Introduction

For more than 100 years, the teaching of surgical skills has been performed using the apprenticeship model of graded responsibility, introduced by William Halsted. Over the years, this approach of “see one, do one, and teach one” has been successfully used to train generations of surgeons in all aspects of open surgery [1].

Today, however, the introduction of laparoscopic surgery and the development of more advanced laparoscopic procedures have shown that this well-tried method of teaching is no longer the ideal model for laparoscopic surgery. This is largely due to the recognition that laparoscopic surgery requires the development of an entirely different set of skills. As a result, there is now need to change the existing system of surgical training [2, 3].

Acquisition of Basic Laparoscopic Skills

The unique features that have made laparoscopy the method of choice for many surgical procedures are the same factors that have necessitated the acquisition of a new, different set of skills. These include the fulcrum effect of the instrument in the trocar, decoupling of the surgeons eyes and hands by an independent camera, changed depth perception of the two-dimensional image, modified haptic feedback, often needed ambidexterity, stereognosis, different exposure techniques, and ergonomics [2, 4].

The number and complexity of laparoscopic procedures, many factors play a role in skill-acquisition. Among them are costs and time constraints. Additionally, because the actions of the trainee cannot easily be controlled by the trainer, as with the open technique, errors can occur that may cause harm to the patient. Thus, it is critical for surgeons to learn these motor skills by more than just passive observation and dismiss the notion that laparoscopic skills can be learned simply by holding the camera [5]. Some have even predicted that robots will eventually steer an independent camera for the surgeon [6] (Fig. 6.1).

Fig. 6.1
figure 1

Robotic arm stearing the camera

Full size image

Also impacting on the acquisition of these new skills are recent regulations put into place to ensure shorter duty hours for surgical residents. While important, there is concern that reduced basic and advanced laparoscopy training in the surgical residency curriculum could lead to a deficiency in laparoscopic training, placing patients at additional risk for injury.

Simulation, Skill Labs and Video Analysis

Training outside of the operating room offers a structured and systematic educational opportunity, in addition to stress modulation. Because the operating room is a stressful place with many distractions, time constraints, concerns for the patient, equipment failures, and interpersonal issues [7, 8], stress modulation was found to enhance performance when fine motor control and complex cognition are required [9].

The effectiveness of simulation has been demonstrated primarily in lower level learners [10]. According to Fitts and Posner, the first two stages of motor skills acquisition can be sufficiently accomplished in simulation labs. These include the cognitive stage (intellectualization of the task) and the integrative (associative) stage (translation into appropriate motor behaviour), which are achieved by practice and feedback. Accomplishing both stages allows one to proceed to the third stage, the autonomous stage, which is mastered in the operating theatre and results in a smooth performance without cognitive awareness [11, 12].

Today, multiple models of simulation are available, though there is no consensus on which dexterity drill should be incorporated into simulation models for the acquisition of appropriate motor skills [2]. As pointed out by Aggarwal et al that it is not a matter of which simulator to use to acquire the skill, but rather the design of the laboratory-based skills training curriculum [13]. Trainees can evaluate their own performance by comparing their results to the standards associated with a particular simulator, and then working to minimize the difference with subsequent exercises (internal feedback). The use of expert evaluators is also important as they can provide external feedback to the trainees, including information about effectiveness and quality of the operating end product (Fig. 6.2). Procedure effectiveness can be evaluated using an objective assessment of various outcome measures, including goal and non-goal directed actions, forces and torques, operating time, etc. The quality of the operative end product can then be assessed by the end product analysis, which includes accuracy, error, tissue damage (e.g. water tightness of anastomosis) and with the histological outcome (total mesorectal excision for instance).

Fig. 6.2
figure 2

Motor skills acquisition process

Full size image

External feedback was found to be critical to the learning process [2, 14, 15]. In particular, summary expert feedback, which takes place after completion of the task, was found to be more efficacious than concurrent feedback, which occurs during completion of the task [16]. It has been reported that there is poor correlation between the procedure effectiveness and the end product analysis [17]. This indicates that a range of pattern of movements during the exercise can result in a similar quality of end product. Interestingly, the end product quality was not adversely affected by the surgeon’s fatigue [17]. However, this was investigated on simulated task on VR and it would be interesting to see the correlation between the quality of complex surgery such as laparoscopic total mesorectal excision and the end product. The end product analysis has also been found to be suited for skills assessment, despite its low reliability [2].

Deliberate practice is one of the components of the integrative (associative) phase of motor skills acquisition. It is most effective when distributed throughout many sessions, as opposed to one long single session, because the intervals between sessions allow knowledge of the new skill to be consolidated [18].

For simulation to be successful, the training must be recreated outside of the operating room for all students of surgery, including those with basic as well as advanced skills. A simulated learning environment can be easily controlled and adjusted to varying levels of difficulty. It can also occur in a more step-wise fashion than one performed in the operating room, where learning relies on random chance and opportunity [8] (Fig. 6.3) The step-wise model for learning a complex surgical procedure is based on the premise of building skills gradually using previous accomplishments, with more advanced skills built on a foundation of basic skills. Every complex surgical procedure can be broken down into several simple tasks that are required to complete most complex operations [19]. One of the first teaching modules for laparoscopic surgery was created by Rosser et al. and involved three basic task stations to teach a two-handed technique, coordination in handling tissue and manipulation of a sewing needle [20].

Fig. 6.3
figure 3

Stepwise approach to learning complex surgical skills

Full size image

Further evolution of the programme led to abandoning the simplified peg exercise program and validating clinically significant exercise models, including vascular control, lesion excision, appendicectomy, mesh repair, perforation closure, and hand-sewn anastomosis [21]. (Fig. 6.4) The basic task analysis and its performance is the first step in the step-wise model of learning the complex surgical tasks. The second step of this process is frequently performed concurrently with the first step, and is often unrecognized. Called visual-spatial training, this step places emphasis on a three-dimensional relationship of anatomic structures and surgical manoeuvres and stresses the importance of proper knowledge of the key relationships of vital structures and dynamic anatomy during an operation. While building on these skills, the trainee can then proceed to the third step, which is practice of the set up and exposure (Fig. 6.3) Interestingly, this step is also under-appreciated by trainees, but valued by experts. In fact, mastering the art of set up and proper exposure enables the surgeon to avoid struggling with poor ergonomics and insufficient exposure during laparoscopic procedures. The sequential steps of the operation become much easier when a proper set up is used [8].

Fig. 6.4
figure 4

Clinically significant exercise models

Full size image

The final step in the step-wise model is the procedural component. Ideally, the student should be able to practice and master the full procedure in the controlled simulated setting. Additionally, while the first three steps can be accomplished with the use of low fidelity simulators, the fourth step can be accomplished with high fidelity inanimate physical models, virtual reality simulators, or cadavers. The procedure should be performed repeatedly in the simulated environment until proficiency is achieved. The term isoperformance was introduced by Jones to describe how learning by two different methods will transfer the same skills, albeit with different efficiency [22]. It is also important to remember that surgical training will always require operating on a real patient, thus the presence of thoughtful mentors to guide the trainee is essential. In fact, technical proficiency is only a single component of the mix; simulation enables the trainee to focus more on the other aspects of the “mix” during clinical exposure, such as obtaining higher-level skills to learn more complex steps of the operation or how to manage complications [8, 23].

Inanimate physical models, including box trainers and bench models, are safe, portable, reproducible, accessible, and readily accepted by novice trainees. They offer a low-fidelity environment for practicing basic, discrete skills and tasks, but not full operations [21]. They also provide true haptic feedback and allow the acquisition of skills that are transferable to complex laparoscopic tasks [24]. Together with the web-based study guidelines, the use of inanimate physical models has been incorporated into the curriculum of the FLS (Fundamentals of Laparoscopic Surgery) programme, endorsed by the American College of Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons [25, 26]. One of the main advantages of the inanimate physical model is the ability to exercise the dynamic coupling of hands, eyes, and the interposed camera, a skill that is crucial in the operating theatre and not achievable using virtual reality simulators [27]. Sroka et al. found that training to proficiency using the FLS simulator in the surgical residency curriculum has resulted in improved resident performance in the operating room [28].

Virtual reality (VR) simulators, for which the setup time is minimal can provide immediate feedback and metrics on error rates, precision, and accuracy [29]. The identification and subsequent management of errors is crucial to safe surgical practice [30]. Grantcharov et al. was able to detect a higher economy of motion and fewer errors while performing laparoscopic cholecystectomy, as well as shorter operative time after using the MIST-VR simulator [31] (Fig. 6.5). This has been confirmed by others [32]. One of the disadvantages of the high-fidelity VR simulator is the cost, though this can be outweighed by the benefits. Additionally, one has to remember that surgical training without use of a simulator is associated with significant expense. Bridges and Diamond investigated the cost of having general surgery residents present in the operating room and estimated the annual cost to be $53 million in the United States in 1997 [33]. Conversely, Aggarwal et al. calculated the transfer effectiveness ratio of a modestly expensive VR simulator to be 2.28 for laparoscopic cholecystectomy, translating into every hour spent on VR simulation, and reducing time to achieve proficiency in vivo by 2.3 h [34], thus limiting the costs of training in the operating room.

Fig. 6.5
figure 5

Mist-VR (virtual reality) simulator

Full size image

More recently, the high-fidelity environment was reproduced using the hybrid ProMIS simulator with synthetic anatomical tray and VR metrics (Fig. 6.6). Precise time measurement, instrument path length, and smoothness of movements can all be recorded for analysis [35]. A study comparing the ProMIS simulator with the cadaver model for laparoscopic left colectomy found that technical skills acquisition was better using the simulator. The main overall occurrence in both models was error in the use of retraction, while the specific occurrence in both models was bowel perforation [36]. Essani et al. found that simulated laparoscopic sigmoidectomy training affected the responsiveness of surgical residents with significantly decreased operating time and anastomotic leak rate [37] (Figs. 6.7, 6.8 and 6.9) Another report, however, found no correlation between the simulator-generated metrics (path length, smoothness of movements) and the content valid outcome measures (accuracy error, knot slippage, leak or tissue damage) [38] (Fig. 6.10).

Fig. 6.6
figure 6

Hybrid ProMIS simulator with synthetic anatomical trays and VR metrics

Full size image
Fig. 6.7
figure 7

Synthetic anatomical tray of ProMIS simulator

Full size image
Fig. 6.8
figure 8

Circular stapling performed with ProMIS simulator

Full size image
Fig. 6.9
figure 9

End result of stapling (ProMIS simulator)

Full size image
Fig. 6.10
figure 10

Simulator registered instrument movement path

Full size image

Animate models (porcine and canine), have also been used in training to enable the trainee to practice on live animals, experience the quality of live tissues, and address haemostasis. Apart from ethical considerations, the main obstacles or deficiencies of this model are the differences in anatomy and the need for technical support.

Other options include human cadaveric models, which more closely reflect reality. Milsom et al. performed one of the first feasibility studies of cadaveric laparoscopic proctosigmoidectomy in 1994, designing a standardized technique of oncologic resection [39]. Studies have found participants in cadaver laboratories to be highly satisfied with the teaching value and reliability of the materials used [40, 41]. The main advantages of a cadaveric model include tissue consistency and preservation of anatomic planes, which are very important for the learning process [42]. Le Blanc et al. compared human cadavers and augmented-reality simulators for acquisition of laparoscopic sigmoidectomy skills, finding cadavers to be more difficult but better appreciated than the simulators [36]. Human cadavers were also found to be superior in laparoscopic colectomy training when compared to high-fidelity virtual reality simulators [43]. A recent study reported that colonoscopy training with deployment of stents for colonic strictures in a cadaver model has content, construct and concurrent validity [44]. The major difficulties encountered with cadaver models include their limited availability, high cost, ethical concerns, need for specialized facilities and personnel, andthe inability to exercise haemostasis.

Video analysis is one of the least examined and least understood training methods in laparoscopic surgery. This is ironic because laparoscopic surgery is often referred to as video surgery. In fact, use of a recording device in the operating room is almost a universal standard today. With video analysis, the trainee has the opportunity to review the recorded material individually or with the trainer, who can then provide the necessary critique. Additionally, material can be stored for future use as a reference tool during independent practice, particularly during a low case volume schedule. Recorded material can be also used for grading and progress evaluation of the trainee. Ideally, review of the video should take place within a few days (preferably 1–2) of the procedure being performed, so that it is still fresh in both the trainee’s and trainer’s memory and the intra-operative comments can be remembered.

In 2008, a systematic review of randomized and non-randomized data by Sturm et al. was inconclusive as to which skills learned during laparoscopic simulation were transferable to the operating theatre [45]. More recently, however, Sroka et al. was able to demonstrate that skills learned from the FLS program improved performance during laparoscopic cholecystectomy [28]. Likewise, a systematic review by Zendejas et al. of simulation-based laparoscopic surgery training was found to have significant benefits when compared with no intervention, and moderately more effective when compared to non-simulation intervention (e.g. video instruction) [46]. Despite the validation of many inanimate and VR simulators, there is only one study demonstrating a direct effect of simulation on improved performance in colorectal surgery. In the study by Palter and Grantcharov, a comprehensive curriculum consisted of a VR simulator, a cognitive training component and cadaver lab training. The curricular-trained residents were found to demonstrate superior performance during right colectomy when compared with conventionally trained residents [47].

Little is known about teaching the new techniques of colon resection with single-incision laparoscopic surgery (SILS) or natural orifice trans-luminal endoscopic surgery (NOTES). The only available report by Buscaglia et al. examined the usage of ProMIS simulator for training in NOTES sigmoidectomy, demonstrated a positive outcome for surgical endoscopists with a 42 % reduction in operating time [48] (Figs. 6.11, 6.12, 6.13 and 6.14).

Fig. 6.11
figure 11

Natural orifice transluminal endoscopic surgery (NOTES) on ProMIS simulator

Full size image
Fig. 6.12
figure 12

Procedural steps for NOTES sigmoidectomy on ProMIS simulator

Full size image
Fig. 6.13
figure 13

NOTES sigmoidectomy on ProMIS simulator using 2 flexible instruments

Full size image
Fig. 6.14
figure 14

NOTES sigmoidectomy on ProMIS simulator using 2 flexible instruments

Full size image

Implementation of Laparoscopic Colorectal Surgery

According to recent reports, the use of laparoscopy in colorectal surgical procedures is gradually increasing, although it has been a very slow process, with varying adoption rates. In 2009, 50 % of all colon resections in the United States were performed laparoscopically [49]. This was up from 31.4 % in 2008, as reported by a different study only a year before [50]. Similarly, in the United Kingdom, laparoscopy was used in more than 40 % of all colectomies performed in 2013 (according to Hospital Episode Statistics) compared with 5 % of procedures performed in 2006.

Many factors are responsible for these increased adoption rates. During the early adoption phase of laparoscopy, there were concerns about oncological safety, due to reports of trocarsite recurrence [51]. This issue was subsequently eliminated with appropriate wound protection, tissue handling, and proper oncological dissection. Other factors responsible for slower adoption included the need for multi-quadrant dissection, advanced laparoscopic techniques (for intra-corporeal vessel control, large surface dissection, bowel transection, and anastomosis), difficult retraction and exposure, increased operating time, and the cost of the laparoscopic equipment.

The implementation of laparoscopic rectal dissection has been even slower than with colectomy. This is due mainly to tumour location within the rigid confines of the pelvis, difficult and unstable retraction, visualization, and poor ergonomics for the surgeon. In 2009 laparoscopic total mesorectal excision ranged from 12 % in the United Kingdom to 19.6 % in Canada and 26 % in Australia in 2008 [52, 53].

Identification of Trainees

When considering potential candidates for laparoscopic colorectal surgery training, three groups should be identified. The first group is general surgery residents who possess basic laparoscopic skills, but are in the process of acquiring colorectal knowledge and advanced laparoscopic skills simultaneously, in order to perform colectomies. The second group is individuals who are trained in general surgery and are undergoing postgraduate training (colorectal surgery or minimally invasive surgery training). This group is adept in the basics of laparoscopy and has sufficient colorectal knowledge, but lacks experience with laparoscopic colectomies. Finally, the third group is surgeons who have never been trained in laparoscopy but have sufficient experience in open colorectal surgery.

Identifying to which group the trainee belongs is critical and will determine which training model is the most suitable for the trainee. As a result of the time constraints of surgical training mentioned earlier, the first group of trainees is likely to be able to complete only basic training in laparoscopic colectomy. Indeed, unless they engage in postgraduate training, it is unlikely that they will become proficient in advanced laparoscopic colectomies or rectal resections. Conversely, the second group of trainees, because they are involved in postgraduate training (colorectal surgery residents or minimally invasive fellows), is capable of developing the full set of advanced skills required for advanced colectomies and rectal dissection. For the third group, it is expected that they will achieve the same set of skills as the first group, albeit through a different training path.

Regardless of the group, it is important to realize that each is comprised of individuals with different learning potential and, thus, will require individual learning curves.

Learning Curve, Proficiency Gain, and Competence

One of the primary reasons behind the slow adoption of laparoscopy into colorectal surgery has been referred to as a “steep learning curve”. However, this description of the learning process is not valid for two reasons. Firstly, the term “learning curve” should be replaced by “proficiency-gain curve”, which more accurately describes the process of increasing levels of technical and non-technical proficiency, rather than simply ‘learning’, which implies a purely cognitive process [54]. Secondly, the term “steep” is a misnomer because it implies rapid acquisition of skills during the time period, quite contrary to what is observed in practice. Therefore, it is more accurate to reason that a “long proficiency-gain curve” is why the adoption process of laparoscopic colorectal surgery has been slower.

There have been many metrics used to describe the learning (proficiency-gain) curve of laparoscopic colorectal surgery. The most commonly used metrics include operative time, conversion rate, complication rate, and readmission rate [55–57]. The main limitations of these individual metrics, however, are their non-transferability throughout different hospitals and individual surgeons [58]. A recent systematic review and multi-centre analysis of multiple metrics, utilizing the risk adjusted CUSUM methods performed by Miskovic et al. estimated the learning curve in laparoscopic colorectal surgery to be between 88 and 152 cases [59]. This number differs from 60 found by Tekkis et al. in 2005 and is in sharp contrast to the range of 11-15 cases identified by Simons et al. in 1995 [57, 60]. This discrepancy can likely be explained by the increasing complexity of the laparoscopic procedures and the application of laparoscopy to more challenging clinical scenarios. Recently, Mackenzie et al .looked at the influence of mentored training on the proficiency-gain curve. They found that 40 cases were required in order for supervised fellows to achieve confidence in laparoscopic colectomy [61].

Monitoring and Assessing the Learning Process

The goal of every training programme is to produce a competent trainee who can individually perform procedures in a safe manner. This competency is difficult to measure prospectively. Indeed, the ultimate method of evaluation used to be the retrospective analysis of clinical outcomes, which were often negative, and included mortality and morbidity data. It is important to recognize that competence is multifactorial and dependent on surgical skills, cognitive factors, personality traits, and decision-making [62].

The proficiency gain should be closely monitored during the training period. Thus far, various tools have been utilized, including the OSATS (Objective Structured Assessment of Technical Skills). Unfortunately, the value of this tool in the assessment of advanced laparoscopic procedures (e.g. colectomies) has been restricted, due to the ceiling effect and the learning curve of the assessor [63]. The Global Assessment Score (GAS) tool on the other hand, has been found to effectively assess and monitor the proficiency gain. This tool evaluates generic task steps for laparoscopic colorectal resection in a formative way, allowing for the identification of areas during the operation that may be more difficult to master and thus require more practice [64]. Another tool designed to evaluate technical competency in a summative manner is the Competency Assessment Test (CAT). Designed by a reiterative expert consensus (Delphi) method, the CAT evaluates the process of performance (instrument use, tissue handling) as well as the end product of the procedures. It has been validated for examining and credentialing use [65].

While maintaining competency is crucial, little has been made available with regard to the individual retention of learned skills. In fact, while institutions with higher case volumes have shown improved outcomes, some argue that it is the number of hours spent on deliberate practice by the individual surgeon that ultimately determines the level of expertise [66, 67]. However, others contend that tracking outcomes is likely to be the only reliable way to assess competency [68].

Safe and accurate operating can also be assessed using the observational clinical human reliability analysis (OCHRA). This concept, proven in other laparoscopic procedures, is based on video analysis of errors made during procedures and allows for identification of underlying performance-shaping factors [69].

Standard Training Models

Apprenticeship, General Surgery

In Europe and in the United States, the general surgery training system is based on a graded responsibility model in the form of a rotation schedule. The trainees rotate through a designated service (e.g. colorectal or general surgery) for a limited amount of time and receive their training from a qualified trainer (apprenticeship model). On average, surgery residents receive the bulk of their laparoscopic colorectal experience during a 2-month rotation in the 4th year of the 5-year residency program in general surgery. It is during that short period of time that the trainee is expected to participate in 15–30 laparoscopic colectomies. However, additional training in laparoscopic colorectal surgery will take place during a 1-year fellowship in colorectal surgery for those who choose to achieve subspecialty certification ”.

The trainee is expected to achieve basic training in laparoscopic colorectal procedures with particular emphasis on safety during such a short period. It is unlikely that proficiency can be fully achieved during such a short period of time. Advanced procedures such as intra-corporeal anastomosis or laparoscopic total mesorectal excision should not be the training goal during this phase of learning.

Dedicated Fellowships and Postgraduate Training in Advanced Laparoscopy

Currently, fellowship training in colorectal surgery with an advanced laparoscopic component, or dedicated minimal access surgery fellowship with a strong colorectal component are considered the ideal and are the most comprehensive forms of training to obtain proficiency in advanced laparoscopic colorectal procedures. These fellowships typically last 1 or 2 years and, and on average, the training program is structured in the form of an apprenticeship. Supervision allows for a shorter proficiency-gain curve and the substantial time period allows the trainee to be exposed to a variety of surgical procedures, including intra-corporeal anastomosis and laparoscopic total mesorectal excision. While for the majority of trainees, fellowships are the continuation of general or specialty training, some surgeons find it difficult to commit to a fellowship, due to the potential impact on their practice and income. However, Schlachta et al. found that within the first year of practice, fellowship-trained surgeons had conversion rates equal to experienced surgeons [70].

Master Class, Short Courses

Master classes or short courses in laparoscopic colorectal surgery are offered as 2 to 7-day intensive educational events, usually on weekends and are a combination of lectures, demonstrations, and practical sessions in the skills laboratory. Basic laparoscopic skills are typically required in order to participate. The laboratory session usually involves cadavers and animal stations are primarily used to introduce the participant to new procedure-specific instrumentation. The majority of short courses focus on laparoscopic colectomy. Courses on laparoscopic rectal resection are rare and reserved for participants who are well versed in laparoscopic colectomy. Participants of short courses were found to increase the number of course-specific procedures that they performed following the course [71]. In addition, they were found to consistently overestimate their performance, as measured by a global rating scale, which raises an issue of adequate credentialing [72, 73].

Preceptorship

This type of training is based on one-to-one supervision of a less experienced surgeon by an expert, who acts as a preceptor. Frequently, inexperienced surgeons in a surgical group are coached by an experienced member of the group (in-house preceptorship) [74]. The supervision period can vary from several cases to several months, depending on the trainee level. It is a very practical method of training. Occasionally, the trainee spends a designated time at the teacher’s institution (out-of-house preceptorship, mini-sabbatical). This method allows the trainee to participate at an institution with a higher volume of cases under the supervision of a busy preceptor, though difficulties can arise in obtaining the necessary hospital/state privileges. In addition, there are potential problems associated with working in an unfamiliar operating theatre, patient population, and/or language. This form of training allows the preceptor to intervene if the situation arises and also allows for direct feedback and constructive criticism. In difficult operations, the preceptor is also on hand to perform the more challenging parts of the procedure [75].

Supervision and Feedback

According to Gagne, an essential component of the external conditions for learning motor skills is the provision of feedback as close to the time of performance as possible [76]. This feedback and constructive criticism are only possible by mentoring and close supervision, both of which impact the trainee’s performance. In fact, intra-operative instruction has been found to decrease the rate of errors in a randomized laparoscopic suture study [5]. Additionally, in a meta-analysis of outcomes of 6064 patients, Miskovic et al. found that trainees with an appropriate level of supervision generated the same complication, conversion, and mortality rates as expert laparoscopic colorectal surgeons. This is extremely important in the context of the modern world where patient safety is paramount. In the same study, the authors compared the outcomes of non-mentored and mentored trainees and found that the experienced trainer can further aid in intra-operative decision-making and the comprehension of anatomy [62]. Case selection for training purposes is also indirectly related to supervision, with laparoscopic sigmoid resection being the easiest [77]. Similarly, appropriate patient selection for training purposes revealed that male sex, past surgical history, obesity, high ASA class, and colorectal fistulae were associated with higher conversion rates [62].

Highly Structured Training Programmes

Reznick and MacRae observed that volume alone does not account for the skill level among practitioners and that deliberate practice is a critical process in the development of mastery and expertise [10]. In the clinical setting, this deliberate practice is best accomplished within the context of a structured and supervised training programme. Many countries have introduced more or less structured curricula for the training of advanced laparoscopic procedures. A primary example of this is the National Training Programme for laparoscopic colonic surgery (NTP, Lapco), which began in 2007 and was funded by the Department of Health for England to provide training for consultants who had not been trained in laparoscopic colorectal surgery. It was a highly transparent, integrated, and structured training programme focused on hands-on training in the operating room, with the consultant in training (trainee) closely supervised and mentored by an experienced laparoscopic colorectal specialist. The NTP also includes laboratory, enhanced recovery, and theatre team training courses, as well as the train-the-trainer courses for faculty (trainers) [78]. The structure involves candidate selection, cadaveric and animal courses, “in-reach” (training centre) and “out-reach” (trainee’s own hospital) supervised operating, for sign-off procedures, and an audit process. Both the trainee and the trainer are obligated to complete the GAS (Global Assessment Score), both of which are submitted electronically to the central Lapco office. Results of this programme have estimated that proficiency could be accomplished within 20–30 cases. At the end of the programme, two unedited videos are required for successful sign off at the end of the training. Mackenzie et al. observed that supervised fellowship of this type is safe and provides training without compromising patient safety, as it reduces learning curve as compared to self-taught surgeons [61].

Practical Training Considerations

It is important to realize that the set of teaching skills used in laparoscopic colorectal surgery training is unique and varies not only among different surgical centres, but also among different trainers from the same teaching programme. Therefore, while it is possible to have a certain level of standardization in the teaching technique during the simulation phase of laparoscopic skills, and during animal or cadaver training (if available), the framework of the teaching techniques of the trainer should also be standardized, as was seen in the National Training Programme (Lapco).

It is expected that the trainer will address and introduce the following basic principles before teaching the new laparoscopic colorectal procedures:

  1. 1.

    The aim is to produce a safe and competent colorectal surgeon who is comfortable with the use of laparoscopy but who uses sound judgment in performing open procedures when necessary.

  2. 2.

    The trainee possesses basic, fundamental laparoscopic skills, including basic laparoscopic ambidexterity.

  3. 3.

    The trainee has been given a thorough explanation of the technique and understands what can be accomplished at each particular stage of the procedure.

  4. 4.

    The trainee has been informed of, and understands, all necessary safety measures.

  5. 5.

    The trainee has been made aware of appropriate patient selection and how a thorough pre-operative workup should be conducted.

  6. 6.

    The trainee is aware how adequate laparoscopic exposure of the operating field is achieved.

  7. 7.

    The trainee has been instructed on and understands the macro-retraction and micro-retraction concept (see below).

  8. 8.

    The trainee is aware that there is a stepwise approach to each procedure.

  9. 9.

    The trainee is aware of the benefits of video recording of the laparoscopic phase and thorough video analysis following the procedure.

  10. 10.

    The trainee has been introduced to different approaches for each procedure.

Further elaboration of these principles and how the training protocol should be structured to address them are described below.

The Safe and Competent Laparoscopic Colorectal Surgeon

It is very important to remember that laparoscopy is a beneficial tool for the right patient in the right situation. With this in mind, it should be emphasized that utilization of open surgery when laparoscopy becomes too difficult is a sign of good judgment and maturity of the surgeon, and not an indication of failure [79].

Basic, Fundamental Laparoscopic Skills

Each trainee beginning the laparoscopic colorectal surgery training program should possess basic fundamental laparoscopic skills. These are most often obtained in the simulation laboratory and by performing procedures such as laparoscopic cholecystectomy and laparoscopic appendectomy. In addition, experience obtained from laparoscopic ventral hernia repair or laparoscopic adhesiolysis exposes the trainee to multiple quadrants of the abdominal cavity. These procedures also enable the trainee to become familiar with the concept of dynamic retraction and to learn how to quickly adjust to a changing anatomical environment, something that is more common in laparoscopic colorectal surgery due to the omnipresence of the small bowel and redundancy and tortuosity of the colon. This is also relevant to the significant variability of both colonic flexures and the sigmoid colon. Difficulty in acquiring the skill of bimanual dexterity (ambidexterity) is well documented in the literature [36, 80]. This skill is necessary in laparoscopic colorectal surgery and verbal feedback and demonstration are necessary in the process of improving this skill [81].

Understanding the Procedure

In the first cases of laparoscopic colon surgery, the trainee is typically preoccupied with adjusting to the new environment (hardware, setup, unfamiliar team, different view of the anatomy). It is therefore imperative to perform a simple and easy to remember role assignment, explaining what task the trainee will perform at each phase of the procedure. In most instances, laparoscopic mobilization of the colon can be achieved by using three working instruments and one camera, in a procedure performed by two surgeons. This translates into an easy to understand role assignment for the trainer, the assistant and the trainee.

It is very common that the main surgeon controls the conduct of the operation by operating the camera and providing retraction (passive role). Thus, the role of the trainee is to perform dissection (active role), either blunt or sharp, and or to help with retraction. Because this concept is very similar to teaching open surgery, it is often perceived that the trainee has performed the procedure when, in fact, the main surgeon has remained in control and orchestrated the entire procedure. This is a very important concept that allows the trainee to build confidence while performing laparoscopic colon procedures by encouraging them to be active assistants if they are not already performing the case.

Mobilization of either the left or right side of the colon always consists of two phases of dissection in the lower and upper quadrants. Before each procedure, the trainee should become familiar with the hand, instrument, and task assignment for each of the parts of the procedure, and regularly review these role assignments. Again, it is important for the trainee to possess sufficient ambidextrous skills.

Laparoscopic colon mobilization can be achieved using several approaches. The trainee should be taught what is expected with each procedure in the majority of patients. This includes the boundaries of what can and cannot be accomplished safely using the laparoscopic technique, and includes identifying unfavourable anatomy. The trainee should also understand the amount of colonic mobilization in each part of the procedure, as well as when to change the approach to another quadrant. Special emphasis should be placed on when to convert the procedure to the extracorporeal phase, and what can be accomplished during this phase. The extracorporeal phase is often as important as the laparoscopic phase, though it accounts for only a fraction of the entire procedure.

Within basic laparoscopic colorectal surgery training, it is not always possible to teach the beginner how to perform all steps of a colectomy during the laparoscopic phase. Some of the final steps can be accomplished more safely and quickly during the extracorporeal phase, e.g. vessel or bowel control. Defining those steps depends on the patient body habitus, complexity of the case, and the surgeon’s experience. During basic training the trainee will often have only the experience of 20 to 30 colectomy cases before finishing the programme and subsequently attempting to perform those procedures independently. It is also important to teach what can be safely and efficiently performed during the extracorporeal phases. The same amount of experience achieved during the postgraduate period, within the context of the structured fellowship, is believed to be more effective and can often incorporate rectal dissection.

Necessary Safety Measures

The trainee should be made aware of all necessary safety measures. These include proper patient positioning on the operating table, prevention of sliding off the table, achieving appropriate steep tilt of the operating table, ensuring adequate padding of joints and bony prominences (to prevent pressure sores and peripheral neuropathy), obtaining safe abdominal access to establish pneumoperitoneum, and safely introducing instruments once the patient is in the tilted position (instruments should be directed towards the anterior abdominal wall to prevent small bowel injury).

Special attention should also be given to safety during the dissection. If a monopolar cautery hook is used, dissection should be performed layer by layer, always visualizing the tissue to be cauterized. If bipolar cautery, radiofrequency or ultrasonic clamping and cutting devices are used, special caution and appropriate exposure should be provided in order to avoid injury to the bowel, ureter, nerve, or vascular structures (marginal colic artery). If an inadvertent bowel injury occurs, most often serosal tears, the trainee should know how to repair simple bowel injuries laparoscopically using a one or two layer suture technique. Finally, special attention should be given to blood vessel control, particularly when ligating the major mesenteric pedicles. All trainees should be well versed and comfortable with all energy sources to be used during the procedure. If the first hemostatic device fails, an automatic rescue plan must be implemented, either by a repeated attempt with the same device, pressure application, control of the squirting pedicle with a clamp or an Endoloop® or another device. If this also fails there should be rapid conversion to a hand-assisted or open procedure.

During the early training phase of laparoscopic colon surgery, the trainer is often in charge of the camera and in full control of the operating field, despite the fact that most of the dissection is performed by the trainee. Continual verbal cues by the trainer should provide sufficient guidance as to how and where to perform retraction or dissection. Explanation of the embryologic layers and identifying the correct tissue plane is often necessary.

Patient Selection and Pre-operative Workup

Although it is not always possible to select the best patient for every teaching case, it should be defined which patients are ideally suited for teaching laparoscopic colorectal surgery. Miskovic et al. as mentioned above, studied this issue [59]. In the authors’ opinion, medium to tall patients with a BMI of 20–26 are likely to have favourable and standard anatomy. Patients with very low BMI (<20) and shorter statue may create a challenge due to thin embryologic layers that are not separated by adipose tissue. This can result in loss of the correct tissue plane resulting in a defect in the mesentery and oozing from the mesenteric vessels. In addition, the small bowel mesentery in very short individuals is difficult to retract and can obscure the operating field. Likewise, in patients with a high BMI (>27) it can be too difficult to expose the colonic mesenteric root. Small bowel obscuring the operating field can be a significant problem. Additional challenges occur when performing vascular pedicle control and during the transection of thick mesentery. Because the part of the colon being dissected is often heavy, its mesentery is prone to fracture during retraction, which can result in mesenteric oozing. Exteriorization or extraction of the specimen will often require a larger than usual incision.

After patient selection, it is critical to complete a thorough pre-operative workup. A significant amount of information can be obtained in advance from the CT scans, which in many cases, have already been performed for oncologic reasons. With information to hand, a reasonable decision about approaching very large tumors laparoscopically can be made. Anatomy of the abdominal cavity should also be studied pre-operatively with the trainee if a CT scan is available.

Operating Field Exposure

In order to perform the procedure successfully and to provide the best possible learning experience, the operating field should be optimally exposed. This is normally accomplished by a steep tilt of the operating table, allowing the small bowel to drop out of view field by gravity. A common problem during the initial phase of a surgeon’s laparoscopic colorectal experience is insufficient tilt of the table, often due to reluctance of the anaesthetist. Thus, recognizing how much tilt can be applied safely is important and can be determined before draping the patient. It should be noted that prolonged tilt can lead to peripheral neuropathy [82].

Another common mistake seen with an inexperienced trainee is a struggle to obtain proper exposure. This can be easily solved by adding one or two extra ports and involving an assistant. Because laparoscopic colorectal procedures are performed over multiple quadrants of the abdominal cavity, it can be easy to lose the proper horizontal camera orientation [6]. Therefore, it can be helpful from time to time to view the entire operative field. This helps not only the person controlling the camera but also the trainee to conceptualize the operating field and adjust the position, as well as the instruments, as needed. The trainer should also keep in mind that inexperienced surgeons are more likely to injure tissue inadvertently during retraction, particularly when the retracting instruments are located beyond the field of view [35]. For this reason, the trainee should be instructed not to grab the bowel while retracting, but to instead gently push on the mesentery or the bowel itself. A useful exercise for teaching the trainee how to gently handle the bowel is to perform “running the bowel” during selected cases.

Once the initial operating field is exposed, it is imperative to maintain it in clean and proper embryologic layers for the entire case. Bloodless conduct of the operation is crucial, especially during teaching cases and the trainer should point out the appropriate embryologic layers. Gas dissection is often helpful and typically occurs once dissection is performed in the proper layer. This is often initiated by incision with a monopolar cautery. Subsequent dissection can be then performed bluntly if a bloodless plane is identified or with the use of monopolar cautery, if appropriate retraction is applied. It is important to remember that Toldt’s fascia is comprised of several layers of thinner fasciae and dissection can be carried out between any of these layers. The deeper layers contain small squiggly vessels that can be disrupted if dissection is performed too deeply, resulting in bleeding and obscured planes of dissection. Since it is more likely that deeper layers of Toldt’s fascia will be entered during the medial to lateral approach, care should be taken to identify the most superficial layer of Toldt’s fascia at the beginning of the retroperitoneal dissection, which should be left in situ.

Macroretraction and Microretraction

It is important for the trainee to understand the concept of macro-retraction and micro-retraction. The term “macro-retraction” refers to retraction of a large organ such as the colon, bladder or omentum. This is often achieved using a laparoscopic grasper. The structure is usually grasped, moved, and held in a position that will allow for finer dissection in the focused field. The grasper is typically kept beyond the operative field and care must be taken to avoid injuring the retracted organ. The term “micro-retraction” refers to providing the necessary tissue tension in the area where finer dissection is performed. This dissection is performed in the field of view and any instrument can provide the retraction. The trainee must be ambidextrous enough to be able to provide both types of retraction with either hand.

Stepwise Approach

A stepwise approach to surgical training has been incorporated into many specialties, including laparoscopic colectomy training, where each procedure is broken down into simpler steps. Trainees are required to perform the same step in each procedure until they have demonstrated proficiency, at which point they advance to the next planned step. This approach allows for a safe and timely progression of the operation, as well as evaluation of the trainee and documentation of the learning curve. Often, the individual steps can be grouped into the larger steps, allowing the fast-learning trainees to become proficient more quickly. The proficiency-gain of each resident should be considered on a case-by-case basis.

Video Recording and Analysis

It is always surprising to see how many details of the operation can be noticed during the video review process that were not seen during the operation. This can often include proper camera positioning to allow both surgeons to orient themselves in the multi-quadrant abdominal field. Other elements include identification of proper tissue planes (retroperitoneal dissection), synchrony and coordination of movement. It is believed that simple video analysis sensitizes the trainee to keep the operating field clear, both by bloodless dissection and proper orientation. This leads to important habits acquired by the trainee, which then allows for clean and anatomical surgery to be performed in the future.

Learning Various Approaches

It is important for the trainee to become familiar with alternative approaches in laparoscopic colorectal surgery. Though one approach can be used in the majority of cases, this is not always the case. For example, while some surgeons prefer the inferior to superior approach for laparoscopic right colectomy, it may not be possible to do so safely if there is a large caecal tumor. Likewise, the medial to lateral approach may not be appropriate when large lymph nodes are found surrounding the ileocolic pedicle. This same medial to lateral approach during left colectomy may also not be possible in very obese individuals, in whom visualisation of the root of the colonic mesentery may be impossible. In these cases, the alternative option of choice would be the lateral to medial approach, which may avoid conversion to open surgery. Once familiar with the alternative approaches, the trainee maintains the necessary skills by periodically using them.

Summary

Teaching the advanced laparoscopic skills needed for colorectal procedures requires a different approach to that used to teach open surgery. Mastering basic laparoscopic skills is a ‘sine qua non’ before advanced training begins. The proficiency-gain curve in laparoscopic colorectal surgery is prolonged and can be shortened by adequate supervision and mentoring of the trainee. Incorporation of the training into the structured curriculum allows for acquisition of the necessary skills without compromising patient safety.