Munther I. Aldoori

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 a significant 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 a year-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 contributed to the 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.

Aortoduodenal fistula and streptococcal myonecrosis.

Pyomyositis is a rare primary bacterial infection of the skeletal muscles. Pyomyonecrosis is the most severe manifestation of this disease and is associated with a potentially devastating outcome. Patients with peripheral vascular disease presenting with pyomyositis may be difficult to distinguish from those with critical ischemia or synthetic graft sepsis. This article reports on a patient with aortobifemoral bypass graft and severe vitamin B12 deficiency who developed pyomyonecrosis and aortoduodenal fistula. This article highlights the etiologic dilemma, diagnostic difficulties, and management challenges inherent in such cases. Pitfalls in our management of this patient are discussed.

Authors's Response 1.

We agree with Laughlan and colleagues that the proportion of laparoscopic appendicectomies performed in our district general hospital is considerably less than those performed in a teaching hospital, and that this could explain why our study did not demonstrate the reduction in SHO operative experience we expected to find. Nevertheless, we believe that our data are likely to reflect the situation in many district general hospitals, with the change in working patterns having a far greater influence on SHO training experiences over the last 10 years. Despite this, the data provided by Laughlan and co-workers suggest that the further popularisation of laparoscopic appendicectomy is likely to contribute to the depletion of SHO training opportunities. This serves to highlight the pressing need to re-examine the way in which junior surgeons are trained.

Authors' Response 3

The suggestion by Khan and colleagues that senior trainees should be formally required to train juniors as part of their own training requirements is an interesting one. This would certainly help to balance the training opportunities between junior and senior trainees, but more detail would be required as to how this would work in practice. With the increasing pressures placed on junior trainees by hospital-at-night, we believe that ring-fenced training opportunities should be identified. Moreover, there should be a formal recognition of contractual time for consultants to train junior surgeons. These aims could be addressed by having dedicated training lists for juniors on a weekly basis.