Background A survey was carried out by the Hospital Authority Surgery Training Subcommittee on "Review of Surgical Services" in late 1992 on all the surgical units in Hong Kong to assess the medical technological advancement for the 1990S. The result was that the majority of respondent thought Laparoscopic Surgery would be the most important advance and would have a wide implication on the provision of surgical services. In 1993, the Training Subcommittee had asked Mr Michael K.W. Li to form a working group of active laparoscopic surgeons in the Hospital Authority to offer recommendations on the training and practice of laparoscopic surgery. The recommendations are listed below. Hospital Authority Recommended Guidelines for Surgeons: Laparoscopic surgery should be practised by the surgeon within his or her own field of speciality. A BASIC LAPAROSCOPIC SURGERY TRAINING COURSE comprising of lectures on theory and practice, together with hands-on experience on basic skills should be attended by the surgeon before embarking on this work. Proctoring by an experienced laparoscopic surgeon on at least 10 cases is mandatory. Thorough understanding of the principles and operations of laparoscopic instruments is mandatory. The surgeon should know the techniques, complications and hazards prior to performing any laparoscopic procedures. Privileging after the proctoring experience by the supervisor is required, who would then make recommendation to the Chief of Service on the surgical competence of the operator. With the rapid development of laparoscopic surgery, many procedures have been described but no surgeon should attempt on any laparoscopic procedure if he or she has not previously performed by the conventional approach. Recommended Guidelines for Hospitals: There should be a team consisting or surgeons, anaesthetists, nurses and technicians trained to undertake laparoscopic surgery. There should be sufficient equipment for the procedures with back up facilities to cover the eventuality of instrument or equipment failures during the course of the operation. There should be a patient load justifying the necessary investment as well as proving sufficient experience to develop and maintain the surgical expertise. Audit facility must be available to monitor the activity and the results of the surgery. A management team that understandss the special needs and is supportive of the concept. The need for a Minimal Access Surgery Training Centre Minimal Access Surgery is rapidly becoming an integral part of general surgery. Training in minimal access surgery is indispensable and has been stressed by many authors.2-8 The introduction of this new technique had been poorly controlled and audited, with the consequence that some surgeons were attempting these operations without due consideration to the different technology and manual skills required. In the past, training courses were mostly on ad hoc basis and were often individual procedure orientated. In Hong Kong, about 40 young surgeons obtain their basic fellowship each year and most are able to embark on laparoscopic surgery after suitable introduction and proctoring by experienced supervisors. The idea of the Minimal Access Surgery Training Centre (MASTC) is to provide a structured introduction of this work covering basic theory, hands-on simulation, and live demonstration of the most commonly applied operations. Tasks of a Minimal Access Surgery Training Centre Besides providing the basic training for laparoscopic surgery, courses for specific advanced surgical procedures can also be organised by the centre. Successful laparoscopic surgery reliess on team effort requiring not only surgeons but also theatre personnel who are skilled in the setting-up and maintenance of modern technological instruments. Hence the centre should also provide training courses for the theatre nurses and technician. The centre can play a co-ordinating role between different clinical specialities, namely Surgey, Obstetrics & Gynaecology, Orthopaedics & Traumatology, Interventional Radiology and Therapeutic Endoscopy, on various combined training programmes and research. An education programme for practising surgeons' continuing medical education is important for this rapidly developing surgical speciality. Training Course for Basic Laparoscopic Surgery The centre's official opening was combined with the first training course. The course content was compiled into a course manual, which also included introductory principles on the field and other selected topics. The training course comprises of lectures introducing the principles of basic laparoscopic surgery, equipment setting-up and instrumentation, and basic laparoscopic operations. It also included CCTV live demonstration of laparoscopic operations and hands-on simulation training on models. Training Models Minimal access surgery training commences with manipulations on artificial training devices and isolated organs and proceeds to operations on anaesthetized animals.6 The practical session exercise on the hand-eye co-ordination, instrument manipulation and tissue dissection. Structured dry laboratory exercises are designed to train the candidates' various skills. Live animal training is becoming less popular for technical, financial and ethical reasons and animal laboratory facilities may be unavailable. Pulsatile organ perfusion (P.O.P.®)9 is one of the models we employed for simulation of the minimal access operative environment. Animal organ or coomplexes are taken from the abattoirs. The major artery of an animal organ coomplex is then cannulated and flushed with heparinized saline. The organ complex is placed in the simulator trainer (which is covered with neoprene mat simulating a genuine pneumoperitoneum) and perfused with coloured fluid by means of an electronically regulated and pressure controlled pump. Using the P.O.P.(r), intraoperative technical problems and complications can be reproduced and methods learned to tackle the problems. Training Requirement Basic training for minimal access surgery should include the completion of approved basic training in general surgery, the premise being that the surgeon must have the judgement, training and capability of proceeding to a traditional open abdominal procedure if circumstances so dictate. The process should be similar to a general surgical residency experience including didactic, hands-on experience, participation as a first assistant and performance of the operation under supervision. After the basic laparoscopic surgery course, the surgeon will receive supervision from senior surgeons in the same or similar procedure until proficiency has been acquired. Certification by their Chief of Service is important before declared as a competent independent operator. Conclusions The rapid development of Minimal Access Surgery exemplifies changes that can revolutionise surgical training. The intrinsic requirements of advanced technology and different manual skills mean that training in this field is of overriding importance. A training centre is vital in providing training and development of advanced minimal access procedures. References 1. Martella AT, Santos GH. Priorities in general surgical training. Am J Surg 1995;169:271-272 2. Chung SCS. Training in minimally invasive surgery in the Asia-Pacific. ELSA 1995; 1: 6-7 3. Cuschieri A. Reflections on surgical training. Surg Endosc. 1993; :73-74 4. Forde KA. Endosurgical training methods: is it surgical training that is out of control? Surg Endosc. 1993;7:71-72 5. Boyston CM, Lansdown MR, Brough WA. Teaching laparoscopic surgery: the need for guidelines. BMJ 1994;308:1023-1025 6. Cutner A, Erian J. Training in minimal access surgery. Br J Hosp Med. 1995;53:226-228 7. Wolfe BM, Szabo Z, Moran ME, Chan P, Hunter JG. Training for minimally invasive surgery. Need for surgical skills. Surg Endosc 1993;7:93-95 8. Hawasli A, Featherstone R, Lloyd L, Vorhees M. Laparoscopic training in residency program. J Laparoendo Surg 1996;6:171-4 9. Szinicz G, Beller S, Bodner W, Zerz A, Glaser K. Simulated operations by pulsatile organ perfusion in minimally invasive surgery. Surg Laparosc Endosc. 1993;3:315-317

29th November, 1995 The Training Centre was officially opened by Mr Peter Woo, JP, Prof the Honorable Arthur K.C. Li, GBS, JP & Dr E.K. Yeoh, JP