The Canadian Laparoscopic FellowshipCMAS, Hamilton, Ontario: The Canadian Laparoscopic Fellowship CMAS, Hamilton, Ontario Mark A Watson MD FRCS Wessex Rotation


Slide2: The Fellowship is one hour from the centre of Toronto….


Slide3: ..half way to the Niagara Falls, famous for it’s wine routes


Slide4: Hamilton is on lake Ontario…


Slide5: and has a large steel works, but you don’t see them much


Slide7: The apartment is on the left by the blue car


St Joseph’s Hospital: St Joseph’s Hospital ..the hospital is quite new and is getting 6 endosuites


Prof M Anvari: Prof M Anvari CMAS: First MIS centre in Canada Minimally Invasive GI practice Training Courses Telemedicine and Telementoring Telerobotics Delivery of Surgical Care to remote environments Dr Caddedu has joined and is also doing lap colorectal. There may be plans for Another surgeon within the next year.


CMAS Training Room: CMAS Training Room Used for courses, and you can practice your skills here


CMAS Computer Simulators: CMAS Computer Simulators Some people will have played on the computer simulators in Hamburg


CMAS Staff: CMAS Staff Manager Course Coordinator IT Running Development 2 Research Nurses 1 Research Facilitator/Database manager Nursing Coordinator Animal laboratory staff – they train on pigs in Canada.


Slide13: The unit has it’s sponsors..


Slide14: When you give talks you get one of these!


Slide15: This is the old Stryker Endosuite..


Slide16: Dis Colon Rectum, 2001. 44(1): p. 10-8 The unit has published it’s results.


Slide17: …and was the third biggest contributor to the COST study


Slide18: Shortest Longest Shortest Longest – nb only one exam at 5 years – end of residency


Canadian Fellowships : Canadian Fellowships No exam req’d if within 2 yrs of CCST MIS Fellowships Hamilton – this is the ACPGBI one. St Michael’s, Toronto Montreal ?Edmonton Colorectal Fellowships with Laparoscopic Component Mount Sinai, Toronto


My Experience at 4 months - Colorectal Cases: My Experience at 4 months - Colorectal Cases


Techniques: Techniques Verres needle 5 mm Optiview port, 5mm camera Harmonic Scalpel Peer retractor All approaches, mainly lateral to medial Triangulation Stryker infra red stents 0 and 30 degree scopes for most cases


Post operative experience: Post operative experience No drains, rarely defunctioned No PCA Most ptts home on day 3. Day Cases. 2 complications – 1 partially obstructed stoma 1 perioperative MI, 2/52 confusional state after an emergency R hemicolectomy for ischaemia


MIS Experience at 4 months – other cases: MIS Experience at 4 months – other cases


Open cases: Open cases


Slide25: Lap parastomal hernia


Other experience: Other experience Mt Sinai Hospital, Toronto McMaster University Hospital CMAS North Bay Hospital, Lake Nippising


Research: Research Research Opportunities are available This is however a clinical Fellowship, not a research fellowship MIS Colorectal Surgery since 1992 Prospective database 10 year data Rectal LR rates x% 5 yr survival y% 10 yr survival z%


Courses - CMAS: Courses - CMAS Live Surgery, Lectures, Training and Animal Lab, each over 2 days Laparoscopy for Residents Advanced Colorectal Course Fundoplication Course Advanced Hernia Course Complex Gastro-oesophageal Course MIS OR Nursing Course Personal animal laboratory session in week 1


Courses - other: Courses - other SAGES Postgraduate Colorectal Course: Denver, Colorado £120 Toronto General Surgery Update Course 5 days - £80 Toronto Diagnosis and Management of the thyroid nodule – 2 days £40 Controversies in the Aetiology, Detection and Treatment of Breast Cancer – 2 days £40 Ethicon Hernia Symposium - free


SAGES - Denver: SAGES - Denver SAGES singalong is mandatory. NB- – the limo is out of G+T


DDW – New Orleans: DDW – New Orleans Each year the unit goes to SAGES and Dr Anvari usually goes to the DDW. If you are thinking of applying for Canada submit something to these meetings. In 2005 SAGES is in Florida and DDW is in Chicago.


Other Commitments: Other Commitments Ward rounds Clinics On call Ward duty None None None None This sounds great, but if you are only doing Colorectal in Years 4 and 5 this may significantly decrease your experience making it more difficult to get through the exam!


Financial Support: Financial Support £1000 pcm £2000 travel allowance Free accommodation, 2 bedroom apartment Licenses, registration and defence covered Cf. CMAS Fellowship C$ 60 000=£24,000 =£12,000 per six months minus tax and expenses, registrations, defence Broadly equivalent.


Fellowship - Objectives: Fellowship - Objectives Learning curve said to be 20 cases Criteria for entering patients into a trial is 20 cases From publications experience estimated 12-15 CRC cases in 6 months Expectations To perform at least 20 cases To see ultra low rectal dissection and pouches To be able to return from trip able to perform most cases unsupervised It may be slightly more!


Summary: Summary Has it been worthwhile? – Yes Would I recommend it? – Yes Is it enjoyable? – Yes Are the same operative numbers available in the UK? – Yes Is the UK behind in MIS Colorectal Training? – No, same issues of training in Canada, US, and elsewhere. There are opportunities out there


Caveat: Caveat No time to learn basic laparoscopic skills in this Fellowship – skill levels recommended by me to benefit from the time in Canada= Intracorporeal suturing Paradoxical working Beneficial to get some experience in UK in addition (before and after) Set up, cost considerations, other approaches Important to have continuity on return Aim for ?50 cases prior to CCST Important to be able to continue as a Consultant


My tips: My tips Any current trainee that doesn’t seek laparoscopic colorectal training will miss out and probably regret it There are opportunities in the UK so seek them out and compete for them Most rotations provide some somewhere Inter-Deanery transfers are possible UK Fellowships may be available next year and will be excellent opportunities


More tips: More tips Try and get a good Laparoscopic training in Years 1-3 Try and get a good Colorectal Training in Years 4-6 Put yourself in a strong position to get the placement of your choice or a Fellowship for the end of your training


..take some warm socks!: ..take some warm socks!


ASSOCIATION OF ENDOSCOPIC SURGEONS OF GREAT BRITAIN AND IRELAND TRAVELLING SCHOLARSHIPS : ASSOCIATION OF ENDOSCOPIC SURGEONS OF GREAT BRITAIN AND IRELAND TRAVELLING SCHOLARSHIPS Ethicon Endosurgery have generously funded a scholarship in memory of David Dunn. This scholarship is to the value of £3,000 and it is anticipated that this would enable a surgeon at the end of his/her training, or a consultant within 5 years of appointment, to make a substantial visit to a unit abroad to learn new skills in endoscopic surgery, with a view to introducing them to the UK. The AESGBI are also awarding 2 Keymed travelling scholarships of £1,000. The purpose of these scholarships is to enable surgeons in training, or young consultants within 5 years of appointment, to extend their experience in minimal access surgery by short visits to one or more centres. There are other opportunities!


Slide41: If anybody would like to know more, then I recommend they go to Duke’s Club events! Look out for the adverts for next year, notification will be soon via the Duke’s Club e list and to members of the ACPGBI There may be Fellowships in the UK too Persons reaching the end of these slides deserve to have any specific questions answered - they can e mail me on mark.watson8@virgin.net