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Which Errors Predict Unsuccessful Lapco Sign-Off?

The Lapco sign-off assessment was introduced to ensure the consultant trainees are reaching a high operative standard before starting independent practice. This involves assessment of two resections by two independent, blinded experts. In conjunction with marking the case using the validated L-CAT form and assessing whether or not the trainee should embark on independent practice, the expert makes comments on the operative performance. The aim of this study was to identify which errors predicted failure to pass the sign-off process.

All of the sign-off assessors’ comments were analysed and the errors were classified; initially into broad categories and then into more specific technical errors. Two levels of logistic regression analysis were then performed to identify which errors predicted ‘failure’. Descriptions of the significant errors are written below; some of the explanations are accompanied by videos from sign-off submissions to demonstrate the errors. The videos are taken from cases which were unsuccessful and include the assessors’ comments regarding the case.

(The errors are classified by Name: Description of the error and odds ratio (OR))

1. Missing information: - The video was deemed incomplete by the assessor with crucial stages of the operation eg port insertion or anastomosis. (OR = 8.7)

2. Distal division of the vascular pedicle: - The pedicle was divided too distally. (OR=2.9)

This is an excerpt from a right hemi-colectomy; the surgeon has dissected out the ileocolic pedicle and is dividing it. The assessors commented the division is too distal.

Distal Division of the pedicle

3. Inadequate resection: - The assessor felt that the resection margins described in pathology report were inadequate for tumour clearance. (OR = 5.8)

4. Small bowel injury: - If the trainee causes actual or potential thermal injury to the small bowel due to inadequate cooling of the energy device. (OR=4.8) 

This is an excerpt from a right hemi-colectomy and the trainee is dissecting the mesocolon from the duodenum. The assessors comment on touch burns to the duodenum during this dissection.

Small Bowel Injury

5. Damage to the mesocolon or mesorectum: - Breach of the corresponding mesentery whilst dissecting the colon or the rectum. (OR=3.4)

This is an excerpt from a sigmoid colectomy; the trainee is dissecting the IMA pedicle. The assessors comment that the dissection starts on the ascending left colic damaging the sigmoid mesocolon before correctly identifying the IMA trunk.

Damage to the Mesocolon

6. Incorrect or unclear plane around pedicle: - The trainee dissects in the incorrect plane around the pedicle or the pedicle was not defined clearly before division. (OR=4.1)

This is a clip from a right hemi-colectomy; the trainee is dissecting the ileocolic pedicle. Both assessors comment that the dissection and division of the pedicle is unclear.

Unclear Dissection of the Pedicle

7. Consistently or often out of plane: - The trainee is frequently or always in the wrong plane during the dissection.(OR = 3.8)

8. Poor anastomotic technique/Dehiscence of the anastomosis: - If the anastomotic technique is deemed poor or if the integrity of the anastomosis raises concern. (OR = 11.6)

This is a clip showing the anastomosis in an anterior resection. There are some serosal tears following the firing of the gun. These are re-enforced by some sutures, however the assessors comment that they are still concerned about the anastomosis.

Poor Anastomosis