in 2006 , national institute for health and clinical excellence ( nice ) recommended laparoscopic surgery as an alternative to open surgery for colorectal resections .
the bowel cancer report commissioned by the cancer services coordinating group revealed that in wales only 9.5% of colorectal resections were performed laparoscopically between 2005 and 2007 . in 2007 ,
the association of laparoscopic surgeons of great britain and ireland set up the national training programme ( lapco ) , intended to train existing consultant surgeons .
although the welsh assembly government did set aside some funds for laparoscopic colorectal training in wales in 2008 , this was used mainly to develop an immersion course for existing consultants and a laboratory based training scheme for registrars , delivered from one centre only .
there was no proposal for an outreach preceptorship style programme to deliver training and support at the point of service delivery . at this time ,
setting up such a service would require  team training with a focus on developing not only the operating surgeon , but also the rest of the team including the anaesthetist and nurses .
a single experienced surgeon ( preceptor ) introduced a preceptorship programme aimed at supporting existing consultants ( preceptees ) wishing to develop laparoscopic colorectal surgery ( lcs ) services at their centre .
preceptees were expected to have attended relevant courses , workshops ( including live animal laboratory ) and be able to demonstrate management support for a new service development .
the programme consisted initially of a minimum 1 day master class at the preceptor 's operating theatre attended by the preceptee and his team where they would observe 2 - 3 laparoscopic colorectal resections .
this was to focus primarily on team development and to facilitate rapport between the preceptor and preceptee .
this was followed by several visits by the preceptor to the preceptee 's hospital to assist in cases . at the first outreach visit the preceptor was accompanied by his own middle grade and theatre nurse .
this was to ensure competent assistance and to supervise and support the nursing team , leaving the preceptor free to concentrate on training the consultant surgeon during the case .
the preceptor and his team were all contracted on an honorary basis by the preceptee 's hospital for each visit .
the number of outreach visits and supervised cases was dependent on the individual preceptee 's progress and stage in their own learning curve .
each case was performed on the basis of a standard step - wise approach to each resection .
patient safety and duration of procedure were paramount considerations and were maintained under control by the preceptor .
preceptorship was tapered at each visit , varying from the preceptor being scrubbed for the entire procedure to providing verbal support only .
case selection was discussed prior to each visit , including a review of relevant pre - operative investigations by the preceptor and the initial cases were standard right hemicolectomy and high anterior resection with progression to more challenging cases as the preceptee gained confidence .
this programme was funded through an educational sponsorship from johnson and johnson ( ethicon endosurgery ) .
a single experienced surgeon ( preceptor ) introduced a preceptorship programme aimed at supporting existing consultants ( preceptees ) wishing to develop laparoscopic colorectal surgery ( lcs ) services at their centre .
preceptees were expected to have attended relevant courses , workshops ( including live animal laboratory ) and be able to demonstrate management support for a new service development .
the programme consisted initially of a minimum 1 day master class at the preceptor 's operating theatre attended by the preceptee and his team where they would observe 2 - 3 laparoscopic colorectal resections .
this was to focus primarily on team development and to facilitate rapport between the preceptor and preceptee .
this was followed by several visits by the preceptor to the preceptee 's hospital to assist in cases . at the first outreach visit the preceptor was accompanied by his own middle grade and theatre nurse .
this was to ensure competent assistance and to supervise and support the nursing team , leaving the preceptor free to concentrate on training the consultant surgeon during the case .
the preceptor and his team were all contracted on an honorary basis by the preceptee 's hospital for each visit .
the number of outreach visits and supervised cases was dependent on the individual preceptee 's progress and stage in their own learning curve .
each case was performed on the basis of a standard step - wise approach to each resection .
patient safety and duration of procedure were paramount considerations and were maintained under control by the preceptor . arrangements for clinical governance considerations at each hospital were met by the preceptee .
preceptorship was tapered at each visit , varying from the preceptor being scrubbed for the entire procedure to providing verbal support only .
case selection was discussed prior to each visit , including a review of relevant pre - operative investigations by the preceptor and the initial cases were standard right hemicolectomy and high anterior resection with progression to more challenging cases as the preceptee gained confidence .
this programme was funded through an educational sponsorship from johnson and johnson ( ethicon endosurgery ) .
the aim of our study was to evaluate the early experience of this programme with regards to the clinical outcome as well as preceptee satisfaction .
a prospective database was maintained to record cases performed as a part of master class or opp .
the programme remains on - going , but for the purpose of this paper data from the start of the programme ( may 2008 ) until july 2010 has been analysed .
follow - up data including mortality , morbidity and length of stay was obtained through postal / telephone questionnaire .
in addition , two neutral observers ( the first and second authors ) used a structured questionnaire to interview each preceptee surgeon either in person or through the post , to obtain some feedback about the programme .
between may 2008 and july 2010 , 11 consultants were inducted and 66 cases ( 20 in master class , 46 as an outreach service ) were performed as a part of this programme .
right hemicolectomy was the most commonly performed operation ( n = 24 ) , but cases also included complex major procedures such as panproctocolectomy and total colectomy for consultants who had already been performing some lcs prior to the programme [ table 1 ] .
cases mix in the master class and outreach service distribution of preceptees with number of cases and preceptor 's visits in total there were 12 intra - operative events ( 18% ) that could have led to conversion [ table 3 ] .
all but one of these events however were managed laparoscopically , therefore conversion rate was low at 1.5% ( 1/66 ) .
this one conversion seen in our series to date was due to difficulty identifying the left ureter during an anterior resection .
significant intra - operative events with possibility of conversion overall 30-day mortality was 1.5% [ table 4 ] .
this was due to a delayed anastomotic leak followed by multi - organ failure in a patient who had a low anterior resection after neo - adjuvant therapy .
there were three anastomotic leaks , one of which occurred at day 20 , resulting in the mortality mentioned above .
another patient required a secondary hartmann 's procedure and the third patient was clinically well and managed conservatively .
there were two cases of post - operative bleeding , one ( part of the master class ) managed with a laparoscopic washout and the other by a laparotomy ( part of the opp ) .
morbidity and mortality during master class and opp median length of hospital stay was 6 days ( range : 2 - 30 ) .
all the patients who underwent lcr for cancer had clear margins with a median lymph node harvest of 11.5 ( range : 2 - 23 ) .
one patient undergoing a low anterior resection had a rectal perforation , the site of which was well clear of the tumour . to evaluate the programme , 11 of the preceptee consultant surgeons from five hospitals
all the respondents found the master class and outreach service to be well organised and all would recommend the service to their colleagues .
the four consultants who were already practising some lcs felt that the programme had improved their practice with regards to safety and confidence .
following the programme , all preceptored consultants have performed laparoscopic cases independently . when the respondents were asked to rate various courses available for developing lcs skills on a visual analogue scale ( 0 - 10 ) , the median score for animal workshops ( 5.5 ) , master class alone ( 7.0 ) , websurg ( 7.0 ) , immersion course ( 8.0 ) were all less than the score for the opp ( 8.5 ) .
all the 11 respondents found the master class to be well organised , with a good case - mix and felt that the preceptor demonstrated all relevant steps and answered all their queries .
they found the direct observation and interaction on a one - to - one basis extremely beneficial .
all 11 respondents felt that the preceptor was approachable for discussing case selection and was flexible with dates of visit .
they also found the preceptor to be supportive , encouraging them to perform as much of each procedure as safely possible .
9 of the 11 preceptored consultants felt the number of outreach visits to be the right amount , while two felt it was less than they required .
one of the two surgeons is very senior and close to retirement , hence the uptake of the laparoscopic approach has been relatively slow .
all the other preceptee surgeons have been undertaking standard right and left side resections routinely and some have progressed to complex , benign and multi - segmental resections , there was unanimous agreement amongst the preceptored consultants that the structured programme had helped improve their practice and all would recommend this programme to their colleagues .
between may 2008 and july 2010 , 11 consultants were inducted and 66 cases ( 20 in master class , 46 as an outreach service ) were performed as a part of this programme .
right hemicolectomy was the most commonly performed operation ( n = 24 ) , but cases also included complex major procedures such as panproctocolectomy and total colectomy for consultants who had already been performing some lcs prior to the programme [ table 1 ] .
cases mix in the master class and outreach service distribution of preceptees with number of cases and preceptor 's visits in total there were 12 intra - operative events ( 18% ) that could have led to conversion [ table 3 ] .
all but one of these events however were managed laparoscopically , therefore conversion rate was low at 1.5% ( 1/66 ) .
this one conversion seen in our series to date was due to difficulty identifying the left ureter during an anterior resection .
significant intra - operative events with possibility of conversion overall 30-day mortality was 1.5% [ table 4 ] .
this was due to a delayed anastomotic leak followed by multi - organ failure in a patient who had a low anterior resection after neo - adjuvant therapy .
there were three anastomotic leaks , one of which occurred at day 20 , resulting in the mortality mentioned above .
another patient required a secondary hartmann 's procedure and the third patient was clinically well and managed conservatively .
there were two cases of post - operative bleeding , one ( part of the master class ) managed with a laparoscopic washout and the other by a laparotomy ( part of the opp ) .
morbidity and mortality during master class and opp median length of hospital stay was 6 days ( range : 2 - 30 ) .
all the patients who underwent lcr for cancer had clear margins with a median lymph node harvest of 11.5 ( range : 2 - 23 ) .
one patient undergoing a low anterior resection had a rectal perforation , the site of which was well clear of the tumour .
to evaluate the programme , 11 of the preceptee consultant surgeons from five hospitals were interviewed .
all the respondents found the master class and outreach service to be well organised and all would recommend the service to their colleagues .
the four consultants who were already practising some lcs felt that the programme had improved their practice with regards to safety and confidence .
following the programme , all preceptored consultants have performed laparoscopic cases independently . when the respondents were asked to rate various courses available for developing lcs skills on a visual analogue scale ( 0 - 10 ) , the median score for animal workshops ( 5.5 ) , master class alone ( 7.0 ) , websurg ( 7.0 ) , immersion course ( 8.0 ) were all less than the score for the opp ( 8.5 ) .
all the 11 respondents found the master class to be well organised , with a good case - mix and felt that the preceptor demonstrated all relevant steps and answered all their queries .
they found the direct observation and interaction on a one - to - one basis extremely beneficial .
all 11 respondents felt that the preceptor was approachable for discussing case selection and was flexible with dates of visit .
they also found the preceptor to be supportive , encouraging them to perform as much of each procedure as safely possible .
9 of the 11 preceptored consultants felt the number of outreach visits to be the right amount , while two felt it was less than they required .
one of the two surgeons is very senior and close to retirement , hence the uptake of the laparoscopic approach has been relatively slow .
all the other preceptee surgeons have been undertaking standard right and left side resections routinely and some have progressed to complex , benign and multi - segmental resections , there was unanimous agreement amongst the preceptored consultants that the structured programme had helped improve their practice and all would recommend this programme to their colleagues .
all the 11 respondents found the master class to be well organised , with a good case - mix and felt that the preceptor demonstrated all relevant steps and answered all their queries .
they found the direct observation and interaction on a one - to - one basis extremely beneficial .
all 11 respondents felt that the preceptor was approachable for discussing case selection and was flexible with dates of visit .
they also found the preceptor to be supportive , encouraging them to perform as much of each procedure as safely possible .
9 of the 11 preceptored consultants felt the number of outreach visits to be the right amount , while two felt it was less than they required .
one of the two surgeons is very senior and close to retirement , hence the uptake of the laparoscopic approach has been relatively slow .
all the other preceptee surgeons have been undertaking standard right and left side resections routinely and some have progressed to complex , benign and multi - segmental resections , there was unanimous agreement amongst the preceptored consultants that the structured programme had helped improve their practice and all would recommend this programme to their colleagues .
since nice recommended laparoscopic surgery as an alternative to open surgery for colorectal cancer , there has been a steady increase in the uptake of lcs across the uk .
the absence of formal training and hence the initial slow uptake of lcs in wales has been addressed by this preceptorship programme .
the unique points of this programme are its flexibility to provide preceptees the opportunity to be trained in selected cases , in their own hospital environment and with their own team .
various recommendations have been made to maintain operator competence , such as a frequency of at least two procedures per month or 24 annually .
a questionnaire survey of association of coloproctology of great britain and ireland ( acpgbi ) members in 2008 revealed that only 25% of colorectal cancers were being treated laparoscopically .
this percentage is variable however with some centres reporting figures as high as 90% for elective laparoscopic colorectal resections .
the concept of preceptorship itself is not new . even in the context of lcs in the uk , this was established in 2004 under the auspices of the specialist associations of laparoscopic surgery and coloproctology .
the model of the programme we describe in this paper is similar in its structure except for the avoidance of any compulsion on the preceptee on achieving specific case numbers .
the authors also believe the hierarchical guidelines developed by the council of the colorectal surgical society of australia and new zealand to be too rigid , with limitations imposed by case selection etc .
this not only prolongs the learning curve but also limits the ability to tailor training depending on an individual surgeon 's ability .
this programme , therefore , allows specific one to one tutoring , facilitating the progress of each individual preceptee at his / her own pace .
although in- house preceptorship is ideal , having been shown to improve lcs workload , very few units in the uk can offer such opportunity at the present time .
as per the acpgbi / association of laparoscopic surgeons of great britain and ireland programme , a preceptor should have performed a minimum of 100 laparoscopic resections .
we however felt that though this may be sufficient to train registrars , a preceptor may need greater experience before taking on the training of consultant peers .
registrar training in a consultant 's own operating theatre is quite different to training a consultant colleague in an alien environment with unfamiliar staff , necessitating a different skillset including a greater level of confidence and good people management skills .
immersion courses are aimed at training the surgeon to operate in a controlled environment at the trainers ' centre of excellence .
even though some immersion courses offer team training , it remains different to training at the point of service delivery .
this paper also highlights the fact that even during the early stages of a preceptee 's learning curve ; intra - operative problems can be surmounted satisfactorily with appropriate guidance from a skilled preceptor as demonstrated by a relatively low rate of conversion of 1.5% .
our preliminary evaluation of this structured training programme reveals that lcs can be developed with acceptable levels of morbidity , mortality and conversion rates .
this finding is confirmed with a previous publication by araujo et al . which has shown comparable outcomes between case matched series of operations performed by preceptors independently and preceptees being trained .
our survey has demonstrated that all the preceptees valued the presence of experienced theatre staff accompanying the preceptor at the first outreach visit . not all anaesthetists ( 2/11 ) attended the master class and hence it is not surprising that most surgeons ( 7/11 ) felt the programme had not materially changed anaesthetic practice in their hospital .
the fact that all of the preceptored consultants were satisfied with the programme and would recommend it to colleagues is very encouraging . the number of visits varied between individuals with the median number of visits per hospital being five .
the lapco programme has specified that a minimum of 20 cases ( an arbitrary number ) would be required to reach a level of competence .
our programme is one of facilitation and not accreditation , which reflects the difference in case numbers performed by each preceptee and also highlights its flexibility to accommodate consultants with varying degrees of expertise .
lcs includes a range of operations with different levels of technical difficulty as well as wide ranging complexity due to different pathological processes such as inflammatory bowel disease , complicated diverticular disease and malignancy .
hence , traditional indicators such as the number of cases operated , conversion rates , mortality and morbidity are not reliable indicators for the assessment of competence .
the programme described in this paper has the flexibility to offer subsequent visits by the preceptor as and when the preceptee starts undertaking more complex cases and indeed , some of the preceptees in this series have already requested a  second round of preceptorship .
the most important aspect of this programme is that training is not continuous but intermittent .
once a preceptee feels confident to perform simpler colorectal resections , he can then be preceptored to perform more complex cases .
as seen from our results , one preceptee has performed a laparoscopic panproctocolectomy as part of this programme . in our programme ,
the median number of cases per preceptee was only five , which is not enough to gain competency in lcs .
the purpose of this programme was to try and combine the existing skills of consultant colleagues in general laparoscopic as well as open colorectal surgery .
competence ( by providing data regarding their lcs workload , conversion rates , complications etc . )
as such an analysis would be a breach of the principles underpinning this programme , which was established as one of facilitation and not aimed at achieving 
this programme is an excellent example of partnership between the national health service ( nhs ) and a private provider ( johnson and johnson ) with the funding serving to backfill the preceptor 's absence from his own nhs commitments and to support research and educational activities in the preceptor 's department .
in our programme , the median number of cases per preceptee was only five , which is not enough to gain competency in lcs .
the purpose of this programme was to try and combine the existing skills of consultant colleagues in general laparoscopic as well as open colorectal surgery .
competence ( by providing data regarding their lcs workload , conversion rates , complications etc . )
as such an analysis would be a breach of the principles underpinning this programme , which was established as one of facilitation and not aimed at achieving 
this programme is an excellent example of partnership between the national health service ( nhs ) and a private provider ( johnson and johnson ) with the funding serving to backfill the preceptor 's absence from his own nhs commitments and to support research and educational activities in the preceptor 's department .
this opp has been shown to be effective in achieving safe transference of skills to surgeons wishing to develop a service for lcs in their own departments , with acceptable levels of morbidity and mortality .
such a programme , delivering one - to - one training at the point of service delivery , may play a vital role in making safe lcs available widely .
 introduction : a single experienced laparoscopic colorectal surgeon introduced an outreach preceptorship programme ( opp ) for laparoscopic colorectal surgery ( lcs ) in wales with the aim of supporting consultants in the early stages of their learning curve , as well as to help avoid some of the problems faced by self - taught laparoscopic surgeons . 
 the structured programme consisted of a minimum 1 day master class at the preceptor 's operating theatre , followed by multiple outreach visits by the preceptor . 
 the aim of this study was to evaluate the effectiveness and early experience of this programme.materials and methods : clinical end - points ( conversions , morbidity / mortality and length of hospital stay ) were analysed from a prospectively maintained database . 
 evaluation of the programme was based on interviews with the preceptee surgeons performed by a neutral observer.results:between may 2008 and july 2010 , 11 consultants ( six hospitals ) were preceptored ( two still in programme ) . 
 66 cases ( 20 in the master class , 46 as an outreach service ) were performed as a part of this programme . clinical outcome : 
 conversion rate and 30-day mortality was 1.5% . 
 morbidity was reported at 12% ( 8/66 ) and median length of stay was 6 days . 
 programme evaluation : all interviewed respondents found the master class and outreach service to be well - organised and would recommend it to their colleagues . 
 the median number of outreach visits per hospital was 5 . 
 all the preceptees have performed independent cases since the programme.conclusion:this opp delivers one - to - one coaching at the point of service delivery and has been shown to be effective in achieving safe transference of skills to those wishing to develop a service for lcs . 