MIST Fellowship Consortium

Curriculum

The fellowship goals and curriculum encompass three broad areas:

Education of the fellows is the primary goal.
Performing research by the faculty and fellows which promotes the advancement of minimally invasive surgery.
Promotion of the consortium and its concept as a superior model for training.

The Educational Curriculum

The fellowship educational goals are outlined in the following two sections of the didactic and skills curricula:

The Didactic Curriculum - (conferences)

The fellows and faculty will meet monthly usually on the second Wednesday of the month except during holidays for didactic teaching which includes journal club, interesting case conference, and M&M. Other conferences are also listed below. At the start of the monthly meetings several items of the fellows will be reviewed for the upcoming month: the case logs of each fellow, the upcoming interesting cases of the faculty, information on faculty absences which would result in extra time for the fellow and research projects planned by each fellow.

MIST Journal Club/ M&M Conference

Held 2nd Wednesday of the month; 6:30 p.m. – 9:00 p.m.
Style of Journal Club
3 Articles – summary of article only; 15-20 minutes each article maximum
M&M /Interesting Case Presentation – 1 hour maximum
Fellows to submit a list of complications from previous month with one fellow presenting one case from each program

August 19, 2009 Host: Haas Topic: Laparoscopic Rectal Surgery
September 10, 2009 Host: Methodist Topic: Treatment of GERD
October 14, 2009 Host: UT Topic: Surgical Treatment of diabetes
November 11, 2009 Host: Methodist Topic: Treatment of Barretts
January 13, 2010 Host: Leggett Topic: Complex Ventral Hernia Repair
February 10, 2010 Host: Haas Topic: Robotic Colorectal Surgery
April 14, 2010 Host: UT Topic: Endoluminal Obesity Therapy
May 12, 2010 Host: Leggett Topic: SILS

All Consortium fellows and faculty are expected to attend. Three articles on the topic is picked by the responsible program fellow one month prior to the club and given to the Program Coordinator, Marcy Medrano. All articles will then be circulated to faculty, fellows and residents who will review the articles.

Each fellow is to submit a list of complications from previous month which was complicated or interesting. Intraoperative video or pertinent films are encouraged for the discussion.

Surgery Grand Rounds

Grand Rounds presentations will be made by each fellow at their home institution on a topic of their choosing. All consortium participants will attend to show support of the presenting fellow.

The Operative Skills Curriculum

Rotations to other practices within the group are important part of the skills curriculum. All rotations involve one fellow staying at the home base and one fellow rotating away. Rotations are agreed upon by the faculty and optional rotations are available upon request of the fellow and approval by the faculty program director. Upcoming interesting cases by faculty will be broadcast to all fellows through the monthly didactic meetings so freely available fellows can travel to the sites to participate or see these unusual cases.

Evaluations of the fellows by the faculty and of the faculty by the fellows will be performed of all teaching sites every quarter during the year and upon the completion of each away rotation. Evaluation forms are provided by and reviewed by the consortium program director for analysis to improve fellow performance and faculty performance.

Maintaining accurate case logs is critical to each fellow. These numbers are vital for hospital privileging which is becoming more restrictive every year. It is mandatory that case logs are entered by each fellow into the Minimally Invasive Fellowship Council Case Log (website: http://www.fellowshipcaselog.org). Case logs need to be printed and brought to the monthly didactic meetings for review. Failure to do so results in the curtailing of operative privileges.

Training certifications are available in laparoscopic adjustable gastric banding, robotic surgery and stapled hemorrhoidopexy. Additional industry sponsored fellow courses are available as well. Courses are scheduled upon request of the fellow and approval of the program director.

The faculty has designated specific operations most commonly performed by the group to be promoted with a skills curriculum and help assure competence in these operations. These training sets promote acquisition of skills which can be applied widely to all minimally invasive surgeries. It is imperative that all fellows work diligently early in the year to complete these skills sets so their operative experience can be maximized.

Laparoscopic Gastric Bypass Training Curriculum

Consortium fellows should be able to receive the skills to be able to perform laparoscopic gastric bypass and surgically manage the bariatric patient who receives gastric bypass. The following skills are required in order to achieve competence as primary surgeon for laparoscopic gastric bypass:

Backwards Rope Pass—laparoscopically pass a marked rope 1meter long with 1 cm marks at every 10cm between graspers with the camera facing the surgeon in less than 1 minute without grasping the rope outside of the 1 cm marks.
Backwards Washer Pass—laparoscopically pass 5 washers from trays 5 cm apart without dropping them with the camera facing the surgeons in less than 1.5 minutes.
Linear Stapler—completely load and fire laparoscopic linear staplers with and without buttressing material. Understand the final staple height and thickness of each staple load and buttressing material to achieve adequate staple line formation.
Circular Stapler—completely fire circular staplers understanding proper tissue compression, purse-string placement, and bowel placement.
Energy Sources—demonstrate competence to the faculty in energy source use including electrocautery and harmonic scalpel.
Suturing and Knot Tying—laparoscopically place a suture into foam with marked points 2 cm apart and tie down 3 consecutive knots in less than 1 minute with the camera in a standard position.
2 Layer anastomosis—laparoscopically perform an intact and patent handsewn 2 layer anastomosis of 1.5 cm in diameter in less than 35 minutes.
Safely perform intraoperative upper endoscopy as approved by faculty in a minimum of 10 cases.
Safely assist the completion of laparoscopic gastric bypass as approved by faculty in a minimum of 10 cases.

Laparoscopic Adjustable Band Training Curriculum

Consortium fellows should be able receive the skills to be able to perform laparoscopic adjustable gastric banding and surgically manage the bariatric patient who receives gastric banding. The following skills are required in order to achieve competence as primary surgeon for laparoscopic adjustable gastric banding:

1. Suturing and Knot Tying—laparoscopically place a suture into foam with marked points 2 cm apart and tie down 3 consecutive knots in less than 1 minute with the camera in a standard position.
2. Energy Sources—demonstrate competence to the faculty in energy source use including electrocautery and harmonic scalpel.
3. Complete the required company course of laparoscopic adjustable banded gastroplasty.
4. Safely perform intraoperative upper endoscopy as approved by faculty in a minimum of 10 cases.
5. Safely assist the completion of laparoscopic adjustable gastric banding as approved by faculty in a minimum of 10 cases.

Laparoscopic Fundoplication Training Curriculum

Consortium fellows should be able to receive the skills to be able to perform laparoscopic fundoplication and surgically manage the reflux patient who receives fundoplication. The following skills are required in order to achieve competence as primary surgeon for laparoscopic fundoplication:

1. Energy Sources—demonstrate competence to the faculty in energy source use including electrocautery and harmonic scalpel.
2. Suturing and Knot Tying—laparoscopically place a suture into foam with marked points 2 cm apart and tie down 3 consecutive knots intracorporally in less than 1 minute with the camera in a standard position.
3. Extracorporal Suturing and Knot Tying—laparoscopically place a suture into foam with marked points 2 cm apart and tie down 5 consecutive knots extracorporally in less than 1 minute with the camera in a standard position.
4. Tacking Devices—demonstrate competence to the faculty in use laparoscopic tacking of mesh to the abdominal wall.
5. Safely perform intraoperative upper endoscopy as approved by faculty in a minimum of 10 cases.
6. Safely assist the completion of laparoscopic fundoplication as approved by faculty in a minimum of 5 cases.

Laparoscopic Colectomy Training Curriculum

1. Backwards Rope Pass—laparoscopically pass a marked rope 1meter long with 1 cm marks at every 10cm between graspers with the camera facing the surgeon in less than 1 minute without grasping the rope outside of the 1 cm marks.
2. Backwards Washer Pass—laparoscopically pass 5 washers from trays 5 cm apart without dropping them with the camera facing the surgeons in less than 1.5 minutes.
3. Linear Stapler—completely load and fire laparoscopic linear staplers with and without buttressing material. Understand the final staple height and thickness of each staple load and buttressing material to achieve adequate staple line formation.
4. Circular Stapler—completely fire circular staplers understanding proper tissue compression, purse-string placement, and bowel placement.
5. Energy Sources—demonstrate competence to the faculty in energy source use including electrocautery and harmonic scalpel.
6. Safely perform lower endoscopy as approved by faculty in a minimum of 10 cases.
7. Safely assist the completion of laparoscopic colectomy as approved by faculty in a minimum of 5 cases.

Laparoscopic Hernia Repair Training Curriculum

Consortium fellows should be able to receive the skills to be able to perform laparoscopic inguinal and ventral hernia repair and surgically manage the patient who receives hernia repair. The following skills are required in order to achieve competence as primary surgeon for laparoscopic ventral and inguinal hernia repair:

1. Backwards Rope Pass—laparoscopically pass a marked rope 1meter long with 1 cm marks at every 10cm between graspers with the camera facing the surgeon in less than 1 minute without grasping the rope outside of the 1 cm marks.
2. Backwards Washer Pass—laparoscopically pass 5 washers from trays 5 cm apart without dropping them with the camera facing the surgeons in less than 1.5 minutes.
3. Energy Sources—demonstrate competence to the faculty in energy source use including electrocautery and harmonic scalpel.
4. Suturing and Knot Tying—laparoscopically place a suture into foam with marked points 2 cm apart and tie down 3 consecutive knots in less than 1 minute with the camera in a standard position.
5. Tacking Devices—demonstrate competence to the faculty in use laparoscopic tacking of mesh to the abdominal wall.
6. Safely assist the completion of laparoscopic inguinal hernia as approved by faculty in a minimum of 5 cases.
7. Safely assist the completion of laparoscopic ventral hernia as approved by faculty in a minimum of 5 cases.

Robotic Training Curriculum

Robotic General Surgery and Robotic Gastric Bypass

Consortium fellows have a unique opportunity to obtain surgical robotic training due to the program being affiliated with a nationally recognized training center known as the Minimally Invasive and Robotics Training Center at Memorial Hermann Hospital-Texas Medical Center. This center is one of a handful of centers across the country sanctioned by Intuitive to train surgeons on the Da Vinci robot. Surgeons from around the world receive training and the center is run by Mr. Peter Herrera who is recognized by Intuitive as one of the most skilled robotics educators in the world. Dr. Wilson and Mr. Herrera perform case observations and 2 day surgeon led training courses of robotic gastric bypass for the last year. Procedures performed by the faculty laparoscopically using robotic assistance include: roux-en-y gastric bypass, bladder augmentation, cholecystectomy, hiatal hernia repair and fundoplication, and splenectomy.

Robotic System Training

Consortium fellows will be allowed to obtain system certification of the Da Vinci surgical robot by notifying the program director and completing the following requirements in the listed order:

1. Observing 4 robotic cases performed by a MIST faculty member.
2. Completing 4 hours of robotic console time in the robotic training lab observed by Mr. Herrera or MIST faculty.
3. Completing the Intuitive online Breeze system training module
4. Completing a one day live animal training lab sponsored by Intuitive
5. Participating in 2 robotic cases in the operating room with time on the console for a portion of each case.

Robotic Fellowship Designation

Consortium fellows will be allowed to receive certification as a robotic fellow and obtain an additional diploma of robotic fellowship. In order to receive this additional certification, the fellow must first complete the robotic system training as outlined above and then complete the following additional requirements.

1. Complete a dry lab small bowel 2 layer hand sewn anastomosis which is intact and patent in 35 minutes or less, The integrity of the anastomosis must be approved by MIST faculty and must be 15 to 20 mm in diameter.
2. Participate in a total of 10 robotic cases in the operating room in which the fellow spends a significant time on the console during each case as judged by MIST faculty. The cases should contain at least 2 different types of operations.

Robotic training is optional and requires a significant commitment by the fellow and faculty. Thus, it should be initiated very early in the academic year if the fellow desires to receive training. Fellows will not be allowed to begin robotic training after the first half of the academic year.

The Consortium Research Curriculum

The Consortium fellowship strongly promotes the performance of research by the fellows and support by the faculty. Minimally invasive surgical research allows for the continued advancement of the specialty. Therefore all faculty agree that each consortium fellow should complete the following research goals during the year:

1. Submit at least one paper for publication to a peer-reviewed journal.
2. Submit at least one video for presentation to a major surgical meeting.
3. Submit at least one abstract for presentation to a major surgical meeting.
4. Submit some research to SAGES—any of the above.

Failure to complete these requirements can result in failure to complete the fellowship. Except when overridden by the program directors, fellows will not be allowed to attend surgical meetings without having first submitted research to that meeting. Fellows are encouraged to work together on research topics and all research ideas should be discussed at the monthly fellowship meetings occurring with journal club or interesting case conference.

The Consortium Fellowship Promotional Goals

The concept of combining independent fellowships and fellows together for academic interaction, skills training and rotations, and research is a unique design of the Consortium fellowship system. Rarely is academic and private practice settings combined in such a way to allow the diversity of training MIST allows. The Consortium desires to promote this concept nationally in all things performed by the faculty and fellows. Thus, MIST promotes the following to achieve greater recognition:

Common Presentation Format—all presentations at meetings, posters at meetings, and papers submitted should reference the Minimally Invasive Surgeons of Texas. Presentations and posters should also include the Consortium logo and the UT logo or Methodist Hospital logo.

Common Consortium Website

Social Events—the Consortium sponsors a variety of events to encourage non-educational interaction among the fellows and faculty. These include an end of the year graduation party and ceremony as well as a fellows and faculty roast. Other events include organized meetings for paintball, skeet shooting, and other sporting activities. Participation in any social events is optional but allows for a tight comradery to develop among the fellows and faculty.

Exit Surveys— The Consortium requires all fellows at the conclusion of their fellowship year to complete exit surveys to show what can be improved upon for future fellows. These surveys have provided valuable feedback for system improvement.