Elsevier

Journal of Surgical Education

Volume 76, Issue 5, September–October 2019, Pages 1364-1369
Journal of Surgical Education

ORIGINAL REPORTS
Stepwise Training in Laparoscopic Surgery for Complex Ileocolonic Crohn's Disease: Analysis of 127 Training Episodes

https://doi.org/10.1016/j.jsurg.2019.03.009Get rights and content

Introduction

The inflammation encountered in Crohn's disease makes a minimally invasive approach challenging due to a thickened mesentery, fistulas, abscesses, and large phlegmons with high reported rates of conversion and septic complications. Aim of this study was to evaluate the feasibility of a stepwise approach to training in laparoscopic surgery for complex Crohn's disease.

Methods

Every surgical procedure was divided in 4 different training tasks: access and exposure, bowel mobilization, division of the mesentery, anastomosis. Extensive adhesiolysis and division and repair of fistulae were considered as additional tasks when present. The laparoscopic competence assessment tool was used to evaluate the safety and proficiency of the surgical performance. The primary outcome was the rate of training tasks successfully completed by surgical trainees.

Results

One hundred and twenty seven training episodes were included and 86 were performed by trainees (67.7%). Fistula division was the less commonly performed training task (25%), while mobilisation and anastomosis were performed by the supervised trainee in 90% and 85% of the cases. Safety and proficiency scores were significantly higher for senior trainees compared to junior trainees.

Conclusions

Laparoscopic surgery for complex Crohn's disease can be safely performed in a supervised setting with acceptable operating time, postoperative length of hospital stay, and 30 day morbidity.

Section snippets

INTRODUCTION

The advent of laparoscopic surgery has dramatically changed the landscape of colorectal surgery for both benign and malignant disease. Laparoscopy offers well-described benefits1 such as decreased pain, lower wound complication rates, improved pulmonary function, earlier resumption of diet and bowel function, better cosmesis and shorter hospital stay2 when compared to open surgery.

However, widespread use of laparoscopy in Crohn's disease (CD) has been more limited due to technical constraints:

Study Settings

All patients undergoing laparoscopic surgery for penetrating or recurrent ileocolonic CD from January 2017 to December 2018 were included in this prospective observational study. Patients undergoing open, single-incision, robotic or hand-assisted surgery were excluded as were patients undergoing emergency operations. The indication for surgical resection was discussed at a dedicated inflammatory bowel disease multidisciplinary team meeting involving gastroenterologists, colorectal surgeons,

RESULTS

One hundred and twenty-seven training episodes were included and 86 were performed by trainees (67.7%). 48 tasks (37.8%) involved penetrating CD with fistula formation, while the remaining 79 included redo surgery for recurrent CD (62.2%). Junior trainees only performed 41 of the 72 tasks they were involved in (56.9%), while senior trainees performed 46 out of 55 tasks (83.6%) p < 0.0001.

Fistula division was the less commonly performed training episode (25%), while mobilisation and anastomosis

DISCUSSION

Despite the benefits of laparoscopic surgery,16 a considerable number of CD patients may be a formidable challenge even for the most experienced laparoscopic surgeon,17 who also has to be prepared to deal with unexpected findings that may require additional surgery, such as proximal strictures, fistulas, abscesses, or phlegmons, which can be identified in about 20% of patients.18 Surgery for CD is technically challenging and the perioperative decision making of when to operate and whether to

CONCLUSIONS

A stepwise training approach can be applied to laparoscopic surgery for complex Crohn's disease with a high rate of tasks successfully performed by supervised trainees and an acceptable profile of postoperative outcomes.

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