Training, proctoring, credentialing in endoscopic surgery

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Abstract
Summary Although the procedures of endoscopic surgery are in many ways, simply a new way of approaching old, familiar problems, certain technical aspects are sufficiently different enough from the common experience of the general surgeon so as to require special training and certification for competency. The introduction of laparoscopic cholecystectomy worldwide showed that many aspects of endoscopic surgery deserved emphasis in training. These include the unique instruments, equipment, and techniques associated with videoendoscopic procedures and, perhaps of even greater importance, the differences in anatomic exposure and perspective afforded by the laparoscope [1–4]. Surgeons used to working in a three-dimensional environment with extensive tactile sensation were forced to learn to operate at a distance from the target tissue using instruments that provided much less feel for the tissues. Direct visualization of the operative field was replaced by a narrow field of view and a magnified, two-dimensional video image, with the video monitor often at an angle to the operative field. Despite these hurdles, the new endoscopic technology was rapidly introduced to clinical practice, stimulated both by the pace of development in the industry and by patient demand for less invasive surgery. But the endoscopic revolution was not accomplished without cost. In the years between 1989 and 1994, many practicing surgeons took brief, 1 or 2 day courses and proceeded to initiate laparoscopic cholecystectomy into their clinical practice with a minimum of experience or expert assistance. Concomitantly, anecdotal experience from oversight institutions and referral centres documented a sharp increase in major, primarily bile duct-related, complications from these procedures, complications that occurred significantly more often than would be expected from open cholecystectomy. Although equipment failure and the early state of the technology accounted for some of these complications, professional organizations and government groups in the United States [5,6] and Europe [7] concluded that many occurred because of inadequate training, minimal supervision and poor endoscopic surgical technique despite the fact that many of the surgeons were otherwise quite experienced open biliary surgeons. More recently, a similar learning curve has been observed for other, more advanced laparoscopic procedures such as antireflux procedures and colectomy [8]. In response, numerous organizations and individuals have proposed or ratified a structured approach to training and credentialing [9–12].

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