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The Challenge of Learning New Techniques in Minimally Invasive Colon and Rectal Surgery
Initiating and completing minimally invasive procedures in colorectal surgery is almost routinely a complex endeavor in spite of being our day-by-day practice. Often, the occurrence of a complication does not depend on performing a technically “perfect” operation. A distinguished set of highly peculiar technical skills is necessary to achieve this objective. Assessing the extent to which a surgeon or his or her team is in possession of these skills, and theoretically qualified to conduct minimally invasive colorectal surgery, is also challenging. In spite of being of central importance for the patient and institutional standpoint of view. Especially when facing a more recent scenario of less available time to learn a progressively increasing number of operations that demand coordinated and successive execution of tasks absolutely unfamiliar to trainee surgeons.
As a result, surgeons who seek to learn minimally invasive, more precise, and less functional impactful pathways never stop facing enduring times during their training period. Furthermore, the availability of proctors qualified to teach all minimally invasive procedures and the number of cases for each indication has been drastically lessened within a single institution. Therefore, we found ourselves in a vicious circle that leads to frustration of the surgeons in training. As a result, the effort to incorporate techniques in minimally invasive colorectal surgery begins during the training period but will not end years after residency or fellowship completion.
Since colorectal laparoscopic surgery entered the clinical scenario, the role of simulation-based training for skills transfer directly to the operating room has been discussed. Despite numerous simulators been tested and surgeons with different degrees of expertise been included and submitted to different training programs, few applicable conclusions have been reached. Thus, it is not surprising that to still justify the use simulation-based training, we might address the example (although highly successful) of the aviation industry as a benchmark.
Take, for example, the case of transanal endoscopic surgery. To become competent in transanal total mesorectal excision (TaTME), a cadaver training model is probably irreplaceable. However, the model was found insufficient to ensure a safe pathway during the early clinical phase of the training since it was not able to prevent the occurrence of specific and severe technical complications. Not even the extremely well-succeeded examples of Lapco training program in the U.K. for laparoscopic colectomy and the countless, extremely successful short-duration courses promoted by institutions like the IRCAD could anticipate the challenge of teaching TaTME to colorectal surgeons specialized in the management of rectal cancer. In my opinion, this might continuously reassure the tremendous responsibility of walking the path of teaching minimally invasive colorectal surgery.
Another important landmark comes from analyzing the issue of robotic colorectal surgery. Since the ratio of its clinical benefit over financial cost (value) remains to be solved, a deliberated restriction of access to the technology ended up seriously jeopardizing attempts at setting the right standards for undertaking a robotic-assisted colectomy. In addition, only recently virtual reality simulators harboring full clinical robotic modules have become available to surgical education.
The challenge remains and we need to better design studies aiming at keeping the patient out of the risk equation. Many specialists in laparoscopic, robotic, and transanal minimally invasive colorectal surgery have dedicated a significant part of their practice to training. Most of them believed that it was possible to reproduce to other young surgeons, the same training pathway they have been guided through. We are fortunate that some of them agreed to contribute to this volume of Clinics in Colon and Rectal Surgery. May all these formidable and tireless surgeons from the Americas and Europe receive our most sincere thanks for having found time in their very tight schedules to contribute to the education of young surgeons and the progress of minimally invasive colorectal surgery.
Ultimately, it is a great honor for me having the opportunity to serve as guest editor of this volume of Clinics in Colon and Rectal Surgery. It was our intent to meet the standards of quality, seriousness, and competence that are a routine aspect of Scott Steele's practice as a surgeon, team leader, and researcher. Therefore, helping to assemble this volume brought me personal aggrandizement and the unforgettable feeling of being part of this distinguished group of world-renowned surgeons and colleagues. Thank you, Scott. Let the simulation begin.
Article published online:
29 March 2021
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