de’Angelis et al. World Journal of World Journal of Emergency Surgery (2023) 18:11 https://doi.org/10.1186/s13017-023-00476-w Emergency Surgery REVIEW Open Access Training curriculum in minimally invasive emergency digestive surgery: 2022 WSES position paper Nicola de’Angelis1,2*, Francesco Marchegiani1, Carlo Alberto Schena1, Jim Khan3, Vanni Agnoletti4, Luca Ansaloni5, Ana Gabriela Barría Rodríguez6, Paolo Pietro Bianchi7, Walter Biffl8, Francesca Bravi9, Graziano Ceccarelli10, Marco Ceresoli11, Osvaldo Chiara12, Mircea Chirica13, Lorenzo Cobianchi5,14, Federico Coccolini15, Raul Coimbra16, Christian Cotsoglou17, Mathieu D’Hondt18, Dimitris Damaskos19, Belinda De Simone20, Salomone Di Saverio21, Michele Diana22,23, Eloy Espin‐Basany24, Stefan Fichtner‐ Feigl25, Paola Fugazzola5, Paschalis Gavriilidis26, Caroline Gronnier27, Jeffry Kashuk28, Andrew W. Kirkpatrick29, Michele Ammendola30, Ewout A. Kouwenhoven31, Alexis Laurent2,32, Ari Leppaniemi33, Mickaël Lesurtel34, Riccardo Memeo35, Marco Milone36, Ernest Moore37, Nikolaos Pararas38, Andrew Peitzmann39, Patrick Pessaux40,41,42, Edoardo Picetti43, Manos Pikoulis38, Michele Pisano44, Frederic Ris45, Tyler Robison46, Massimo Sartelli47, Vishal G. Shelat48, Giuseppe Spinoglio49, Michael Sugrue50, Edward Tan51, Ellen Van Eetvelde52, Yoram Kluger53, Dieter Weber54 and Fausto Catena55 Abstract Background Minimally invasive surgery (MIS), including laparoscopic and robotic approaches, is widely adopted in elective digestive surgery, but selectively used for surgical emergencies. The present position paper summarizes the available evidence concerning the learning curve to achieve proficiency in emergency MIS and provides five expert opinion statements, which may form the basis for developing standardized curricula and training programs in emer- gency MIS. Methods This position paper was conducted according to the World Society of Emergency Surgery methodology. A steering committee and an international expert panel were involved in the critical appraisal of the literature and the development of the consensus statements. Results Thirteen studies regarding the learning curve in emergency MIS were selected. All but one study consid- ered laparoscopic appendectomy. Only one study reported on emergency robotic surgery. In most of the studies, proficiency was achieved after an average of 30 procedures (range: 20–107) depending on the initial surgeon’s experience. High heterogeneity was noted in the way the learning curve was assessed. The experts claim that further studies investigating learning curve processes in emergency MIS are needed. The emergency surgeon curriculum should include a progressive and adequate training based on simulation, supervised clinical practice (proctoring), and surgical fellowships. The results should be evaluated by adopting a credentialing system to ensure quality standards. *Correspondence: Nicola de’Angelis nic.deangelis@yahoo.it Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. de’Angelis et al. World Journal of Emergency Surgery (2023) 18:11 Page 2 of 23 Surgical proficiency should be maintained with a minimum caseload and constantly evaluated. Moreover, the training process should involve the entire surgical team to facilitate the surgeon’s proficiency. Conclusions Limited evidence exists concerning the learning process in laparoscopic and robotic emergency sur- gery. The proposed statements should be seen as a preliminary guide for the surgical community while stressing the need for further research. Keywords Emergency surgery, Minimally invasive surgery, Robotic surgery, Laparoscopy, Training curriculum in surgery Background drafting and invited an International Expert Panel to pro- Minimally invasive surgery (MIS), including laparoscopic vide a critical revision of the manuscript. and robotic approaches, is widely accepted and adopted The process included two steps: (1) perform a review in elective digestive surgery [1–5]. On the contrary, its of the available literature describing the learning pro- application in emergency settings is reserved for a num- cess and training in minimally invasive emergency diges- ber of selected interventions, mainly approached by lapa- tive surgery using a systematic approach; (2) develop roscopy [6, 7]. Based on a recent WSES survey conducted evidence-based statements/recommendations concern- amongst 415 surgeons from 67 different countries, lapa- ing the standards to achieve in MIS for an emergency roscopy was employed for primary emergencies in more surgeon. than 50% of patients by only 28.7% of participants [8]. This position paper was written according to the For robotic surgery, only 1% of the surgeons declared to methodology described by the WSES [16]. As recom- use it for more than 25% of the patients with primary mended, the GRADE system proposed by the Cochrane emergencies, but, of note, 83.4% of the interviewed sur- Collaboration (https://​train​ing.​cochr​ane.​org/​intro​ducti​ geons declared to have never used a robotic platform for on-​grade) was adopted to report the level of evidence. either elective or emergency surgery [8]. Indeed, the use The consensus on the position paper statements was of robotic surgery for emergency procedures is a matter assessed through a web survey (by Google Form) open of debate due to the resources needed (e.g., trained nurs- to all the members of the steering committee and the ing staff, specific equipment availability, dedicated opera- experts’ panel, as well as the board of governors members tive theater) and the related costs [8–11]. Moreover, the of the WSES. The consensus was reached if a statement emergency surgeon willing to perform MIS for surgical was associated with ≥ 70% of agreement. Otherwise, the emergencies, such as acute cholecystitis, diverticulitis, or statement was re-discussed by email or videoconference, appendicitis, must have achieved an adequate proficiency modified, and resubmitted to the experts’ vote until con- and technical skills in the elective setting to ensure opti- sensus was reached. mal outcomes. The learning process and skills required for elec- Literature review tive digestive MIS are largely documented in the lit- Methods erature [12–15], whereas the corresponding process in Review question, selection criteria, and search strategy emergency surgery has been rarely investigated. This The present systematic review of the literature aimed is probably related to a lack of established benchmarks, to answer to the following focus question: what are the standards, and goals in the curriculum of the emergency training process and learning curve in minimally invasive surgeon. emergency digestive surgery? This review was performed following the Cochrane Project rationale and design Collaboration-specific protocol [17] and was reported The World Society of Emergency Surgery (WSES) pro- according to the Preferred Reporting Items for System- moted the present position paper to provide a scoping atic Reviews and Meta-Analyses (PRISMA) statement review of the literature describing the learning curve in [18]. Studies describing the learning curve in general MIS for emergency digestive/abdominal procedures. The surgery emergencies and urgencies were searched in the available evidence will constitute the base upon which to following databases up to July 2022: Medline (through develop consensus statements and define future research PubMed), Embase, and Cochrane Library. A specific activities. Under the aegis of the WSES, an organiz- research query was used for each database, using the ing committee (composed of Fausto Catena, Nicola following keywords and MeSH terms: robotic, robotic de’Angelis, Jim Khan, and Dieter Weber) constituted surgery, robotics, robot-assisted, minimally invasive sur- a Steering Committee in charge of the position paper gery, minimally invasive surgery, laparoscopy, minimally de’Angelis et al. World Journal of Emergency Surgery (2023) 18:11 Page 3 of 23 invasive surgical procedures, laparoscopic surgery, learn- The risk of bias of the included studies was assessed ing curve, learning curves, learning, training. according to the MINORS scoring system [19]. The According to the PICOS format, the following items MINORS system attributes a score of 0 if the item is were used to select the articles retrieved from the litera- not reported, 1 if the item is reported but inadequate, ture search: or 2 if the item is reported and adequate. The global P, population: digestive surgeons in training (residents highest score is 16 for non-comparative studies and 24 and fellows) or graduated emergency surgeons. for comparative studies. I, intervention: digestive surgery interventions per- formed using a MIS approach in emergency settings. C, comparison: open surgery, minimally invasive sur- Results gery (different technique), or no comparison. Literature search and selection O, outcomes: surgeon’s learning curve on any outcome, Initially, 14,284 records were identified. After duplicate such as operative time or postoperative outcomes. removal, 13,567 articles were screened upon title and S, study design: due to the expected paucity of studies abstract. The majority were excluded because non-per- on the topic in the literature, all types of study design tinent to the review question or did not meet all selec- were considered, except case reports. tion criteria. Forty-five articles underwent a full-text The literature search and selection were limited to evaluation, and 13 studies were finally included in this studies written in English. Articles not discriminat- review (Fig. 1). The list of the excluded articles after full ing between emergency and elective settings were not text evaluation is reported in Additional file 1: Table S1. included, whereas those reporting mixed series were considered eligible only if the percentage of emergency procedures was ≥ 50%. Studies in which the emergency Study characteristics procedures were performed by several surgeons without The included studies were published between 2008 and a specific analysis were not included. Articles report- 2022. All were case series carried out in Asia (n = 6), ing hybrid procedures such as hand-assisted laparo- Europe (n = 5), North America (n = 1), or South Amer- scopic interventions were also excluded. Finally, articles ica (n = 1). The characteristics of the included studies assessing pediatric and transplant procedures were not are summarized in Table 1. Overall, 4557 minimally considered. invasive emergency procedures were described, of The literature search and selection were performed which the great majority (85%) was represented by by two independent reviewers (FM, CAS). According to emergency laparoscopic appendectomy. Only one study the PRISMA methodology, all records were first merged reported the learning curve in emergency robotic sin- in a single database; duplicates were removed, and the gle-site cholecystectomy [20]. remaining articles were reviewed for relevance on title Great heterogeneity in the learning curve assess- and abstract. Records were excluded only when both ment was noted; six studies described the chronologi- reviewers classified them as non-pertinent. In case of cal distribution in groups and their evaluation [21–26]; disagreement, a third reviewer (NdeA) was involved in one study used the moving average method [27]; two assessing the admissibility of the study. Finally, the two studies used the cumulative sum (CUSUM) analysis reviewers performed an independent full-text analysis to [20, 28]; two studies adopted both the moving aver- finalize the inclusion of the potentially pertinent articles. age method and the CUSUM analysis [29, 30]; and two studies applied the procedural-based assessment [31, Data extraction and qualitative synthesis 32]. Moreover, six studies evaluated the learning pro- An electronic spreadsheet was filled with data extracted cess of resident surgeons [21, 27, 29–32], four of gradu- from the original studies selected during the system- ated surgeons [20, 22, 23, 28], and three involved both atic review. The following items were collected: first residents and consultants [24–26]. Varying levels of author’s name, year of publication, scientific journal surgical experience were reported in the single studies. name, type of study design, time frame of the study, number of patients/procedures evaluated, pathologi- Qualitative synthesis of the literature cal state requiring surgical intervention, type of surgi- Learning curve in emergency laparoscopic appendectomy cal intervention, number of surgeons involved, surgeon performed by residents experience, operative surgical outcomes, postoperative In 2008, Jaffer et al. [29] published a study reporting surgical outcomes, learning curve calculation method, the learning curve of a single surgical resident perform- expected learning curve. ing 40 cases of laparoscopic appendectomy. By using the de’Angelis et al. World Journal of Emergency Surgery (2023) 18:11 Page 4 of 23 Fig. 1 Flowchart of the literature search and selection moving average method and the CUSUM analysis, the In 2016, Abdelrahman et al. [31] published an analy- authors demonstrated that the operative time significantly sis of the higher surgical trainee’s curriculum from the decreased after 20 procedures, indicating the achievement 3rd to the 8th year. Different from the other studies, the of the learning curve plateau. However, it is noteworthy authors adopted the procedural-based assessment (PBA) that the study included a 6% of negative appendicitis, which method, which allows rating the operating surgeon with may lower the difficulty of the emergency procedure. an increasing level of competence. Levels were defined Similarly, Kim et al. [27] reported in 2010 the experi- as follows: level 0 (L0C), insufficient evidence observed ence of a single 2nd year resident dealing with open and to support a judgment; level 1 (L1C), inability to perform laparoscopic appendectomies. The surgeon’s previous the procedure under supervision; level 2 (L2C), ability to experience consisted of 30 open appendectomies super- perform the procedure under supervision; level 3 (L3C), vised by a senior surgeon. According to the moving aver- ability to perform the procedure with minimum supervi- age method, the subgroup analysis performed on the sion; level 4 (L4C), competency to perform the procedure laparoscopic group demonstrated a significant reduction unsupervised and to deal with eventual complications. in the operative time after 30 cases. Length of stay and The authors investigated the achievement of three L4C complication rate were comparable across the consecu- ratings in 69 residents’ curricula on six index interven- tive intervention groups. tions, among which laparoscopic appendectomy. The Lin et al. [21] in 2010 reported the learning process of L4C was achieved in a median of 107 (20–206) appen- six residents who performed laparoscopic appendectomy. dectomies. The authors compared this number with the Based on previous reports, the authors compared the national threshold to obtain the surgical certification surgical outcomes of the resident’s initial 20 laparoscopic (80 procedures), highlighting the need for a 35% higher appendectomies (cases performed during the learning caseload. In 2017, the same research group published an curve) with the subsequent 20 cases. A significant reduc- update of the study adopting the same methodology and tion in the operative time and rate of postoperative com- performing an analysis of the gradient of competence plications was observed with the increasing experience of evolution [32]. Concerning appendectomy, the third the residents. The length of hospital stay and conversion level 4 PBA proficiency was reached after 95 cases. The to open surgery did not change over time. study investigated the trajectory of the learning curve Table 1 Studies reporting on learning curve during urgent/emergent minimally invasive surgery References Study design Time period Surgical Nb. of pts/ Type of Surgeons Surgeon Groups Outcomes Main results Estimated emergency procedures intervention involved experience calculation (on which learning curve and methods LC was evaluated) Jaffer et al Retrospective May Appendicitis 40 Laparoscopic 1 NR 4 groups OT OT was signifi- 20 cases are (2008) [29] observational 2005 appendec- (10 pts each) CR cantly shorter sufficient to gain study - tomy - after 20 cases competences in - prospectively November according to (p < 0.0001). term of opera- de’Angelis et al. World Journal of Emergency Surgery collected 2006 moving aver- CR decreased tive time and database age method after 20 cases conversion rate and CUSUM Kim et al Retrospective March Appendicitis 103 Laparoscopic 1 Single ­2nd year Subgroup OT OT was signifi- The LC is (2010) [27] observational 2008 (50 laparo- and open resident analysis for LOS cantly shorter reached after 30 study with - scopic, 53 appendec- who had laparoscopic CR after 30 cases operations (2023) 18:11 subgroup December open) tomy performed > 30 cases: LOS and CR analysis 2008 open appen- 5 groups were compa- dectomies (10 pts each) rable (Supervised) - according to moving aver- age method Lin et al Retrospective January Appendicitis 240 Laparoscopic 6 Residents 2 groups OT OT was signifi- The LC is (2010) [21] observational 2002 appendec- (FLS certified; (120 pts LC; POC cantly shorter reached after 20 study - tomy trained in basic 120 pts after LOS after the LC. cases only for OT December laparoscopy LC) CR (p = 0.005). 2007 in wet and POC rate was simulation significantly laboratories reduced for 2–4 years after the LC. while assisting (p = 0.04) in simple LOS and CR laparoscopic were not surgeries different (Supervised) between the two groups Page 5 of 23 Table 1 (continued) References Study design Time period Surgical Nb. of pts/ Type of Surgeons Surgeon Groups Outcomes Main results Estimated emergency procedures intervention involved experience calculation (on which learning curve and methods LC was evaluated) Liao et al Retrospective July Appendicitis 30 Laparoscopic 1 At least 30 3 groups OT OT were Significant (2013) [22] observational 2009 single port conventional (10 pts each) POC longest in the improvement study with - appendec- three-port - LOS first group in OT after the subgroup June tomy laparoscopic consecutively CR (P = 0.017). No first 10 cases. An analysis 2010 appendectomy assigned TTOI difference in experience of 30 CR, TTOI, LOS, cases achieved POC an OT equiva- lent to conven- tional three-port laparoscopic de’Angelis et al. World Journal of Emergency Surgery appendectomy First 10 cases had a much steeper down- ward slope of OT. (–1.5 min/ (2023) 18:11 case) Abdelrahman Retrospective August Appendicitis / Laparoscopic 69 Higher surgical According to Procedural- Three consult- The proficiency et al observational 2007 and open trainees from procedural- based assess- ant-validated is reached (2016) [31] study - appendec- ­3rd to ­8th year based assess- ment PBAs at level after 107 cases August tomy ment 4 (competent (median) 2014 to perform The number is independently 35% higher than and deal with the number complications) imposed to cer- are reached tify the trainee after 107 cases Kim et al Retrospective March Appendicitis 120 Laparoscopic 1 More than 500 4 groups OT OT were long- Surgical skills (2016) [23] observational 2013 single port open appen- (30 pts each) POC est in group A can be achieved study - appendec- dectomy; - LOS and shortest after 30 opera- February 2015 tomy more than 500 consecutively CR in group D tions and more laparoscopic assigned TTOI (P = 0.012) experienced sur- appendectomy The mean OT gical skills after was shortened 90 operations after 30 opera- tions, it was further short- ened after 90 operations No difference in POC, LOS, TTOI, CR Page 6 of 23 Table 1 (continued) References Study design Time period Surgical Nb. of pts/ Type of Surgeons Surgeon Groups Outcomes Main results Estimated emergency procedures intervention involved experience calculation (on which learning curve and methods LC was evaluated) de’Angelis et al. World Journal of Emergency Surgery Mán et al Retrospective January Appendicitis 600 Laparoscopic 10 5 residents 4 groups OT OT was signifi- The LC is (2016) [24] observational 2006 appendec- (2—3 years of (100 pts resi- POC cantly shorter reached after 20 study - tomy surgical experi- dents LC; LOS in both groups cases both for December ence) 100 pts con- CR (residents and residents and 2009 Completed sultant LC; consultants) consultants a two- 219 residents after the com- (2023) 18:11 week basic after LC; pletion of the laparoscopic 181 consult- LC (P < 0.05) skills course ants after LC) The OT was and assisted - significantly in other consecutively different laparoscopic assigned between the procedures two groups, (Supervised) before and 5 consultants after the com- (8—9 years of pletion of the surgical experi- LC (P < 0.05) ence) Regularly performed other surgical procedures independently (Supervised) Page 7 of 23 Table 1 (continued) References Study design Time period Surgical Nb. of pts/ Type of Surgeons Surgeon Groups Outcomes Main results Estimated emergency procedures intervention involved experience calculation (on which learning curve and methods LC was evaluated) Brown et al Retrospective August Appendicitis / Laparoscopic 84 Higher surgical According to Procedural- Three consult- The proficiency (2017) [32] observational 2007 appendec- trainees from procedural- based assess- ant-validated is reached study - tomy 3rd to 8th year based assess- ment PBAs at level after 95 cases August ment 4 (competent (median) 2016 to perform independently and deal with complications) are reached after 95 cases de’Angelis et al. World Journal of Emergency Surgery Significant variance was observed in the gradients of all LC related to both the (2023) 18:11 caseload between the first level 3 and the first level 4 PBA (P = 0.001), and between the first and third level 4 PBAs (P < 0.001). Significant variance was also observed in the gra- dients of all learning curves related to time between the first and third level 4 PBA (P = 0⋅025), but not related to the period between the first level 3 and first level 4 PBA (P = 0.732) Page 8 of 23 Table 1 (continued) References Study design Time period Surgical Nb. of pts/ Type of Surgeons Surgeon Groups Outcomes Main results Estimated emergency procedures intervention involved experience calculation (on which learning curve and methods LC was evaluated) Kim et al Retrospective October Appendicitis 150 Laparoscopic 3 Resident A (50 pts each OT CUSUM for According to the (2020) [30] observational 2015 appendec- (1st year resident) Surgical failure OT exhibited OR, the LC varies study - tomy 96 surgeries - peaks at the depending on November comprising according to 24th, 18th, surgical experi- 2016 19 appendec- moving aver- and 31st cases ence ranging de’Angelis et al. World Journal of Emergency Surgery tomies and age method for residents from 11 to 35 performed 4 and CUSUM A, B, and C, cases based on laparoscopic respectively a multidimen- appendecto- In terms of sional analysis mies.) surgical failure, Resident B residents A, B, (2023) 18:11 (2nd year, par- and C reached ticipated in 272 steady states general surger- after their 35th, ies comprising 11th, and 16th 42 appendec- cases, respec- tomies and tively performed 3 No significant laparoscopic difference in appendecto- surgical failure mies) but resident Resident C A showed a (3rd year, par- relatively equal ticipated in 510 distribution of general surger- surgical failure ies comprising throughout 98 appendec- the study tomies and period, performed 4 whereas laparoscopic residents B and appendecto- C experienced mies) surgical failure earlier on Page 9 of 23 Table 1 (continued) References Study design Time period Surgical Nb. of pts/ Type of Surgeons Surgeon Groups Outcomes Main results Estimated emergency procedures intervention involved experience calculation (on which learning curve and methods LC was evaluated) Lee et al Retrospective May Appendicitis 1948 Laparoscopic 41 8 surgeons 2 groups OT After a PSM: OT The LC is (2021) [25] observational 2008 single port 33 residents (483 pts LC; POC was signifi- reached after 40 study - appendec- (training 1465 pts after LOS cantly longer cases November tomy protocol: at LC) CR in group 1 2014 list 10 cases HRR than in group as assistant Mortality 2 (p < 0.001) then first three POC, LOS, procedures CR, HRR and supervised) mortality were comparable The rate of de’Angelis et al. World Journal of Emergency Surgery incisional hernia tended to be larger in group 1 than in group 2 Ussia et al Retrospective January Appendicitis 1173 Laparoscopic 73 9 attendings Comparison OT After a PSM: Not specified (2023) 18:11 (2021) [26] observational 2013 appendec- 64 residents after PSM: POC LOS was signif- study - tomy (asked to spec- (409 pts LOS icantly longer December tate several attendings Mortality in attend- 2018 cases before 409 pts resi- ings group assisting) dents) (p < 0.007) OT, POC and mortality rate were compa- rable After stratifica- tion: OT was significantly reduced only in edematous and suppura- tive cases as the number of years of train- ing increased CUSUM for OT showed a reduction in OT for attend- ings at around 300 cases (more than 30 pts/surgeon) Page 10 of 23 Table 1 (continued) References Study design Time period Surgical Nb. of pts/ Type of Surgeons Surgeon Groups Outcomes Main results Estimated emergency procedures intervention involved experience calculation (on which learning curve and methods LC was evaluated) Angeramo Retrospective June Postoperative 132 Various laparo- 3 National 3 groups OT CR was 50 re-laparos- et al. [28] observational 2000 complications scopic proce- board-certified (50, 52 and 30 POC higher in the copies might study - in colorectal dures (Lavage colorectal pts each) LOS first group be needed December surgery and loop surgeons - CR (P = 0.02) to achieve an 2019 ileostomy; according to Mortality OT was appropriate LC resection, redo CUSUM analy- higher in the reducing OT anastomosis; sis (for OT) first group and CR de’Angelis et al. World Journal of Emergency Surgery lavage and (P = 0.003) drainage; Overall anastomosis postoperative takedown; morbidity wall repair; was lower in bowel repair; the last group (2023) 18:11 adhesiolysis; (P = 0.01) internal hernia Major morbid- reduction) ity, mortality and LOS were comparable across the LC Kubat et al. Retrospective May Acute chol- 150 Robotic single 1 Experienced 3 groups OT OT was signifi- The LC is [20] observational 2012 ecystitis, biliary (76 elective port cholecys- minimally inva- (48, 47 and 55 POC cantly shorter reached after study with - pancreatitis, surgery, 74 tectomy sive surgeon pts each) LOS in elective 48 operations, subgroup August choledo- urgent sur- (both in multi- - CR interventions inclusive of analysis 2013 cholithiasis, gery) port robotic according to HRR compared urgent and elec- severe chronic cholecystec- CUSUM analy- Mortality with urgent tive cases cholecystitis, tomy and in sis (for OT) interventions In the subgroup symptomatic single-incision Subgroup (P < 0.05) analysis, the first cholelithiasis, laparoscopic analysis for LOS was phase of the gallbladder cholecystec- urgent cases: longer in CUSUM chart polyposis tomy) 3 groups urgent cases was 25% longer (35, 34 and 15 (P = 0.003) in urgent cases pts each) compared to elective cases Pts patients; LC learning curve; NR not reported; OT operative time; POC postoperative complications; LOS length of stay, CR conversion rate; TTOI time to oral intake; CUSUM cumulative sum; HRR hospital re-admission rate; PSM propensity score matching; FLS fundamentals of laparoscopic surgery Page 11 of 23 de’Angelis et al. World Journal of Emergency Surgery (2023) 18:11 Page 12 of 23 and found a significant gradient related to caseload when analyses were performed considering different groups of comparing the first level 3 PBA and the first level 4 PBA consecutive interventions: those performed during the and between the first and the third level 4 PBA. learning curve period (the first 100 laparoscopic appen- In 2020, Kim et al. [30] published an analysis of 150 dectomies for both residents and consultants) and those laparoscopic appendectomies performed by residents performed thereafter (219 cases for residents and 181 with a growing level of seniority and experience. Three for consultants). A significant difference in the OT was residents, at the first, second or third year of training, reported between residents and consultants both during performed 50 consecutive laparoscopic appendecto- the learning curve period and after the learning curve mies; no significant differences were shown in operating completion in favor of consultants. However, a reduc- time (OT) between the three operating residents. Using tion in OT was also observed within each group after the the moving average method and the CUSUM analysis, completion of the learning curve. the authors reported a decreasing tendency in OT for Lee et al. [25] reported the results of a series of 1948 all residents, with the achievement of peaks between the SPLA performed by 8 attending surgeons and 33 resi- ­18th and 3­ 1st cases. When analyzing the need for takeover dents. By setting the learning curve achievement thresh- by the supervisor during the procedure (defined as sur- old at 40 procedures, the authors compared the early gical failure), the steady state on the CUSUM curve was cases vs. the subsequent ones. They demonstrated a reached between the ­11th and ­35th cases. significant reduction in OT after the completion of the learning curve, whereas the rate of intraoperative and Learning curve in emergency laparoscopic appendectomy postoperative complications was not different over time. performed by graduated surgeons In 2021, Ussia et al. [26] retrospectively investigated the In 2013, Liao et al. [22] reported on the learning curve laparoscopic appendectomies performed in a single sur- of single-port laparoscopic appendectomy (SPLA) for gical unit for six years by nine attending surgeons and 64 noncomplicated appendicitis. The operations were per- residents. The 1173 patients operated on were compared formed by a single surgeon trained in laparoscopic after a propensity score matching, which derived two surgery. Thirty SPLA were considered; 3 groups of 10 groups of 409 patients each. The results showed that only consecutive SPLA were compared. A significant decrease the hospitalization was significantly longer in the attend- in OT was observed after 10 cases. Moreover, the study ings group compared to residents. When the results were showed that an OT equivalent to a conventional three- stratified by the inflammatory stage of appendicitis, a port laparoscopic appendectomy was achieved after 30 significant reduction in OT was present in edematous SPLA cases. No differences were found in the conversion and suppurative cases. This reduction was progressive rate, time to resumption of oral intake, length of hospital according to the year of training, but was not confirmed stay, and postoperative complication rate between the 3 when including gangrenous appendicitis in the analysis. groups of consecutive SPLA. In 2016, Kim et al. [23] investigated the SPLA learn- Learning curve in emergency laparoscopic revisional ing curve in 120 patients admitted to the emergency colorectal surgery performed by graduated surgeons department with acute appendicitis. The operations were Angeramo et al. [28] published in 2022 a study describ- performed by a single surgeon whose experience was ing the learning curve in emergency laparoscopy applied estimated in more than 500 laparoscopic appendectomies to treat complications of elective laparoscopic colorectal and more than 500 conventional open cases. Accord- surgery. Between 2000 and 2019, 132 patients underwent ing to the chronological order, 4 groups of 30 consecu- a re-operation for postoperative complications by three tive procedures each were compared. A decrease in the US board-certified colorectal surgeons. The CUSUM OT was observed after 30 cases; no further improvement method was used to determine the threshold number of was reported until 90 operations were completed. No dif- procedures to be performed to reach a stable operative ferences were shown between the four groups concern- time. Three groups of consecutive procedures (50, 52, ing the rate of postoperative complications, the time to and 30 cases respectively) were compared. A higher con- resumption of oral intake, and the length of hospital stay. version rate and a longer operative time were observed during the first 50 cases compared to the subsequent Learning curve in emergency laparoscopic appendectomy cases. Also, the overall morbidity decreased over time, performed by residents and senior surgeons with the lowest rate for the last 30 cases. No differences In 2016, Mán et al. reported a series of 600 laparoscopic were reported concerning major morbidity, mortality, appendectomies performed by 5 residents having two or and mean length of stay. The authors concluded that 50 three years of surgical experience and by 5 consultants laparoscopic interventions should be performed to com- having eight or nine years of surgical experience [24]. The plete the learning curve. de’Angelis et al. World Journal of Emergency Surgery (2023) 18:11 Page 13 of 23 Learning curve in emergency laparoscopic and robotic should continue to perform a caseload of elective MIS cholecystectomy performed by graduated surgeons procedures to remain proficient in emergency MIS. In 2016, Kubat et al. [20] described the learning curve PS-1. There is a need for further studies assessing of robotic single-site cholecystectomy in a case series of with reliable methods the learning curve process of the first 150 patients operated on by a single surgeon. surgeons in the management of the most common The operator was experienced in both multiport robotic emergencies currently approached with minimally cholecystectomy and single-incision laparoscopic chol- invasive surgical techniques, such as appendicitis, ecystectomy. Only 74 (49.3%) patients underwent an cholecystitis, gastro-intestinal perforations, bowel urgent intervention. The surgeon’s learning curve for OT, obstruction, and incarcerated herniae. including both urgent and elective cases, was reached The concept of a learning curve has very old ori- after 48 operations. A subgroup analysis revealed that gins, described in 1885 by Ebbinghaus as the reten- the initial learning curve for urgent cases was 25% longer tion of memorized information [33]. Today, we refer to than for elective cases. The authors suggested that devel- the process of granting adequate expertise in a given oping proficiency in elective cases first may aid the adop- domain [34]. Particularly in surgery, it requires the rep- tion of robotic technology in the urgent setting. etition of a minimum number of procedures to achieve proficiency [13, 35–37]. Despite the fact that this rep- Study quality assessment resents the basis of surgical education, there need to The selected studies were judged of poor to moderate be more studies elucidating the process of the surgical quality, with MINORS scores ranging from 8 to 18 [19] learning curve, particularly in the emergency setting (Table 2). There was great heterogeneity in the methods [38, 39]. This potentially translates into disparities in and outcomes used to assess the learning curve. This is medical education between residency programs, coun- one of the main limitations, which hampers any pooled tries, and regions [39, 40]. Most of the time, the sur- data analyses and claims for caution in the interpretation geon who starts to work autonomously at the end of and generalizability of the results. The type of training residency has not yet reach full proficiency in all pos- received by the residents and consultant surgeons was sible domains of emergency surgery. Mackrill et al. [41] rarely described (Table 3), with no standardized pre-clin- demonstrated that a standardized intervention, such as ical training curriculum, including simulation in surgery the laparoscopic appendectomy, has different outcomes and hands-on on animal models. Only two studies [21, if performed by registrars or consultants in Australia. 24] reported the preclinical training process consisting of As known, the growing experience is accompanied by a surgical simulation and training on animal model but the progressive amelioration of the surgical outcomes even authors do not specify the time dedicated to training. after the formal learning curve is completed, meaning These data highlight the need for further studies to after approximately 20–30 cases. identify and test the effectiveness of specific training Each minimally invasive procedure may be associ- programs to be implemented during the residency (and ated with a different learning process, so data about thereafter) until the surgeons reach proficiency in emer- laparoscopic appendectomy cannot be generalized to gency MIS. laparoscopic cholecystectomy or robotic procedures. Furthermore, laparoscopic appendectomy is a proce- Position statements dure with repeated anatomy which does not include Based on the review of the literature presented above, some of the skills required in laparoscopy such the the following position statements (PS) were proposed suturing task. Differently, laparoscopic cholecystec- and voted by the Expert Panel. For each statement, tomy introduces an anatomical variability without the supporting literature, the evidence level, and con- offering the suturing task to the trainer. The literature sensus’s strength are reported. Most of the experts lacks studies investigating even the most common sur- involved works in a university hospital/academic center gical emergencies that are nowadays approached by (72.2%) or tertiary care center (27.8%). Most of them MIS, such as appendicitis, cholecystitis, gastrointes- has been performing MIS for surgical emergencies for tinal perforations, bowel occlusion, and incarcerated 10–20 years (44.4%) or more than > 20 years (22.2%). hernias. Only 13 articles were found in the present sys- Only half of them have access to a robotic platform tematic review, and 85% of the treated cases consisted for surgical emergencies, but with difficult accessibil- of a laparoscopic appendectomy. ity (27.8%) or only during daytime (11.1%). The experts It should also be considered that the learning process of were trained and reached proficiency in MIS in differ- an elective procedure may be extended to an emergency ent ways. They all believe that an emergency surgeon one, at least concerning the main technical aspects. Table 2 MINORS scores assessing the risk of bias in non-randomized studies Clearly Inclusion of Prospective Endpoints Unbiased Follow-up < 5% Prospective Adequate Contemporary Baseline Adequate TOTAL stated consecutive data appropriate assessment appropriate Lost to calculation control groups equivalence statistical MINORS aim patients collection to study aim of study to study aim follow of study size group of groups analyses SCORE endpoint up Jaffer 2 2 2 2 0 2 0 0 NA NA NA NA 10/16 et al. [29] Kim 2 2 0 2 0 2 0 0 2 2 1 2 15/24 et al. [27] Lin et al. 2 2 0 2 0 2 0 0 NA NA NA NA 8/16 [21] Liao 2 2 1 2 0 2 0 0 2 1 2 2 16/24 de’Angelis et al. World Journal of Emergency Surgery et al. [22] Abdel- 2 2 1 2 0 2 0 0 NA NA NA NA 9/16 rahman et al. [31] (2023) 18:11 Kim 2 2 0 2 0 2 0 0 NA NA NA NA 8/16 et al. [23] Mán 2 2 0 2 0 2 0 0 2 2 2 2 16/24 et al. [24] Brown 2 2 1 2 0 2 0 0 NA NA NA NA 9/16 et al. [32] Kim 2 2 2 2 0 2 0 1 2 2 1 2 18/24 et al. [30] Lee et al. 2 2 0 2 0 2 0 0 2 2 1 2 15/24 [25] Ussia 2 2 0 2 0 2 0 0 2 2 2 2 16/24 et al. [26] Anger- 2 2 1 2 0 2 0 0 NA NA NA NA 9/16 amo et al. [28] Kubat 2 2 2 2 0 2 0 0 2 2 1 2 17/24 et al. [20] Page 14 of 23 de’Angelis et al. World Journal of Emergency Surgery (2023) 18:11 Page 15 of 23 Table 3 Characteristics of the training process in urgent/emergent minimally-invasive digestive surgery described in the selected studies Variable Type(s) of Training process Reference intervention considered Use of surgical Training on animal Proctoring / Progressive Previous simulators model Supervised training in surgical experience surgeries complexity in open (number of surgery procedures) Jaffer et al. [29] Laparoscopic appen- NR NR ✓ NR NR ✓ ✓ dectomy (NR) Kim et al. [27] Laparoscopic and NR NR NR open appendectomy (NR) > 30 open appendec- ✓ ✓ ✓ tomies Lin et al. [21] Laparoscopic appen- NR NR dectomy FLS certification; wet (NR) lab and simulation ✓ for 2–4 years Liao et al. [22] Laparoscopic single NR NR NR NR ✓ ✓ port appendectomy Abdelrahman et al. Laparoscopic and NR NR NR ✓ [31] open appendectomy (NR) Kim et al. [23] Laparoscopic single NR NR NR NR ✓ ✓ ✓ ✓ port appendectomy Mán et al. [24] Laparoscopic appen- NR dectomy Training box for Live animals for (NR) ✓ ✓ 2 weeks 2 weeks Brown et al. [32] Laparoscopic appen- NR NR NR ✓ ✓ ✓ dectomy (NR) Kim et al. [30] Laparoscopic appen- NR NR ✓ ✓ dectomy (NR) Lee et al. [25] Laparoscopic single NR NR NR ✓ ✓ port appendectomy (3) Ussia et al. [26] Laparoscopic appen- NR NR NR ✓ ✓ ✓ dectomy (NR) Angeramo et al. [28] Various laparoscopic NR NR procedures (Lavage (NR) and loop ileostomy; resection, redo anas- tomosis; lavage and drainage; anastomo- sis takedown; wall repair; bowel repair; adhesiolysis; internal hernia reduction) Kubat et al. [20] Robotic single port NR NR NR NR NR cholecystectomy NR not reported in the article Goksoy et al. [42] accurately investigated the learn- confidence [43, 44]. Kubat et al. [20] described the same ing curve in the elective setting of laparoscopic inguinal progression in robotic single-site cholecystectomies, hernia repair, concluding that the spectrum of difficulty who suggested that the learning curve could be acceler- should be extended gradually and after the completion ated by first acquiring the skills necessary to complete of the learning curve. This is confirmed by two recent elective cases. This concept is not new when considering series of robotic abdominal hernia repair where a small the studies by Stam et al. [45] and Naguib et al. [46] who number of patients were treated for strangulated hernias. highlighted that laparoscopic colorectal resections for The number of emergency cases increased over the time, diverticular disease are technically challenging and more showing an extension of the surgeon’s indications and difficult than the resections performed for oncological de’Angelis et al. World Journal of Emergency Surgery (2023) 18:11 Page 16 of 23 indications in an elective setting. The study by Miskovic trainers, no previous experience was published assessing et al., based on an international multicenter analysis of the safety and efficacy of a surgical procedure. The sys- 4852 cases, confirmed that the learning curve in colorec- tem accredited less than 50% of the surgeons who applied tal surgery should include difficult cases like emergency at the beginning [66] but the effects of this selection, even surgery only in the later stages [47]. if highly debated, produced an improvement in surgical Type of recommendation: Expert opinion. outcomes [67–69]. A recent paper published by Mori Strength of consensus: 77.8% et al. [70] showed that in the context of acute cholecysti- PS-2. To achieve proficiency, surgical proctoring tis, the qualified surgeons outperformed their colleagues and dedicated surgical fellowships may have a role in terms of 30 and 90-day mortality. Similarly, Biondo that deserves further evaluation. Credentialing sys- et al. showed that surgeon specialization in colorectal tems should be developed to ensure quality standards surgery was associated with lower morbidity, mortality, among different training programs. and anastomotic dehiscence rate following emergency While in the elective setting surgical proctorship is colorectal resections, compared to the same interven- adopted, no literature is available concerning surgical tions performed by general surgeons [71]. proctoring in the emergency setting. This is not surpris- The impact of sub-specialization may be even more ing considering the impossibility, by definition, of sched- relevant if considering advanced surgical technologies, uling an emergency procedure. However, adopting new like robotic surgery, which require additional training procedures or technologies should always be accompa- and regular application. However, there needs to be more nied by proctoring to assist surgeons at the beginning universally accepted quality standards or credentialing of their new activity and support them in difficult situa- systems to qualify a surgeon as expert in robotic sur- tions even when the learning curve is completed [48–52]. gery. Some certifications have been proposed in certain In the emergency setting, telesurgery and telementor- specific surgical domains, but most of the time by inde- ing including telestration, may have a valuable role that pendent stakeholders. Recently, a consensus conference should be further evaluated and applied while using MIS was held to reply to the public health fear of an increased techniques [10, 53–56]. operative risk for patients undergoing robotic surgery There is an increasing trend toward post-residency sur- [72]. This initiative engaged experts in the field and pro- gical sub-specialization, which may become necessary to duced 76 items in three areas: prerequisite education and deliver expert care and master advanced surgical tech- training qualifications, surgeon’s performance assess- nologies that cannot be completely acquired during resi- ment, ongoing monitoring and surveillance. Despite the dency [57]. In the United States, subspecialization, which systematic approach, the consensus was not evidence- is pursued on a voluntary basis, is chosen by the majority based but relied upon the experience of the participants. of general surgeons before starting an independent activ- Nevertheless, it offered an open frame to adopt in vari- ity [58]. The importance of fellowship certification has ous robotic surgery fields as emergency surgery. These been recognized in several countries with a documented models can be useful to delineate the specific curriculum improvement in surgical outcomes [59, 60]. A good train- of an emergency surgeon endowed with MIS skills and ing program can reduce the learning time while maxi- to verify the maintenance of the acquired competencies mizing the teaching process; even the simple observation [72–74]. of a standardized procedural step can shorten the learn- Scientific societies, such as the WSES, should take ing curve [61] and promote proficiency [62–65]. the lead role in developing educational curricula, like In the field of emergency surgery, fellowships may the promotion of fellowships in specific sub-specialties represent valuable formal training that allows surgeons of surgery, the development of an accreditation system to achieve the additional experience needed to operate ensuring the quality standards of the fellowship, the con- independently in emergency settings, particularly if the stitution of a board to deliver specialized training cer- surgeon wishes to practice MIS. Another valid option, tificates to surgeons having proved their scientific and which emerged in the literature to verify and maintain clinical competences and skills through an established a good surgical quality level, is the “qualification or cre- procedural volume and case diversity. dentialing system”. In 2004, the Japan Society for Endo- Type of recommendation: Expert opinion. scopic Surgery established a minimally invasive surgical Strength of consensus: 80.6% skill qualification system as a strategy to lower the rate of PS-3. Training with surgical simulation systems and major postoperative complications after minimally inva- virtual reality should be standardized and continu- sive gastrointestinal surgery [66]. Despite the existence of ously implemented to maintain adequate proficiency several systems to assess the proficiency of residents and and acquisition of new skills. de’Angelis et al. World Journal of Emergency Surgery (2023) 18:11 Page 17 of 23 The educational process in MIS requires the acquisi- Type of recommendation: Expert opinion. tion of technical skills before facing a real clinical sce- Strength of consensus: 88.9% nario. The compelling educational value of simulation in PS-4. A minimum caseload should be guaranteed surgery has made simulation a dedicated field of research in the emergency setting to gain and maintain profi- [75]. Simulation training may be performed in dry and ciency in MIS. wet labs and by recurring to virtual reality. Evidence- The learning process in MIS is longer and more com- based curricula for teaching laparoscopic appendectomy plex than open surgery because it requires fine percep- and cholecystectomy already exist and can be readily tual and motor abilities [86]. The skills gained during implemented in practice [76, 77]. Their impact on clini- MIS practice will degrade without use, indicating that cal outcomes have been demonstrated; for instance, the once acquired, they should be put into practice shortly adoption of a structured proficiency-based robotic train- and performed regularly [87]. Most reports on this topic ing curriculum for robotic inguinal hernia repair focus- are not related to experienced surgeons, but it is well ing on virtual reality simulation, inanimate bio tissue accepted that a minimum number of surgical procedures simulation, and live proctorship was able to positively is required in each domain to reach proficiency. Unfor- impact the clinical outcomes and hospital costs [78]. tunately, no evidence is available to establish how many Nevertheless, there are logistic and ethical constraints to cases a surgeon should perform over time to maintain the widespread of dry and wet labs that will probably lead proficiency. Furthermore, the influence of the transversal to an increased use of virtual reality [79]. competencies in different surgical domains, in elective A meta-analysis published in 2016 by Alaker et al. [80] and emergency settings, has never been investigated. showed that virtual reality training can improve opera- There is evidence that high-volume surgeons have bet- tive performance compared to others systems such as ter outcomes than colleagues working in low-volume box trainers or video trainers. However, when comparing centers for colorectal [88], esophageal [89], and hepato- expert surgeons, novices and inexperienced operators, biliary [90] minimally invasive interventions. Also for the study was not able to capture the category of sur- emergency general surgery, data suggest an association geons who benefitted the most from such training. between low-volume surgery and a higher risk of post- Some widely adopted simulation programs are avail- operative adverse events [91], particularly in frail popu- able to teach and train in MIS, but no specific program is lations [92, 93]. Nonetheless, it is difficult to generalize available concerning emergency surgery. Interesting pre- these results to MIS in the emergency setting [94]. liminary studies are emerging in this field but not related In some contexts, such as rural areas, the volume of to MIS and with difficult reproducibility [81]. laparoscopic procedures performed by a single surgeon Technical elements are even more important where the may be insufficient to safely reach proficiency and over- technology is the tool to operate on the patient. As the come the learning curve [95], raising a stringent problem Fundamentals of Laparoscopic Surgery (FLS) emerged of initial training and continuing education of surgeons as a tool to teach and assess the fundamental knowledge and surgical teams. Bruns et al. [96] reported that a reor- and technical skills required to safely perform basic lapa- ganization of the acute surgical team could benefit the roscopic surgery [82, 83], the Fundamentals of Robotic patient and the hospital. A recent survey published by Surgery (FRS) was conceived to assess and certify the Ceresoli et al. [8] showed that the main factor related to robotic surgery skills [84]. Despite the simplicity of the the adoption of laparoscopy in the emergency setting was educational system, it seems undeniable that a proper the surgeon’s personal experience in elective MIS. Coc- mastering of the instruments should be the first step to colini et al. [97] claimed that one of the pillars of emer- efficiently start the robotic activity. Furthermore, with gency general surgery should be the continuous exposure the advent of new robotic platforms, the assessment of to surgical activity, which mostly consists of elective a universal standard could represent a milestone even procedures. The proposed concept would go beyond the though each robot shows an interface specificity. “cumulative volume” analysis. Rotations into a daily elec- The simulation field is not free from debate. The lit- tive surgical activity could allow the surgeon to reach the erature is very specific, and it is difficult to evaluate the proficiency in MIS necessary to face difficult emergent results of the single studies when extrapolated from the cases. Not only the single procedure investigated but the local context. In addition, cost-effectiveness should be total amount of procedures performed by the surgeon proven, considering the elevated prices of the simulators. in different domains should be considered while adopt- However, stakeholders ranging from hospital managers ing MIS. Furthermore, an analysis of the weak area of the to patients are showing a growing interest in mandatory surgeon’s curriculum could guarantee the adoption of simulation prior to clinical activity [85]. implementing measures in a less demanding setting. de’Angelis et al. World Journal of Emergency Surgery (2023) 18:11 Page 18 of 23 There is a lack of consensus concerning the interac- Research agenda tion between different techniques, such as laparos- A research agenda was established considering the lim- copy and robotics. Despite the perception that the two ited available evidence concerning the training in MIS in techniques are very similar in approach, views and dis- emergency settings: section [98], several studies suggested that previous lapa- roscopic experience has a limited impact on the robotic • Further studies are needed to determine the learn- proficiency [99, 100]. This finding, associated with the ing curve of most emergency procedures performed shortened learning curve for robotic surgery, should in MIS. The existing key performance indicators in encourage the adoption of this technology to approach emergency surgery should be considered when deter- technically demanding cases [101, 102]. mining the outcomes for a learning curve evaluation Type of recommendation: Expert opinion. [115, 116]. Strength of consensus: 91.7% • Future studies should include the evaluation of the PS-5. Training programs should target the entire baseline experience of the involved surgeons, includ- surgical team, whose experience is of utmost impor- ing previous preclinical training and simulation. They tance to facilitating surgeons’ proficiency in MIS in should adopt multidimensional indicators of profi- emergency settings. ciency in the learning curve analysis such as patient- The success rate of MIS is determined by a multifacto- reported outcomes and long-term results. Further- rial combination of the surgeon’s experience and skills, more, these studies should report the real costs and the institution’s equipment and organization, and the sur- sustainability of emergency MIS, particularly con- gical team’s competence and specialization. Thus, train- cerning the adoption of advanced technologies such ing, proctoring and continuous education should target as robotic surgery. the operating surgeon and the entire surgical team. • A specific registry should be adopted to collect and The surgical team is of foremost importance during assess the type of interventions performed, the surgi- emergency surgery, as demonstrated in the daily trans- cal volume, the outcomes, and the procedure-related mission of competence from the surgeons who had com- parameters (such as oncologic or patient-reported pleted the learning curve to colleagues in the learning outcomes). These data may allow the evaluation of phase [99, 103]. the real benefits linked to the adoption of MIS in Moreover, the competence of the nursing staff and the emergency settings. anesthesiology team may also significantly impact the • Based on the current evidence and derived from surgical outcomes [104]. the elective surgery literature, a training curriculum Interprofessional collaboration is recognized as a should be defined and proposed to the surgical com- potential way to improve professional practice and munity. Existing models, such as the laparoscopic healthcare outcomes [105]. It becomes mandatory when cholecystectomy-specific assessment tool (LCAT) the adoption of new surgical technologies generates new [117], could be translated to different procedures organizational challenges [106]. In fact, MIS offers a and they could help standardize the evaluation of the shared view of the surgical field and gives the opportu- training. Where not available, a structured assess- nity to the entire team to understand the procedure and ment should be developed, inspired from the avail- monitor the operation progress, but it needs the estab- able evidence in the specific field. The assessment lishment of a new interpersonal routine [107]. Laparos- should be the complete evaluation of the candidate, copy is burdened by the physical stress of the surgical considering technical and non-technical skills, medi- team, whereas robotic surgery offers a less physically cal and surgical knowledge, decision appropriateness, demanding approach, but introduces a console creating and ability to deal with reactions and complications. a physical distance of the surgeon from the team, mediat- • The comprehensive curriculum for surgeons in train- ing communication through a microphone [108, 109]. In ing should include information related to the hours this context and maybe more in an emergency scenario, of preclinical training, the definition of the step-up a team of well-trained people is the key factor for a suc- approach through the training and the number of cessful robotic program [110] and should represent the procedures as assistant as well as operator. Further- standard also in emergency MIS. Some strategies to ame- more, the curriculum should include all the available liorate team work were described, and the emerging solu- adopted techniques. Although the training pathway tions to improve technical skills and communication rely may be adapted to geographical and cultural differ- on simulation [111–114]. ences, it will be important to promote quality stand- Type of recommendation: Expert opinion ard achievements during surgical training. The devel- Strength of consensus: 97.2% oped training curriculum should be diffused under de’Angelis et al. World Journal of Emergency Surgery (2023) 18:11 Page 19 of 23 the supervision of the WSES to the academic provid- Consent for publication Not applicable. ers of education. To ensure educational excellence, the initiatives adopted by Scientific Societies involved Competing interests in the educational process should be integrated into a The authors declare that they have no competing interests. common pathway. Author details 1 Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP‑HP, University of Paris Cité, Clichy, Paris, France. 2 Faculty of Medicine, University of Paris Est, UPEC, Créteil, France. 3 Department Conclusion of Colorectal Surgery, Queen Alexandra Hospital, University of Portsmouth, The training curriculum of the emergency surgeon apply- Southwick Hill Road, Cosham, Portsmouth, UK. 4 Intensive Care Unit, Bufalini Hospital, Cesena, Italy. 5 Department of General Surgery, IRCCS Policlinico San ing MIS remains under investigation. It appears to be Matteo Foundation, Pavia, Italy. 6 Department of Surgery, General and Pediat- poorly standardized and poorly investigated for major ric Surgery, Panama City, Panama. 7 Division of General and Robotic Surgery, surgical emergencies. In this context, the WSES provided Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy. 8 Division of Trauma and Acute Care Surgery, Scripps Memorial Hospital this position paper to summarize the available evidence La Jolla, La Jolla, CA, USA. 9 Healthcare Administration, Santa Maria Delle Croci and propose a successful training pathway in emergency Hospital, Ravenna, Italy. 10 General Surgery, San Giovanni Battista Hospital, MIS. USL Umbria 2, Foligno, Italy. 11 General and Emergency Surgery, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy. 12 General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy. 13 Department of Digestive Surgery and Liver Transplantation, Michal- Abbreviations lon Hospital, Grenoble University, Grenoble, France. 14 Department of Clinical, MIS Minimally invasive surgery Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy. 15 General, WSES World Society of Emergency Surgery Emergency and Trauma Department, Pisa University Hospital, Pisa, Italy. 16 Riv- PRISMA Preferred Reporting Items for Systematic Reviews and erside University Health System Medical Center, Riverside, CA, USA. 17 General Meta-Analyses Surgery Department, ASST-Vimercate, Vimercate, Italy. 18 Department of Diges- CUSUM Cumulative sum tive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, PBA Procedural-based assessment Belgium. 19 Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh, OT Operating time UK. 20 Department of General and Metabolic Surgery, Poissy and Saint‐Ger- SPLA Single-port laparoscopic appendectomy main‐en‐Laye Hospitals, Poissy, France. 21 Unit of General Surgery, San Bene- PS Position statements detto del Tronto Hospital, av5 Asur Marche, San Benedetto del Tronto, Italy. FLS Fundamentals of laparoscopic surgery 22 Digestive and Endocrine Surgery, Nouvel Hôpital Civil, University of Stras- FRS Fundamentals of robotic surgery bourg, Strasbourg, France. 23 IRCAD, Research Institute Against Digestive LCAT​ Laparoscopic cholecystectomy-specific assessment tool Cancer, Strasbourg, France. 24 Department of General Surgery, Hospital Valle de Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain. 25 Depart- Supplementary Information ment of General and Visceral Surgery, Medical Center University of Freiburg, Freiburg, Germany. 26 Department of HBP Surgery, University Hospitals The online version contains supplementary material available at https://​doi.​ Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, org/​10.​1186/​s13017-​023-​00476-w. UK. 27 Eso‑Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, Pessac, France. 28 Department of Surgery, Additional file1 (DOCX 25 KB) Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel. 29 Department of General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada. 30 Digestive Surgery Unit, Acknowledgements Health of Science Department, “Magna Graecia” University Medical School, Not applicable. “Mater Domini” Hospital, Catanzaro, Italy. 31 Department of Surgery, Hospital Group Twente ZGT, Almelo, Netherlands. 32 Unit of HPB and Service of General Author contributions Surgery, Henri Mondor University Hospital, Creteil, France. 33 Department FC, NdA, JK and DW were responsible for the conception of the study and of Gastrointestinal Surgery, University of Helsinki and Helsinki University its methodology. FC, NdA, JK and DW constituted a steering committee and Hospital, Helsinki, Finland. 34 Department of HPB Surgery and Liver Transplan- invited an international expert panel. FM, CAS and NdeA conducted the tation, AP‑HP Beaujon Hospital, University of Paris Cité, Clichy, France. 35 Unit systematic review of the literature and wrote the first draft of the manuscript. of Hepato‐Pancreato‐Biliary Surgery, General Regional Hospital “F. Miulli”, All authors were involved in the statement evaluation and consensus process. Acquaviva delle Fonti, Bari, Italy. 36 Department of Clinical Medicine and Sur- All authors critically reviewed the manuscript and approved the final version. gery, Federico II” University of Naples, Naples, Italy. 37 Ernest E Moore Shock All authors read and approved the final manuscript. Trauma Center at Denver Health, University of Colorado, Denver, CO, USA. 38 3Rd Department of Surgery, Attikon General Hospital, National and Kapodis- Funding trian University of Athens (NKUA), Athens, Greece. 39 University of Pittsburgh No funding or resources was received for the preparation of this article. The School of Medicine, Pittsburgh, PA, USA. 40 Visceral and Digestive Surgery, authors received a WSES institutional waiver for this publication. Nouvel Hôpital Civil, University of Strasbourg, Strasbourg, France. 41 Institute for Image‐Guided Surgery, IHU Strasbourg, Strasbourg, France. 42 Institute Availability of data and materials of Viral and Liver Disease, INSERM U1110, Strasbourg, France. 43 Department The datasets used during the current study are available from the correspond- of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Parma, ing author on reasonable request. Parma, Italy. 44 1St General Surgery Unit, Department of Emergency, ASST Papa Giovanni Hospital Bergamo, Bergamo, Italy. 45 Division of Digestive Surgery, University Hospitals of Geneva and Medical School, Geneva, Switzerland. Declarations 46 Minimally Invasive Surgery Fellow, Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Ethics approval and consent to participate Portland, OR, USA. 47 Department of Surgery, Macerata Hospital, Macerata, Not applicable. de’Angelis et al. World Journal of Emergency Surgery (2023) 18:11 Page 20 of 23 Italy. 48 Department of General Surgery, Tan Tock Seng Hospital, Singapore, 15. Chua D, Syn N, Koh YX, Goh BKP. Learning curves in minimally invasive Singapore. 49 IRCAD Faculty Member Robotic and Colorectal Surgery‐ IRCAD, hepatectomy: systematic review and meta-regression analysis. Br J Strasbourg, France. 50 Department of Surgery, Letterkenny University Hospital, Surg. 2021;108(4):351–8. https://​doi.​org/​10.​1093/​bjs/​znaa1​18. Donegal, Ireland. 51 Department of Surgery, Trauma Surgery, Radboud 16. Bala M, Kashuk J, Moore EE, Catena F, Leppaniemi A, Ansaloni L, University Medical Center, Nijmegen, Netherlands. 52 Department of Digestive et al. Establishing position papers by the WSES. World J Emerg Surg. Surgery, UZ, Brussels, Belgium. 53 Department of General Surgery, Rambam 2018;13:1. https://​doi.​org/​10.​1186/​s13017-​018-​0163-8. Healthcare Campus, Haifa, Israel. 54 Department of Trauma Surgery, Royal Perth 17. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al. Hospital, Perth, Australia. 55 Department of General and Emergency Surgery, Cochrane handbook for systematic reviews of interventions. New York: Bufalini Hospital‐Level 1 Trauma Center, Cesena, Italy. Wiley; 2019. 18. Moher D, Liberati A, Tetzlaff J, Altman DG. 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