Endoscopic submucosal dissection (ESD) is the gold standard for the treatment of sizable benign and sessile neoplasms of the large bowel.1,5 ESD requires a unique set of skills including the ability to finely control, in 3 dimensions, the moving scope tip with an “active” needle knife extended from the scope. Because ESD requires that each part of the polyp be separately and sequentially cut and detached, tissue is only cut when the scope tip is moving. This is not the case when a snare or endoscopic biopsy forceps is used during which the scope tip is held steady and the working channel tool advanced and then withdrawn. Acquiring the skill set necessary to cut tissue while moving the scope tip as well as other component skills such as bowel wall injections and cap retraction and dissection are a real challenge.

Unfortunately, routine therapeutic and diagnostic colonoscopy do not afford opportunities to learn to finely control the moving scope tip with an instrument extended. In Asia where the incidence of gastric cancer is much higher, would be advanced endoscopists learn ESD in the thick walled stomach where perforation is much less likely. Typically, 50-60 gastric ESD cases are done prior to embarking on a colonic ESD. In the US and most countries of the Western world, colorectal ESD skills must be obtained and acquired in a different manner since the incidence of gastric neoplasms is much lower. It well recognized that ESD training in the West is extremely difficult. Whereas endoscopy simulators can teach basic endoscopic skills they are not yet, in the opinion of the authors, platforms where advanced skills can be acquired. A clinical master and apprentice system has been used in Japan and also been suggested for the West4 but this approach is problematic in that before it can be implemented the trainee must first acquire, to some extent, the unique skill set needed for ESD. Some experts in this field stress the importance of ex vivo animal tissue platforms.2,3,6,7,9,10 Not long ago, Ohata et al went even further and suggested that motivated trainees could obtain the ESD skill set soley by working in animal models.7 The authors of the current chapter are in full agreement and have been developing such a program for over 12 years.8

This chapter describes a new teaching approach that utilizes inanimate and ex-vivo animal teaching models in order to learn and repeatedly practice the new skills. The hypothesis is that it is possible to acquire the skills needed to do colorectal ESD in humans by repeatedly using the component and collective skill set to do ex vivo cases. Thus, inanimate and ex vivo models are not used just as a means of introducing a trainee to ESD or an advanced skill but as the setting where the skill(s) is actually acquired by practicing and performing procedures again and again. Another unique feature of this teaching approach is that, in addition to providing trainees the chance to do many actual ESD resections, it also separately teaches important component skills that are needed for both ESD and advanced endoscopic procedures in general.

One major advantage to this approach is that the training is not dependent on the clinical volume of colon polyp cases which varies and may be low. The rate limiting factor is the availability of the trainee. This fact makes it possible for a dedicated trainee to acquire the skill sets in a predictable length of time.