Refinement of existing surgical procedures is ubiquitous by surgeons and device technology developers alike. However, the past half-century has seen an unprecedented rise in new operations. In general surgery, the development of laparoscopy has led to a legion of new ways to perform existing procedures and a paradigm shift in skillset, almost unrecognisable to that of a traditionally-trained "open" surgeon.  In hindsight, the methodology of learning laparoscopic surgery was at best haphazard; at worst, dangerous with a concomitant rise in morbidity and mortality.

Similarly, the introduction of robotic surgery has shown benefits of shortened hospital stays and complication rates, tempered by increased intraoperative times, cost and increased training burden of the new technique.⁹

The belated introduction of structured courses such as Fundamentals of Laparoscopic Surgery course¹⁰ followed the more routine use of laparoscopy in gynaecology and general surgery, such that it is now the normative approach worldwide. More recently, the introduction of robotic surgery had been accompanied by a greater awareness of the difficulties in introducing surgeons to new technology requiring novel skills and an increased reliance upon simulation in addition to proctorship for training and credentialing.¹¹

Proceduralists benefit from standardised, validated curriculums for teaching competence focused upon specific skills.¹² There are a number of methods wherein a structured curriculum for teaching a new skill or procedure can be developed.  The most ubiquitous is the "expert opinion" method, with variations upon the rigour with which it is created. The older "hot-tubbing" approach involved a group of experts discussing and creating a curriculum within a set time frame.  The more formal, validated approach requires a defined expert-level opinion formed via an iterative forecasting method via multiple rounds seeking consensus, also known as the Delphi method.  For example, utilisation of the Delphi process to develop a proficiency-based progression course in training for robotic surgery.¹³ Benefits of the Delphi approach include the validation of a formal consensus opinion as well as the statistical significance of reaching consensus via Cronbach's alpha. However, in addition to defining the curriculum, a further demonstration of the use of a skills curriculum over existing teaching paradigms is required.¹⁴ A second limitation is the lack of a readily accessible group of experts when the technology is only newly developed or a novel surgical procedure wherein the number of experts may not be enough to utilise Delphi methodology¹⁵; thus, the option of informal expert consensus is likely to continue in future with caveats in place.

The creation of a formal, structured curriculum for a novel surgical procedure must be adjusted to suit the local environment.  The curriculum must be structured to suit local nuances of device availability, preference of technique, and patient demographic. Validating the content of a curriculum towards a particular region is often conducted via Delphi methodology similar to above, with the expert group derived entirely from the defined area.^16,17 In doing so, the teaching method and assessment are more relevant for the country or region with greater applicability when extended into the credentialing environment.  However, with greater specificity, there is a loss of generalisability; the potential for bias dependent upon ethnicity and place of qualification must be recognised by the assessor.¹⁸ Such deficiencies in procedure would need to be noted by the credentialing body.

One of the most powerful aspects of a validated curriculum is the ability to discern a novice from an expert surgeon. The definitions of these are highly debatable and is most notably determined by surrogate competency markers such as case-volume load or time-based (years in practice).  There is a move towards standardised, reproducible content assessment, which often requires the use of a simulator.  Via direct observation or retrospective video review of a surgical operation upon a simulator, a trained assessor can rate them upon predefined metrics, utilising construct validity to determine whether the assessment score relates to the allocated group of experts or surgeons.  The preferred approach of a simulator removes the requirement for statistical adjustment for patient comorbidities such as body habitus, previous surgery or adhesions.  However, its transferability to "real-life surgery" is an extra consideration that often needs to be validated prior to use as a high-stakes assessment methodology. Defining criteria for credentialing to determine "expert status" utilising consensus methodology has been applied in robotic¹⁹ and laparoscopic surgery.  Development of learning curve phases from "competent" to "proficient", then "mastery" of procedures²⁰ allows for a more nuanced comparison of the level of expertise.

The authors declare that they have no conflict of interest.