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Maintaining surgical skills for military general surgery: the potential role for multivisceral organ retrieval in military general surgery training and practice
  1. David O'Reilly1,2,
  2. J Lordan2,
  3. C Streets3,4,
  4. M Midwinter5,6 and
  5. D Mirza2
  1. 1Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
  2. 2Department of Hepatobiliary and Transplant Surgery, University Hospitals Birmingham, Birmingham, UK
  3. 3Oesophagogastric Surgery Unit, University Hospitals Bristol, Bristol, UK
  4. 4DCA General Surgery, Joint Medical Command, DMS Whittington, Lichfield, UK
  5. 5NIHR Surgical Reconstruction & Microbiology Research Centre, University of Birmingham, Birmingham, UK
  6. 6Clinical Unit, Royal Centre for Defence Medicine, Birmingham, UK
  1. Correspondence to Wg Cdr David O'Reilly, Academic Department of Military Surgery and Trauma, ICT Centre, Vincent Drive, Edgbaston B15 2SQ, UK; djoreilly{at}doctors.org.uk

Abstract

The closure of the Medical Treatment facility in Camp BASTION and the return to contingency operations presents a new challenge in training and maintaining the skills of military surgeons. Multivisceral organ retrieval presents a unique opportunity to practice some of the more unusual techniques required in military surgery in the National Health Service. This article details the experience that organ retrieval offers and matches this to the needs of military surgeons. National Organ Retrieval Service teams need skilled surgeons, and a mutually beneficial partnership is in prospect.

  • MEDICAL EDUCATION & TRAINING

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The past decade of intense military operational activity and the exposure of Defence Medical Services (DMS) surgical teams to the management of combat casualties has provided excellent opportunities for surgeons to experience the realities of war surgery.1–3 Deployment of surgical registrars has allowed them to gain experience of the management of severe ballistic injury while acting as a force multiplier for the military surgical cadre. With the closing of the Medical Treatment Facility at Camp BASTION, this opportunity has ended. The DMS now faces the challenges of (as far as practicable) rapidly achieving the excellent clinical capability that was established in Afghanistan during contingency operations. To do this, it is necessary to maintain relevant training and exposure for surgical trainees and consultants alike. Doing so requires the maintenance and development of a set of military and clinical skills that are not readily provided by routine National Health Service (NHS) practice alone.

Strategies to ameliorate this problem include modifications to training,4 consultant appointments in major trauma centres (MTCs), specific training courses and trauma-focused fellowships, possibly overseas. However, many of the operative skills required of military general surgeons are not a frequent or mainstream part of civilian practice. We propose to supplement current training with the additional, relevant surgical opportunities afforded by multivisceral abdominal organ retrieval. This is available in the NHS and may address a subset of the training requirement.

The need

There have been several attempts to define the skill set required of a military surgical team.2 ,5–7 All are based on the reality of the surgical requirements of recent deployments. Despite the fact that contingency operations will have altered injury patterns and constrained resources requiring modified operative management,8 this remains the best basis for determining our future needs. The most comprehensive list is given in a German analysis (Table 1).6

Table 1

Techniques required of military surgeons

Of the abdominal techniques listed, only hernia repair, laparotomy, appendicectomy, cholecystectomy, bowel resection and anastomosis, stoma formation, proctology and treatment of peritoneal abscess are part of the core training of general surgeons.9 In 2002, a survey found that 21% of surgical trainees had never performed a splenectomy for trauma.10 Gastrectomy and Kocher's manoeuvre, once commonplace in the treatment of peptic ulceration, are now largely confined to placements in oesophagogastric and hepatopancreaticobiliary surgery departments, respectively. The latter also provides the only exposure to the hepatic and pancreatic techniques listed. Surgical subspecialisation further limits surgical trainees’ exposure to the non-abdominal techniques in Table 1, a problem reflected in US experience.11 In particular, the formal separation of vascular from general surgery will require the DMS either to establish and deploy parallel cadres or to provide additional training to allow surgeons from one cadre to be credentialed in the militarily relevant elements of the other. The former will be challenging (the current combined cadre is approximately half-manned) and costly; the latter lacks a precedent and will depend on the cooperation of external agencies including training units, programme directors, specialty advisory committees and the General Medical Council (GMC). The needs of civilian trauma surgeons require separate analysis and are not considered here.

Current training response

Military surgery is a recognised general surgery subspecialty. Procedure-based assessments (PBAs) of operations relevant to military surgery were recently introduced into the general surgery curriculum.4 PBAs are formative assessments of a trainee's skills, intended to aid in their development. This formal emphasis on the broader skill set required for war surgery is welcome, but does not itself provide training opportunities. The DMS placement strategy now strongly favours consultant appointments in MTCs and trainees are encouraged to seek rotation through these units. The management of blunt civilian trauma does not commonly lead to operative interventions that reflect the surgical exposures required in military practice. Few MTCs have yet established designated trauma surgery training posts. Even in large MTCs, the trauma workload is spread between at least 12 registrar-level surgeons since this is the minimum number required to maintain European Working Time Directive-compliant rotas. An individual's exposure to the management of complex trauma is correspondingly diluted. Overseas fellowships may provide an excellent opportunity to experience high-volume trauma training but these are extremely expensive for the Service and therefore limited in number. Training courses based on animal models (Exercise Surgical Training Denmark) and cadavers (the Military Operational Surgical Training course)2 ,12 have been used extensively to prepare surgeons for deployment in recent conflicts. However, they are expensive and provide a one-off opportunity to practice advanced techniques in models that are either anatomically incorrect (pigs) or have altered tissue characteristics with no vascular perfusion (cadavers).

Multivisceral organ retrieval

The National Organ Retrieval Service (NORS) was setup in 2010 to resolve the former disorganised, fragmented system for organ retrieval. There are currently eight multivisceral abdominal organ retrieval centres and five thoracic organ retrieval centres in the UK. Each abdominal team has a designated region from which they carry out 90% of their retrievals. From April 2012 to April 2013, there were 2748 retrievals carried out by the 8 UK abdominal retrieval teams. The number of retrievals has increased by 50% between 2010 and 2014, and it is predicted to increase by a further 50% by 2020.13 NORS has developed an intensive audit system to monitor the quality of organ retrieval, particularly the incidence of injuries and use of organs retrieved, including the reason for non-use.

In the case of a donation after brain death (DBD) leading to retrieval of the liver, pancreas, kidneys and small bowel, a laparotomy is performed, followed by a right medial visceral rotation (Cattell–Braasch manoeuvre). The infra-renal inferior vena cava (IVC) and aorta (or common iliac arteries) are exposed and slung. The superior mesenteric artery (SMA) is then exposed and slung. The liver is partially mobilised to prevent traction injuries. The hepatoduodenal ligament is then dissected: the common bile duct is identified and divided to allow flushing of the biliary tree. The hepatic arteries are identified, with particular attention to the preservation of any accessory or replaced hepatic arteries arising from the SMA. The portal vein is exposed at the upper border of the pancreas. The common hepatic artery is exposed to the coeliac axis, exposing the splenic artery and left gastric artery, and the supra-coeliac aorta may then be dissected and slung. A median sternotomy is performed, and the left and right pleura are opened. The pericardium is opened exposing the beating heart and IVC as it enters the right atrium.

The aorta and portal vein are cannulated to allow perfusion with preservative fluid. The descending thoracic or super-coeliac aorta is clamped, perfusion begins and the IVC in the abdomen and the thorax are divided to allow blood to vent. The cold phase has now begun. There is a limit to the permissible cold ischaemia time before reperfusion with the recipient's arterial blood. This varies between organs. Time is now a factor, and the surgeon needs to be efficient while skilled and safe.

Ice is placed into the abdomen and thorax to cool the organs. Once the perfusion fluid has circulated, the organs are dissected and removed with attached structures, such as the diaphragm, adrenal gland or spleen. The iliac blood vessels are removed and transported with the liver and pancreas, to allow vessel grafting during transplantation, and spleen and lymphatic tissue are sent with each organ to allow future tissue typing. Occasionally, the vessels of the neck may be dissected if there is a particular requirement (due to poor quality donor vessels or a particular anticipated need of the recipient). Frequently, the abdominal team will retrieve the heart for future valve transplantation if the thoracic team is not present. The body is then closed. The procedure is modified when fewer organs are to be retrieved or when a cardiothoracic team is simultaneously retrieving heart and/or lungs for transplantation.

In donation after cardiac death (DCD), death is confirmed after treatment withdrawal, cardiac arrest and subsequent asystole of at least 5 min, which means the organs lose perfusion prior to starting the retrieval. Therefore, a rapid laparotomy is performed, followed by cannulation of the aorta (usually within 1–2 min following knife-to-skin) and preservative fluid infusion, sternotomy, clamping of the descending thoracic aorta and blood venting through the IVC in the abdomen and thorax. Ice is introduced and the entire dissection, as described above, is conducted in the cold phase. Organ function is severely affected by the period of warm ischaemia that may begin before asystole and includes the 5 min stand-off and transfer from the site of treatment withdrawal to the operating room. Given this, the initial stage of a DCD retrieval is conducted under the same degree of urgency as one might experience during an emergency department (ED) thoracotomy. The non-technical aspects of surgery required in this setting translate to wartime surgery.

The abdominal, thoracic and vascular techniques that are deployed during organ retrieval are highlighted in bold in Table 1. There is considerable freedom to vary the amount of dissection that is performed in the warm and cold phases. While experienced retrieval surgeons often work quickly in the cold phase, trainees often find it more comfortable to operate with the body perfused, which allows vessels to be palpated and normal operative cues to be followed during dissection. So long as the retrieval operation is not compromised, there is no reason that the operation should not be modified to optimise it for trauma training. For example, if the pancreas is not being retrieved, a formal splenectomy can be performed during the warm phase as splenic tissue is sent with each organ for tissue typing. While DCD donors offer no warm-phase dissection, the challenge of rapid abdominal and thoracic access and quickly controlling the major vessels has obvious parallels in trauma. This demands similar skill, speed and attention to crew-resource management while the cold phase dissection still offers an unrivalled anatomy lesson relevant to emergency surgical exposure and access.

Synergies between NORS and DMS requirements

Table 1 clearly demonstrates the benefits of military general surgeons participating in organ retrieval. NORS is currently staffed by a mixture of consultant transplant and hepatopancreaticobiliary (HPB) surgeons, registrars and non-training fellows. The combination of these varies between retrieval centres, but the third group is crucial to the service in many parts of the country. Most of these surgeons are recruited from overseas, and the long-term sustainability of this model is a cause for concern. Following recent expansion of HPB consultant numbers, there is now an excess supply of general surgical trainees obtaining a certificate of completion of training (CCT) with an HPB interest.14 Expansion of the number of HPB trainees involved in organ retrieval is therefore not possible. Military trainees and consultants may, after a period of training, be afforded the opportunity to participate in organ retrieval rotas, which would be to the mutual benefit of both the retrieval service and military general surgery. While a training placement in HPB and liver transplant surgery is the natural base for this, it is not necessary. In the authors’ unit, a senior general surgery trainee is released from elective duties with the sarcoma unit to work on the organ retrieval rota. In any collaboration between the DMS and NORS of the kind suggested, the needs of the retrieval service, and ultimately of organ recipients, must remain paramount.

Organ retrieval is not a panacea for the challenges in training military surgeons. In most cases, the donor's physiology is stable (DBD) or ended (DCD) so communication between surgeons and anaesthetic staff is less crucial than in damage control surgery; the operative field is not (normally) obscured by haemorrhage; the limbs are not explored; and the techniques used are those of exposure and, to a lesser extent, resection—reconstruction is not a feature.

Even minimal exposure as an assistant will benefit a trainee, but optimum skill transfer to trauma requires supervised operating. The Specialty Advisory Committee in general surgery has agreed that 15 cases may count towards a trainee's experience of emergency laparotomy. Independent retrieval requires further experience so that the surgeon can be familiar with the vascular abnormalities that will be encountered. This is of less relevance to trauma surgery.

Trainees can be exposed to retrieval in a number of ways: through placement in transplant units, by inclusion on a retrieval rota while pursuing research or by an intensive period of secondment. The relative benefits of these approaches require further evaluation if this proposal is pursued. Exposure for consultants is more problematic due to the demands of their NHS roles. An intensive placement, perhaps during pre-deployment training, is feasible. However, it would add to an already demanding burden. A selective approach, tailored to individual needs, would be appropriate.

Conclusion

Abdominal multivisceral organ retrieval is the ultimate laparotomy and takes the surgeon to parts of the retroperitoneum and thorax otherwise not seen during standard surgical training. Furthermore, surgeons of any grade can be reacquainted with the relevant anatomy and surgical exposures, by spending a period of time with a retrieval unit. We believe it has a role to play as an adjunct to other strategies in the DMS's response to the challenge of maintaining surgeons’ skill base for contingency operations.

References

Footnotes

  • Contributors DO'R and MM initiated the project. JL and DM advised on the technical details of retrieval and the NORS policy framework. CS advised on the Defence surgical policy framework. DO'R drafted the manuscript with a substantial contribution by JL. All authors contributed to revisions. DO'R is guarantor.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.