Skill sets and competencies for the modern military surgeon: Lessons from UK military operations in Southern Afghanistan

Introduction

British military forces remain heavily committed on combat operations overseas. UK military operations in Afghanistan (Operation HERRICK) are currently supported by a surgical facility at Camp Bastion, in Helmand Province, in the south of the country. There have been no large published series of surgical workload on Operation HERRICK. The aim of this study is to evaluate this information in order to determine the appropriate skill set for the modern military surgical team.

Method

A retrospective analysis of operating theatre records between 1st May 2006 and 1st May 2008 was performed. Data was collated on a monthly basis and included patient demographics, operation type and time of operation.

Results

During the study period 1668 cases required 2210 procedures. Thirty-two per cent were coalition forces (ISAF), 27% were Afghan security forces (ANSF) and 39% were civilians. Paediatric casualties accounted for 14.7% of all cases. Ninety-three per cent of cases were secondary to battle injury and of these 51.3% were emergencies. The breakdown of procedures, by specialty, was 66% (1463) orthopaedic, 21% (465) general surgery, 6% (139) head and neck, 5% (104) burns surgery and a further 4% (50) non-battle, non-emergency procedures. There was an almost twofold increase in surgical workload in the second year (1103 cases) compared to the first year of the deployment (565 cases, p < 0.05).

Discussion

Surgical workload over the study period has clearly increased markedly since the initial deployment of ISAF forces to Helmand Province. A 6-week deployment to Helmand Province currently provides an equivalent exposure to penetrating trauma as 3 years trauma experience in the UK NHS. The spectrum of injuries seen and the requisite skill set that the military surgeon must possess is outside that usually employed within the NHS. A number of different strategies; including the deployment of trainee specialist registrars to combat hospitals, more focused pre-deployment military surgery training courses, and wet-laboratory work are proposed to prepare for future generations of surgeons operating in conflict environments.     

Avoiding cavity surgery in penetrating torso trauma: the role of the computed tomography scan

INTRODUCTION

Surgical decision-making in torso trauma is complex. This paper looks at the role of the computed tomography scan in this decision-making process.

PATIENTS AND METHODS

Patients with significant torso trauma (high velocity gunshot wound [HVGSW], blast, stab) admitted to a military role 2 (enhanced) hospital facility during a 7-week period of Operation HERRICK 9 (Afghanistan, October to November 2008) are reported. The management of those patients undergoing a CT scan as part of the decision-making process at the time of admission is discussed.

RESULTS

Twenty eight patients with significant torso trauma were admitted to the facility during the study period; HVGSW (n = 15), blast (n = 9), stab (n = 4). Thirteen patients underwent a CT scan as part of the surgical decision-making process; HVGSW (n = 5), blast (n = 8). Imaging confirmed torso integrity in 12 patients, one of whom subsequently had a laparotomy for vascular control for on-table haemorrhage during lower limb surgery. One patient had a confirmed thoraco-abdominal injury, which was treated conservatively with tube thoracostomy and ‘active observation’.

CONCLUSIONS

A CT scan formed part of the surgical decision-making process in about half of the patients admitted with significant torso trauma, and helped prevent unnecessary laparotomy in this forward military environment. Those patients with a blast injury were more likely to undergo CT scanning than those where the mechanism of injury was a HVGSW.     

Fact or Infection: Do Surgical Trainees Know Enough About Infection Control?

INTRODUCTION

There exists a high level of non-compliance with basic infection control measures by medical staff. One explanation may be a lack of familiarity with contemporary infection control guidelines. As surgical trainees represent a key group of stakeholders responsible for the delivery of recommended infection control practice, we assessed knowledge of infection control guidelines amongst current UK surgical trainees.

MATERIALS AND METHODS

Without warning, during the annual meeting of the UK Association of Surgeons in Training (ASiT), participating surgical trainees were asked to complete a questionnaire examining their basic knowledge of infection control and methicillin-resistant Staphylococcus aureus (MRSA) based on recently published guidelines.

RESULTS

A total of 52 trainees (13 higher surgical trainees [HSTs]; 39 basic surgical trainees [BSTs]) returned completed questionnaires in the study. BSTs demonstrated a higher level of knowledge of infection control, outperforming the HSTs in 7 out of 11 questions. Of surgical trainees, 61.5% were misinformed regarding the prevalence of MRSA blood-stream infections and 69% were unaware of policies for transfer of MRSA-positive patients. Analysis revealed areas of concern in regards to an adequate general level of knowledge of infection control in surgical trainees, particularly in some key areas.

CONCLUSIONS

To ensure patient safety and reduce hospital-acquired infections, it is vital that focused, co-ordinated programmes of education, in this rapidly changing field, are prioritised and formalised into surgical training, selection and assessment.     

Future of vascular surgical training: the trainees' views

INTRODUCTION

In the UK, surgical training includes all aspects of general surgery. Vascular surgery is not an independent specialty. We wished to assess the views of vascular trainees in UK on the future of vascular surgery and training.

MATERIALS AND METHODS

Trainees were surveyed in 2003, 2004 (after introduction of the European Working Time Directive) and 2005, concentrating on four areas – future practise of vascular surgery, role of endovascular training, vascular specialisation and future training.

RESULTS

The majority of trainees want to practise vascular surgery alone. In 2003, 80% thought training should include endovascular techniques. By 2005, all trainees regarded training as mandatory as endovascular techniques would represent a significant part of their future work. Opinion changed on training; from 4 years general then 2 years vascular surgery (qualification in general surgery) to 2 years general and 4 years vascular surgery (specialist qualification in vascular surgery; P < 0.0001). Opinion also changed, that vascular surgery should spilt from general surgery to form its own speciality (P < 0.0007).

CONCLUSIONS

Trainees now regard training in endovascular techniques and endovascular aneurysm repair as mandatory. The majority wish to specialise from general surgery and achieve a separate qualification in vascular surgery.     

Amputation and the assessment of limb viability: perceptions of two hundred and thirty two orthopaedic trainees

INTRODUCTION

The management of complex extremity injury, which may require assessment of limb viability and performance of amputation, is a challenge to those involved in its emergent and definitive care. Concern exists regarding the exposure of orthopaedic trainees to such cases due both to changes in training and centralisation of trauma services.

SUBJECTS AND METHODS

This is a web-based observational study by survey, investigating the confidence and perceived adequacy of training of UK orthopaedic specialist trainees in the assessment of limb viability and amputation surgery. 222 responses from 888 trainees were required to achieve a < 5% error rate with 90% confidence; 232 surveys were completed.

RESULTS

Trainee confidence in dealing with the assessment of limb viability is high despite infrequent exposure to cases. The majority of trainees perceive their training in limb viability assessment as adequate. For performance of amputation, exposure is minimal, confidence is lower and 36% of trainees regard their training as inadequate.

CONCLUSIONS

Limb viability assessment is an area in which trainees feel confident and well trained. There is, however, a perceived training inadequacy in amputation surgery and a corresponding lack of confidence for many trainees, irrespective of training year. This is the first study to offer an insight into specific training experiences of junior orthopaedic surgeons at a national level and it should drive the development of opportunities for trainees to develop skills in amputation surgery.     

Training in the practical application of damage control and early total care operative philosophy �C perceptions of UK orthopaedic specialist trainees

INTRODUCTION

Despite improvements in the outcome of individuals sustaining significant injury, the optimum management of fractures in traumatised patients remains an area of debate and publication. There is, however, a paucity of studies regarding the specifics of acquired experience and training of junior orthopaedic surgeons in the practical application of these skills. Our null hypothesis is that, despite alteration in surgical training, the perceived confidence and adequacy of training of UK orthopaedic specialist trainees in the application of damage control orthopaedics (DCO) and early total care (ETC) philosophy is unaffected.

PATIENTS AND METHODS

A web-based survey was sent to a sample of orthopaedic trainees. From 888 trainees, 222 responses were required to achieve a 5% error rate with 90% confidence.

RESULTS

A total of 232 responses were received. Trainees reported a high level of perceived confidence with both external fixation and intramedullary devices. Exposure to cases was sporadic although perceived training adequacy was high. A similar pattern was seen in perceived operative role with the majority of trainees expecting to be performing such operations, albeit under varying levels of supervision. In a more complicated case of spanning external fixation for a ‘floating knee, trainees reported a decreased level of perceived confidence and limited exposure. One-third of trainees reported never having been involved in such a case. In contrast to nationally collated logbook data, exposure to and perceived confidence in managing cases involving ETC and DCO were similar.

CONCLUSIONS

Despite changes in the training of junior orthopaedic surgeons, trainee-reported confidence and adequacy of training in the practical application of DCO and ETC was high. Exposure to cases overall was, however, seen to be limited and there was a suggestion of disparity between current operative experiences of trainees and that recorded in the national trainee logbook.     

The use and effectiveness of cadaveric workshops in higher surgical training: a systematic review

INTRODUCTION

The aim of this systematic review is to describe the use of cadavers in postgraduate surgical training, to determine the effect of cadaveric training sessions on surgical trainees'' technical skills performance and to determine how trainees perceive the use of cadaveric workshops as a training tool.

METHODS

An electronic literature search was performed, restricted to the English language, of MEDLINE®, Embase™, the Cumulative Index to Nursing and Allied Health Literature (CINAHL®), Centre for Agricultural Bioscience (CAB) Abstracts, the Educational Resources Information Center (ERIC™) database, the British Education Index, the Australian Education Index, the Cochrane Library and the Best Evidence in Medical Education website. Studies that were eligible for review included primary studies evaluating the use of human cadaveric surgical workshops for surgical skills training in postgraduate surgical trainees and those that included a formal assessment of skills performance or trainee satisfaction after the training session.

RESULTS

Eight studies were identified as satisfying the eligibility criteria. One study showed a benefit from cadaveric workshop training with regard to the ability of trainees to perform relatively simple emergency procedures and one showed weak evidence of a benefit in performing more complex surgical procedures. Three studies showed that trainees valued the experience of cadaveric training.

CONCLUSIONS

Evidence for the effectiveness of cadaveric workshops in surgical training is currently limited. In particular, there is little research into how these workshops improve the performance of surgical trainees during subsequent live surgery. However, both trainees and assessors hold them in high regard and feel they help to improve operative skills. Further research into the role of cadaveric workshops is required.     

Laparoscopy for Penetrating Thoracoabdominal Trauma: Pitfalls and Promises

Background:

How should the stable patient with penetrating abdominal or lower chest trauma be evaluated? Evolving trends have recently included the use of diagnostic laparoscopy. In September 1995 we instituted a protocol of diagnostic laparoscopy to identify those patients who could safely avoid surgical intervention.

Design:

Prospective case series.

Materials and Methods:

Hemodynamically stable patients with penetrating injuries to the anterior abdomen and lower chest were prospectively evaluated by diagnostic laparoscopy, performed in the operating room under general anesthesia, and considered negative if no peritoneal violation or an isolated nonbleeding liver injury had occurred. If peritoneal violation, major organ injury or hematoma was noted, conversion to open celiotomy was undertaken.

Results:

Seventy consecutive patients were evaluated over a two-year period. The average length of stay (LOS) following negative laparoscopy was 1.5 days, and for negative celiotomy 5.2 days. There were no missed intra-abdominal injuries following 30 negative laparoscopies, and 26 of 40 laparotomies were therapeutic. The technique also proved useful in evaluation of selected blunt and HIV+ trauma vic-tims with unclear clinical presentations. However, while laparoscopy was accurate in assessing the abdomen following penetrating lower chest injuries, significant thoracic injuries were missed in 2 out of 11 patients who required subsequent return to OR for thoracotomy.

Conclusions:

Laparoscopy has become a useful and accu-rate diagnostic tool in the evaluation of abdominal trauma. Nevertheless, laparoscopy still carries a 20% nontheraputic laparotomy rate. Additionally, significant intrathoracic injuries may be missed when laparoscopy is used as the pri-mary technique to evaluate penetrating lower thoracic trauma.     

Visuospatial and technical ability in the selection and assessment of higher surgical trainees in the London deanery

INTRODUCTION

Despite awareness of the limitations of current selection and competency assessments, there is little consensus and alternatives have not been readily accepted. Essential surgical skills include visuospatial and technical ability. The aim of this study was to survey current methods of higher surgical trainee selection and assessment. We suggest ways to improve the process.

MATERIALS AND METHODS

Nine surgical training programmes in the London deanery were surveyed through questionnaires to programme directors, existing trainees and examination of deanery publications.

RESULTS

Testing of visuospatial and technical ability was piloted at selection only in a single general surgical department. Practical skills were assessed in 3/9 (33%) specialties (ENT, plastic and general surgery). Once selected, no specialty tested visuospatial and technical ability. Practical skills were tested in only 1/9 (11%) specialties (plastic surgery). The remaining 8/9 (89%) were ‘assessed’ by interview.

CONCLUSIONS

Lack of visuospatial and technical ability assessment was identified at selection and during higher surgical training. Airlines have long recognised early identification of these qualities as critical for efficient training. There is a need for more objective methods in this area prior to selection as time to assess surgical trainees during long apprenticeships is no longer available. We advocate a suitably validated competency-based model during and at completion of training.     

Analysis of Orthopaedic Research Produced During the Wars in Iraq and Afghanistan

Background

Military orthopaedic surgeons have published a substantial amount of original research based on our care of combat-wounded service members and related studies during the wars in Iraq and Afghanistan. However, to our knowledge, the influence of this body of work has not been evaluated bibliometrically, and doing so is important to determine the modern impact of combat casualty research in the wider medical community.

Questions/purposes

We sought to identify the 20 most commonly cited works from military surgeons published during the Iraq and Afghanistan conflicts and analyze them to answer the following questions: (1) What were the subject areas of these 20 articles and what was the 2013 Impact Factor of each journal that published them? (2) How many citations did they receive and what were the characteristics of the journals that cited them? (3) Do the citation analysis results obtained from Google Scholar mirror the results obtained from Thompson-Reuters’ Web of Science?

Methods

We searched the Web of Science Citation Index Expanded for relevant original research performed by US military orthopaedic surgeons related to Operation Iraqi Freedom and Operation Enduring Freedom between 2001 and 2014. Articles citing these studies were reviewed using both Web of Science and Google Scholar data. The 20 most cited articles meeting inclusion criteria were identified and analyzed by content domain, frequency of citation, and sources in which they were cited.

Results

Nine of these studies examined the epidemiology and outcome of combat injury. Six studies dealt with wound management, wound dehiscence, and formation of heterotopic ossification. Five studies examined infectious complications of combat trauma. The median number of citations garnered by these 20 articles was 41 (range, 28–264) in Web of Science. Other research citing these studies has appeared in 279 different journals, covering 26 different medical and surgical subspecialties, from authors in 31 different countries. Google Scholar contained 97% of the Web of Science citations, but also had 31 duplicate entries and 29 citations with defective links.

Conclusions

Modern combat casualty research by military orthopaedic surgeons is widely cited by researchers in a diverse range of subspecialties and geographic locales. This suggests that the military continues to be a source of innovation that is broadly applicable to civilian medical and surgical practice and should encourage expansion of military-civilian collaboration to maximize the utility of the knowledge gained in the treatment of war trauma.

Level of Evidence

Level IV, therapeutic study.     

Managing the open abdomen in a district general hospital

Introduction

The need to manage an open abdomen is becoming more common in general surgical practice and a variety of methods of temporary abdominal closure (TAC) are available. The evidence for the efficacy of the various forms of TAC as well as the subsequent definitive fascial closure (DFC) rates and complications comes mainly from large trauma series in the US, which represent a different patient population to those in the UK in whom TAC is usually required.

Methods

All cases of open abdomen management in our hospital over a five-year period were reviewed to ascertain the methods of TAC used, our success in achieving DFC and the applicability of managing such cases in a district hospital environment.

Results

Nineteen patients underwent TAC, with two deaths (10.5%) and an overall DFC rate at hospital discharge of 12/17 (70.6%). The median lengths of critical care and hospital stays were 19.5 and 38.0 days respectively. Thirteen out of seventeen survivors had at least one significant complication.

Conclusions

The management of the open abdomen can be achieved safely in a district general hospital setting with acceptable outcomes for the non-trauma patients commonly seen in UK practice but it is a resource intensive and expensive undertaking.     

Local Anaesthetic Inguinal Hernia Repair Performed Under Supervision: Early and Long-Term Outcomes

INTRODUCTION

Local anaesthetic inguinal hernia repair may be technically demanding. There are minimal data regarding the outcomes of local anaesthetic hernia repair by trainees in comparison with consultants.

PATIENTS AND METHODS

All consecutive local anaesthetic repairs performed by trainees and one consultant over a 9-year period were reviewed. Operation time, volume of local anaesthetic used, early and long-term complications were assessed. A postal survey was conducted to assess chronic groin pain and satisfaction rates.

RESULTS

A total of 369 repairs were reviewed of which 265 repairs were performed by the consultant and 104 by trainees. The male-to-female ratio was 25:1 and the median age of the study group was 61 years (range, 18–93 years). The volume of local anaesthetic used was significantly higher for trainees than the consultant (42 ml versus 69 ml; P = 0.03). The operative time for the consultant and the trainees was 35 min and 40 min (P = 0.8). The day-case rate was higher for the consultant than the trainees (84% versus 69%; P = 0.02). Three patients operated by trainees required conversion to a general anaesthetic repair. No difference was noted in chronic groin pain (consultant 28% versus trainees 32%; P = 0.52) on the postal survey. The median follow-up was 5 years (range, 2–7 years).

CONCLUSIONS

Local anaesthetic inguinal hernia repair can be performed safely by surgical trainees under consultant supervision with minimal short- and long-term morbidity. A large volume dilute solution of Lignocaine and Marcaine is recommended when hernia repair is undertaken by trainees.     

Should Vascular Surgeons be Trained in Endovascular Techniques? – An Observational Study

INTRODUCTION

The aim of this study was to determine if there is a satisfactory cover for interventional radiology and whether vascular surgeons have received sufficient training in endovascular techniques.

MATERIALS AND METHODS

This was an observational study based on questionnaires sent to radiology and vascular trainers and vascular trainees in England. A total of 50 NHS trusts were chosen randomly to take part in the study and 320 questionnaires were sent out with an overall consultant response rate of 57%.

RESULTS

Of vascular consultants in the study group, 53% have had experience in endovascular procedures. Overall, 87% felt that there were not enough radiologists to fulfil the demand and 64% would like further training in endovascular procedures. In addition, 69% would like to be involved in a vascular rota without the general component. Similarly, 81% of radiologists felt that the demand was not being met, as emergency interventional radiology cover was not available on most nights in 65% of the trusts. Of responders, 72% would not object to training of vascular trainees in interventional work and 43% would be happy to be involved in training. Some 33% would accept a vascular trainee for 1 year.

CONCLUSIONS

Integrated fellowship in vascular surgery and interventional radiology has been implemented and tested in a number of centres in the US. This approach could be implemented in some of the larger vascular units in the UK.     

The spectrum of injuries resulting from posterior abdominal stab wounds: a South African experience

Introduction

The spectrum of injury associated with anterior abdominal stab wounds (SWs) is well established. The literature on the spectrum of organ injury associated with SWs to the posterior abdomen, however, is limited.

Methods

We reviewed our experience of 105 consecutive patients who had established indications for laparotomy managed over a 4-year period in a high volume trauma service in South Africa.

Results

Of the 105 patients, 97 (92%) were male and the overall mean age was 24 years. Fifty-seven patients (54%) had immediate indications for laparotomy. The remaining 48 patients (46%) initially underwent active clinical observation and the indications for laparotomy became apparent during the observation period. Of the 105 laparotomies performed, 94 (90%) were positive and 11 (10%) were negative. Of the 94 positive laparotomies, 92 were therapeutic and 2 were non-therapeutic. A total of 176 organ injuries were identified: 50 (53%) of the 94 patients sustained a single organ injury while the remaining 44 (47%) sustained multiple organ injuries. The most commonly injured organs were the colon (n=63), spleen (n=21) and kidney (n=19).

Conclusions

The pattern of intra-abdominal injuries secondary to SWs to the posterior abdomen is different to that seen with the anterior abdomen. Colonic injury is most commonly encountered, followed by injuries to the spleen and kidney. Clinicians must remain vigilant because of the potential for occult injuries.     

The Advanced Trauma Operative Management course in a Canadian residency program

Background

The Advanced Trauma Operative Management (ATOM) course was first introduced into Canada in 2003 at the University of Toronto, with senior general surgery residents being the primary focus. We present an assessment of the course in this Canadian general surgery residency program.

Methods

We compared trainees'' pre-and postcourse self-efficacy scores and multiple choice question (MCQ) examination results, using paired t tests and resident (n = 24) and faculty (n = 7) course ratings made according to a 10-item, 5-point Likert scale. Faculty were previously trained as ATOM instructors.

Results

Mean pre-and postcourse self-efficacy scores were 68.9 (standard deviation [SD] 24.0) and 101.4 (SD 14.8), respectively (p < 0.001). Mean pre-and post-MCQ scores were 16.4 (SD 3.2) and 18.8 (SD 2.7), respectively (p = 0.006). On the Likert scale (1 = strongly disagree, 5 = strongly agree), all faculty and residents rated the following items as 4–5: objectives were met; knowledge, skills, clinical training, judgment and confidence improved; the live animal is a useful representation of clinical trauma; and the course should be continued but would be more appropriate for the fourth rather than the fifth year of residency. Residents rated as 1–2 the item that the human cadaver would be preferable for learning the surgical skills. Of 24 residents, 20 rated as 3 or less the item stating that the course prepares them for trauma management more adequately than their regular training program.

Conclusion

Self-efficacy, trauma knowledge and skills improved significantly with ATOM training. Preference was expressed for the live animal versus cadaver model, for ATOM training in the fourth rather than fifth year of residency and for the view that it complements general surgery trauma training. The data suggest that including ATOM training in Canadian general surgical residency should be considered.     

Adrenal gunshot wound: Laparoscopic approach. Report of a case

INTRODUCTION

Although there is no debate that patients with peritonitis or hemodynamic instability should undergo urgent laparotomy after penetrating abdominal injury, it is also clear that certain stable patients may be managed without operation. Controversy persists regarding use of laparoscopy.

PRESENTATION OF CASE

We report a case of gunshot wounds with bullet in left adrenal gland and perirenal subcapsular hematoma. The patients had no signs of peritonitis but in the observation period we noted a significative blood loss, so we performed an exploratory laparoscopy.

DISCUSSION

We found the bullet in adrenal parenchyma. The postoperative period was regular and the patient was discharged without any local or general complication.

CONCLUSION

Although the data are still controversial, the importance of the laparoscopic approach is rapidly increasing also in case of penetrating trauma of the abdomen. This technique assumes both a diagnostic and therapeutic role by reducing the number of negative laparotomies.     

The Emergency Surgical Team – The Way Forward in Emergency Care?

INTRODUCTION

With reduced working hours and shift patterns, surgical training and continuity of patient care is being put at risk. We have devised a system for managing the emergency surgical patients in an effort to counteract these perceived problems. This study describes the emergency surgical team and audits its activity.

PATIENTS AND METHODS

The emergency surgery team concept is described in detail. Over a 2-week period, general surgical referral data, patient management and operative activity were audited.

RESULTS

A total of 229 patients were referred to the emergency surgical team with 159 treated conservatively, 45 underwent operative intervention and 25 were discharged without admission. Of the emergency surgical team referrals, 58% had gallstone pathology, appendicitis or constipation/non-specific abdominal pain. Average daily number of patients under the care of the emergency surgical team was 26 (range, 10–40).

CONCLUTIONS

The consultant-led emergency surgical team look after many of the acutely sick surgical patients. Our system not only provides good teaching opportunities but ensures optimal continuity of patient care in a busy district general hospital. Such an approach to emergency surgical care has been successfully developed to optimise training opportunities and improve patient care in a setting of reduced working hours and shift systems in our hospital.     

Challenges in the training of military surgeons: experiences from Dutch combat operations in southern Afghanistan

Background

To improve care for battle casualties, we analyzed the surgical workload during the Dutch deployment to Uruzgan, Afghanistan. This surgical workload was compared with the resident surgical training and the pre-deployment medical specialist program.

Methods

Patient data from the trauma registry (2006–2010) at the Dutch Role 2 Medical Treatment Facility (MTF) were analyzed. The case logs of chief residents (n = 15) from the general surgery training program in the Netherlands were used for comparison.

Results

The trauma registry query yielded 2,736 casualties, among whom 60 % (1,635/2,736) were classified as disease non-battle casualties and 40 % (1,101/2,736) as battle casualties. During the study period, 1,427 casualties (336 pediatric cases) required 2,319 surgical procedures. Each graduating chief resident handled an average of 1,444 cases, including 165 laparotomies, 19 major vessel repairs, 28 amputations, and 153 fracture stabilizations, during their residency. Residents had limited exposure to injuries requiring a thoracotomy, craniotomy, nephrectomy, IVC repair, or external genital trauma.

Conclusions

The injuries treated at the Dutch Role 2 MTF were often severe, and exposure to pediatric cases was much higher than reported for other combat hospitals in Iraq and in Afghanistan. The current civilian resident training does not equip the trainees with the minimally required competences of a fully trained military surgeon. The recognition in the Netherlands of military surgery as a subspecialty within general (trauma) surgery, with a formal training curriculum, should be considered. The introduction of a North Atlantic Treaty Organization Military (and Disaster) Surgery standard may facilitate the achievement of this aim.     

Bladder injuries in emergency/expedited laparoscopic surgery in the absence of previous surgery: a case series

INTRODUCTION

The use of laparoscopy as a diagnostic and therapeutic tool is being used increasingly in the emergency setting with many of these procedures being performed by trainees. While the incidence of iatrogenic injuries is reported to be low, we present six emergency or expedited cases in which the bladder was perforated by the suprapubic trocar.

CASES

Three cases were related to the management of appendicitis, two to negative diagnostic laparoscopies for lower abdominal pain and one to an ectopic pregnancy. Management of the bladder injuries varied from a urinary catheter alone to laparotomy with debridement of the abdominal wall due to sepsis and later reconstruction. Four of the six cases were performed by registrars.

CONCLUSIONS

Although the incidence of bladder injury is low, its importance is highlighted by the large number of laparoscopies being performed. In addition to catheterisation of the patient, care must be taken with the insertion of low suprapubic ports and consideration should be made regarding alternative sites. Adequate laparoscopic supervision and training in port site planning is required for surgical trainees.     

Whose Appendicectomy? – Do Laparoscopic Appendicectomies Impair SHO Training?

INTRODUCTION

Open appendicectomy is an ideal procedure for junior surgical trainees to develop operative skills. However, in recent years, we have noticed a decline in the number of appendicectomies performed by basic surgical trainees and a shift towards increasing use of laparoscopic appendicectomy. The aim of this study was to determine whether the growing popularity of laparoscopic appendicectomy is having a detrimental impact on the training experience of SHOs.

PATIENTS AND METHODS

We undertook a retrospective review of all cases of appendicectomies performed in one district hospital over a 7-year period (August 1999 to August 2006.) A standard performa was used to extract data from the original case notes of these patients relating to the operating surgeon and technique.

RESULTS

Data were obtained for 857 appendicectomies. Between February 2002 and July 2003, there was asignificant decline in the proportion of appendicectomies performed by SHOs from 78.7% to 29.3% (P < 0.001). Either side of this decline there were no significant changes in the proportion of SHO appendicectomies. The number of appendicectomies performed laparoscopically only began to rise after February 2004, with ayear-on-year increase. The number of appendicectomies performed by SHOs remained stable during this time. No laparoscopic appendicectomy was performed by an SHO.

CONCLUSIONS

We found no evidence that the popularisation of laparoscopic appendicectomy has contributedtothe decline of appendicectomies performed by SHOs. Nevertheless, with the continual rise in popularity of this procedure, it is important to balance training opportunities for both junior and higher surgical trainees.