Training and Determination of Competence
Laparoscopic exposure to the spine requires a high degree of skill. Criteria include:
- Formal fellowship or residency training in an accredited general surgery residency program (or its foreign equivalent). This residency or fellowship training must have conferred upon the surgeon a wide range of experiences in general abdominal surgery, familiarity with open anterior spinal access, and a broad experience in basic vascular surgery procedures.
- Privileges and experience in basic laparoscopic skills as defined in Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Guidelines for Granting of Privileges for Laparoscopic and Thoracoscopic General Surgery.
- Privileges and extensive experience in advanced laparoscopic procedures: For the general surgeon, examples of such procedures would include endoscopic adrenalectomy, Nissen fundoplication, extensive adhesiolysis, laparoscopic splenectomy, and laparoscopic colectomy. Specific skills required include, but are not limited to, suturing, major vessel ligation, extensive dissection of tissue planes, as well as retraction and manipulation of bowel.
- The most serious intra-operative complication that may occur, and which is the primary reason a co-surgeon is required for spine access, is a major vascular injury. The aorta, vena cava, and iliac arteries and veins may all be mobilized during the operation. Any of these structures may be injured and require emergent repair. For this reason, the co-surgeon performing the exposure must have training in and the ability to perform basic vascular surgery in order to perform these exposures. Residency or fellowship training must, therefore, have conferred upon the surgeon basic vascular surgical skills, including but not limited to, the ability to safely achieve mobilization of major vascular structures and safely repair both minor and major arterial and/or venous injuries
- Specific training for endoscopic spine access must include at least one of the following:
- Documentation of formal training in laparoscopic spine access during residency training or fellowship
- Documentation of extensive experience with open retroperitoneal access surgery
- Formal course, skills lab, and/or preceptorship in spine access as defined in the SAGES document Framework for Post-Residency Training and Education. A preceptorship is highly desirable
Principles of Privileging
Principles of privileging have been formulated and published in a SAGES document entitled "Principles of Privileging in Endoscopic and Laparoscopic Surgery."
Principles include:
Appropriate Training and Qualifications
An applicant for privileges must document that he has fulfilled the criteria for training and competence as defined above. An applicant must have a license to practice medicine in his/her state.
Uniformity of Standards
Within the parameters and definition of distinct roles for the surgeon participants, uniform standards should be developed which apply to all hospital staff requesting privileges to serve as part of the surgical team performing collaborative laparoscopic surgery. Criteria must be established relative to each role that are medically sound but not unreasonably stringent and that are universally applicable to all those wishing to obtain privileges. The goal must be the delivery of high quality patient care.
Responsibility for Privileging
The privileging structure and process remain the individual responsibility of each hospital. It should be the responsibility of each surgical department, through its Chief, to recommend individual surgeons for privileges in collaborative laparoscopic spine surgery as for other procedures performed by members of the department (e.g., privileges for the general surgeon should be granted through the department of surgery). At its discretion, a hospital may set up a joint privileging committee specifically designated to privilege teams of collaborative surgeons.
Proctoring
Proctoring of applicants for privileges in endoscopic spinal access by a qualified, unbiased surgeon experienced in endoscopic spinal access surgery or advanced laparoscopic surgery is recommended. The proctor should always be appointed by, and serve as an agent of, the medical staff's privileging committee.
Monitoring of Endoscopic Performance
To assist the hospital privileging body in the ongoing renewal of privileges, there should be a mechanism for monitoring each surgical endoscopist's procedural performance. This should be done through existing quality assurance mechanisms and should include monitoring utilization, diagnostic, and therapeutic benefits to patients, complications, and tissue review in accordance with previously developed criteria.
Continuing Education
Continuing medical education related to endoscopic spinal access surgery should be required as part of the periodic renewal of privileges. Attendance at appropriate local or national meetings and courses is encouraged.
Renewal of Privileges
For the renewal of privileges, an appropriate level of continuing clinical activity should be required. In addition to satisfactory performance as assessed by monitoring of procedural activity through existing quality assurance mechanisms, continuing medical education relating to endoscopic spinal access surgery should also be required.
