Current status of endoscopy training for surgeons in Korea: a narrative review

Abstract

Flexible gastrointestinal (GI) endoscopy is a fundamental skill in surgical practice, offering both diagnostic and therapeutic capabilities for a wide range of GI diseases. In Korea, the incidence estimates for gastric and colorectal cancers rank among the highest worldwide, underscoring the critical need for well-trained endoscopists. Surgeons play a pivotal role in managing GI diseases, reinforcing the necessity of systematic and comprehensive endoscopic education. This paper reviews the status of surgical endoscopy education in Korea, focusing on its historical evolution, structured training programs for residents and fellows, certification processes, and continuing medical education initiatives. Despite significant advancements led by organizations such as the Korean Surgical Society, challenges persist, including disparities in training opportunities across institutions and limited access to advanced therapeutic endoscopy. To address these issues, strategic recommendations include standardizing educational curricula, optimizing residency workloads for dedicated endoscopy training, enhancing simulation-based education through high-fidelity simulators and artificial intelligence, and fostering international collaboration to encourage global best practices. Implementing these strategies will strengthen Korea’s GI endoscopy education system, ensuring that future surgeons are well-prepared to meet the evolving demands of patient care.

INTRODUCTION

Flexible gastrointestinal (GI) endoscopy is an essential component of surgical practice, providing diagnostic and therapeutic capabilities for a variety of GI diseases [1–3]. In Korea, where the incidence of gastric and colorectal cancers is the highest worldwide, there is a significant demand for well-trained endoscopists [4,5]. Surgeons play a key role in diagnosing and treating diseases of the colon and upper GI tract; therefore, systematic and comprehensive educational programs for surgeons’ endoscopic learning are necessary [6–9].

The history of endoscopy education in Korea has evolved in line with global trends, driven by advancing medical technology and an increasing emphasis on early cancer detection [5,10]. Endoscopic education for surgeons includes medical education, residency programs, and specialized fellowships focusing on advanced endoscopic techniques. Several surgical endoscopic societies, led by the Korean Surgical Society (KSS), have played a key role in establishing standardized educational protocols to ensure that surgical residents and fellows acquire appropriate skills [5–7,11]. Despite these developments, there remain challenges, including the diversity of educational opportunities among educational institutions and the development of programs for education on complex therapeutic endoscopic procedures. Recently, the issue of a certification system for endoscopists, including surgeons, has become a social issue because of controversy over the qualifications of doctors participating in the national cancer screening program. This review explores the current situation of surgical endoscopy education in Korea and proposes ideas for future improvements.

A BRIEF HISTORY OF THE EVOLUTION OF ENDOSCOPY

Endoscopy, a technique for visually examining internal organs with an endoscope, has undergone significant evolution over time. Ancient Greek and Roman physicians employed specula to inspect body cavities, and Hippocrates documented rectal examinations [12,13]. The foundation of modern endoscopy can be traced to 1805 when Philipp Bozzini developed the Lichtleiter, an instrument that used candlelight and mirrors for internal visualization [13,14]. In 1895, the surgeon Howard Kelly introduced sigmoidoscopy, enabling direct examination of the rectum and sigmoid colon [2,12].

During the 19th and early 20th centuries, rigid endoscopes improved with the integration of electric lighting [13,15]. However, their inflexibility caused patient discomfort, prompting the development of semi-rigid and flexible endoscopes. In the 1930s, Rudolf Schindler introduced a semi-rigid gastroscope, and in 1968, William McCune pioneered endoscopic retrograde cholangiopancreatography (ERCP), revolutionizing the diagnosis and treatment of biliary and pancreatic diseases [15–17]. By the mid-20th century, Hirschowitz [18] had introduced fiberoptic technology that made endoscopy more flexible and effective.

Endoscopy has advanced beyond diagnostics to therapeutic applications with the active involvement of surgeons. In 1973, Wolf and Shinya [19] introduced endoscopic polypectomy, which significantly reduced the risk of colorectal cancer. In 1975, Ponsky and King [20] developed colonoscopic tattooing for precise surgical markings. Further advancements include percutaneous endoscopic gastrostomy by Gauderer and Ponsky [21] in 1981, which facilitated feeding tube placement, and endoscopic band ligation for esophageal varices developed by Van Stiegman et al. [22] in 1990.

In the 1980s, video endoscopy replaced fiberoptic endoscopes with charge-coupled device sensors for high-resolution imaging [12]. This advancement improved real-time observations and medical training. Around the same period, endoscopic ultrasonography was introduced, providing deeper tissue imaging [12]. Despite these innovations, visualization of the small intestine remained challenging. This led to the development of capsule endoscopy by Iddan et al. [23] in 2000, which allowed a swallowing camera to capture images while moving through the GI tract.

In Korea, gastroscopy was first introduced in the 1960s [12]. The use of flexible fiberoptic endoscopy expanded in the 1970s and 1980s, leading to significant progress in diagnostic and therapeutic endoscopy [6]. Korean specialists have contributed to advancements in endoscopic submucosal dissection and minimally invasive procedures. Today, Korea is recognized as a global leader in endoscopic innovation and continues to advance the field through cutting-edge technology and research.

ENDOSCOPY TRAINING FOR SURGICAL RESIDENTS

Endoscopy training is widely recognized as a challenging skill to both teach and learn. Proficiency in endoscopy is largely acquired through clinical experience and repeated practice, making structured training programs crucial for surgical residents. Curricula include both theoretical and practical components. Trainees receive didactic education on endoscopic principles and GI pathology, followed by supervised, hands-on training in diagnostic procedures, such as upper endoscopy (esophagogastroduodenoscopy, EGD) and colonoscopy [6,7,11]. A critical aspect of this training is image documentation and interpretation, which enhances diagnostic accuracy and helps trainees develop a systematic approach to identifying abnormalities. Although both the United States and Korea have established programs for endoscopy training, their approaches differ in terms of structure and implementation [5,6,24].

In the United States, the American Board of Surgery mandates endoscopic training as part of general surgery certification [24,25]. All board-certified general surgeons are required to complete a standardized flexible endoscopy curriculum. One of the core components of this curriculum is the Fundamentals of Endoscopic Surgery (FES) program, designed to assess both knowledge and technical skills. The FES program includes didactic learning materials, a multiple-choice examination, and a hands-on skills assessment. The written exam consists of 80 multiple-choice questions administered in a 90-minute computerized test to evaluate theoretical knowledge. The hands-on skills test assesses technical proficiency in essential endoscopic maneuvers, such as navigation, loop reduction, retroflexion, mucosal evaluation, and targeting, using an endoscopy simulator. FES certification is available at regional test centers and major surgical meetings, including the Society of American Gastrointestinal and Endoscopic Surgeons Annual Meeting and the American College of Surgeons Clinical Congress [24,25].

In contrast, Korea has developed its own structured colonoscopy training program for surgical residents, which integrates hands-on training with clinical experience [26]. During the training period, surgical residents are required to rotate through the endoscopy unit for approximately 1 to 2 months. Throughout this period, they actively participate in diagnostic and therapeutic endoscopic procedures under supervision. Additionally, residents must complete a standardized hands-on training course followed by an evaluation to ensure competency. Surgical residency programs in Korea cover a broad range of essential skills, including bowel anastomosis, trauma, intensive care unit management, and basic and advanced laparoscopic surgery. Endoscopy and ultrasonography training is specifically conducted during the second year of residency. The endoscopic training program for surgical residents focuses on providing both the technical proficiency and clinical knowledge essential for performing endoscopies.

The standardized hands-on endoscopic training program in Korea follows a structured approach and is typically delivered over a half-day period. The training is divided into several phases. For example, during colonoscopy training, residents first watch a training video on the system and perform basic endoscopic procedures. This initial orientation is followed by a hands-on training session focusing on endoscope navigation and basic insertion techniques. Subsequently, the second training video covers endoscopic anatomy and documentation practices. The residents then proceed to additional hands-on sessions to practice the endoscopic loop reduction technique under direct supervision. The training concludes with a hands-on test in which residents receive feedback on their performance. Training materials, including video clips, cover four core topics (system setup, insertion technique, anatomy awareness, and documentation) and supplement hands-on training. Each video has a runtime of approximately 5 minutes. Hands-on training is typically conducted in small groups, with six or seven residents participating at a time and supervised by three or four instructors. Training is conducted at a ratio of one instructor to two trainees, allowing each resident to receive personalized instruction and practice. A checklist-based assessment is used during endoscopy training to assess competency. The checklists for EGD and colonoscopy are presented in Figs. 1 and 2, respectively. Each step of the procedure is assessed on a pass/fail basis, and residents must successfully complete all components to become certified. This structured approach enables surgical residents to develop both the technical skills and clinical judgment necessary to perform safe and effective endoscopy.

Fig. 1.

Checklist for esophagogastroduodenoscopy training in surgical residents.

Fig. 2.

Checklist for colonoscopy training in surgical residents.

While both the American and Korean endoscopic training programs emphasize structured learning and hands-on practice, the American system integrates endoscopy as a standardized requirement for all general surgeons through FES certification, whereas the Korean system includes endoscopy training within surgical residency through a specialized, competency-based endoscopy program [6,24,26]. The Korean approach emphasizes direct patient interaction during endoscopy rotations and intensive, supervised, hands-on training sessions to ensure residents gain adequate experience. As surgical education continues to evolve, further advancements in simulation-based training and artificial intelligence-assisted endoscopy may enhance the learning experience of future generations of surgeons.

ENDOSCOPY TRAINING FOR SURGICAL FELLOWS

Endoscopic training of fellows and specialists in Korea is a critical component of advanced surgical education. Unlike the structured but relatively shorter training required for residents, fellowship and specialist training programs are more extensive and specifically designed to ensure that surgeons develop the advanced endoscopic skills necessary for independent practice. These programs are overseen by multiple professional societies, each with its own set of requirements and training pathways. Several key societies play a role in the endoscopy training of surgical fellows. The Korean Society of Gastrointestinal Endoscopy (KSGE) and the Korean Society of Coloproctology (KSCP) mandate a 1-year fellowship program for surgeons specializing in GI endoscopy or colorectal surgery [5,27]. Additionally, the Korean Society of Digestive Endoscopy (KSDE) requires specialists to complete at least 500 cases of gastroscopy and 300 cases of colonoscopy to obtain certification. In addition to these standardized training programs, many hospitals have developed their own internal training programs to offer additional hands-on experience and skill development opportunities for their fellows.

The training requirements set by the KSGE underscore high procedural volumes [5,27]. Fellows in a 1-year fellowship program are expected to complete a minimum of 1,000 gastroscopies and 150 colonoscopies. Additionally, they are encouraged to perform at least 30 ERCPs and 30 therapeutic endoscopy procedures to enhance their interventional skills [5]. However, owing to the exceptionally high case volume requirements, only a small number of surgeons are enrolled in this gastroenterology-based endoscopic training program each year. In fact, fewer than ten surgical trainees participate annually, in stark contrast to the large number of physicians who undergo similar training. The primary reason for this low enrollment is the requirement to perform 1,000 gastroscopies, which is often too high for surgical trainees, making it difficult for many to fulfill the criteria within the designated training period.

To address these challenges and provide a more specialized training pathway for surgeons, the KSCP, which primarily consists of colorectal surgeons, established an alternative colonoscopy training program [27]. This program is specifically tailored to meet surgical needs and ensures that colorectal surgeons receive structured education during colonoscopy. The eligibility criteria for hospitals offering KSCP-certified endoscopy training require at least one certified endoscopist to serve as an instructor and at least one colonoscopy session per week to be performed by a surgeon. In addition to hospital-based training, professional endoscopy clinics can serve as training centers if they meet specific requirements. These include having at least two certified endoscopists, ensuring that each endoscopist performs at least 300 diagnostic colonoscopies annually, and maintaining a minimum of 100 therapeutic colonoscopies per year. To obtain certification in colonoscopy from the KSCP, trainees must complete a structured training program at an approved teaching hospital or professional clinic. They are required to perform at least 150 supervised colonoscopies during a 1-year training period and must pass a written examination to demonstrate their theoretical knowledge and clinical competency. The certification process ensures that trainees attain a sufficient level of expertise before they can practice independently [27].

Currently, approximately 30 hospitals across Korea are recognized as KSCP-certified training centers, with about 120 experienced endoscopists serving as instructors. Each year, around 50 trainees complete the KSCP colonoscopy training program and are equipped with the necessary skills to perform high-quality endoscopic procedures. The structured nature of this training program allows colorectal surgeons to develop expertise in both diagnostic and therapeutic colonoscopy while receiving continuous guidance from experienced mentors [27].

Endoscopy training for surgical fellows in Korea is rigorous and requires significant investments of time and effort. Although gastroenterology-based endoscopy training programs require an exceptionally large number of gastroscopy cases, the alternative pathway provided by the KSCP offers a more feasible and structured approach for colorectal surgeons. Both training programs play a crucial role in advancing the quality of endoscopic care and ensuring that specialists are equipped to perform endoscopic procedures safely and effectively. Continuous development of these training programs will further enhance the expertise of surgeons and contribute to the ongoing evolution of endoscopic techniques in Korea.

OTHER ENDOSCOPY TRAINING PROGRAMS

Various other endoscopy training programs exist at individual hospitals or academic societies. One such initiative is the Colonoscopy Academy of the National Cancer Center, Korea, a specialized program aimed at delivering comprehensive colonoscopy education to GI or surgical fellows [11]. This program incorporates an intensive, structured curriculum combining didactic learning, hands-on training, and supervised procedural experience to ensure proficiency in both diagnostic and therapeutic colonoscopy (Table 1). Fellows receive systematic instruction in scope handling, navigation techniques, loop reduction, and lesion identification, with an emphasis on early cancer detection and advanced endoscopic interventions. The academy employs a competency-based approach that uses video-based education, live demonstrations, and direct mentorship from experienced endoscopists. Additionally, participants must complete a designated number of supervised procedures, ensuring they acquire both the technical expertise and clinical judgment required for independent practice [11].

Table 1.

Seven steps of the Colonoscopy Academy of National Cancer Center (CAN) course

Step	Course	Contents
1	Orientation (1st week)	Learn administrative work and computer-related work
2	Understanding(2nd–5th week)	Learn about colon anatomy with atlas conferences or participation in colorectal surgery Watch ≥50 cases of colonoscopic procedures performed by trainers Colonoscopy practice using a model colon for ≥10 hours Practical insertion skill test with training model at the end of this step
3	Basic (6th–12th week)	Begin the withdrawal procedure Perform ≥35 cases of colonoscopy withdrawal Perform ≥15 cases of sigmoidoscopy procedure Trainees should be relieved by the trainer, if the procedure is not completed within 3 minutes
4	Beginner’s(13th–24th week)	Begin insertion procedure Perform ≥100 cases The trainees should be relieved by the trainers on the basis of the following indications: (1) The trainee does not reach the splenic flexure within 5 minutes (2) The cecal intubation is not completed within 10 minutes (3) The patient complains of severe pain (4) The trainee proceeds no further at any site for 3 minutes
5	Intermediate(25th–36th week)	Increase the CIR ≥90% Increase the CIR within 10 minutes to ≥70% Begin the simple polypectomy Perform ≥50 cases of polypectomy
6	Advanced(37th–48th week)	Increase the CIR ≥95% Increase the CIR within 5 minutes to ≥70% Begin the EMR procedure Perform ≥20 cases of EMR
7	Complete ceremony(48th week)	To achieve the completion of qualification for CAN, the trainers should perform ≥500 cases of colonoscopic procedures during the course Receive the completion certificate of CAN

CIR, cecal intubation rate; EMR, endoscopic mucosal resection.

All procedures performed during this step were observed individually by the trainers.

The Gastroscopy School for Surgeons (GSS) is the first structured gastroscopy training program for surgeons in Korea, designed to enhance the endoscopic skills of surgical residents and fellows [7]. Established at Seoul St. Mary’s Hospital, this program addresses the growing need for structured gastroscopy education among surgeons, given the expanding role of endoscopy in minimally invasive and intraoperative procedures. The GSS program is divided into a 12-week course for general surgeons and a 20-week course for GI surgery fellows, integrating theoretical education, dry lab hands-on training, and supervised clinical practice. The curriculum covers gastroscope handling, luminal observation, tumor localization, postgastrectomy surveillance, biopsy techniques, and therapeutic endoscopy, ensuring participants develop practical competencies. During the training, participants are required to perform 30 to 180 gastroscopies under expert supervision with a 1:1 trainer-to-trainee ratio for personalized guidance and real-time feedback. The evaluation was conducted using Miller’s prism framework, allowing trainees to advance through various levels of skill acquisition. A participant survey confirmed the program’s effectiveness, with most trainees attaining proficiency in gastroscopy and acknowledging its significance in surgical practice. The GSS program underscores the necessity of bridging the educational gap in endoscopy training for surgeons in Korea and highlights the importance of expanding structured training opportunities nationwide [7].

The Endoscopy Academy for Beginners, organized by the Korean Laparoscopic Surgeons’ Association of Community Hospitals, is a structured training program designed to equip surgeons with essential endoscopic skills through intensive, hands-on education [28]. This program provides a four-session curriculum that combines theoretical lectures, model-based training, and supervised clinical practice at designated hospitals. Participants gain practical experience in gastroscopy and colonoscopy techniques, lesion identification, biopsy skills, and therapeutic endoscopy, focusing on safe and effective procedural execution. The training follows a stepwise approach, starting with basic scope handling and structural management and progressing to advanced techniques such as polypectomy, lesion diagnosis, and complication management. Conducted in small-group settings, the academy ensures personalized instruction and hands-on practice, enabling participants to develop confidence and proficiency in endoscopic procedures. By offering systematic and practical learning experiences, this program serves as a valuable opportunity for physicians seeking to enhance their endoscopy expertise.

ENDOSCOPY CERTIFICATION AND CONTINUING MEDICAL EDUCATION

The KSS has established an endoscopic certification program to ensure that surgeons cultivate standardized competencies in both diagnostic and therapeutic endoscopy [26]. This program, coupled with continuing medical education (CME), strives to enhance endoscopic skills while upholding high-quality clinical care. The certification process requires candidates to complete a designated number of supervised endoscopic cases and to demonstrate competence in gastroscopy, colonoscopy, and therapeutic interventions such as polypectomy, biopsy, and hemostasis. According to updated regulations, candidates must accumulate at least 300 colonoscopy cases or 500 gastroscopy cases, or instead complete 150 supervised colonoscopies or 200 supervised gastroscopies within a 1-year fellowship program under a certified instructor [26]. Candidates who have already obtained endoscopic specialist certification from a recognized society, including the KSGE, KSCP, or KSDE, may also qualify for certification. Upon successful completion, surgeons receive KSS certification, enabling them to practice independently and supervise trainees. Certification remains valid for 5 years, after which renewal occurs through continued education and clinical practice.

CME is crucial for maintaining certification and ensuring that surgeons stay current with the innovations in endoscopic techniques. The KSS provides structured CME courses that integrate theoretical education, hands-on training, and clinical case discussions. These courses address essential topics such as endoscopic anatomy, scope handling, lesion detection, biopsy techniques, and advanced therapeutic procedures. The training follows a competency-based approach, allowing participants to develop both diagnostic and interventional endoscopic skills in a supervised environment. To maintain certification, surgeons must acquire at least 30 CME credits over a 5-year period, with a minimum of 12 credits coming from KSS-endorsed endoscopy training courses. These credits can be obtained by participating in KSS-endorsed academic conferences, hands-on workshops, or research meetings held by affiliated societies [26].

The KSS’s endoscopic certification and training program serves a pivotal role in standardizing endoscopy education for surgeons in Korea. By offering structured training and competency-based learning, the program ensures that surgeons gain the skills needed to perform safe and effective endoscopic procedures. Integrating CME courses also promotes lifelong learning and ongoing skill refinement. Future directions for the program include expanding simulation training, incorporating artificial intelligence-assisted endoscopy, broadening access to regional training centers, and fostering international collaboration with global surgical endoscopy societies. Through these efforts, the KSS aims to continually advance the quality of surgical endoscopy education and clinical practice, ultimately enhancing patient care and surgical outcomes in Korea.

DISCUSSION

As with other medical education programs, no shortcut exists for endoscopy education, and proficiency can only be gained through extensive training and practice. Endoscopy is an essential skill surgeons must acquire to diagnose and treat patients. It is unfortunate that many younger doctors are reluctant to pursue careers in surgery or to apply surgical techniques in practice; thus, academic societies and senior surgeons have a responsibility to provide improved training environments and standardized training in techniques. Based on the discussion thus far, areas that warrant future consideration are described below.

Several strategic recommendations can be implemented to address existing challenges and further enhance GI endoscopy education for Korean surgeons. First, standardizing educational programs across institutions is essential to ensure equitable access to basic and advanced endoscopy training [6]. It is necessary for educational institutions that train all surgical residents and fellows to establish guidelines mandating uniform exposure to diagnostic endoscopy and therapeutic endoscopic techniques such as polypectomy and endoscopic mucosal resection. This will help reduce educational quality gaps between high- and low-volume institutions and ensure that all trainees achieve a consistent level of proficiency. Second, optimizing residents’ workload balance is important to ensure that sufficient time is devoted to endoscopy education without compromising surgical responsibilities. Implementing dedicated time blocks for endoscopy in residency and fellowship programs can improve educational efficiency and skill acquisition. Third, competency re-evaluation and continuing education should be prioritized to maintain high standards of practice [8]. Regular workshops, refresher courses, and competency assessments can help surgeons stay up-to-date with the latest developments and refine their skills over time. Fourth, investing in high-fidelity simulators and immersive workshops to enhance simulation-based learning can bridge the gap between theoretical knowledge and practical applications. These tools can help trainees practice complex procedures in a risk-free environment and build confidence and competence before performing the procedures on patients. Moreover, expanding the use of artificial intelligence and machine learning can revolutionize how trainees develop diagnostic and technical skills. Artificial intelligence-enabled learning platforms integrated into simulation training modules can provide real-time feedback on lesion detection, classification, and procedural accuracy. This approach not only improves diagnostic accuracy but also reduces interobserver variability, thereby improving the overall quality of training. Finally, increasing access to advanced procedural training through international fellowships and case-based exchange programs can expose trainees to high-volume centers and cutting-edge technologies. Collaborating with leading institutions where advanced endoscopic procedures are well established—such as in Japan and Europe—can provide valuable hands-on experience and promote the adoption of global best practices. By addressing and continuing to evolve these areas, Korea can further strengthen its GI endoscopy education system to better prepare surgeons to meet the evolving needs of patient care and contribute to the advancement of this field.

CONCLUSION

Structured and comprehensive training programs for GI endoscopy in Korea continue to ensure that surgeons are adequately prepared to perform high-quality diagnostic and therapeutic procedures. Ongoing advancements in simulation training, artificial intelligence, and international collaboration will further enhance the quality of endoscopy education. By addressing existing challenges and implementing standardized training protocols, Korea can continue to lead endoscopy education and patient care outcomes.