Re: Bridging the training gap in laparoscopic colorectal surgery
Greg Wynn , Pasquale Berlingieri , Owen Epstein 
1. Consultant Laparoscopic Colorectal Surgeon, ICENI Centre, Colchester
2. Research Fellow in Screen-Based Simulation, Centre for Screen-Based Medical Simulation Centre, Royal Free Hospital, London
3. Professor of Gastroenterology, Centre for Gastroenterology, Royal Free Hospital, London
We read the letter by Kang and Tabbakh with interest (BMJ 2012;345:e6683). We agree that a training gap exists in laparoscopic colorectal surgery despite industry sponsored fellowships and increased uptake by consultant surgeons which is largely due to the success of the Lapco national training programme (http://www.lapco.nhs.uk/). It is, however, important to address skills training of all trainee surgeons because European Working Time legislation restricts the time available for senior trainers to teach during working hours.
The time has come to reconsider the method by which laparoscopic skills training is delivered and how this might map to the Intercollegiate Surgical Curriculum Programme. We also need objective markers of competency to benchmark a surgeon’s technical ability prior to performing in the operating theatre. High fidelity virtual reality simulators meet these requirements by providing computer generated safety and efficiency metrics that track the learning curve trajectory. In addition, there is evidence that skills learnt on virtual reality simulators are effectively transferred to the operating theatre (1). By embedding laparoscopic simulators into the early phase of a training curriculum, it is possible to assess aptitude and provide a training platform to master the complex range of laparoscopic skills required to perform a colectomy. Moreover, self-directed learning on simulators can occur outside of hospital working hours and is not subject to the limitations imposed by the Working Time legislation.
The Royal Free Medical Simulation Centre, in conjunction with the ICENI Centre in Colchester, has pioneered a virtual reality laparoscopic colorectal curriculum designed for surgical trainees and consultants wishing to develop or enhance their technical and operative skills (2). Using the Lap Mentor (Simbionix, Cleveland, Ohio, US) the stepwise structured curriculum requires the acquisition of a series of skills tasks before progressing to mastery of a laparoscopic sigmoid colectomy in a virtual environment (http://www.youtube.com/watch?v=9rjJCNGwrK0). Trainees are certificated once they have achieved metrics expected from an experienced colorectal surgeon who has performed over 100 laparoscopic resections.
Virtual reality simulators provide the opportunity to shorten the learning curve for trainees without the constraints of restricted working hours and allow a competency-based learning experience in a safe environment. We believe that this approach meets some of the critical challenges facing both trainee and trainer in an era when operating time is restricted and it is no longer acceptable to “see one, do one, teach one”.
1. Larsen CR, Soerensen JL, Grantcharov TP, Dalsgaard T, Schouenborg L, Ottosen C, et al. Effect of virtual reality training on laparoscopic surgery: randomised controlled trial. BMJ 2009; 338:b1802
2. Reed N, Berlingieri P, Wynn G. The virtual reality laparoscopic colorectal curriculum. Ann R Coll Surg Engl (Suppl) 2012; 94:16-17
Competing interests: No competing interests