Fellowship Designation Descriptions and Criteria

An advanced fellowship in colorectal surgery will not substitute for an ACGME accredited colorectal residency and will not allow the fellow to apply for entry to the examination process provided by the American Board of Colon and Rectal Surgery. Fellowships can provide broad based colorectal training intended for international candidates who are not certified or eligible for certification by the American Board of Surgery. These fellowships should include all aspects of colorectal diseases including endoscopy, surgical resection, anorectal disease and should provide MIS exposure.

Alternatively, fellowships can be developed for candidates who have completed an ACGME-accredited general surgery and possibly an ACGME-accredited colorectal surgery residency, who desire focused further training in a specific area such as: pelvic floor disorders, MIS techniques, inflammatory bowel disease or oncologic surgery.

A minimum of 100 complex colorectal operative cases should be performed during the fellowship. All fellowships must have an educational program that includes teaching conferences. Preoperative and postoperative care of the complex colorectal patient must be included in the program. 

An advanced GI fellowship consists of broad-based training in complex gastrointestinal and abdominal operations. The intent of such fellowships should be to train the general surgeon to do advanced and complex cases in various areas of the gastrointestinal tract and abdominal wall. The fellow should be exposed to and participate in at least 150 advanced cases in the areas of bariatrics, advanced minimally invasive surgery, HPB, flexible endoscopy, complex laparoscopic ventral hernia repair*, and/or advanced colorectal surgery. For the purpose of this designation, “advanced” or “complex” GI operations refers to those procedures not generally performed in sufficient numbers to achieve competency within the context of General Surgery residency.

Although it will be presumed that such fellowships will not meet the criteria for any of the specifically categorized areas of GI Surgery within the Fellowship Council, it is encouraged that the fellowship concentrate in two or three focused areas (e.g. HPB and foregut surgery, or bariatric and flexible endoscopy). This focus should allow for clarity of purpose and intent in the description of the training program, as well as the requisite exposure to the technical, cognitive and practice/systems issues to confer a level of competence in such disciplines.

The programs must provide a minimum of one year, in-depth experience in the pre- and postoperative management of patients who have complex gastrointestinal abdominal pathology as well as acquisition of technical skills within these areas. Exposure to techniques in those domains with both open and minimally invasive approaches is highly encouraged and expected. *Hernia cases can be included in the cases as defined in Advanced GI MIS.

Case Log Minimums

• 65 Defined Category MIS Cases
  • 20 Foregut
  • 25 Bariatric
  • 10 Inguinal Hernia
  • 10 Ventral Hernia
  • Only complex (not basic) MIS Cases will count for credit.  A “Complex MIS Case” is defined as any laparoscopic or thoracoscopic operation with the exception of a cholecystectomy, appendectomy, or diagnostic laparoscopy as these are considered “basic MIS cases.” Complex MIS cases done robotically or with a SILS technique will count for credit; however, basic MIS cases done robotically or via a SILS approach will still be treated as basic MIS cases. MIS inguinal and ventral hernias are considered complex MIS cases and there is no limit regarding how many hernia cases may be counted for credit in addition to the defined hernia category minimums.
  • All Defined Category MIS Cases must be performed using an MIS approach and the fellow must serve as either the Primary Surgeon (PS) or Teaching Assistant (TA) for all of these cases.
• 85 Additional Complex MIS Cases
  • Up to 15 complex foregut, bariatric, or hernia cases may be performed using an open approach and will count for credit towards these 85 cases.
  • The fellow must serve as either PS or TA in at least 60 of these 85 cases. The fellow may serve as First Assistant (FA) in up to 25 of these 85 cases.
  • These 85 cases may consist of any complex MIS case type, including either the defined category case types (foregut, bariatric, or hernia) or other case types (colorectal, hepatobiliary, solid organ, thoracic, etc.).
• 150 Total Complex MIS Cases

Flexible Endoscopy

• 50 Upper or Lower Endoscopies
  • Can be diagnostic or therapeutic
  • Endoscopies performed as part of a logged MIS case (e.g. EGD performed during fundoplication) will count for endoscopy credit

An Advance Thoracic fellowship is an additional year of training for surgeons already completing or intending to complete an ACGME-approved cardiothoracic fellowship or equivalent. Completion of this fellowship does not fulfill eligibility for board certification. It is also intended for international trainees and surgeons seeking specialized focused training in thoracic surgery before returning to their institution. The emphasis is on minimally invasive techniques including robotic surgery. Principles of thoracic oncology, patient selection and perioperative management should all be strongly emphasized.

Case Log Minimums

• 100 total cases (not including bronchoscopies and endoscopies)
  • 20 pulmonary anatomic resections (Lobes, segmentectomies etc.)
  • 10 esophageal resections
  • 10 benign esophageal (paraesophageal hernia, diverticulum resection, heller myotomy etc.)
  • 10 chest/pleural (decortications, pleurectomy, blebs, chest wall etc.)
  • 5 mediastinal
• 45 additional Thoracic Cases
• 25 Bronchoscopies required (Do not count towards 100 minimum requirements)
• 25 Endoscopies (Do not count towards 100 minimum requirement)
• 5 Advanced fiberoptic procedures (Endoscopic) (EMR, POEM, Stent, Robotic/Navigational bronchoscopy, EBUS, Mediastinoscopy, laser, ridged endoscopy etc.)
• At least 50 of the total cases and 25 of the defined category cases should be minimally invasive
• For the 45 additional thoracic cases, requirements can be filled by either by major cases from define categories, non-anatomic lung resections or advance endoscopic procedures.
• Bronchoscopies and endoscopies performed during major lung and esophageal cases can be counted towards the 25 required diagnostic bronchoscopies and endoscopies.

A Bariatric fellowship provides exclusively or predominantly bariatric surgical training. The institution sponsoring the fellowship must be certified by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) or be actively engaged in the application process. Fellows finishing bariatric fellowships should have completed the minimum number of cases required to allow them to be “certified” as a bariatric surgeon at the completion of their training.

The 35 undesignated cases can include internal hernias, band removals, band repositioning, etc. A simple port change is not acceptable towards the 100- case count. 80% of the primary bariatric surgeries must be performed using minimally invasive techniques. As an additional point of clarification, the ASMBS currently does not make any distinction between laparoscopic and robotic procedures. Fellows must have demonstrable experience in the preoperative evaluation and assessment as well as postoperative follow-up and assessment of patients.

Current ASMBS guidelines require a minimum of 100 cases with 51 as Primary Surgeon and must include a combination of restrictive procedures (bands and sleeves) and malabsorptive procedures. 50 of the 100 cases must be bariatric operations that include an anastomosis (eg: RNY Gastric Bypass or Duodenal Switch with BPD), 10 restrictive cases (e.g. sleeve gastrectomy operations and/or adjustable gastric banding procedures), and at least 5 revisional procedures.

A complex GI fellowship consists of broad-based training in complex gastrointestinal and abdominal operations. The intent of such fellowships should be to train the general surgeon to do advanced and complex cases in various areas of the gastrointestinal tract and abdominal wall. The fellow should be exposed to and participate in at least 150 advanced cases in the areas of bariatrics, advanced minimally invasive surgery, HPB, flexible endoscopy, complex laparoscopic ventral hernia repair*, and/or advanced colorectal surgery. For the purpose of this designation, “advanced” or “complex” GI operations refers to those procedures not generally performed in sufficient numbers to achieve competency within the context of General Surgery residency.

Although it will be presumed that such fellowships will not meet the criteria for any of the specifically categorized areas of GI Surgery within the Fellowship Council, it is encouraged that the fellowship concentrate in two or three focused areas (e.g. HPB and foregut surgery, or bariatric and flexible endoscopy). This focus should allow for clarity of purpose and intent in the description of the training program, as well as the requisite exposure to the technical, cognitive and practice/systems issues to confer a level of competence in such disciplines.

The programs must provide a minimum of one year, in-depth experience in the pre- and postoperative management of patients who have complex gastrointestinal abdominal pathology as well as acquisition of technical skills within these areas. Exposure to techniques in those domains with both open and minimally invasive approaches is highly encouraged and expected. *Hernia cases can be included in the cases as defined in Advanced GI MIS.

Fellows must complete procedure requirements with the following category minimum.

100 total core procedures minimum

• 30 Inguinal Hernia Repairs
  • 15 of these must be done via an MIS approach (Laparoscopic or Robotic)
  • 10 of these must be recurrent hernias
• 30 Ventral/Incisional Hernia Repairs (3-10 cm width or length)
  • These could be performed via a variety of techniques including onlays, retrorectus, IPOM.
  • 15 of these must be performed as MIS extraperitoneal

• 25 Ventral/Incisional Hernia Repairs (>10cm width or length)
  • These can be either External Oblique releases or Transversus Abdominis releases or preperitoneal via any approach
• 15 Atypical hernia cases
  • These include operations for groin pain, repair of parastomal hernias, surgery for infected mesh including potential management of hernia recurrence concomitantly, hernias in the setting of an enteric fistula, subxiphoid, flank, suprapubic hernias.
• In addition to the 100 core cases, fellows must complete the following additional requirements:
  • 5 clinic evaluations for groin pain
  • Completion of the FC Hernia Curriculum which is currently under development
  • Documentation of competence in at least 5/8 FC Hernia EPAs.

An HPB fellowship program provides concentrated exposure to patients with both benign and malignant pancreatic, biliary, and liver diseases. While absolute numbers of operative cases have not yet been defined for a specific disease, a minimum of 100 total major operative HPB cases are required (no variance allowed), and the fellow must act in the Primary Surgeon role for at least 70 of these major cases.

A minimum of 25 major liver, 15 complex biliary, and 25 major pancreas cases are required. The remaining 35 major operative HPB cases may be within any of these categories. Within the liver category, at least 20 cases (no variance allowed) of these procedures must be either hemi-liver resection, trisectionectomy, right posterior/anterior sectionectomy, central hepatectomy, and/or in situ donor hemihepatectomy. Within the pancreas category, at least 20 cases (no variance allowed) must be pancreaticoduodenectomies.

Principles of management of patients with malignant and benign conditions in a multi-disciplinary fashion are required.

Basic HPB cases which do not count towards these minimum requirements include cholecystectomy, liver, and pancreas biopsy (any technique). Liver transplant, donor hepatectomy, and donor pancreatectomy are not required but may account for up to 20% of one category (pancreas, biliary or liver), with a maximum of 20% of total requirements. Experience in MIS pancreas (5 cases min), MIS liver (5cases min), hepatic hilar dissection, intra-operative ultrasonography, and hepatic tumor ablation are required. The programs must provide a minimum of one year of in-depth experience in the pre and postoperative management of patients with simple and complex HPB pathology as well as the acquisition of technical skills for performing complex HPB operations.