Implementation of IDEAL framework of UK training programme for TaTME

Background: As international concern grows regarding the reported early oncological outcomes and technical challenges of transanal total mesorectal excision (TaTME), there is a need for a structured and robust quality assurance process to ensure safe introduction and monitoring of a novel surgical technique. The IDEAL framework has been advocated to guide such a process. The aim of this study was the report the application of IDEAL framework in the development and implementation of TaTME training in the UK. Methods: A five-stage outline (idea, development, exploration, assessment, and long-term study) was applied to describe the development, delivery and assessment of the TaTME training initiative in the UK. Surveys that incorporated the experience of both learners and more experienced surgeons of TaTME, together with experts in education, initiated the process with concepts and development of the training initiative explored at a centrally co-ordinated pilot training programme. Key components included a cadaver training workshop and a formal proctorship process. Data were recorded on demographics, tumour location, intraoperative, post-operative and histological outcomes. Educational assessment of technical progress was performed using custom-made Global Assessment Scoring (GAS) forms which were completed by both learners and proctors. Long-term outcomes were captured at 24 months. Results: Five selected pilot sites were used by 10 colorectal surgeons during the training initiative and 24 cases were proctored in this period in the exploration phase. Median operative time reduced from initial 331±90 [195-610] to 283±62 [195-340] minutes in the final case. No visceral injuries were reported however there was one conversion to open (4.2%). Histological assessment reported as intact mesorectal TME specimens with clear distal margin and no bowel or tumour perforation in all cases. One case had positive circumferential margin (4%). Assessment of educational outcomes showed GAS score 5 (independent performance) was achieved by case 5 in most operative steps. Long-term follow up showed no evidence of local or regional recurrence but three liver and one lung metastasis at 24 months. Conclusions: Dissemination of a new surgical technique within the confines of IDEAL framework demonstrates the feasibility and safety of surgical training programme for TaTME at a national level.