A rural, community-based program can train surgical residents in advanced laparoscopy

BACKGROUND: Advanced laparoscopy requires mastery of complex surgical skills. A steep learning curve, lack of an adequate number of cases, and a shortage of experienced staff are reasons cited as barriers to the acquisition of these skills by surgical residents. We hypothesize that advanced laparoscopy can be taught during residency without additional fellowship training. STUDY DESIGN: ast surgical residents who completed training at our rural, community-based, 140-bed hospital from 1992 to 2000 were contacted by mailed surveys and a followup telephone interview. Advanced laparoscopy was defined as cases other than cholecystectomy, appendectomy, and diagnostic laparoscopy. Five attending surgeons routinely perform advanced laparoscopy. RESULTS: The response rate to the survey was 93.3% with 15 of 18 graduates currently practicing general surgery and 100% of the surgeons performing advanced laparoscopy. Laparoscopic herniorrhaphy, splenectomy, colectomy, Nissen fundoplication, and adrenalectomy were performed by 12 (85.7%), 10 (71.4%), 11 (78.6%), 13 (92.9%), and 9 (64.3%) surgeons, respectively. Eight (57.1%) surgeons reported confidence to perform advanced laparoscopy immediately after residency. All graduating chief residents from the last 3 years expressed this confidence. On average each of two chief residents from the past 3 academic years graduated with 99 basic and 50 advanced laparoscopic cases. CONCLUSIONS: A rural, community-based program can train residents to perform advanced laparoscopy. Increasing the volume of advanced cases handled by resident correlates with increasing confidence in graduates.     

The revised ACGME laparoscopic operative requirements: how have they impacted resident education?

Background

Laparoscopic surgery has been an essential component of surgical education for the last two decades. The Accreditation Council for Graduate Medical Education (ACGME) changed the requirements for laparoscopic cases beginning with graduates in 2008, and the Fundamentals of Laparoscopic Surgery program was introduced over a decade ago as a method of measuring competency with laparoscopic techniques. The purpose of this study was to determine what changes have been made to meet these requirements and how these changes have impacted general surgery residents in their preparation to perform both basic and complex laparoscopic procedures upon completion of residency.

Methods

A 23-question survey was distributed electronically to all fourth- and fifth-year residents of United States general surgery residency programs. Respondents were queried about demographics, perception of surgical education, and their level of preparedness to perform laparoscopic cases upon graduation.

Results

The survey was completed by a total of 321 residents (174 fourth-year and 147 fifth-year). Nineteen percent of respondents indicated that they anticipated problems meeting the new ACGME guidelines and 18.7% of all respondents indicated that changes had been made to their program to meet those new requirements. The majority of residents felt they had adequate laparoscopic training upon graduation, but there was a disparity between program types. Despite this finding, more than one-third of respondents believed that it would be necessary to seek additional laparoscopic training post-residency graduation.

Conclusion

Residency training programs have had to keep pace with evolving technology while preparing future surgeons to perform with confidence upon completion of residency training. The majority of residents feel their training has been adequate, but there are also a great number who believe they will need to continue their education in laparoscopic surgery to keep pace with this ever-evolving field.     

Broad-based fellowships: a cornerstone of minimally invasive surgery education and dissemination

Aware of the trends in surgery and of public demand, many residents completing a 5-year training program seek fellowships in minimally invasive surgery (MIS) because of inadequate exposure to advanced MIS during their residency. A survey was designed to evaluate the effectiveness of a broad-based fellowship in advanced laparoscopic surgery offered in an academic health science center. The questionnaire was mailed to all graduates. Data on demographics, comfort level with specific laparoscopic procedures, and opinions regarding the best methods of acquiring these skills were collected. Most of the surgeons entered the fellowship directly after residency. The majority of these surgeons are academic surgeons. Fellows performed a median of 187 cases by the end of their training and felt comfortable operating on foregut, hindgut, and end organ. A full year of training was found to be the best format for appropriate skill transfer. A broad-based MIS fellowship meets the needs of both academic and community surgeons desiring to perform advanced laparoscopic procedures.     

Surgical endoscopy training is integral to general surgery residency and should be integrated into residency and fellowships abandoned

It is a basic premise that laparoscopic procedures are an integral part of the practice of general surgery. Currently, general surgery training programs as a whole are failing to provide residents with significant surgical experience in advanced laparoscopic procedures. The teaching of advanced laparoscopic procedures can and should be incorporated into the 5-year surgical residency. The challenge for Program Directors is that it is time to restructure general surgery training so that additional fellowship training is not required to provide an adequate experience in this fundamental part of general surgery.     

The outcome of research training during surgical residency

BACKGROUND/PURPOSE: Graduates of a university surgical residency program were surveyed to identify the timing of specialty selection and the impact that studying in a research laboratory had on subsequent acceptance into a fellowship program. METHODS: Between 1975 and 1990, 86 residents completed general surgery training at UCLA Medical Center. A survey was sent to all graduates to determine the focus of their previous laboratory research and when they selected their eventual surgical specialty. Responses were received from 67 of the 86 graduates (78%). RESULTS: Forty-eight of the sixty-seven respondents (72%) took one or more years of surgical research during residency. Postresidency fellowship training was selected by 55 of 67 (82%); 50 applied to fewer than five programs; 49 of 55 (89%) received one of their top three choices. Twenty-seven of the sixty-seven residents pursued an academic career (40%). Residents who performed at least 2 years of research were more likely to become academicians (53%) than residents who did 1 year or less of research (22%). Only 39 of 67 residents (58%) had selected a specialty after 2 years of clinical training; 28 more made the selection after the third clinical year. All residents interested in cardiac surgery (n = 18) or plastic surgery (n = 4) prior to research were accepted into fellowships in those specialities, whereas only 37% of those who had an interest in other fields pursued the same specialty (P < 0.0001). Residents performing research in general surgery (n = 9), surgical oncology (n = 18), cardiac surgery (n = 14), and plastic surgery (n = 3) were more likely to practice in that specialty than those doing research in other specialty laboratories. CONCLUSIONS: General surgery residents performing research in a specialty laboratory are likely to pursue fellowship training relating to that field. Those who select a career in cardiac or plastic surgery prior to research are most likely to enter into these fields as their eventual specialty. Residents who perform 2 or more years of laboratory research publish more papers and often pursue an academic career.     

Bariatric surgery training in the United States.

BACKGROUND: To provide evidence of the status of bariatric surgical education in the accredited surgery training programs in the United States. METHODS: A questionnaire was sent by mail to the 251 accredited surgery residency training programs, including the 48 minimally invasive surgery fellowship programs, in the United States. RESULTS: There was a 100% response to the questionnaire. Of the 251 surgery residency training programs and 48 minimally invasive surgery fellowship programs, 185 (73.7%) and 43 (89.6%) performed bariatric surgery, respectively. The open Roux-en-Y gastric bypass was the dominant procedure (85.1%), followed by laparoscopic Roux-en-Y gastric bypass (60.9%), in the residency programs; the laparoscopic Roux-en-Y gastric bypass was the dominant procedure (70.1%) in the minimally invasive fellowship programs. CONCLUSIONS: Bariatric surgery has been mainstreamed into accredited training programs in the United States.     

Minimally invasive surgery: the evolution of fellowship

BACKGROUND: The field of postgraduate minimally invasive surgery/gastrointestinal surgery (MIS/GIS) training has undergone substantial growth and change. To determine whether fellowships are meeting a strategic need in training, we conducted a survey to assess the current status and trends of change in MIS/GIS fellowships. METHODS: A survey was distributed to fellows currently in MIS/GIS programs in the United States and Canada in 2003 and 2006. Fellows were asked to describe demographics as well as their experience both during fellowship and residency. We compared this with aggregate data of resident experience through the Accreditation Council for Graduate Medical Education (ACGME) case logs, data tracked by industry, and program data from the Fellowship Council (FC) web site. RESULTS: There were 54 responses to the 75 surveys distributed in 2006 (72% response rate). MIS fellows performed more laparoscopic cases during their residency than the average graduating chief resident, but did not feel competent to perform advanced laparoscopic surgery. However, combining fellowship numbers with residency numbers does suggest that the total experience provides competency in a wide variety of procedures. CONCLUSIONS: It seems that the MIS/GIS Fellowship is meeting a real need among graduating surgical residents; fellows felt unprepared for clinical practice at the completion of residency. It is encouraging to note the improvements in fellowship structure, standards, and overall experience, brought by the efforts of the FC. It is hoped that this report of the state of MIS fellowship with a comprehensive review of current data will aid in further evaluation and improvement.     

Perceived Proficiency in Minimally Invasive Surgery Among Senior Ob/Gyn Residents

Background and Objectives:

To assess self-perceived proficiency in minimally invasive surgical procedures among fourth-year Ob/Gyn residents in the United States and to evaluate trends in self-perceived proficiencies by comparing the current survey to a similar survey distributed in 2001.

Methods:

A Web-based survey was sent out to all fourth-year residents in accredited obstetrics and gynecology programs in the United States. The residents completed the online survey regarding their perceived proficiency in performing minimally invasive procedures. These results were compared with the results from a similar survey performed in 2001. The residents were also asked about teaching methods and the importance of minimally invasive surgery training during residency.

Results:

We received responses from 248 senior residents. Of these, 65.1% thought emphasis on laparoscopic surgery training should be increased or greatly increased, and 97.1% thought laparoscopic skills were important for building a successful practice. Perceived proficiencies in advanced laparoscopic procedures, such as total laparoscopic hysterectomy and supracervical hysterectomy, were significantly higher compared with our results in 2001. Residents also seemed to feel more comfortable performing basic and advanced hysteroscopic procedures. Of respondents, 56.8% felt that a fellowship in minimally invasive surgery would be beneficial to them following graduation.

Conclusion:

Senior Ob/Gyn residents seem to feel more comfortable performing advanced laparoscopic procedures at graduation than they did 7 years ago. The majority feels that the emphasis on training in minimally invasive surgery should be increased.     

Laparoscopy training in United States obstetric and gynecology residency programs.

OBJECTIVES: To assess laparoscopic training curriculums in US Obstetrics and Gynecology residency programs. METHODS: A list of E-mail addresses was obtained for the accredited Obstetrics and Gynecology residency programs in the US from the CREOG Directory of Obstetric-Gynecologic Residency Programs and Directors. An E-mail survey containing 8 questions regarding laparoscopy training was sent to all residency directors with current E-mail addresses. RESULTS: Seventy-four residency directors responded to the survey for a response rate of 41%. Residency programs from all sections of the US were included in the study. Results of the survey indicate that 69% of residency programs had implemented a formal laparoscopy training program. At least half of the program directors surveyed stated that lack of faculty time and funds were the main barriers to laparoscopic surgery training. Seventy-two percent of those surveyed thought that in the future the health-care industry would demand proof of competency in laparoscopy as standard of care. CONCLUSIONS: Most US Obstetrics and Gynecology residency programs have implemented a formal laparoscopy training curriculum, use more than one method to train their residents, and involve almost half of their faculty on average in training residents to perform laparoscopic surgery.     

Telementoring: an important enabling tool for the community surgeon

This study evaluated the efficacy of telementoring as an enabling tool for community general surgeons to perform advanced laparoscopic surgical procedures. We present a series of 19 patients who underwent advanced laparoscopic surgical procedures in two community hospitals, between November 2002 and July 2003, by four community surgeons with no formal advanced laparoscopic training. Each surgeon was telementored by an expert surgeon from a tertiary care hospital. Telementoring was achieved with real-time two-way audio-video communications over Internet Protocol or Integrated Services Digital Network lines with bandwidths from 385 kbps to 1.2 mbps. The procedures included 10 bowel resections, 5 Nissen fundoplications, 2 splenectomies, 1 reversal of a Hartmann procedure, and 1 ventral hernia repair. Two of the 19 procedures (11%) were converted to open. There were no intraoperative complications and two postoperative complications (11%). The primary surgeon considered telementoring useful in all cases (median score, 4 of 5). The mentor was also comfortable with the quality of the laparoscopic surgery performed (median score, 4 of 5). Telecommunication bandwidth for audio and video transmission was found to be a critical factor in the quality of telementoring process. Telementoring is safe and feasible. It allows community surgeons with no formal advanced laparoscopic training to benefit from expert intraoperative advice during the performance of advanced laparoscopic procedures. It may also reduce health-care costs by avoiding the need to refer and transfer patients to tertiary care centers.     

The effect of vascular fellowships on general surgical residency training.

To answer the controversial question of whether or not vascular fellowships detract from general surgical training, questionnaires were sent to directors of 41 approved vascular fellowship programs, 41 residency directors in the same institutions, and 40 residency directors in university programs without approved fellowships. Overall response rate was 74% (93% of vascular fellowship directors, 63% of same-institution residency directors, and 65% of residency directors without vascular fellowships). Thirty-four per cent of fellowship directors and 38% of same-institution residency directors indicated that the fellowship has reduced the vascular surgery case load of residents. In institutions with fellowships, general surgery residents performed an average of 71 major vascular procedures and first assisted on 44, whereas residents performed 65 major vascular procedures and assisted on 47 in institutions without fellowships. Overall, 79% of fellowship directors and 62% of same-institution general surgical directors indicated that the fellowship improved the quality of vascular surgical training. Only 15% of same-institution residency directors and 3% of fellowship directors felt that the fellowship detracted from the general surgical experience. Fifteen per cent of institutions without approved fellowships have now initiated vascular fellowship programs, and an additional 23% plan to begin such fellowships. No fellowship directors plan to abolish their programs, although 8% plan to decrease the number of fellows in order to increase general surgery resident participation. Among the majority of institutions studied, vascular fellowships have not adversely affected general surgical training, and often enhanced it.     

Employment and satisfaction trends among general surgery residents from a community hospital

BACKGROUND: Physician satisfaction is an important and timely issue in health care. A paucity of literature addresses this question among general surgeons. PURPOSE: To review employment patterns and job satisfaction among general surgery residents from a single university-affiliated institution. METHODS: All general surgery residents graduating from 1986 to 2006, inclusive, were mailed an Institutional Review Board-approved survey, which was then returned anonymously. Information on demographics, fellowship training, practice characteristics, job satisfaction and change, and perceived shortcomings in residency training was collected. RESULTS: A total of 31 of 34 surveys were returned (91%). Most of those surveyed were male (94%) and Caucasian (87%). Sixty-one percent of residents applied for a fellowship, and all but 1 were successful in obtaining their chosen fellowship. The most frequent fellowship chosen was plastic surgery, followed by minimally invasive surgery. Seventy-one percent of residents who applied for fellowship felt that the program improved their competitiveness for a fellowship. Most of the sample is in private practice, and of those, 44% are in groups with more than 4 partners. Ninety percent work less than 80 hours per week. Only 27% practice in small towns (population <50,000). Of the 18 graduates who practice general surgery, 94% perform advanced laparoscopy. Sixty-seven percent of our total sample cover trauma, and 55% of the general surgeons perform endoscopy. These graduates wish they had more training in pancreatic, hepatobiliary, and thoracic surgery. Eighty-three percent agreed that they would again choose a general surgery residency, 94% of those who completed a fellowship would again choose that fellowship, and 90% would again choose their current job. Twenty-three percent agreed that they had difficulty finding their first job, and 30% had fewer job offers than expected. Thirty-five percent of the graduates have changed jobs: 29% of the residents have changed jobs once, and 6% have changed jobs at least twice since completing training. Reasons for leaving a job included colleague issues (82%), financial issues (82%), inadequate referrals (64%), excessive trauma (64%), and marriage or family reasons (55% and 55%, respectively). One half to three fourths of the graduates wished they had more teaching on postresidency business and financial issues, review of contracts, and suggestions for a timeline for finding a job. CONCLUSIONS: Although general surgical residencies prepare residents well technically, they do not seem to be training residents adequately in the business of medicine. This training can be conducted by attendings, local attorneys, office managers, and past residents with the expectation that job relocations can decrease and surgeon career satisfaction can increase.     

Gynecological laparoscopy in residency training program: Dutch perspectives

Background Implementation of laparoscopy into residency training is difficult. This study was conducted to assess the current state of implementation of laparoscopic surgery into gynecological residency program, to identify factors influencing laparoscopic skills training, and to find solutions toward better training and implementation. Methods In 2003 a questionnaire was sent to all 68 postgraduate year 5 and year 6 residents in obstetrics and gynecology in The Netherlands. The questionnaire addressed demographics, performance of laparoscopy, self-perceived competence, simulator training, and factors influencing laparoscopic training in residency. Results Of the 68 residents, 60 (88%) responded; 46 (37%) were men and 78 (63%) women. Men showed significant higher mean self-perceived competence in some laparoscopic procedures than women. Of the respondents, 20% had no advanced laparoscopic gynecologist present in their teaching hospital. Residents felt that simulator training is important in relation to their performance in the operating room. Of all gynecological teaching hospitals in the Netherlands, 55% did not have the opportunity of simulator training. Of the respondents who had the possibility of simulator training, 33% did not use the simulator voluntarily. Residents who trained on a simulator felt training was significantly more important (p = 0.02) than residents who never practiced on a simulator. Respondents’ laparoscopic skills were subjectively evaluated in the operating room (92%) or were evaluated based on the number of laparoscopic procedures performed as primary surgeon (49%). Of the respondents, 47% were satisfied with their current laparoscopic skills and 27% also felt prepared for the more advanced procedures. Not having been primary surgeon in nonacademic teaching hospitals and even more so in academic teaching hospitals (p < 0.05) was a limiting factor in acquiring laparoscopic skills. Conclusions Incorporation of basic laparoscopic procedures into residency training has been successful; however, advanced procedures are not. Simulator training is still in its infancy in The Netherlands, is not frequently used voluntarily, and should be mandatory during residency. Acquired laparoscopic skills on a simulator and in the operating room should be objectively assessed, and above all, training of trainers is imperative.     

Laparoscopic practice patterns among North American urologists 5 years after formal training

PURPOSE: We assessed urologist laparoscopy practice patterns 5 years after a postgraduate training course in urological laparoscopic surgery. Results were compared to findings from similar studies performed on the same cohort at 3 and 12 months after training. MATERIALS AND METHODS: Between January 1991 and November 1992, 11, 2-day university sponsored, postgraduate laparoscopic surgery training programs were held. A survey was mailed to the 322 North American participants in the summer of 1997 to determine current laparoscopic use and experience. RESULTS: Of the 166 respondents (51% response rate) 53.6% (89) had performed 1 or more laparoscopic procedures in the previous year, compared to 84% 1 year following course completion. Of the respondents 37% believed their laparoscopic experience was sufficient to maintain skills compared to 66% at 1 year. Of the respondents 6% had performed more laparoscopic procedures while 82% had performed fewer than anticipated. Reasons cited for decreased use included decreasing and/or lack of indications, increased cost, decreased patient interest, higher complication rates, decreased institutional support and increased operative time. Respondents practicing in academic or residency affiliated centers, or those who had completed residency after 1980 were more likely to have performed more procedures than anticipated (p = 0.044) compared to community based colleagues. CONCLUSIONS: Laparoscopic use by urologists trained in the postgraduate setting is decreasing. Few respondents are maintaining the skills acquired during the original training course. Decreased use appears to be multifactorial.     

Survey of residency training in laparoscopic and robotic surgery

PURPOSE: We determined the current status of residency training in laparoscopic and robotic surgery in the United States and Canada. MATERIALS AND METHODS: A total of 1,188 surveys were sent via the Internet to all 1,056 current urology residents and 132 program directors with an Internet address registered with the American Urological Association. RESULTS: Responses were received from 372 residents (35%) and 56 program directors (42%). Of respondents 47% reported greater than 100 laparoscopic procedures performed yearly by 1 (36%) or more (51%) faculty members. Robotic procedures were performed at 54% of the institutions, mainly consisting of prostatectomy and pyeloplasty. At all institutions laparoscopic radical nephrectomy was performed and those at 69% of the institutions believed that it is the gold standard for renal tumors today. Urologists were involved in 87% of adrenal surgeries and 54% of respondents believed that is the gold standard approach. However, only 35% of respondents had participated in laparoscopic adrenalectomy. Of respondents 36%, 42% and 17% reported that laparoscopic donor nephrectomy was performed by only urologists, only a nonurology transplant team and shared equally, respectively. Of respondents 41% planned on performing laparoscopic donor nephrectomy in the next year. Laparoscopic needle ablation renal surgery was done in 51% of the programs and percutaneous needle ablation was done in 63%. None of the respondents (0%) believed that it is the gold standard but 51% believed that ablative procedures look promising for renal tumors. Of respondents 39% had participated in robotic radical prostatectomy and 53% thought that it looked promising but was not the gold standard. Of respondents 31% believed that they will be performing robotic surgery after residency, 30% were unsure and 29% will not be using the robot. Overall 38% of residents thought that their laparoscopic experience was at least average or acceptable. CONCLUSIONS: A large number of laparoscopic urological procedures are being performed at training institutions with robotic procedures being performed at 54% of respondent facilities. Residents are participating in most cases but only 38% consider their laparoscopic experience to be satisfactory. A need still exists for increased laparoscopic training for residents, which can be accomplished by expanding training facilities and increasing the number of faculty members performing laparoscopic procedures.     

Urology practice patterns after residency training in laparoscopy

PURPOSE: Laparoscopic training has been incorporated into many urology residency programs. Although the impact of laparoscopic training courses has been examined, the impact of residency training in laparoscopy on subsequent urology practice patterns has not been assessed. MATERIALS AND METHODS: Urologists completing their residency from 1977 through 1999 at Tulane University and the University of California-San Diego were sent anonymous questionnaires in September 2000. The questionnaires evaluated practice demographics, operative experience in laparoscopy during residency, and the role of laparoscopy in the urologist's current practice. Factors impacting the decision to perform or not perform laparoscopy were evaluated. RESULTS: Sixty-one former residents (67%) responded to the questionnaire. Urologists were more likely to perform laparoscopic procedures if they had been trained during their residency (69%) than if they had no experience during residency (34%; p < 0.025). Intensity of laparoscopic experience in residency did not appear to correlate with ongoing practice, with 73% of residents having <15 cases during residency training continuing to perform laparoscopy compared with 67% of residents doing 15 to 80 laparoscopic cases. Urologists who had been trained in laparoscopy during residency cited the need for more training (47%) and inadequate case volume (47%) as reasons for not currently performing laparoscopy. Among those who had received residency training, the most common reasons given were inadequate case volume (61%) and increased operative time (57%). CONCLUSIONS: This survey suggests that laparoscopic procedures are more likely to be performed by physicians who have received training during residency. As the number of urologists who have been trained in laparoscopy during residency increases, shifts in practice patterns will continue to evolve, along with advances in urologic laparoscopy.     

Survey of senior resident training in urologic laparoscopy,robotics and endourology surgery in Canada

Introduction:

We determined the status of Canadian training during senior residency in laparoscopic, robotic and endourologic surgery.

Methods:

Fifty-six residents in their final year of urology residency training were surveyed in person in 2007 or 2008.

Results:

All residents completed the survey. Most residents (85.7%) train at centres performing more than 50 laparoscopic procedures yearly and almost all (96.4%) believe laparoscopic radical nephrectomy is the gold standard. About 82% of residents participated in a laparoscopic partial nephrectomy in 2008, compared to 64.7% in 2007. Of the respondents, 66% have participated in a laparoscopic prostatectomy and 54% believe the procedure has promising potential. Exposure and training in robotic-assisted laparoscopic procedures seem to be increasing as 35.7% of 2008 residents have access to a surgical robot and 7% consider themselves trained in robotic-assisted procedures. Most residents (71.4%) train at centres that perform percutaneous ablation. However, 65% state the procedure is performed solely by radiologists. Percutaneous nephrolithotomy is widely performed (98.2%), but only 37.5% of residents report training in obtaining primary percutaneous renal access. Despite only 12.5% of residents ranking their laparoscopic experience as below average or poor, an increasing proportion of graduating residents are pursuing fellowships in minimally-invasive urology.

Conclusion:

Laparoscopic nephrectomy is commonly performed and is considered the standard of care by Canadian urology residents. Robotic-assisted surgery is becoming more common but will require continued evaluation by educators who will ultimately define its role in the urological residency training curriculum. Minimally-invasive surgical fellowships remain popular, as Canadian residents do not feel adequately trained in certain advanced procedures. Urologists must strive to learn and adapt to new technologies or risk losing them to other specialties.     

Assessment of microvascular anastomosis training in otolaryngology residencies: Survey of United States program directors

Objective

To assess current microvascular training strategies in otolaryngology residency programs.

Study Design

Cross-sectional study.

Setting

U.S. otolaryngology residency programs.

Subjects and Methods

A total of 104 U.S. otolaryngology program directors received surveys inquiring about program size, the presence of fellowship training in microvascular surgery, the number of microvascular cases per month, the use of microvascular animal laboratory, and whether residents, fellows, or co-attendings assist in the anastomoses.

Results

A 51 percent response rate was achieved, and of the 54 programs that responded, 78 percent reported no microvascular fellowship positions in plastics or head and neck reconstruction. A total of 52 percent reported performing three or fewer microvascular surgeries per month. Of the programs that did not have a microvascular fellow, only five (12%) performed eight or more surgeries per month. A total of 65 percent of the programs reported that residents assist during the anastomosis at least 75 percent of the time. Of the programs where residents assist 75 percent or more of the time, 70 percent have a formal training in microvascular technique ranging from demonstrating laboratory competencies to multiday courses. A total of 48 percent of the responding programs report having an animal laboratory for microvascular surgery. All animal laboratories used the rat as the model.

Conclusion

Many programs find value in providing residents with microvascular training, both in the operating room and in the laboratory. Only a small minority of programs without fellowship positions responded that they perform microvascular surgery on a regular basis (4 or more surgeries per month).     

Training surgeons in endoscopic retrograde cholangiopancreatography

Background General surgeons commonly perform upper gastrointestinal endoscopy in practice, but few perform endoscopic retrograde cholangiopancreatography (ERCP), partly because of limited training opportunities. This report focuses on the value of an ERCP fellowship training program to a broad-based, mature residency in surgery and our observations on the experience required for surgeons to be trained in advanced interventional ERCP. Methods Since the program was initiated in 1992, 13 ERCP fellows have been trained for individual periods of 6 to 14 months. This study investigated all procedures with fellow involvement (2,008 cases) from among a total experience of 3,641 ERCPs. Data collected included type of ERCP (diagnostic/therapeutic), fellow success in cannulating the duct of interest, and faculty success in cases of fellows who failed. Of the 13 fellows, 9 had previous endoscopy experience, but none had training in ERCP. Results An 85% cannulation rate was accepted as successful, and cannulation rates for each fellow were calculated for each 3-month period. The 85% mark was reached by 4 (31%) of 13 fellows in the first period, 2 of 13 fellows (15%) in the second period, 5 of 11 fellows (45%) in the third period, 7 of 10 fellows (70%) in the fourth period, and 1 of 1 fellow (100%) in the fifth period of training. On the average, it took 7.1 months and 102 ERCPs for trainees to reach desired success levels. Success came more promptly with prior exposure to endoscopy. Fellows without prior endoscopic experience required 148 cases to reach 85% success. Resident surgical experience with major pancreatic resections increased threefold after establishment of the fellowship. Conclusions Training in ERCP is possible within the scope of a surgical fellowship in a reasonable length of time and experience. Complication rates remain low even with fellow involvement. Establishment of an ERCP program increases the focus and experience of pancreas surgery in a surgical residency for chief residents. Presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) meeting, Hollywood, FL, USA, 15 April 2005