Minimally Invasive Surgery Fellowship Program

Dr. Wilson in OR with Fellow - photo by Scott Holmes

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 Operative Skills Curriculum

Dr. Wilson with Fellow - photo by Scott Holmes 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:

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:

Energy Sources—demonstrate competence to the faculty in energy source use including electrocautery and harmonic scalpel.
Safely perform intraoperative upper endoscopy as approved by faculty in a minimum of 10 cases.
Safely assist the completion of laparoscopic fundoplication as approved by faculty in a minimum of 5 cases.

Laparoscopic Colectomy Training Curriculum

Consortium fellows should be able to perform these skills to be able to perform laparoscopic colectomy. The following skills are required in order to achieve competence as primary surgeon for laparoscopic colectomy:

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.
Safely perform lower endoscopy as approved by faculty in a minimum of 10 cases.
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:

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.
Tacking Devices—demonstrate competence to the faculty in use laparoscopic tacking of mesh to the abdominal wall.
Safely assist the completion of laparoscopic inguinal hernia as approved by faculty in a minimum of 5 cases.
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

Da Vinci Robot with Fellow - photo by Scott Holmes 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. Armando Garcia who is recognized by Intuitive as one of the most skilled robotics educators in the world. Dr. Wilson and Mr. Garcia 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

Program Orientation with Armando Garcia must be scheduled prior to September 16, 2011 for progression to step 2. This is the responsibility of each fellow to contact Armando by email: Jose.garcia@memorialhermann.org, or by cell phone at 832.877.3526 to schedule a one on one orientation of the da Vinci systems. This will take approximately 2 hours.
Each fellow must register with Intuitive Surgical Incorporated to create an account. From that account, online teaching modules may be accessed and completed. Once completed, a print out must be turned into Armando Garcia for record. Armando Garcia can collaborate with Intuitive to help create the account. This must be completed by October 1, 2011 for progression to set three.
Following the minimum requirements of the orientation and completion of online modules, each fellow will be granted access to the Surgical Innovation and Robotics Institute at Memorial Hermann Texas Medical Center: 6411 Fannin Street, Houston, Texas, 77030. Armando Garcia will supply a code to the center to access the da vinci Surgical Simulator. Please note that working on the simulator is a first come first serve basis so it is very likely that someone may be utilizing the simulator at the time you wish to practice. It is highly recommended that you call Armando Garcia in advance to avoid conflict. Each fellow will then be able to practice the necessary skills required to progress to step 4. Each module must be completed and a documented score of 90% or higher must be verified with Armando Garcia.
Surgical skills training can be scheduled once all simulation modules are verified. Armando Garcia and Peter Herrera will communicate on your behalf with Intuitive Surgical. The surgical skills training lab is an 8 hour commitment from 8-5, Monday through Friday without exception. Please communicate your schedule with your respective attending physicians, as this is a zero tolerance policy. Intuitive Surgical will not grant a certification of completion if the surgical skills lab protocol is not followed.
Ten cases as the primary operator must be performed following the skills lab in order to obtain a UT MIST Robotic Fellowship Certification. It is the responsibility of each fellow to submit the necessary case logs to Armando Garcia for records. It is the judgment of each fellows attending physician to support the ten cases.
Congratulations, a UT MIST Robotic Fellowship Certification may now be granted. Erik Wilson will review each applicant’s file prior to receiving the certification. He may or may not need to communicate with the fellow applying, or each attending physician to verify completion of any steps. This certification will not only be accepted at any institution that requires a da vinci lab as a prerequisite, but it will certainly exceed most minimum requirements. A letter of support may be requested if needed at future hospitals where you will be operating.

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:

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

Robotic Fellowship Designation

Da Vinci Robot interface - Dr. Wilson - photo by Scott Holmes 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.

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.
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:

Submit at least one paper for publication to a peer-reviewed journal.
Submit at least one video for presentation to a major surgical meeting.
Submit at least one abstract for presentation to a major surgical meeting.
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 are 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

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.