Importance of Colonoscopy Skills for Surgeons

Colonoscopy skills are important for general and colorectal surgeons.[1] Currently, only a few surgeons possess the competence in this skillset due to a lack of interest, a paucity of training opportunities, and their failure to realize the benefits of colonoscopy in clinical practice. Colonoscopy is crucial for investigating various gastrointestinal (GI) symptoms like rectal bleeding, chronic diarrhea, and abdominal pain. Preoperative colonoscopy is paramount in cases of piles in the elderly with altered bowel habits. Multiple fistulae-in-ano and high or complex fistulae-in-ano warrant colonoscopy before any surgery to exclude anorectal Crohn’s disease or tuberculosis. A patient with a fissure-in-ano present in an atypical location or a patient who has imaging suggesting colonic stricture or malignancy would also benefit from a diagnostic colonoscopy. Colorectal cancer is becoming a significant public health challenge in India, with over 40,000 individuals affected annually. Colonoscopy is considered the “Gold Standard” for early detection and screening. Colonoscopy before surgery in colorectal cancer cases allows the surgeon to evaluate the exact location of the tumor and the presence of any synchronous polyps. Preoperative colonoscopic tattooing or intraoperative colonoscopy can help the surgeon to accurately find the limits of resection during laparoscopic colectomy. Colonoscopic polypectomy before or after the resection of a colorectal tumor can be performed by trained surgeons. Hot snare polypectomy, endoscopic mucosal resection (EMR) can be easily learnt and done by surgeons. Intraoperative colonoscopy is useful to check the integrity of colorectal anastomosis with the air insufflation test, and staple line bleeding can be easily tackled by hemoclip application to the bleeding site. Combined colonoscopy and laparoscopy hybrid surgeries are gradually gaining popularity in cases like a large sessile polyp in the right colon. Colonoscopic resection of a polyp can be assisted by laparoscopic surgeons who could perform seromuscular suturing of any suspected area of breach in the muscularis propria or frank perforation during such a difficult polypectomy. Furthermore, the polyp in the caecal pole can be easily resected with a linear stapling device once colonoscopic intubation of the terminal ileum ensures GI continuity. Colonoscopic rescue of postsurgical complications is gaining importance. A stricture due to a previous staple hemorrhoidectomy or low rectal staple anastomosis can be managed with colonoscopic balloon dilatation. Colonoscopic sponge insertion and drainage can be a lifesaver in colorectal anastomotic leaks. Rise in minimally invasive endoscopy procedures for various colorectal disorders demands that surgeons acquire competence in colonoscopy. Surgeons, who already possess good hand-eye coordination and an understanding of two-dimensional and three-dimensional anatomy from open and laparoscopic surgeries, often have a shorter learning curve for flexible endoscopy and can become highly competent with structured training. India’s large population and the need for widespread GI services mean, relying solely on gastroenterology specialists is inadequate and inappropriate. General surgeons with basic endoscopy skills can help to meet this massive demand efficiently, especially in rural areas. But there is a lack of adequate training opportunities for surgeons in India. Surgical societies like the Indian Association of GI Endo Surgeons, Association of Colorectal Surgeons of India, and Association of Surgeons of India are aware that endoscopy skills are not optional but essential for modern surgical practice. Structured training programs are being developed to facilitate this acquisition of skills. Simulation-based colonoscopic training facilitates and expedites the achievement of competence in colonoscopy skills.[2-5] St. Mark’s colon simulator, GI Mentor and GI Express (Surgical Science, Sweden), and Mikoto Colonoscopy simulator (R Zero Inc, Japan) are the commonly used simulator models for hands-on training for surgeons nowadays. Studies have shown that trainees who undergo simulation-based training reach competency milestones sooner than those who rely merely on traditional methods. Although 150–200 colonoscopic procedures are usually required to achieve competence, simulator training drastically reduces the required number to reach competence.[6,7] Competence is assessed based on a combination of procedural volume, technical skills, cognitive knowledge, and key performance indicators, which align with international standards set by governing bodies like the Joint Advisory Group on GI Endoscopy in the UK or the American Society for GI Endoscopy. Caecal Intubation rate of >90% in all cases and >95% for screening colonoscopies, adenoma detection rate of ≥25% in men aged above 50 years, and caecum to anus withdrawal Time of at least 6 min are some of the quality indicators to define a good colonoscopist! Both surgeons and medical gastroenterologists could perform colonoscopy, but the primary distinction between them is in volume and scope. A gastroenterologist’s practice is heavily centered on high-volume endoscopy service and medical management, while a surgeon’s expertise lies in comprehensive surgical care, using the colonoscopy to make surgical decisions and manage some surgical complications. To conclude, colonoscopy training for surgeons is paramount in this era of minimal access surgery. Simulation-based short structured training is the most practical and effective way to train interested surgeons on basic colonoscopy navigational skills.[2,8,9] A well-structured, focused training is essential to perform therapeutic procedures like EMR or endoscopic submucosal resection. One to 2-year-long endoscopy fellowships can be taken by endoscopy enthusiasts to gain competence to manage complex GI pathologies. Accredited structured colonoscopy training for surgeons is the need of the hour.