Page 52 - Journal of World Association of Laparoscopic Surgeons

Review of Laparoscopic Cholecystectomies by Consultants vs Surgery Residents
Surgical Technique Table 1: Comparison of laparoscopic cholecystectomies performed by
After an infraumbilical incision, open method of creating surgeons and residents
pneumoperitoneum was used. Four ports were then inserted: two Surgeons Residents
10-mm ports in the subumbilical and subxiphoid regions, and two (n = 231) (n = 111) p value
5-mm trocars in the right hypochondrium. Meticulous dissection Mean duration of operation 49 (27–78) 57 (33–97) 0.12
was carried out at Calot’s triangle and around gallbladder using (minutes)
bipolar electrocautery and dissection hook, respectively. The cystic Major complications 15 12 0.06
duct and cystic artery were clipped separately with metallic clips • Intraoperative
and then divided. One operator and two assistants complete an Bowel thermal injury 1 0
operation. In our study, the one who identified and dissected the Bile duct injury 0 0
structures in Calot’s triangle was considered the principle surgeon. Bile leak 4 3
Residents were introduced to laparoscopic techniques by Hemorrhage 3 2
lectures, seminars, and demonstrations. Subsequently, surgical
residents assisted in operations as camera operators, and then Hematomas at trocar site 0 0
progressed to being first assistants, and then operated as the first • Postoperative
surgeons after acquiring appropriate skills. Inflammation at port site 4 4
All operations by surgical trainees were performed under Paralytic ileus 1 2
the instruction and supervision of an experienced laparoscopic Jaundice 2 1
surgeon. Conversion to laparotomy 2 4 0.17
The routine blood investigations of all the patients were sent Mortality rate (%) 0 0 0.22
(like complete hemogram, liver function tests, and renal function Mean hospital stay (days) 2.3 3.5 0.33
tests) and they all had electrocardiography, chest X-ray, and Return to normal activity 15.1 16.7 0.27
abdominal ultrasound scan done preoperatively.
After LC, two patients operated on by a surgeon and one
Statistical Analysis by a resident became jaundiced, and endoscopic retrograde
The Statistical Package for the Social Sciences was used to collect all cholangiopancreatography was performed. These patients
the data. An unpaired t test was used, and the mean duration of the underwent a papillotomy because of common bile duct stones,
surgery, the mean duration of hospital stay, and the number of days which were successfully removed.
needed for resuming daily activities were compared. To compare
the complication rates, conversions to open surgery, and mortality conclusIon
2
rates, a X test was used. A probability of <0.05 was accepted as We conclude that when surgical residents perform LC after sufficient
significant. An independent researcher reviewed the results. training in laparoscopy and under proper supervision and guidance,
results favorable outcomes are achieved. The learning and experienced
surgeons must be aware of the possible complications and the
The data comparing patients who underwent LC by surgeons and necessary prerequisites that should be taken for their prevention.
residents are in Table 1.
The mean duration of the operation was 49 minutes for the references
surgeons and 57 minutes for residents (p = 0.12). Neither conversion 1. Cagir B, Rangraj M, Maffuci L, et al. The learning curve for
rate to laparotomy (p = 0.17) nor complication rate (p = 0.06) was laparoscopic cholecystectomy. J Laparoendosc Surg 1994;4(6):
significantly different between surgeons and residents. Finally, the 419–427. DOI: 10.1089/lps.1994.4.419. http://www.ncbi.nlm.nih.gov/
mean hospital stay was 2.3 days and 3.5 days, respectively (p = 0.33). pubmed/7881146 (accessed November 5, 2016).
2. Hunter JG. The learning curve in laparoscopic cholecystectomy.
dIscussIon Minim Invasive Ther Allied Technol 1997;6(1):24–25. DOI: 10.3109/
13645709709152820.
Considerable concerns exist that shortening the time period 3. Pariani D, Fontana S, Zetti G, et al. Laparoscopic cholecystectomy
of training will compromise the competence of new surgeons. performed by residents: a retrospective study on 569 patients. Surg
The surgical trainees must obtain adequate operative experience Res Pract 2014;2014:912143. DOI: 10.1155/2014/912143.
without any unfavorable outcomes to the patient. This retrospective 4. Reynolds W Jr. The first laparoscopic cholecystectomy. J Soc
study has shown that the level of the principle operating Laparoendosc Surg 2001;5(1):89–94. http://www.ncbi.nlm.nih.gov/
pubmed/11304004 (accessed February 25, 2017).
surgeon does not predict the mortality or morbidity in patients 5. Friedman RL, Pace BW. Resident education in laparoscopic
undergoing LC. cholecystectomy. Surg Endosc 1996;10(1):26–28. DOI: 10.1007/
Several authors have criticized that the laparoscopic generation s004649910005. http://www.ncbi.nlm.nih.gov/pubmed/8711600
of surgeons start their training in biliary surgery with less experience (accessed March 4, 2017).
6
with the open technique; however, studies have shown that less 6. Hodgson WJ, Byrne DW, Savino JA, et al. Laparoscopic cholecystectomy.
experience in open cholecystectomy does not influence the safety The early experience of surgical attendings compared with that
7
of LC. Instead, surgeons who started LC after their residency of residents trained by apprenticeship. Surg Endosc 1994;8(9):
encountered more biliary complications than did their colleagues 1058–1062. DOI: 10.1007/BF00705719. http://www.ncbi.nlm.nih.gov/
pubmed/7992175 (accessed March 4, 2017).
who learned LC during their residency. 5 7. Böckler D, Geoghegan J, Klein M, et al. Implications of laparoscopic
All similar studies’ results indicate that with proper training cholecystectomy for surgical residency training. J Soc Lapa-
and guidance, surgical residents can achieve a satisfactory level of roendosc Surg 1999;3(1):19–22. http://www.ncbi.nlm.nih.gov/
competence in this procedure. 3 pubmed/10323164 (accessed February 25, 2017).

44 World Journal of Laparoscopic Surgery, Volume 12 Issue 1 (January–April 2019)