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13/05/2007

Brush up on your laparoscopic skills.

Laparoscopic skills consist of access, dissection, haemostasis and reconstruction.  These skills are initially best acquired in a skills lab environment and improved through practice. 

See and do as much laparoscopic surgery as possible.  Appendicectomy is a perfect model for learning how to interpret a 30 degree laparoscope image, handle bowel, use diathermy to divide a mesentery, mobilise the caecum, secure an endo-loop, intracorporal suturing etc. Another great teaching operation is TEP hernia repair.

Get yourself a dry simulator, station it in the Dept. Surgery and practice suturing and tying knots but intra and extra corporaly.  Research has shown that such simulators enable to maintain competency, in contrast to units without access to simulators where the trainees have to re-learn competency in the clinical setting.  Again, always use a 30 degree scope.  Practice whilst looking forward with the scope (much harder than looking down).  Encourage your boss/SpR to join in.
 

Visit a large volume unit

Allows you to watch designated cases with feedback/interaction.  Take your anaesthetist and entire theatre team to see and talk about all aspects of the surgery. 

Bristol (Colorectal & Urology),
Eastbourne (Urology),
Basingstoke, Guildford (Colorectal & Urology),
Dundee, Oxford (Colorectal), 
Newcastle (Urology & Colorectal).
Colchester, Dartford, St Mark's (Colorectal) in the UK.
Taunton, Gravitas Ltd Wirral (Bariatric)

Leuven, Bordeaux, Strasbourg or Milan in Europe (Colorectal).
 

Invite an expert to your hospital

Colorectal:

Jean-Louis Dulucq
, Institute of laparoscopic Surgery, Hopital Bagatelle MSBP, 203 Route de Toulose, 33401 Bordeaux Talence, France. Tel. 33 (0)5 57 12 35 21.  Fax 33 (0)5 57 12 34 20.   E-mail: info@ils-chirurgie.com

Joel Leroy, IRCAD - European Institute of Telesurgery, 1 Place de l'Hôpital FR-67091, Strasbourg (France) E-mail: Joel Leroy@ircad.u-strasbg.fr

Antonio Lacey, Hospital Clinic, Barcelona, Spain

Guy-Bernard Cadiere, St Pierre, Brussels, Belgium.

Andre D’Hoore, Dept. Abdominal Surgery, University Clinic, Gasthuisberg, Herestrat 49, 3000 Leuven, Belgium. andre.dhoore@uz.kuleuven.ac.be
www.uzleuven.be/diensten/abdominal_surgery/


Urology:

Chris Eden,

The North Hampshire Hospital
Aldermaston Road
Basingstoke
Hampshire
RG24 9NA

The Royal Surrey County Hospital
Egerton Road
Guildford
Surrey GU2 7XX
T: 01483 464046
F: 01483 406626      edenprivatesec@hotmail.com


Mark Wright,
Bristol Royal Infirmary 
Tel., 0117 9282725  Janet.Hooker@ubht.nhs.uk

Frank Keeley,
Southmead Hospital,
NBT Bristol
Tel., 0117 9595144  frank_keeley@bui.ac.uk 


Bariatric:


Richard Welborn
Taunton & Somerset NHS Foundation Trust
Musgrove Park Hospital
Taunton
Somerset
TA1 5DA
Tel., 01823 333444   rw@surgeryforweightloss.org

David Kerrigan
Gravitas Ltd,
SPIRE Murrayfield Hospital,
Thingwall, Merseyside, UK
CH61 1AU.
Tel., 0842515515

Vincent Frering, Lyon France.
Centre de Consultations Spécialisées de la Sauvegarde
25, Av des Sources
69009 LYON FRANCE
Tel : +33(0)437 497 010
Fax +33(0)437 497 013

George Fielding, Associate Professor Surgery,
NYU mrdical centre
TCH SUR
530 First Avenue
New York NY 10016

+1 212 263 3166

National (England) Training Centres in LCR surgery 2008.


In 2008 the DOH identified 11 centers who will lead the way in providing training for the country's colorectal surgeons in laparoscopic colorectal surgery (LCRS) for patients with bowel cancer.  
  • Freeman Hospital Newcastle
  • Bradford Royal Infirmary
  • Castle Hill Hospital Hull
  • Queens Medical Centre Nottingham
  • John Radcliffe Hospital Oxford
  • Queen Alexander Hospital Portsmouth
  • Colchester-Guildford-St Marks' Hospitals
  • Basingstoke & Frimley Park 
  • Kings & St Thomas' Hospitals
  • St Mary's & Royal Marsden Hospitals
  • Bristol, Yeovil & Plymouth

This is an initiative led by Prof. Mike Richards and Teressa Moss from the Cancer Action Team and funded by the DOH.  Up until now there has been no structured training strategy for introducing laparoscopic colorectal cancer resection, a highly complex and relatively new surgical procedure to mainstream UK surgical practice.  

The main aim of the consortiums is to ensure the safe delivery of the highest possible quality of patient care across the whole country.  

The whole process is coordinated from a central office Hull.  All interested trainees must register with the Hull Office:

                            Helen Procter or Claire Acey;
                            Academic Surgical Unit, 
                            Castle Hill Hospital, 
                            Castle Rd, 
                            Cottingham, 
                            East Yorkshire, 
                            HU16 5JQ.


Tel., 01482 624315        Fax., 10482 623274

h.procter@hull.ac.uk      c.l.acey@hull.ac.uk     



Remember that there is no recognised mechanism of training delivery, content and quality.  Newcastle and Bristol offer cadaveric workshops.  Oxford, Basingstoke/Frimley and Bradford offer 2-3 day immersion courses of about 6 cases.  Some centers advocate that the surgeon and patient travel to the training centre.  10 assume that prospective trainees have already attended a dry and wet lab.


The SWLaparoscopic Consortium provides support through formal training (dry and wet labs and/or animal labs for trainees with limited laparoscopic experience), as well as cadaveric operating, self-directed learning, performance assessment and clinical mentoring in a way that is easily accessible to learners.

Remember that unlike the other centres, the SWLC team members are comitted to travel to trainees trusts to deliver one to one supervised teaching.



Apply for a fellowship

Bristol - Colorectal, urology & UGI  
Oxford – Colorectal/gynae (Stortz)
Colchester, St Mark's, Leeds, Plymouth, Nottingham – Colorectal (Ethicon EndoSurgery)
 
Cleveland Clinic USA - British Urology Foundation

BOSS-Ethicon & Gravitas (Wirral) - Bariatric
Taunton - Bariatric    


If necessary, apply for a six months out of programme appointment  or just go on a visit!

Apply for an Association of Laparoscopic Surgeons Travelling Scholarship.  Three are available for £3,000 and £1,000 to senior trainees or consultants within 5 years of appointment. Closing date is the end of March 2009 (see Useful LINKS).


Write to:  Mr Mark Vipond, Hon Secretary ALS, At the Royal College Surgeons England, 35-43 Lincoln’s Inn Field, London, WC2A3PE.

 

Go on a dry and wet lab course and attend a MasterClass

Preferably the former should be hands on and the latter envolve one to one discussion.  Ethicon EndoSurgery and Covidien Masterclass registrations occur through their local sales representative liaising with their Professional Education department.  What happens next will depend on surgeon's profile and objectives. 


The two day courses based around the dry (learn suturing and knot tying) and wet labs at Hamburg  www.esi-online.de (Ethicon EndoSurgery) and Elencourt (Covidien) are very good for building up a team spirit with your operating team,  learn intra-corporeal suturing and undertake simulated anterior resection/rectopexy etc.  You can also see how good the Harmonic scalpel and Ligasure is at dividing large vessels in the pig model.  The model is useful for learning anterior resection, rectopexy, small bowel anastomosis etc. 

The Ethicon Endo-Surgery courses have been run along regional lines as has faculty since 2006.  The participating faculty are all ALS preceptors who are prepared to then mentor the trainees through their further development.  Course run in February.


ASiT have in the past offered three Covidien sponsored, two day masterclasses in laparoscopic urology (April) and colorectal surgery (March & June) at the Elancourt Training Centre Paris. The courses are open to ASiT members who have entered their final two years of training. Each application should include a covering letter and a brief summary of your relevant laparoscopic experience including previous course attendances, a letter of support from your current trainer & a copy of your current curriculum vitae including referees. Please enclose with your application proof of ASiT membership or a completed application for membership. Deadline for applications - January

NB. All applicants must disclose any laparoscopic courses they have already attended including those sponsored by other companies; failure to do so will result in disqualification from the prize. Please enclose with your application proof of ASiT membership or a completed application for membership.

Please send your applications to: Emma Carter, Covidien Healthcare Laparosocopic Masterclasses 2009, Association of Surgeons in Training, The Royal College of Surgeons of England, 35-43 Lincoln’s Inn Fields, London WC2A 3PE


Other Enquiries:

    Julian Foster,

    Covidien (UK) Commercial Ltd,

    154 Fareham Rd.,

    Gosport,

    Hamshire,

    PO13 OAS

    Tel: +44(0) 1329 224836

    Fax: +44 (0) 1329 224400


Please remember: 

Get the support of your colleagues, theatre manager and writen support of your Clinical Director, Medical Director and the local Clinical Effectiveness Committee.  Speak to your hospitals new technology group and perhaps more importantly the procurement manager.    We would encourage you to work in partnership with another consultant within your deparment whenever possible and develop a team approach.  Develop a business case.  Please feel free to use one of ours.  Remember, there is no specific definition of competence assessment and there are no regulations!


Get yourself a mentor or preceptor

Whilst the ACGBI and ALS  position statement on cancer surgery and preceptorship www.alsgbi.org/als/pages/als_profs.php  its principles still remain valid.


In summary, each surgeon should

  • attend a wet/dry and/or animal lab
  • observe 10 live case
  • train their theatre team to a suitable standard
  • have funding committed and suitable equipment available
  • have the support of their trust
  • be preceptored for 4-6 cases
  • have the support of colleagues
  • have a caseload that would allow a minimum of two lap resections each month
  • Urologists should start doing nephrectomy as the marker procedure.

We would council that watching 6 cases and getting a mate to watch 4-6 cases is not only a recipe for disaster but litigation. Get the skills first and be honest with yourself.  Develop your skills and service with like minded colleague.  

Choose your preceptor carefully - someone whom you know who is very experienced and respect is a good bet.  Take your team, including anaesthetist and a colleague when you visit. 

Choose sensible cases when your preceptor visits eg two high anterior resections, two right hemicolectomies and make sure that they do not get canceled.  Encourage your mentor to come several times.  We would suggest a minimum of 12 cases.  Offer to pay for their petrol etc.  

When you do start on your own, choose an easy case.  If you are worried – convert early! Video the operation and be critical with yourself when you view it.  Collect all your data. Please keep out of the pelvis in your first 50 cases.  Remember if you are to avoid criticism you need the cases to go well!  

If it is all going well and you think you know what you are doing, invite your preceptor back again to observe you through some more cases.  Ask them to perform a more advanced case eg APER, Hartman reversal, Pyeloplasty.

For Urologists, submit your audit results to the BAUS annual laparoscopic nephrectomy audit and aim to perform a minimum of 12 marker cases per annum.  In 2002, data on 263 nephrectomies were returned and by 2004 this had increased to 598, with complications falling from 10 to 4%. 

Registration with the BAUS nephrectomy audit can be done online or by contacting:

Frank Keeley, Southmead Hospital, NBT Bristol 

Tel., 0117 9595144  frank_keeley@bui.ac.uk  


We would suggest that you introduce laparoscopic surgery by a combination of stealth and evolution. Be transparent and honest. Collect a comprehensive set of data, be happy to have it externally reviewed eg BAUS audit as you never know when it will come in handy.

When you have sucessfully completed 30 cases, go and see your mentor again.  We would then suggest that you then visit another high volume unit eg., Bristol (Tony Dixon) Guilford (Tim Rockall) or St Mark's (Robin Kennedy), Newcastle (Alan Horgan) for colorectal cases or Bristol (Mark Wright, Frank Keeley), Basingstoke (Chris Eden), Newcastle for urology in the UK or, go to a European Center.  If you can afford it visit Russell Stitz and John Lumley in Brisbane.  

For Bariatric surgery, go and see Richard Welbourn (Taunton), David Kerrigan (Wirral).  It is also woth pushing the boat out and visit George Fielding and Christine Ren at NYU Medicle Centre. 530 First Ave Ste 105, New York, NY 10016  Phone: (212) 263-3166 Fax: (212) 263-3757


All rights reserved © 2006. Bristol Surgery.
SPIRE Hospital, Bristol. 
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Contact: Claire Trenberth - 0117 9804051
claire.TRENBERTH@spirehealthcare.com
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