons of Great Britain and Ireland and the Association of Coloproctology of Great Britain and Ireland is worthy of mention. these initiatives have tended to exist in isolation.

they probably represent the best way to address the issue of transfer of technol- ogy for surgeons in practice. Although MIS fellowships have the advantage of training trainers for academic health sciences centers or surgeons who will go into the community. Several publications have shown that fellows have similar outcomes as do staff for spleen surgery [57]. The necessary ingredients to skill acquisition for advanced MIS proce- dures (laparoscopic colorectal surgery) for a practicing surgeon include in- troduction through short courses. organ. Whether broad-based. In an ideal world where there are enough trainers. Mini-sabbaticals. which usually are given in the teacher’s insti- tution. ADVANCED LAPAROSCOPIC SKILLS IN COLORECTAL SURGERY 1001 be established and they likely will be influenced by the nature of the medical system in each country. The clinical outcomes of lapa- roscopic colorectal cases from an attending surgeon coming out of an MIS fellowship was equal to that of his mentor in his first year of practice [58]. and the authors believe that curriculum devel- opment with input from experts in knowledge transfer needs to occur. there is no better alternative than an MIS fel- lowship. guided practice with feedback is essential to develop the high level of visuospatial perceptual abil- ity (observation and performance with feedback) that is necessary for ad- vanced MIS. Summary Acquisition of advanced technical skills requires commitment. Despite the value of all other teaching methods. the residency en- vironment should provide this training. the 10-year rule). and discipline (eg. For residents in training. . Dabbling is not a recipe for success. Profitable mini-sabbaticals usually have involved surgeons experi- enced in traditional open surgery spending time with an experienced laparos- copist doing enough cases to become comfortable with the performance of routine cases. time. they have had minimal impact for the training of practicing surgeons so far. they have paralleled the validation of MIS surgery. pa- tience. Most be- lieve that they are the best way to attain a high level of proficiency in advanced MIS. Although such programs face many hurdles. Fellowships MIS fellowships in North America have proliferated from approximately 20 15 years ago to about 190 today. Fellowships eliminate the learning curves. it needs to incorporate hands-on training. Mini-sabbaticals To get the most from a mini-sabbatical. or subspe- cialty focused. access to skill stations. have tended to involve a commitment of a few months (2–6 months). and access to preceptorship or mini-sabbatical.

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