Correlation between consultant presence and clinical outcome for trauma laparotomy - Implications for surgical training.

Abstract

Background: Surgical training relies on graduated levels of responsibility, where incrementally less supervision is required as the trainee progresses. Emergency trauma laparotomy is both a high risk operation and an important training opportunity; a balance must be maintained between ensuring patient safety and allowing trainee surgeons to develop independent competence. This study set out to assess whether consultant presence at trauma laparotomy results in improved outcomes and to develop criteria for consultant attendance.

Methods: We retrospectively analysed 1300 trauma laparotomies at a tertiary South African trauma centre, comparing consultant-present (n = 611) and trainee-led (n = 689) cases. Multivariable logistic regression estimated adjusted odds ratios for mortality and complications, controlling for injury severity and physiology.

Results: Consultant-present patients were sicker (ISS 13 vs 9, p < 0.001) and more often underwent damage control surgery (27% vs 11%, p < 0.001), with higher crude mortality (11% vs 6%, p < 0.001). After adjustment, consultant presence was not associated with mortality (adjusted OR 1.44, 95% CI 0.91-2.27, p = 0.12) or complications. A residual excess persisted in the highest acuity groups (ISS ≥ 16, adjusted OR 2.35; penetrating trauma, 2.15).

Conclusions: Mandating a consultant surgeon at each trauma laparotomy is unnecessary and trainees are capable of safely and effectively performing trauma laparotomy in appropriately selected patients. The presence of a consultant surgeon reflects the acuity and severity of the injury in each individual patient. Whether trainee-led surgery is equally safe in the most severely injured remains unconfirmed.