1 Bariatric and Metabolic Fellowship Core Curriculum for the RCS National Surgical Fellowship Scheme 1 This programme aims to enhance the delivery of metabolic surgery through world-class fellowships in the UK. Currently one fellow per centre (North Tyneside, Sunderland, Luton and Dunstable, Imperial, UCH and Taunton) supported by an unconditional grant from an industrial partner for professional development of a metabolic surgery service, and intended to be applicable to other RCS-Approved Fellowships as and when approved Fellowships will usually be undertaken post CCT or within the last 12 months of ST training will be considered The fellowships are RCSEng approved in high volume centres providing specialist bariatric services OBJECTIVES Management of the patient who is morbidly obese and an understanding of the surgical treatment of morbid obesity including early and late complications Knowledge of the different patterns of presentations of complications To gain experience in Gastric Bypass and at least one other bariatric procedure and receive mentorship through the learning curve Produce work of scientific value in the field of bariatric and metabolic surgery Engage in teaching of junior medical staff and allied healthcare professionals Present and debate the management of patients at the bariatric MDT KNOWLEDGE Epidemiology of obesity Pathophysiology of morbid obesity and the metabolic syndrome Therapeutic options for morbid obesity Indications for weight loss and metabolic surgery The principles of perioperative management of the obese patient Types of operations performed and mechanisms of action Complications of metabolic surgery and their management Revisional metabolic surgery Long term management of the bariatric patient following surgery Essential components of a bariatric service Psychology of the morbidly obese patient
2 CLINICAL SKILLS History and examination of the obese patient Interpretation of investigations in the obese patient Preoperative evaluation and optimization Assessment of the post-operative bariatric patient Management decisions for early and late complications of bariatric surgery TECHNICAL SKILLS (see PBA forms: Level 4 competency in gastric band or sleeve required) Laparoscopic access in the morbidly obese (level 4) Roux en Y gastric bypass (level 4) o Repair of internal hernia after gastric bypass Insertion of laparoscopic gastric band (Level 2) o Aspiration of band port o Emergency release of band for slippage o Repositioning of band after slip Sleeve gastrectomy (Level 2) Participate in Revisional surgery for obesity (level 4) The management of general surgery in the super morbidly obese PROFESSIONAL ATTRIBUTES Participation and presentation of cases at bariatric MDT meetings Participation in departmental morbidity and mortality audit Knowledge of patient support group meetings Involvement in the debate and presentation of evidence-based surgery: fellows are expected to participate in the Bariatric and Metabolic Trainees Collaborative Involvement in surgical education with evidence of teaching and training: fellows are expected to participate in the BOMSS annual training day To facilitate this process support will be considered to attend the annual meetings of BOMSS and IFSO-EC. TARGET LOGBOOK (per 12 months) Total number of weight loss operations (primary surgeon in >51%) 100 Minimum stapling/anastomotic operations 50 Minimum banding 10 Minimum revisional (Level 2) 5
3 Evidence of reflection on a validated logbook will be required at the end of the fellowship. We encourage the regular use of the attached PBAs to achieve this. At the end of the fellowship, depending on the industrial partner, fellows will be invited to complete a Bariatric Fellowship Evaluation Document for quality assurance. Declaration This document has been drafted on behalf of the Education, Training and Research Committee of BOMSS by H Noble, A Osborne, D Mahon and R Welbourn. The framework of the curriculum is based on the bariatric section of the ISCP General Surgery Curriculum 2 and takes influence from the curricula of The Fellowship Council 3 and ASMBS 4. 1. http://www.rcseng.ac.uk/surgeons/training/fellowships/national-fellowship-register/national-fellowshipregister/general-surgery 2. https://www.iscp.ac.uk/documents/syllabus_gs_2010.pdf 3. http://fellowshipcouncil.org/documents/bariatricsurgery.pdf 4. http://s3.amazonaws.com/publicasmbs/top5/september2012/asmbs.core.curriculum.fellowship.training.pdf
4 GENERAL SURGERY PBA: LAPAROSCOPIC GASTRIC BAND INSERTION Text in [RED] specific to bariatric surgery I. Consent Rating Comments C1 Demonstrates sound knowledge of indications and contraindications including alternatives to surgery C2 Demonstrates awareness of sequelae of operative or non-operative management C3 Demonstrates sound knowledge of complications of surgery C4 Explains the procedure to the patient / relatives / carers and checks understanding C5 Explains likely outcome and time to recovery and checks understanding II. Pre-operation planning Rating Comments PL1 PL2 PL3 PL4 Demonstrates recognition of anatomical and pathological abnormalities (and relevant comorbidities) and selects appropriate operative strategies / techniques to deal with these Demonstrates ability to make reasoned choice of appropriate equipment, materials or devices (if any) taking into account appropriate investigations e.g. x-rays Checks materials, equipment and device requirements with operating room staff Checks patient records, personally reviews investigations III. Pre operative preparation Rating Comments PR1 PR2 PR3 PR4 PR5 PR6 PR7 Checks in theatre that consent has been obtained Gives effective briefing to theatre team Ensures proper and safe positioning of the patient on the operating table Demonstrates careful skin preparation Demonstrates careful draping of the patient s operative field Ensures general equipment and materials are deployed safely (e.g. catheter, diathermy) Ensures appropriate drugs administered IV. Exposure and closure Rating Comments E1 E2 Demonstrates knowledge of optimum skin incision / portal / access Achieves an adequate exposure through purposeful dissection in correct tissue planes and identifies all structures correctly
5 E3 E4 Completes a sound wound repair where appropriate Protects the wound with dressings, splints and drains where appropriate V. Intra operative technique: global (G) and task-specific items (T) Rating Comments IT1 (G) IT2 (G) IT3 (G) IT4 (G) IT5 (G) IT6 (G) IT7 (G) IT8 (G) IT9 (G) IT10 (G) IT11 (G) IT12 (G) IT13 (T) IT14 (T) IT15 (T) IT16 (T) IT17 (T) IT18 (T) Follows an agreed, logical sequence or protocol for the procedure Consistently handles tissue well with minimal damage Controls bleeding promptly by an appropriate method Demonstrates a sound technique of knots and sutures/staples Uses instruments appropriately and safely Proceeds at appropriate pace with economy of movement Anticipates and responds appropriately to variation e.g. anatomy Deals calmly and effectively with unexpected events/complications Uses assistant(s) to the best advantage at all times Communicates clearly and consistently with the scrub team Communicates clearly and consistently with the anaesthetist Selects appropriate incision and enters abdominal cavity safely Dissects angle of His. Repairs hiatus hernia if present Creates pars flaccida retro gastric tunnel safely Inserts and positions band around stomach correctly Performs appropriate fixation with gastro-gastric sutures Tunnels tubing and secures port to abdominal wall appropriately Performs appropriate abdominal wall closure VI. Post operative management Rating Comments PM1 PM2 PM3 PM4 Ensures the patient is transferred safely from the operating table to bed Constructs a clear operation note Records clear and appropriate post operative instructions Deals with specimens. Labels and orientates specimens appropriately
6 Performance Level Rating Comments Level 0 Level 1 Level 2 Level 3 Level 4 Insufficient evidence observed to support a summary judgement Unable to perform the procedure, or part observed, under supervision Able to perform the procedure, or part observed, under supervision Able to perform the procedure with minimum supervision (needed occasional help) Competent to perform the procedure unsupervised (could deal with complications that arose) GENERAL SURGERY PBA: LAPAROSCOPIC ROUX EN Y GASTRIC BYPASS I. Consent Rating Comments C1 Demonstrates sound knowledge of indications and contraindications including alternatives to surgery C2 Demonstrates awareness of sequelae of operative or non-operative management C3 Demonstrates sound knowledge of complications of surgery C4 Explains the procedure to the patient / relatives / carers and checks understanding C5 Explains likely outcome and time to recovery and checks understanding II. Pre-operation planning Rating Comments PL1 PL2 PL3 PL4 Demonstrates recognition of anatomical and pathological abnormalities (and relevant comorbidities) and selects appropriate operative strategies / techniques to deal with these Demonstrates ability to make reasoned choice of appropriate equipment, materials or devices (if any) taking into account appropriate investigations e.g. x-rays Checks materials, equipment and device requirements with operating room staff Checks patient records, personally reviews investigations III. Pre operative preparation Rating Comments PR1 PR2 PR3 PR4 PR5 Checks in theatre that consent has been obtained Gives effective briefing to theatre team Ensures proper and safe positioning of the patient on the operating table Demonstrates careful skin preparation Demonstrates careful draping of the patient s
7 PR6 PR7 operative field Ensures general equipment and materials are deployed safely (e.g. catheter, diathermy) Ensures appropriate drugs administered IV. Exposure and closure Rating Comments E1 E2 E3 E4 Demonstrates knowledge of optimum skin incision / portal / access Achieves an adequate exposure through purposeful dissection in correct tissue planes and identifies all structures correctly Completes a sound wound repair where appropriate Protects the wound with dressings, splints and drains where appropriate V. Intra operative technique: global (G) and task-specific items (T) IT1 (G) Follows an agreed, logical sequence or protocol for the procedure IT2 (G) Consistently handles tissue well with minimal damage IT3 (G) Controls bleeding promptly by an appropriate method IT4 (G) Demonstrates a sound technique of knots and sutures/staples IT5 (G) Uses instruments appropriately and safely IT6 (G) Proceeds at appropriate pace with economy of movement IT7 (G) Anticipates and responds appropriately to variation e.g. anatomy IT8 (G) Deals calmly and effectively with unexpected events/complications IT9 (G) Uses assistant(s) to the best advantage at all times IT10 (G) Communicates clearly and consistently with the scrub team IT11 (G) Communicates clearly and consistently with the anaesthetist IT12 (G) Selects appropriate incision and enters abdominal cavity safely IT13 (T) Creates retro-colic tunnel or splits omentum IT14 (T) Identifies DJ flexure and measures limb lengths IT15 (T) Performs jejuno-jejunal anastomosis IT16 (T) Closes jejuno-jejunal mesenteric defect adequately IT17 (T) Creates gastric pouch. Repairs hiatus hernia if present IT18 (T) Performs gastric pouch-jejunal anastomosis IT19 (T) Performs adequate leak test Rating Comments
8 IT20 (T) IT21 (T) Closes Petersen s and mesocolic defects adequately Performs appropriate abdominal wall closure VI. Post operative management Rating Comments PM1 PM2 PM3 PM4 Ensures the patient is transferred safely from the operating table to bed Constructs a clear operation note Records clear and appropriate post operative instructions Deals with specimens. Labels and orientates specimens appropriately Performance Level Rating Comments Level 0 Level 1 Level 2 Level 3 Level 4 Insufficient evidence observed to support a summary judgement Unable to perform the procedure, or part observed, under supervision Able to perform the procedure, or part observed, under supervision Able to perform the procedure with minimum supervision (needed occasional help) Competent to perform the procedure unsupervised (could deal with complications that arose) GENERAL SURGERY PBA: LAPAROSCOPIC SLEEVE GASTRECTOMY I. Consent Rating Comments C1 Demonstrates sound knowledge of indications and contraindications including alternatives to surgery C2 Demonstrates awareness of sequelae of operative or non-operative management C3 Demonstrates sound knowledge of complications of surgery C4 Explains the procedure to the patient / relatives / carers and checks understanding C5 Explains likely outcome and time to recovery and checks understanding II. Pre-operation planning Rating Comments PL1 PL2 PL3 Demonstrates recognition of anatomical and pathological abnormalities (and relevant comorbidities) and selects appropriate operative strategies / techniques to deal with these Demonstrates ability to make reasoned choice of appropriate equipment, materials or devices (if any) taking into account appropriate investigations e.g. x-rays Checks materials, equipment and device requirements with operating room staff
9 PL4 Checks patient records, personally reviews investigations III. Pre operative preparation Rating Comments PR1 PR2 PR3 PR4 PR5 PR6 PR7 Checks in theatre that consent has been obtained Gives effective briefing to theatre team Ensures proper and safe positioning of the patient on the operating table Demonstrates careful skin preparation Demonstrates careful draping of the patient s operative field Ensures general equipment and materials are deployed safely (e.g. catheter, diathermy) Ensures appropriate drugs administered IV. Exposure and closure Rating Comments E1 E2 E3 E4 Demonstrates knowledge of optimum skin incision / portal / access Achieves an adequate exposure through purposeful dissection in correct tissue planes and identifies all structures correctly Completes a sound wound repair where appropriate Protects the wound with dressings, splints and drains where appropriate V. Intra operative technique: global (G) and task-specific items (T) IT1 (G) Follows an agreed, logical sequence or protocol for the procedure IT2 (G) Consistently handles tissue well with minimal damage IT3 (G) Controls bleeding promptly by an appropriate method IT4 (G) Demonstrates a sound technique of knots and sutures/staples IT5 (G) Uses instruments appropriately and safely IT6 (G) Proceeds at appropriate pace with economy of movement IT7 (G) Anticipates and responds appropriately to variation e.g. anatomy IT8 (G) Deals calmly and effectively with unexpected events/complications IT9 (G) Uses assistant(s) to the best advantage at all times IT10 (G) Communicates clearly and consistently with the scrub team IT11 (G) Communicates clearly and consistently with the anaesthetist IT12 (G) Selects appropriate incision and enters abdominal Rating Comments
10 IT13 (T) IT14 (T) IT15 (T) IT16 (T) IT17 (T) IT18 (T) IT19 (T) cavity safely Performs perigastric dissection of omentum from greater curve of stomach Divides short gastric vessels Mobilises stomach dividing posterior gastric adhesions. Repairs hiatus hernia if present Creates sleeve over bougie with appropriate stapling techniques Performs adequate leak test Retrieves resected stomach Performs appropriate abdominal wall closure VI. Post operative management Rating Comments PM1 PM2 PM3 PM4 Ensures the patient is transferred safely from the operating table to bed Constructs a clear operation note Records clear and appropriate post operative instructions Deals with specimens. Labels and orientates specimens appropriately Performance Level Rating Comments Level 0 Level 1 Level 2 Level 3 Level 4 Insufficient evidence observed to support a summary judgement Unable to perform the procedure, or part observed, under supervision Able to perform the procedure, or part observed, under supervision Able to perform the procedure with minimum supervision (needed occasional help) Competent to perform the procedure unsupervised (could deal with complications that arose) Education, Training and Research Committee August 2013 (Revision due August 2015)