|Year : 2014 | Volume
| Issue : 4 | Page : 185-189
A structured preceptorship programme for laparoscopic colorectal surgery in Wales: An early experience
Michael Rees1, Avanish Saklani2, Parin Shah1, Puthucode Haray3
1 Department of Surgery, Prince Charles Hospital, Merthyr Tydfil, Wales, United Kingdom
2 Department of Surgery, Princess of Wales Hospital, Bridgend, United Kingdom
3 Department of Surgery, Prince Charles Hospital, Merthyr Tydfil, Wales; Department of Coloproctology, University of Glamorgan, Pontypridd, United Kingdom
|Date of Submission||27-Jun-2013|
|Date of Acceptance||29-Oct-2013|
|Date of Web Publication||23-Sep-2014|
Modular Building 2, Prince Charles Hospital, Merthyr Tydfil, Wales, CF47 9DT
Source of Support: None, Conflict of Interest: None
Introduction: A single experienced laparoscopic colorectal surgeon introduced an outreach preceptorship programme (OPP) for laparoscopic colorectal surgery (LCS) in Wales with the aim of supporting consultants in the early stages of their learning curve, as well as to help avoid some of the problems faced by self-taught laparoscopic surgeons. The structured programme consisted of a minimum 1 day master class at the preceptor's operating theatre, followed by multiple outreach visits by the preceptor. The aim of this study was to evaluate the effectiveness and early experience of this programme. Materials and Methods: Clinical end-points (conversions, morbidity/mortality and length of hospital stay) were analysed from a prospectively maintained database. Evaluation of the programme was based on interviews with the preceptee surgeons performed by a neutral observer. Results: Between May 2008 and July 2010, 11 Consultants (six hospitals) were preceptored (two still in programme). 66 cases (20 in the master class, 46 as an outreach service) were performed as a part of this programme. Clinical outcome: Conversion rate and 30-day mortality was 1.5%. Morbidity was reported at 12% (8/66) and median length of stay was 6 days. Programme evaluation: All interviewed respondents found the master class and outreach service to be well-organised and would recommend it to their colleagues. The median number of outreach visits per hospital was 5. All the preceptees have performed independent cases since the programme. Conclusion: This OPP delivers one-to-one coaching at the point of service delivery and has been shown to be effective in achieving safe transference of skills to those wishing to develop a service for LCS.
Keywords: Colorectal, laparoscopic, preceptorship, training
|How to cite this article:|
Rees M, Saklani A, Shah P, Haray P. A structured preceptorship programme for laparoscopic colorectal surgery in Wales: An early experience
. J Min Access Surg 2014;10:185-9
|How to cite this URL:|
Rees M, Saklani A, Shah P, Haray P. A structured preceptorship programme for laparoscopic colorectal surgery in Wales: An early experience
. J Min Access Surg [serial online] 2014 [cited 2020 Jul 4];10:185-9. Available from: http://www.journalofmas.com/text.asp?2014/10/4/185/141512
| ¤ Introduction|| |
In 2006, National Institute for Health and Clinical Excellence (NICE) recommended laparoscopic surgery as an alternative to open surgery for colorectal resections.  The Bowel cancer report commissioned by the cancer services coordinating group revealed that in Wales only 9.5% of colorectal resections were performed laparoscopically between 2005 and 2007.  In 2007, the Association of Laparoscopic Surgeons of Great Britain and Ireland set up the National Training Programme (LAPCO), intended to train existing consultant surgeons. However, this programme had funding to cover training only in English regions. Therefore, an alternative approach was needed in Wales to train existing surgeons. Although the Welsh Assembly Government did set aside some funds for laparoscopic colorectal training in Wales in 2008, this was used mainly to develop an immersion course for existing consultants and a laboratory based training scheme for registrars, delivered from one centre only. There was no proposal for an outreach preceptorship style programme to deliver training and support at the point of service delivery. At this time, very few hospitals in Wales had an existing established laparoscopic colorectal service. Setting up such a service would require 'team training' with a focus on developing not only the operating surgeon, but also the rest of the team including the anaesthetist and nurses.
The Outreach Preceptorship Programme (Opp)
A single experienced surgeon (preceptor) introduced a preceptorship programme aimed at supporting existing consultants (preceptees) wishing to develop laparoscopic colorectal surgery (LCS) services at their centre. Preceptees were expected to have attended relevant courses, workshops (including live animal laboratory) and be able to demonstrate management support for a new service development. The programme consisted initially of a minimum 1 day master class at the preceptor's operating theatre attended by the preceptee and his team where they would observe 2-3 laparoscopic colorectal resections. This was to focus primarily on team development and to facilitate rapport between the preceptor and preceptee. This was followed by several visits by the preceptor to the preceptee's hospital to assist in cases. At the first outreach visit the preceptor was accompanied by his own middle grade and theatre nurse. This was to ensure competent assistance and to supervise and support the nursing team, leaving the preceptor free to concentrate on training the consultant surgeon during the case. The preceptor and his team were all contracted on an honorary basis by the preceptee's hospital for each visit.
The number of outreach visits and supervised cases was dependent on the individual preceptee's progress and stage in their own learning curve. Each case was performed on the basis of a standard step-wise approach to each resection. Patient safety and duration of procedure were paramount considerations and were maintained under control by the preceptor. Arrangements for clinical governance considerations at each hospital were met by the preceptee. Preceptorship was tapered at each visit, varying from the preceptor being scrubbed for the entire procedure to providing verbal support only. Case selection was discussed prior to each visit, including a review of relevant pre-operative investigations by the preceptor and the initial cases were standard right hemicolectomy and high anterior resection with progression to more challenging cases as the preceptee gained confidence.
This programme was funded through an educational sponsorship from Johnson and Johnson (Ethicon Endosurgery® ) .
| ¤ Aim|| |
The aim of our study was to evaluate the early experience of this programme with regards to the clinical outcome as well as preceptee satisfaction.
| ¤ Materials and methods|| |
A prospective database was maintained to record cases performed as a part of master class or OPP. The programme remains on-going, but for the purpose of this paper data from the start of the programme (May 2008) until July 2010 has been analysed. Follow-up data including mortality, morbidity and length of stay was obtained through postal/telephone questionnaire. In addition, two neutral observers (the first and second authors) used a structured questionnaire to interview each preceptee surgeon either in person or through the post, to obtain some feedback about the programme.
| ¤ Results|| |
Between May 2008 and July 2010, 11 consultants were inducted and 66 cases (20 in Master class, 46 as an outreach service) were performed as a part of this programme. Right hemicolectomy was the most commonly performed operation (n = 24), but cases also included complex major procedures such as panproctocolectomy and total colectomy for consultants who had already been performing some LCS prior to the programme [Table 1]. The indication for surgery was predominantly colorectal cancer (65.5%). The median number of outreach visits per hospital was five [Table 2].
|Table 2: Distribution of preceptees with number of cases and preceptor's visits|
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In total there were 12 intra-operative events (18%) that could have led to conversion [Table 3]. All but one of these events however were managed laparoscopically, therefore conversion rate was low at 1.5% (1/66). This one conversion seen in our series to date was due to difficulty identifying the left ureter during an anterior resection.
|Table 3: Significant intra-operative events with possibility of conversion|
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Overall 30-day mortality was 1.5% [Table 4]. This was due to a delayed anastomotic leak followed by multi-organ failure in a patient who had a low anterior resection after neo-adjuvant therapy. The patient did not have a covering ileostomy. The overall morbidity was 12% (8/66). There were three anastomotic leaks, one of which occurred at day 20, resulting in the mortality mentioned above. Another patient required a secondary Hartmann's procedure and the third patient was clinically well and managed conservatively. There were two cases of post-operative bleeding, one (part of the master class) managed with a laparoscopic washout and the other by a laparotomy (part of the OPP). There was one full thickness abdominal wound dehiscence (part of OPP).
Median length of hospital stay was 6 days (range: 2-30). All the patients who underwent LCR for cancer had clear margins with a median lymph node harvest of 11.5 (range: 2-23). One patient undergoing a low anterior resection had a rectal perforation, the site of which was well clear of the tumour.
To evaluate the programme, 11 of the preceptee consultant surgeons from five hospitals were interviewed. All the respondents found the master class and outreach service to be well organised and all would recommend the service to their colleagues. The four consultants who were already practising some LCS felt that the programme had improved their practice with regards to safety and confidence. Following the programme, all preceptored consultants have performed laparoscopic cases independently.
When the respondents were asked to rate various courses available for developing LCS skills on a visual analogue scale (0-10), the median score for animal workshops (5.5), master class alone (7.0), websurg® (7.0), immersion course (8.0) were all less than the score for the OPP (8.5).
All the 11 respondents found the master class to be well organised, with a good case-mix and felt that the preceptor demonstrated all relevant steps and answered all their queries. They found the direct observation and interaction on a one-to-one basis extremely beneficial. The visiting theatre staff from other hospitals also found the master class experience helpful.
All 11 respondents felt that the preceptor was approachable for discussing case selection and was flexible with dates of visit. They also found the preceptor to be supportive, encouraging them to perform as much of each procedure as safely possible. 9 of the 11 preceptored consultants felt the number of outreach visits to be the right amount, while two felt it was less than they required.
All surgeons except two are currently performing LCS in their hospitals. One of the two surgeons is very senior and close to retirement, hence the uptake of the laparoscopic approach has been relatively slow. All the other preceptee surgeons have been undertaking standard right and left side resections routinely and some have progressed to complex, benign and multi-segmental resections,
There was unanimous agreement amongst the preceptored consultants that the structured programme had helped improve their practice and all would recommend this programme to their colleagues.
| ¤ Discussion|| |
Since NICE recommended laparoscopic surgery as an alternative to open surgery for colorectal cancer, there has been a steady increase in the uptake of LCS across the UK.  This however has highlighted the need of appropriate training for surgeons. The absence of formal training and hence the initial slow uptake of LCS in Wales has been addressed by this preceptorship programme. The unique points of this programme are its flexibility to provide Preceptees the opportunity to be trained in selected cases, in their own hospital environment and with their own team.
Various recommendations have been made to maintain operator competence, such as a frequency of at least two procedures per month or 24 annually.  A Questionnaire Survey of Association of Coloproctology of Great Britain and Ireland (ACPGBI) members in 2008 revealed that only 25% of colorectal cancers were being treated laparoscopically.  This percentage is variable however with some centres reporting figures as high as 90% for elective laparoscopic colorectal resections. ,
The concept of preceptorship itself is not new.  Even in the context of LCS in the UK, this was established in 2004 under the auspices of the specialist associations of laparoscopic surgery and coloproctology.  However, the national LAPCO programme has largely replaced this preceptor programme in England. The model of the programme we describe in this paper is similar in its structure except for the avoidance of any compulsion on the preceptee on achieving specific case numbers. The authors also believe the hierarchical guidelines developed by the Council of the Colorectal Surgical Society of Australia and New Zealand to be too rigid, with limitations imposed by case selection etc. This not only prolongs the learning curve but also limits the ability to tailor training depending on an individual surgeon's ability.  This programme, therefore, allows specific one to one tutoring, facilitating the progress of each individual preceptee at his/her own pace. Although in- house preceptorship is ideal, having been shown to improve LCS workload, , very few units in the UK can offer such opportunity at the present time.
As per the ACPGBI/Association of Laparoscopic Surgeons of Great Britain and Ireland programme, a preceptor should have performed a minimum of 100 laparoscopic resections. We however felt that though this may be sufficient to train registrars, a preceptor may need greater experience before taking on the training of consultant peers. Registrar training in a consultant's own operating theatre is quite different to training a consultant colleague in an alien environment with unfamiliar staff, necessitating a different skillset including a greater level of confidence and good people management skills. Supervision and training needs to be provided without condescension whilst not compromising patient safety. Immersion courses are aimed at training the surgeon to operate in a controlled environment at the trainers' centre of excellence. Even though some immersion courses offer team training, it remains different to training at the point of service delivery. This point has been shown in the feedback from the preceptees in our programme. This paper also highlights the fact that even during the early stages of a preceptee's learning curve; intra-operative problems can be surmounted satisfactorily with appropriate guidance from a skilled preceptor as demonstrated by a relatively low rate of conversion of 1.5%.
Our preliminary evaluation of this structured training programme reveals that LCS can be developed with acceptable levels of morbidity, mortality and conversion rates. This finding is confirmed with a previous publication by Araujo et al. which has shown comparable outcomes between case matched series of operations performed by preceptors independently and preceptees being trained.  Our survey has demonstrated that all the preceptees valued the presence of experienced theatre staff accompanying the preceptor at the first outreach visit. Not all anaesthetists (2/11) attended the master class and hence it is not surprising that most surgeons (7/11) felt the programme had not materially changed anaesthetic practice in their hospital. The fact that all of the preceptored consultants were satisfied with the programme and would recommend it to colleagues is very encouraging.
The number of visits varied between individuals with the median number of visits per hospital being five. The LAPCO programme has specified that a minimum of 20 cases (an arbitrary number) would be required to reach a level of competence. Our programme is one of facilitation and not accreditation, which reflects the difference in case numbers performed by each preceptee and also highlights its flexibility to accommodate consultants with varying degrees of expertise.
LCS includes a range of operations with different levels of technical difficulty as well as wide ranging complexity due to different pathological processes such as inflammatory bowel disease, complicated diverticular disease and malignancy. Hence, traditional indicators such as the number of cases operated, conversion rates, mortality and morbidity are not reliable indicators for the assessment of competence. , The programme described in this paper has the flexibility to offer subsequent visits by the preceptor as and when the preceptee starts undertaking more complex cases and indeed, some of the preceptees in this series have already requested a 'second round' of preceptorship. The most important aspect of this programme is that training is not continuous but intermittent. Once a preceptee feels confident to perform simpler colorectal resections, he can then be preceptored to perform more complex cases. As seen from our results, one preceptee has performed a laparoscopic panproctocolectomy as part of this programme.
In our programme, the median number of cases per preceptee was only five, which is not enough to gain competency in LCS. The purpose of this programme was to try and combine the existing skills of consultant colleagues in general laparoscopic as well as open colorectal surgery. This paper deliberately makes no attempt to demonstrate that the preceptees have achieved 'competence' (by providing data regarding their LCS workload, conversion rates, complications etc.) as such an analysis would be a breach of the principles underpinning this programme, which was established as one of facilitation and not aimed at achieving 'competency' nor to provide 'accreditation'.
This programme is an excellent example of partnership between the National Health Service (NHS) and a private provider (Johnson and Johnson® ) with the funding serving to backfill the preceptor's absence from his own NHS commitments and to support research and educational activities in the Preceptor's Department.
| ¤ Conclusion|| |
This OPP has been shown to be effective in achieving safe transference of skills to surgeons wishing to develop a service for LCS in their own departments, with acceptable levels of morbidity and mortality. Such a programme, delivering one-to-one training at the point of service delivery, may play a vital role in making safe LCS available widely.
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[Table 1], [Table 2], [Table 3], [Table 4]