Mentoring Complex Laparoscopic Surgery in Children: Lessons Learnt from Laparoscopic Choledochal CYST Excision

Abstract

BACKGROUND: With advances in laparoscopic surgery, many pediatric surgical conditions can now be treated minimally invasively. However, acquiring the skills in the operations of complex conditions such as choledochal cysts remains a challenge. Here, we summarize the experiences in mentoring the learning of laparoscopic choledochal cyst excision in a tertiary referral center in China. METHODS: Having accumulated experience and necessary skills in performing more simple laparoscopic surgery (inguinal hernia; appendicitis; laparoscopic anorectoplasty), the “learning” surgeon decided to embark on performing choledochal cyst excision laparoscopically. The data of first 10 patients (June 2010 to January 2011) were reviewed. RESULTS: 10 cases were successfully operated during the study period laparoscopically. The “training” surgeon performed the first case with the “learning” surgeon as assistant. For the second and third cases, the “learning” surgeon carried out the dissection and excision of the choeldochal cyst and the jejunojejunostomy, while the hepaticojejunostomy was done by the “training” surgeon. The fourth and fifth cases were performed by the “learning” surgeon with the “training” surgeon assisting and helping out only at necessary steps during the procedure. For six to eighth cases, the “learning” surgeon was assisted by surgical trainees with the training” surgeon unscrubbed and advised if required. The ninth and tenth cases were operated independently by the “learning” surgeon. The average time of operation for the ten cases was 4.5 hours (range 3.5-6.0 hours). Two patients had minor postoperative bile leak, which resolved with conservative management. All patients were discharged between 7 to 10 days. At three month follow up, there was no evidence of anastomotic stricture. CONCLUSION: The teaching of complex laparoscopic surgery in children is a step-wise process and in the case of choledochal cyst excision, it can be smoothly and quickly learnt in the hands of an advanced laparoscopic surgeon.