Over the last 20 years, there has been an evolution from conventional open to laparoscopic colorectal surgery. Laparoscopic colorectal surgery is the most significant technical development in colorectal surgery, and has a significant impact on training and patient outcomes. The expanded use of laparoscopy has improved early postoperative outcomes, permitting smaller incisions, accelerating gastrointestinal recovery, causing less pain, and reducing hospital stay, usually by 2 to 3 days.

There are fundamental differences in the skills required for laparoscopic surgery as compared to open surgery. The use of long instruments with the associated fulcrum effect and lack of tactile sensation, combined with a two-dimensional
image of which only the tips of the instruments are visible, provides a different set of challenges to the operating surgeon and to training individuals in laparoscopic techniques. The wide acceptance of more routinely performed laparoscopic abdominal procedures such as cholecystectomy and appendectomy has made development of laparoscopic skills among trainee surgeons more common, but laparoscopic colorectal surgery provides a number of specific difficulties which makes it more challenging to learn and perform.

Laparoscopic colorectal surgery involves operating in between one and four abdominal quadrants. It is necessary to divide vessels of a significant size and often remove a large specimen. Formation of a bowel anastomosis is often required and there are a variety of different operations that can be performed, meaning there is learning required for a number of different procedures. Perhaps the biggest difference between laparoscopic colorectal surgery and most other laparoscopic procedures is the extensive dissection required to mobilize the colon. This means that the trainee really needs to understand the mechanics of dissection, rather than say performing a gastrojejunal anastomosis. Two-handed skills become of paramount importance to maintain progress during procedures, where extensive dissection is required.

Training surgeons in laparoscopic colorectal surgery does pose difficulties in terms of case numbers as it has been recognized that there is a measurable learning curve in acquiring the required skills in order to reach a steady state in terms of technique, time, and complications. We assessed the learning curve for right-and left-sided laparoscopic colonic resections. Using cumulative sum control chart (CUSUM) analysis and adjusting for case mix, we reported that 55 cases were required for right-sided resections and 62 for left-sided resection. This was consistent with other studies that reported a learning curve between 30 and 70 cases. A problem is that the average general surgery resident graduates with an average of 1 abdominoperineal resection, 7 rectal resections, and 20 to 30 colon resections logged during their training. Once in practice, the average general surgeon performs approximately 10 colorectal resections per year, which complicates completion of a laparoscopic learning curve.

Currently, training in advanced colorectal surgery is generally obtained by undertaking a colorectal fellowship after completion of residency training. The availability of laparoscopic colorectal training, however, has been restricted to a limited number of specialized centers. This is changing, particularly following publication of the COST trial, as more colorectal surgeons are proactively seeking training. Laparoscopic colorectal workshops, utilizing both animal and human cadaver models, have been developed, often in conjunction with industry support, in order to facilitate training, and try to shorten the learning curve. However, training with experienced surgeons who consistently perform a significant number of laparoscopic colorectal procedures remains the optimal way to acquire the required skills.