Training in minimally invasive surgery: experience of paediatric surgery trainees in Europe

Dear Editor Since its implementation three decades ago, minimally invasive surgery (MIS) has become an essential part of the armamentarium of the paediatric surgeon. For some conditions, such as appendicitis and cholelithiasis, MIS has become the standard of treatment, and for others, such as pyloric stenosis, it has shown superiority over open surgery in an RCT1. MIS procedures were initially pioneered by a few trained paediatric surgeons, but with time they have been integrated into the paediatric surgery training curriculum1. Nonetheless, only a few studies exist on the actual exposure of paediatric surgery trainees to MIS procedures during their years of surgical education. A recent study2 analysed MIS exposure among US and Canadian paediatric surgery trainees, based on national data reports of paediatric surgery fellowships, and reported significant variability in MIS exposure among trainees. Yet, little is known about the MIS exposure of paediatric surgery trainees in Europe. The aim of this survey was to evaluate the variability of MIS training in European paediatric surgery training programmes. Of 617 questionnaires sent, 433 responses were received (70.2 per cent response rate) from 21 European countries, with an estimated population of 995 trainees. Respondents were 59.8 per cent women with a median age of 31 (i.q.r. 29–34) years. The survey included questions on 25 different minimally invasive procedures (Table S1). The first analysis concerned which procedures had been performed at least once by trainees, irrespective of the duration of training. The main finding was that the majority of trainees had never performed some common minimally invasive emergency procedures, including laparoscopic reduction of intussusception, laparoscopic pyloromyotomy, thoracoscopy for empyema, or laparoscopic ovarian detorsion (Fig. 1a). Some 67 per cent of the respondents reported challenges in performing MIS in their department (Fig. S1). Training in paediatric minimally invasive surgery in Europe a Minimally invasive procedures performed at least once by participants. Only four procedures were performed at least once by more than half of trainees (laparoscopic appendicectomy (simple and for peritonitis), exploratory laparoscopy, and laparoscopic cholecystectomy). b Comparison of procedures performed between countries where paediatric surgical care is non-centralized versus centralized. Trainees from countries with centralization had higher procedure numbers than those from other countries for laparoscopic appendicectomy (P < 0.001), laparoscopic pyloromyotomy (P < 0.001), laparoscopic Fowler Stephens I (P < 0.001) and II ( P < 0.001) procedures, and thoracoscopic lobar resection (P = 0.049). The difference was not statistically significant for laparoscopic choledochal cyst resection (P = 0.735), minimally invasive pyeloplasty (P = 0.918), thoracoscopy for empyema (P = 0.868) and thoracoscopic tracheo-oesophageal fistula (EA/TEF) repair (P = 0.352) (Chi square test). Numbers of procedures undertaken using minimally invasive techniques were also evaluated. The data showed low exposure to the vast majority of paediatric MIS procedures; only 4 of the 25 procedures had been performed by more than 50 per cent of trainees (Fig. 1a). A Dutch single-centre study3 from 2008 reported a higher case exposure of these procedures performed by trainees (60 per cent). Another survey4 among paediatric surgical trainees in the UK from 2009 reported that 0–10 per cent of appendicectomies were performed laparoscopically, and about 50 per cent of responding trainees were permitted to be the principal operator in these procedures. These studies also indicated great variability in training and exposure in Europe. This may reflect the diverse organization of paediatric surgical care in Europe, with only some countries having adopted centralization of services5. Interestingly, the data showed that the number of years spent in a general surgery department correlated with greater numbers of procedures performed for some higher-complexity thoracoscopic procedures (thoracoscopic lobar resection, thoracoscopic repair of tracheo-oesophageal fistula), whereas years spent in paediatric surgery training did not (Tables S2–S4). Conversely, gastrointestinal and urological procedures (usually representing the higher-caseload procedures) showed no significant differences, regardless of type of training. This could indicate that spending time in a general surgery department enables trainees to have access to procedures of higher complexity during their subsequent paediatric training. In a subgroup analysis, trainees who also trained in general surgery were found to have had more years of training overall, which could introduce a bias regarding the number of procedures. Trainees from countries with centrally organized paediatric care reported higher numbers for specific procedures of low and medium difficulty (Fig. 1b), and were more satisfied with their supervision and teaching compared with those from countries without centralized paediatric care. In addition, satisfaction with supervision and teaching (modified Schoen–Fuhrman score) was significant greater in centralized countries (supervision P < 0.001; teaching P = 0.001). It is well known that centralization of care for rare diseases improves clinical and training outcomes. The present data suggest that centralization of rare diseases could also have a beneficial impact on training in MIS procedures as well as the satisfaction of trainees. This study might represent a first step towards an optimized uniform training curriculum for paediatric MIS in Europe. The authors have no funding to declare. Moritz Markel (Writing—original draft), Martin Lacher (Supervision), Nigel Hall (Data curation, Methodology, Validation), Illya Martynov (Formal analysis), Alexander Siles Hinojosa (Project administration), Juan Carlos de Augustin Asensio (Supervision), Caroline Fortmann (Resources), Maria Hukkinen (Visualization), Annika Mutanen (Investigation), Kathryn Ford (Project administration), Mathilde Glenisson (Project administration), Arnaud Bonnard (Supervision, Validation), Godosis Dimitrios (Project administration), Nick Zavras (Investigation), Maria Malowiecka (Project administration), Dariusz Patkowski (Validation), Elisa Zambaiti (Project administration), Gloria Pelizzo (Visualization), Martin Salö (Project administration), Tomas Wester (Supervision), Anders Telle Hoel (Project administration), Kristin Bjornland (Validation), Delphine Arni (Project administration), Barbara Wildhaber (Supervision), Ayse Karagöz (Project administration), Gonca Topuzlu Tekant (Supervision), Catarina Barroso (Project administration), Jorge Manuel Nunes Correia-Pinto (Validation), Ramon Gorter (Data curation, Investigation), Ernst van Heurn (Validation), Helena Reusens (Project administration), Henri Steyaert (Supervision), Ruta Dagilyte (Project administration), Arunas Strumila (Project administration), Christoph Arneitz (Project administration), Holger Till (Supervision, Validation), Vojtech Dotlacil (Project administration), Michal Rygl (Supervision), Miro Jukic (Project administration), Zenon Pogorelic (Supervision), Tudor Enache (Project administration), Laura Balanescu (Supervision), Salvatore Cascio (Validation, Writing—review & editing), Augusto Zani (Conceptualization, Supervision, Validation, Writing—review & editing), and Luca Pio (Conceptualization, Supervision, Validation, Writing—review & editing). The authors declare no conflict of interest Supplementary material is available at BJS online. The data that support the findings of this study are available from the corresponding author upon reasonable request.

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