Mentored Trainees Obtain Comparable Operative Results to Experts in Complex Laparoscopic Colorectal Surgery

Laparoscopic Reversal of Hartman’s Procedure (LRHP) is a demanding laparoscopic colorectal procedure usually performed by experienced surgeons. The aim of this study is to evaluate the impact of an expert monitoring on the quality and results of LRHP performed by trainee surgeons.

Materials and methods:
Fourty-two LRHP were performed between 2000 and 2008. The procedure was standardized by an expert in colorectal surgery. This included port placement, adhesiolysis, rectal stump management, splenic flexure mobilization, and colorectal anastomosis with early introduction of the anvil through the stoma. Trainee surgeons (experience inferior to 20 colorectal surgeries) were mentored by an expert surgeon (experience over 2,000 colorectal procedures). Operative time, conversion, complications and post-operative outcome were measured. The group of patients operated upon by the senior colorectal surgeon was compared to the group of patients operated upon by the trainee surgeons while being mentored by the senior surgeon.

Each group included 21 patients. All patients underwent LRHP successfully and no mortality occurred. No intra-operative significant difference was observed between the group of trainees and experts: operative time was of 131 minutes (range: 70-230) vs. 132 minutes (range: 60-240); conversion rate: 2 (1 ureteral injury in the trainee’s group, repaired intra-operatively and 1 difficult adhesiolysis in the expert’s group). Complications occurred in 6 patients (14%), 3 requiring re-operation (7%). Two complications occurred in the trainee’s group (1 early anastomotic stricture requiring re-operation, 1 late stenosis requiring endoscopic dilation). Four complications occurred in the expert’s group (two patients were re-operated upon during the first 30 days, 1 for a post-operative obstruction and 1 for an early post-operative fistula) and two were treated medically (1 port site infection, 1 rectorrhagia). The patient post-operative outcomes were comparable in both groups: oral intake: 3 vs. 2 days; hospital stay: 6 vs. 7.5 days.

Performing these difficult but standardized laparoscopic procedures offers the same results as when performed by trainees mentored by an expert surgeon, or carried out by an expert. The observed complication rate (14%) was comparable to that of experienced centres (131 to 48%2, including anastomotic leaks2; ureteral injury1, anastomotic strictures1,2 and re-operations (3.31 to 19%2). The expert mentoring does not prevent all intra-operative complications in challenging procedures, but can solve intra-operative technical problems that make the trainee more confident. Additionally, no intra-operative complication was encountered. Trainee mentoring and procedure standardization will probably increase their ability to perform more advanced procedures without any additional risk for the patient. Mentoring should be promoted as it can be performed locally or remotely through modern interactive technology.

1. Haughn C, Ju B, Uchal M, Arnaud JP, Reed JF, Bergamashi R. Complication rates after Hartmann’s reversal: open vs. laparoscopic approach. Dis Col Rect 2008;51:1232-1236.
2. Aydin HN, Remzi FH, Tekkis PP, Fazio VW. Hartmann’s reversal is associated with high postoperative adverse effects. Dis Col Rect 2005;48:2117-2126.

Session: Podium Presentation

Program Number: S037

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