Simulation and training in transluminal endoscopy

Natural orifice transluminal endoscopic surgery (NOTES) is the most recent advancement in minimally invasive surgery of the abdomen. Similar to any newly introduced surgical technique, the extent of clinician training will play a critical role in reducing errors and increasing the safety of the procedure. Therefore, it is of utmost importance to develop an optimal training approach before widespread use of the procedure. This approach must demonstrate effectiveness in teaching and evaluating proficiency and be simultaneously cost-effective. Furthermore, it must provide didactic and hands-on training to ensure proper understanding of the complexities of the NOTES procedure. Hands-on training could begin with inanimate simulators and then move on to animate simulation, followed by case observation and finally case proctoring. Training novice learners such as residents and fellows in the future may be accomplished with a new hybrid fellowship using both inanimate and animate models to teach laparoscopic, advanced endoscopic, and hybrid techniques. However until this formal postgraduate training becomes available, the optimal teaching approach should include didactics, early use of virtual reality, and animate models in settings such as minifellowships with mentoring, case observation, and on- and off-site case proctoring to master skills.