As published in the American Journal of Surgery (February 2010, Volume 199, Number 2) Re-published at OnSurg by permission of our collaborative partners at the Association of Women Surgeons.
Authors: Giselle G. Hamad MD FACS and Myriam Curet MD
Minimally invasive surgery (MIS) or laparoscopic surgery plays a vital role in residency training in a number of surgical disciplines, including general surgery, surgical oncology, colorectal surgey, pediatric surgery, and thoracic surgery. The tremendous patient demand for MIS over the past two decades has resulted in surgeons rapidly embracing this technique. Many general surgery residencies cover basic laparoscopy within their residency program; however, the experience with more advanced cases is variable. This career resource guides the interested medical student and physician to opportunities for fellowship training in MIS. It includes a discussion of the specialty, training requirements, grant funding, research fellowships and pertinent societies as well as references.
Key Words: Laparoscopic surgery, Minimally invasive surgery, Endoscopy, Fellowship
Minimally invasive surgery (MIS), or laparoscopic surgery, plays a vital role in residency training in a number of surgical disciplines, including general surgery, surgical oncology, colorectal surgery, pediatric surgery, and thoracic surgery. Because of the limitation in tactile sensation, the lack of three-dimensional visualization, and the distance separating the surgeons’ hands from the target organs, MIS requires a completely different skill set than open surgery. Acquiring laparoscopic skills remains a formidable challenge.
Most general surgery residencies include basic laparoscopic procedures within their residency case repertoire, including diagnostic laparoscopy, laparoscopic cholecystectomy, and laparoscopic appendectomy. The experience with more advanced laparoscopic cases such as antireflux surgery, inguinal and ventral herniorrhaphy, solid organ surgery, colorectal surgery, gastric and intestinal resections, and donor nephrectomy is more variable.
Because of the tremendous patient demand for MIS over the past two decades, many surgeons have rapidly embraced this technique, including those with scant training in MIS. Unfortunately, significant complication rates have been reported from surgeons performing MIS procedures early in their learning curve (1). Therefore, a structured curriculum which combines didactic teaching with MIS skills training is essential.
Residency programs currently utilize laboratory training-inanimate and animate (2-4) as well as simulation in their MIS curriculum. In 2005, the Residency Review Committee (RRC) revised the laparoscopic and endoscopic minimum case requirements for graduates of surgical residencies (5). These requirements include 60 basic laparoscopic surgeries, 25 advanced laparoscopic surgeries, 35 upper endoscopies, and 50 colonoscopies.
Residents who are considering laparoscopic bariatric surgery should definitely consider a laparoscopic fellowship, as it is nearly impossible to receive adequate training in laparoscopic bariatric surgery during a general surgery residency.
Surgeons interested in further training in MIS may wish to consider pursuing a fellowship in MIS. This career resource guides the interested medical student and physician to opportunities for fellowship training in MIS.
Most minimally invasive surgery fellowships require that the individual have completed a general surgery residency program and be board eligible in general surgery.
The Fellowship Council was created to promote high quality fellowship training in minimally invasive surgery, gastrointestinal surgery, hepatobiliary/pancreatic surgery, and flexible endoscopy. It represents 130 programs which have received accreditation from the Council. A fellowship match process managed by the National Resident Matching Program (NRMP) was instituted in 2004. Most minimally invasive surgery fellowships require completion of a general surgery residency and board eligibility in general surgery. The application deadline is in September and the match list submission deadline is in November.
A wide variety of fellowship programs are available. Most are one year in duration. Some programs combine a year of research with a year of clinical training. The clinical experience may include flexible endoscopy, colorectal surgery, solid organ surgery, and bariatric surgery.
Residents who are considering a career in laparoscopic bariatric surgery should strongly consider pursuing fellowship training. The learning curve is steep; for full competence for laparoscopic gastric bypass, for example, the learning curve is reported to be approximately 100 cases (7) . Therefore, it is difficult to receive adequate training during a general surgery residency to perform laparoscopic bariatric surgery safely.
At present, there is no board certification in minimally invasive surgery.
MIS Research Opportunities and Funding
Medical students interested in MIS should identify a faculty member at their medical school who has a background in minimally invasive surgery and an interest in mentoring. The medical student’s advisor or dean may be helpful in identifying MIS faculty. The student should meet with the MIS faculty member to discuss shadowing in the operating room and possible research opportunities.
Surgery residents interested in a career in MIS should approach MIS faculty members at their institution to find research opportunities. Their mentor, advisor, or program director may provide guidance. In addition, grants are available for research from a number of surgical societies (see below). Other intramural funding opportunities may be available at their institution.
There are several funding opportunities for research in minimally invasive surgery. SAGES offers research awards annually for study support. The Association of Women Surgeons, in conjunction with Ethicon Endo-Surgery, Inc. and Genomic Health, offers a grant that may be applied to research in innovative minimally invasive surgery, surgical education, and bariatric surgery. The Association for Surgical Education has funding to support educational research. Other possible sources of funding include the American College of Surgeons and the Society of University Surgeons. State and local public health departments and local charitable organizations may also offer research support.
Professional Societies for Minimally Invasive Surgery
SAGES (www.SAGES.org) was founded in 1981 primarily as an organization for surgeons performing flexible endoscopy. Since then, SAGES has embraced both endoscopy and MIS. In the early 1990s, SAGES assumed a leadership role in defining standards for emerging technologies in general surgery. The society’s missions include educating residents and practicing surgeons, providing guidelines for training and granting of privileges, evaluating emerging technologies, developing standards of practice, and supporting endoscopic and laparoscopic research. SAGES presents an annual scientific session and postgraduate courses. Candidate SAGES membership status for residents and fellows is available through the SAGES Website.
Society of Laparoendoscopic Surgeons (SLS)
The SLS (www.SLS.org) is a multidisciplinary organization which was established to ensure the highest standards for the practice of laparoscopic, endoscopy, and MIS. Its members represent many MIS specialities, including general surgery, gynecologic laparoscopy, and endourology. SLS disseminates information to its members through its Websites, publications, videos, conferences, and other electronic media.
Society for Surgery of the Alimentary Tract (SSAT)
SSAT (www.SSAT.com) is an organization for surgeons interested in surgery of the alimentary tract. The objectives of the SSAT are to educate and investigate the diseases and functions of the alimentary tract, to present a forum for presentating of such knowledge, and to provide training opportunities, funding for research, and scientific publications. SSAT holds its annual meeting during Digestive Disease Week and abstracts are published in the Journal of Gastrointestinal Surgery.
- Podnos YD, Jimenez JC, Wilson SE, Stevens CM, Nguyen NT. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg. 2003 Sep;138(9):957-61.
- Fried GM, Feldman LS, Vassiliou MC, et al. Proving the value of simulation in laparoscopic surgery. Ann Surg. 2004 Sep;240(3):518-25; discussion 25-8.
- Fried GM, Derossis AM, Bothwell J, Sigman HH. Comparison of laparoscopic performance in vivo with performance measured in a laparoscopic simulator. Surg Endosc. 1999 Nov;13(11):1077-81; discussion 82.
- Swanstrom LL, Fried GM, Hoffman KI, Soper NJ. Beta test results of a new system assessing competence in laparoscopic surgery. J Am Coll Surg. 2006 Jan;202(1):62-9.
- Residency Review Committee. 2005 [cited 2008 March 14]; Available from:http://www.acgme.org/acWebsite/RRC_440/440_policyArchive.asp
- Ahlberg G, Heikkinen T, Iselius L, Leijonmarck CE, Rutqvist J, Arvidsson D. Does training in a 3irtual reality simulator improve surgical performance? Surg Endosc. 2002 Jan;16(1):126-9.
- Schauer P, Ikramuddin S, Hamad G, Gourash W. The learning curve for laparoscopic Roux-en-Y gastric bypass is 100 cases. Surg Endosc. 2003 Feb;17(2):212-5.
Giselle G. Hamad MD FACS
Assistant Professor of Surgery
University of Pittsburgh
Division of Minimally Invasive Bariatric and General Surgery
300 Halket Street, #5518
Pittsburgh, PA 15213
Myriam Curet MD
Associate Professor of Surgery
Stanford University Medical Center
Director, Minimally Invasive Program
Stanford University Medical Center
9 Woodhill Drive
Redwood City, CA 94061
Link to descriptions in other gen surg subspeciaties:
- Training in Breast Surgery
- Training in Surgical Oncology
- Training in Trauma/Critical Care
- Training in Pediatric Surgery
- Training in Bariatric Surgery
- Training in Colorectal Surgery
- Training in Surgical Critical Care
- Training in Minimally Invasive Surgery
- Training in Endocrine Surgery
- Training in Plastic Surgery
- Training in Transplant Surgery
- Training in Vascular Surgery