Is direct consultant supervision of all trauma laparotomies necessary?

  • Ross David Weale Wessex Deneary http://orcid.org/0000-0001-9296-527X
  • Victor Y Kong University of the Witwatersrand
  • Joanna Blodgett University College London
  • George V Oosthuizen University of KwaZulu-Natal
  • John L Bruce University of KwaZulu-Natal
  • Wanda Bekker University of KwaZulu-Natal
  • Vassil Manchev University of KwaZulu-Natal
  • Grant L Laing University of KwaZulu-Natal
  • Damian L Clarke University of the Witwatersrand
Keywords: trauma, general surgery, laparotomy

Abstract

Introduction: This study examines the nature of trauma laparotomies performed primarily by trainees and those performed under the direct supervision of a consultant.

Materials and Methods: A retrospective review was undertaken at the Pietermaritzburg Metropolitan Trauma Service (PMTS), South Africa. All patients who underwent a trauma laparotomy were included. Admission physiology, organ injury and outcome were assessed. Statistical comparison using STATA was performed. Chi-squared analysis was used for categorical variables and unpaired T-test for physiology.

Results: A total of 562 patients for trauma laparotomy were identified. Ninety percent (506/562) were male and the mean age was 30 years. The in hospital mortality was 7% (40/562). A consultant was present at 35% of cases (197/562). Consultantlead operations were found to have a higher rate of mortality 16% vs 2% (32/197 vs 8/365: p < 0.001) and ICU 45% vs 25% (89/197 vs 91/365: p < 0.001) than trainee only. Significant differences in many parameters of admission physiology were identified. Consultant-lead procedures had a higher lactate (3.7 vs 2.9: p 0.0043), respiratory rate (RR) (22 vs 20: p 0.0005), heart rate (HR) (102 vs 96: p 0.0035) and a lower systolic blood pressure (SBP) (115 vs 122: p 0.0001) diastolic blood pressure (DBP) (69 vs 73: p 0.0350) pH (7.34 vs 7.36: p 0.0216) base excess (BE, mEq/L) (-4.1 vs -2.5: p 0.0036) and bicarbonate (HCO3, mEq/L) (21.3 vs 22.5: p 0.0043) than trainee only procedures. Consultants were more likely to be called in for a gunshot than a stab wound (p < 0.001). Of the solid organ injuries, consultants are more likely to be called in for cases with liver injury 23% vs 16% (45/197 vs 58/365: p 0.005) and pancreatic injury 15% vs 3% (30/197 vs 11/365: p < 0.001).

Conclusion: Trainees can safely undertake a subset of trauma laparotomies. However, patients with deranged physiology and complex hepatobiliary injuries should be operated on directly by a consultant.

Author Biographies

Ross David Weale, Wessex Deneary
Department of General Surgery, Wessex Deanery, United Kindgom
Victor Y Kong, University of the Witwatersrand

Department of Surgery, University of the Witwatersrand, Johannesburg; and Department of Surgery, University of KwaZulu-Natal, Durban, South Africa

Joanna Blodgett, University College London
Department of Epidemiology, University College London
George V Oosthuizen, University of KwaZulu-Natal
Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
John L Bruce, University of KwaZulu-Natal
Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
Wanda Bekker, University of KwaZulu-Natal
Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
Vassil Manchev, University of KwaZulu-Natal
Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
Grant L Laing, University of KwaZulu-Natal
Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
Damian L Clarke, University of the Witwatersrand

Department of Surgery, University of the Witwatersrand, Johannesburg; and Department of Surgery, University of KwaZulu-Natal, Durban, South Africa

Published
2018-11-08
How to Cite
Weale, R., Kong, V., Blodgett, J., Oosthuizen, G., Bruce, J., Bekker, W., Manchev, V., Laing, G., & Clarke, D. (2018). Is direct consultant supervision of all trauma laparotomies necessary?. South African Journal of Surgery, 56(4), 23-27. Retrieved from http://sajs.redbricklibrary.com/index.php/sajs/article/view/2649
Section
Trauma