ESCP Fellowships 2021–2022 Update

ESCP offered 3-month Functional Disorder Fellowships and 6-month Robotics Fellowships for 2021-2022. Fellows report here on their experiences.

Click on a fellow's name to read their report

Sponsors

6-month Robotics Fellowships were sponsored by Intuitive

3-month Functional Disorder Fellowships were sponsored by Medtronic

Jeremy Meyer

From: University Hospitals of Geneva, Switzerland

Visited: Amphia Hospital, Netherlands

Supervisors: George van der Schelling, Rogier Crolla, Jan Wijsman

I am very grateful to the European Society of Coloproctology (ESCP), Intuitive Surgical, as well as to Dr Rogier Crolla, Dr George van der Schelling and Dr Jan Wijsman and the whole team of Amphia Hospital, for this unique training opportunity and for having welcomed me at Amphia Hospital in the Netherlands, for a fellowship in robotic colorectal surgery.

Amphia Hospitals was the perfect centre to make the transition from laparoscopy to robotics. First cases of robotic colorectal resections were performed in Amphia Hospital as early as 2012, and the centre has since cumulated over 1,100 robotic colorectal procedures, first using the Da Vinci Si and now using the Da Vinci Xi. The case load is important, with three full days purely dedicated to robotic digestive surgery per week.

Dr Rogier Crolla, Dr George van der Schelling and Dr Jan Wijsman are top notch mentors and excellent surgeons in the field of robotic surgery, performing not only robotic colorectal resections but also robotic Nissen procedures, robotic abdominal wall surgery and robotic Whipple procedures on a regular basis. They have a systematic step-by-step approach, which helps shorten the learning curve and accelerate teaching while maintaining the highest standards of care. Moreover, their excellent academic knowledge confirmed them as the perfect trainers for this fellowship.

As a fellow, I was first shown all the possibilities in terms of patient’s positioning, ports placements and choice of instruments. Thereafter, I was shown standardized procedures as bedside assistant, and on the second console of the Da Vinci Xi. After a short time, I was performing the procedures under supervision, and then independently. Being in Amphia Hospital allowed me to refine my skills in terms of robotic right hemicolectomy with intra-corporeal anastomosis with/without complete mesocolic excision, robotic left hemicolectomy with intra-corporeal handsewn anastomosis, robotic sigmoid colectomy with stapled/handsewn intra-corporeal anastomosis, robotic anterior resection with partial/total mesorectum excision, robotic abdomino-perineal excision with intersphincteric/extrasphincteric dissection, robotic subtotal colectomy and robotic rectopexy.

Moreover, this fellowship was a great academic opportunity and offered numerous possibilities to be involved in research and publications. So far, this has led to five publications in the field.

• J. Meyer, J. Wijsman, R. Crolla, G. Meurette, F. Ris, G. van der Schelling, 'A comprehensive step-by-step approach for totally robotic right hemicolectomy with intra-corporeal anastomosis: a video vignette', submitted
• J. Meyer, J. Wijsman, R. Crolla, G. van der Schelling, 'Implementation of totally robotic right hemicolectomy: lessons learned from a prospective cohort', submitted
• J. Meyer, R. Crolla, G. van der Schelling, 'Comment on: Intracorporeal Versus Extracorporeal Anastomosis in Robotic Right Colectomy: A Multicenter, Triple-blind, Randomized Clinical Trial', Annals of Surgery Open. 4(1):e241, March 2023.
• J. Meyer, G. van der Schelling, R. Crolla, 'Comment on: Robotic versus laparoscopic surgery for middle and low rectal cancer', Lancet Gastroenterology and Hepatology, January 2023
• J. Meyer, G. van der Schelling, J. Wijsman, F. Ris, R. Crollia, 'Predictors for selective flexure mobilization during robotic anterior resection for rectal cancer: a prospective cohort analysis', Surgical Endoscopy, April 2023

This fellowship was an invaluable experience and a highlight in my training. I am extremely grateful to everyone who has made this possible, including my supervisors, the medical, nursing and administrative teams of Amphia Hospital for their warm welcome and making everything happens, the ESCP education committee and, of course, Intuitive Surgical.

I strongly believe that robotic surgery will soon become the new standard of care in minimally invasive colorectal surgery.

On a more personal aspect, this fellowship allowed me to discover Breda, a wonderful city with rich history, Zeeland, Texel islands and the rest of the Netherlands and its lovely and warm people. I will certainly come back.

Fellowship sponsored by Intuitive

Kapil Sahnan

From: UK

Visited: Vall D’Hebron, Barcelona, Spain

Supervisors/Trainers: Professor Eloy Espin Basany (lead), Dr Francesc Vallribera, Dr Alejandro Solis, Dr Miquel Kraft

I am extremely grateful to the colorectal unit at the Vall D’Hebron Hospital, the ESCP education committee and Intuitive for this opportunity. The unit led by Professor Espin has four robotically trained surgeons who perform ~300 robotic resections a year.

The unit is incredibly hospitable, and all the staff were extremely welcoming, kind and patient with me as I embarked on my robotic learning curve. I was given the opportunity to work through their modular training approach to robotic surgery and began to understand robotic surgery and the various nuances in ways I had not appreciated before.

With respect to robotic surgeries, I became familiar with right hemicolectomies with intracorporeal anastomosis, partial/complete mesocolic excision, abdominoperineal resection, ventral mesh rectopexy, retrorectal cyst surgery and TTSS (Transanal transection and single-stapled anastomosis).

The Unit has a very modular approach to understanding and training in robotic surgery. As a novice before my fellowship, I was sent operative videos to help understand the standardised operative approaches, I started as a bedside assistant and then adopted a modular approach to operating on the robotic platform before operating as the main surgeon. Through this approach, I began to appreciate the fundamentals and grow from a strong foundation to achieve robotic competence.

The academic unit at the Vall D’Hebron is incredibly prolific and varied. There is a weekly academic meeting that follows the clinical handover and updates for each of the projects are discussed. The unit’s research output includes clinical trials, educational videos and database registry work.

I have been fortunate to contribute to some of the educational video content from the unit and look forward to a collaborative academic partnership in the future.

The unit is exceptional in many other fields other than robotic surgery and I had the opportunity to work with the other fantastic attendees (Dr Sanchez, Dr Marti, Dr Marinello) and learnt about the results driven approaches to surgical site infection, the detection of anastomotic leak and training junior residents.

My time with Professor Espin in Barcelona has been a career highlight and I feel that I have not only developed my robotic competencies but also have matured and grown as a surgeon. I have made some lifelong friendships in Barcelona, and I look forward to future collaborations with my Catalan friends and colleagues.

Fellowship sponsored by Intuitive

Constantinos Simillis

From: UK

Visited: Queen Alexandra Hospital, Portsmouth, UK

Supervisor: Professor Jim Khan

I am grateful to the European Society of Coloproctology (ESCP) for this great training opportunity provided to me through the six-month ESCP Colorectal Robotic Surgery Fellowship. Also, I would like to thank Intuitive for funding this fellowship. I would like to thank Professor Jim Khan for his dedicated teaching and support during this fellowship.

I completed my six-month ESCP Colorectal Robotic Surgery Fellowship at Queen Alexandra Hospital in Portsmouth, United Kingdom, under the supervision of Professor Khan. This is a hospital with three da Vinci robots shared between specialties, and with 3-4 dedicated colorectal robotic theatre lists a week. The colorectal department has four consultants who are trained in robotic colorectal surgery and the robotic fellow can join any of the robotic colorectal theatre lists. Professor Khan is the main supervisor for the robotic fellowship, and he is a world-renowned robotic surgeon with significant skills and vast experience in robotic colorectal surgery. At the same time, Professor Khan is a committed robotic trainer, dedicated to training robotic fellows to reach the highest standards.

This fellowship was dedicated mostly to performing Anterior Resection or Abdominoperineal Excision of the Rectum (APER), with Total Mesorectal Excision (TME), for rectal cancer. A modular approach to robotic surgical training is followed, and the robotic fellow is expected to perform different parts (modules) of the procedure during surgery. For example, the different modules of the procedure performed by the robotic fellow during an Anterior Resection include patient positioning, port placement, robot docking and undocking, proximal dissection of the inferior mesenteric artery and vein, mobilisation of the descending and sigmoid colon, mobilisation of the splenic flexure, total mesorectal excision (TME), stapling of colon and rectum, and colorectal anastomosis. Every procedure was performed in a standardised way, which made learning easier and faster. During the course of the fellowship, the robotic fellow safely progresses through the different stages of the procedure and allowed to perform more and more parts of the procedure under the expert supervision of Professor Khan. Through this step-by-step modular approach to robotic training, and through positive structured feedback, I was able to significantly improve my robotic skills and peform robotic colorectal surgery safely and independently.

This fellowship has accelerated and significantly advanced my robotic operative skills by observing and performing high volume colorectal robotic surgery and through complete immersion into robotic colorectal surgery over a 6-month period. I have performed significant parts of the procedure for over 50 Anterior Resections or APERs. My colorectal subspecialty of interest is advanced colorectal malignancy, and I had the opportunity to be actively involved in beyond TME robotic surgeries, including pelvic sidewall dissection, cystectomy, oophorectomy, hysterectomy, and vaginectomy. In addition, the robot was used for transanal resection of rectal tumours. Furthermore, during the fellowship I was actively involved in Robotic Right Hemicolectomies, with Complete Mesocolic Excision (CME) and intracorporeal anastomosis. Most operating was performed with the da Vinci Xi dual console, with a few cases performed with the da Vinci X.

The robotic fellow can follow, understand, and be actively involved in the operative decision-making process during robotic colorectal surgery. In addition, the robotic fellow reviews the postoperative patients on the ward daily and takes major responsibility in the patients’ perioperative care. In addition, the robotic fellow can attend the colorectal cancer MDT and learn the different aspects of preoperative planning including selection criteria for the patients and preoperative diagnostic studies. There are multiple opportunities for the robotic fellow to be involved in research which is expected to lead to presentations and publications.

During this robotic fellowship I have gained invaluable robotic surgical skills and have accelerated my robotic learning curve under expert supervision and guidance, along with gaining experience in setting up a robotic colorectal service.

Fellowship sponsored by Intuitive

Gaetano Gallo

From: Italy

Visited: The Royal London Hospital, Barts Health NHS Trust, UK

Supervisor: Mr Pasquale Giordano, Consultant Surgeon and Honorary Senior Lecturer, Pelvic Floor & Abdominal Wall Service Clinical Lead

I owe a huge debt of gratitude to Mr Giordano who warmly welcomed me to the Royal London Hospital. I would like to thank him for his friendship and mentorship.

I was involved in surgery for faecal incontinence, constipation, rectal prolapse, perianal, pilonidal and rectovaginal fistulas and haemorrhoids (both office-based and operating room procedures). For these procedures (e.g. dearterialization and mucopexy; anolift), Mr Giordano is considered one of the leading
experts and promoters.

Moreover, although my primary focus was on proctology and functional disorders, Mr Giordano has considerable experience in dealing with complex abdominal wall reconstructions as well as colorectal cancer treatment. For this reason, I had the opportunity to assist in surgery for both these conditions and multidisciplinary team meetings.

I was actively involved in research projects, many of which are in progress, and I hope to publish the related articles in the coming few months.

Apart from the activity at the Royal London Hospital, I followed the outpatient and surgical activities of Mr Giordano in two other places, The Holly Private Hospital and The London Clinic in which he performed not just surgical procedures in the operating theatre but also colonoscopies and office-based procedures.

The procedures below are only a part of what I have had the opportunity to observe/assist/perform:

I attended multi-disciplinary team meetings on colorectal cancer, abdominal wall and pelvic floor
diseases, and training sessions on THD Anolift. I also contributed to the following publications:

• 'Minor Anorectal Conditions', Colorectal Surgery, 7th edition. Sue Clark and Phil Tozer (editors)
• 'THD Anolift for advanced haemorrhoidal disease: a video vignette'. Giordano P, Schembari E, Cocco F, Gallo G. Colorectal Dis. 2022 Aug; 24(8):1018-1019. doi: 10.1111/codi.16134. Epub 2022 Apr 15. PMID: 35368135
• Special Issue 'From Precancerous Lesions to Anal Cancer: Screening, Diagnosis and Treatment',  Frontiers in Oncology ISSN 2234943X

This fellowship has inspired me in innumerable ways but there is one aspect that I would like to mention more than the others. Clinical practice and surgeon-patient relationship (communication, trust, decision–making and patient satisfaction) in the UK is substantially different from Italy. One of the things that struck me, in addition to the surgical skills acquired, and will affect my future activities is Mr Giordano's ability to discuss with patients highlighting the pros and cons of each type of procedure.

I strongly believe that, especially in the treatment of proctological and pelvic floor diseases, which are often functional, patient's quality of life is at risk and for this reason the impact of the discussion is decisive.

The technical and non-technical skills acquired are and will be of great benefit for my clinical practice and for my patients.

Fellowship sponsored by Medtronic

Necdet Fatih Yasar

From: Turkey

Visited: Proctology and Pelvic Floor Clinical Center, University Hospital of Pisa, Italy

Supervisor: Professor Gabriele Naldini

I would like to express my gratitude to the ESCP for being awarded ESCP 3-month Fellowship (June-August 2022) at the Proctology and Pelvic Floor Clinical Center at the University Hospital of Pisa under the supervision of Professor Gabriele Naldini. I also extended my placement for an extra three months until December 2022 to get maximum benefit from this clinical fellowship.

Since the Proctology and Pelvic Floor Clinical Center at the University Hospital of Pisa is solely dedicated to proctology and pelvic floor diseases, I had a great opportunity to increase my experience in this specific field.

To start with proctology, I have learned more details about the treatment of hemorrhoidal disease, anal fissure, and fistula including all the available techniques. I have observed, assisted, and was the first surgeon in procedures such as Milligan-Morgan, stapling procedure, fissurectomy and myotomy, application of botox, flap, LIFT, VAAFT, FiLAC for perianal fistula, management of rectovaginal fistula with/out graciloplasty, as well as EPSIT and Bascom procedures for pilonidal sinus. Proctology and Pelvic Floor Clinical Center at the University Hospital of Pisa is one of the pioneer centers to use mesenchymal stem cells for proctological diseases such as fistula.

For pelvic floor diseases, I had the chance to observe in the multidisciplinary outpatient clinic where we examined the patients with urogynecologists. Also, I learned how to use endoanal and perineal ultrasound and anal manometry in decision-making in pelvic floor diseases. I increased my experience in sphincter repair and learned about Delorme and Altemeier procedures.

University Hospital of Pisa is a great centre for training in robotic surgery. Every Tuesday, I observed, assisted, and even partially did robotic surgery such as ventral mesh rectopexy for isolated rectal prolapse or colpoproctosacropexy for more complex pelvic organ prolapse and lateral suspension of pelvic organ prolapse. Sacral nerve modulation was another modality, that I have learned, for the treatment of fecal incontinence. Besides all these procedures, I observed the rehabilitation of pelvic floor disease patients using biofeedback.

During my fellowship, I attended the pelvic floor diseases masterclass in Pisa and had the opportunity of learning from experts from other high-volume centers not only from Italy but all around Europe and also shared our experience with other colleagues from other hospitals. I had the opportunity to use the simulator for robotic surgery whenever I wanted without any limitation. Periodically, we also did educational sessions using operative videos with Professor Naldini. Every Friday, there was an audit where we discussed the patients in a warm and friendly atmosphere and planned the surgeries for the next week.

I have participated in five pieces of research and wrote a paper titled 'Could the robotic technology be the answer to reduce mesh erosion complication in pelvic floor suspension surgery?' that will be submitted.

Understanding the complexity of pelvic floor diseases and the importance of co-working with other departments such as urogynecology, gastroenterology, and pelvic floor rehabilitator has changed my attitude toward pelvic floor diseases.

Overall, I had a great experience with this clinical fellowship and learned so much in the field of proctology and pelvic floor diseases that will change my daily practice. I believe that I can establish a pelvic floor unit in my university, co-working with urogynecology and gastroenterology, and hopefully would start a pelvic floor rehabilitation unit as well. In addition to the operative techniques that I learned or improved, I learned to do endoanal and perineal ultrasounds, which I will start to do in my daily routine.

I am grateful to ESCP and Medtronic for providing me with this fellowship opportunity and would like to express my sincere gratitude to Professor Gabriele Naldini and all consultant surgeons at the Proctology and Pelvic Floor Clinical Center at the University Hospital of Pisa.

Fellowship sponsored by Medtronic