Laparoscopic cholecystectomy as a teaching operation: comparison of outcome between residents and attending surgeons in 1,747 patients

Structured feedback and operative video debriefing with critical view of safety annotation in training of laparoscopic cholecystectomy: a randomized controlled study

BACKGROUND

The learning curve in minimally invasive surgery (MIS) is lengthened compared to open surgery. It has been reported that structured feedback and training in teams of two trainees improves MIS training and MIS performance. Annotation of surgical images and videos may prove beneficial for surgical training. This study investigated whether structured feedback and video debriefing, including annotation of critical view of safety (CVS), have beneficial learning effects in a predefined, multi-modal MIS training curriculum in teams of two trainees.

METHODS

This randomized-controlled single-center study included medical students without MIS experience (n = 80). The participants first completed a standardized and structured multi-modal MIS training curriculum. They were then randomly divided into two groups (n = 40 each), and four laparoscopic cholecystectomies (LCs) were performed on ex-vivo porcine livers each. Students in the intervention group received structured feedback after each LC, consisting of LC performance evaluations through tutor-trainee joint video debriefing and CVS video annotation. Performance was evaluated using global and LC-specific Objective Structured Assessments of Technical Skills (OSATS) and Global Operative Assessment of Laparoscopic Skills (GOALS) scores.

RESULTS

The participants in the intervention group had higher global and LC-specific OSATS as well as global and LC-specific GOALS scores than the participants in the control group (25.5 ± 7.3 vs. 23.4 ± 5.1, p = 0.003; 47.6 ± 12.9 vs. 36 ± 12.8, p < 0.001; 17.5 ± 4.4 vs. 16 ± 3.8, p < 0.001; 6.6 ± 2.3 vs. 5.9 ± 2.1, p = 0.005). The intervention group achieved CVS more often than the control group (1. LC: 20 vs. 10 participants, p = 0.037, 2. LC: 24 vs. 8, p = 0.001, 3. LC: 31 vs. 8, p < 0.001, 4. LC: 31 vs. 10, p < 0.001).

CONCLUSIONS

Structured feedback and video debriefing with CVS annotation improves CVS achievement and ex-vivo porcine LC training performance based on OSATS and GOALS scores.

The distribution of robotic surgery in general and visceral surgery departments in Switzerland - a nationwide inquiry

Objectives

Since its introduction as a clinical technique, robotic surgery has been extended to different fields of surgery. However, the indications as well as the number of robotic procedures varied in different institutions. The aim of this investigation was to evaluate the current use of robotic surgery in general and digestive surgery in Switzerland.

Methods

All Swiss surgical departments that are recognized training institutes for postgraduate training in surgery by the Swiss Institute of Medical Education (SIWF) were queried with a detailed questionnaire regarding the use of robotic surgery techniques and were analyzed regarding hospital size and type of hospital.

Results

Ninety-three departments were queried, and 67 % (n=63) answered the survey. Fifty-eight were public, and five were private institutions. Seventeen (26 %) of the queried departments used robotic surgery in digestive surgery. Four out of 17 (23 %) of the departments that performed robotic surgery were private hospitals, while 13 (77 %) were public institutions. In the majority of departments, robotic surgery of the rectum (n=12; 70.6 %) and colon (n=11; 64.7 %) was performed, followed by hernia procedures (n=8; 47.1 %) and fundoplication (n=7; 41.2 %). Less frequently, pancreatic resections (n=5; 29.4 %), cholecystectomy (n=4; 23.5 %), adrenalectomy (n=4; 23.5 %), gastric bypass (n=3; 17.7 %), gastric sleeve (n=3; 17.7 %), hepatic procedures (n=2; 11.7 %), or small bowel resections (n=1; 5.9 %) were performed as robotic procedures. More than 25 procedures per year per department were performed for hernia surgery (n=5 departments), gastric bypass (n=2 departments), cholecystectomy, fundoplication, and colon surgery (each n=1 department).

Conclusions

The number and range of robotic procedures performed in Switzerland varied widely. Higher accreditation for general surgery or subspecialization of visceral surgery of the department was positively associated with the use of robotic techniques, reflecting an unequal availability of robotic surgery.

Multicenter retrospective cohort Italian study on elective laparoscopic cholecystectomy performed by the surgical residents

PURPOSE

This retrospective multicenter cohort study aimed to evaluate the clinical outcomes (mortality rate, operative time, complications) of elective laparoscopic cholecystectomy (LC) when performed by a surgical resident in comparison to experienced consultant in the backdrop of Italian academic centers.

METHODS

Retrospective review of all patients undergoing elective LC between January 2016 and January 2022 at six teaching hospitals across Italy was performed. Cases were identified using the Current Procedural Terminology (CPT) code 5123 (LC without cholangiogram). All cases of emergency surgery, ASA score > 3, or when cholecystectomy was performed with another surgical procedure, were excluded. All suitable cases were divided into 2 groups based on primary surgeon: consultant or senior resident. Main outcome was complication rates (intraoperative and peri/postoperative); secondary outcomes included operative time, the length of stay, and the rate of conversion to open.

RESULTS

A total of 2331 cases (1425 females) were included, of which, consultants performed 1683 LCs (72%), while the residents performed 648 (28%) surgeries. The groups were statistically comparable regarding demographics, history of previous abdominal surgery, operative time, or intraoperative complications. The rate of conversion to open cholecystectomy was 1.42% for consultant and none for resident (p = 0.02). A statistically significant difference was observed between groups regarding the average length of stay (2.2 ± 3 vs 1.6 ± 1.3 days p = 0.03). Similarly, postoperative complications (1.7% vs 0.5%) resulted in statistically significant (p = 0.02) favoring resident group.

CONCLUSIONS

Our study demonstrates that in selected patients, senior residents can safely perform LC when supervised by senior staff surgeons.

Comparison of surgical outcomes of emergent laparoscopic cholecystectomy for acute cholecystitis between attending surgeons and senior residents: A propensity-matched analysis

INTRODUCTION

Emergent laparoscopic cholecystectomy (LC) is routinely performed for acute cholecystitis (AC) at our institution. This study was conducted to investigate the feasibility and safety of emergent LC for AC performed by senior residents.

MATERIALS AND METHODS

Data from 362 patients with AC who underwent emergent LC between January 2012 and June 2020 were retrospectively reviewed. Of these patients, 328 were operated on by senior residents (SR), and 34 were operated on by the attending surgeon (AS). Clinical characteristics and surgical and postoperative outcomes were compared between the SR and AS groups. Propensity score matching was used to minimize selection bias. When the operator was an SR, the LC was assisted by the AS.

RESULTS

Before matching, in the SR group, more patients had a history of abdominal surgery, and C-reactive protein and white blood cell counts were significantly higher. In the image findings, the minor axis of the gallbladder (GB) was longer, and the wall of the GB was thicker in the SR group. After propensity score matching, 28 pairs were identified. There were no significant differences in operative time (83 vs 88 minutes, P = .92), the amount of blood loss (25 vs 10 mL, P = .13), conversion to open surgery (3.6% vs 3.6%, P = 1), postoperative complications (7.2% vs 0%, P = .74), and postoperative hospital stay (4 vs 4 days, P = .87).

CONCLUSION

Emergent LC for AC performed by SR under supervision appears to be feasible and safe.

Magnetic resonance cholangiopancreatography enhanced by virtual reality as a novel tool to improve the understanding of biliary anatomy and the teaching of surgical trainees

Objective

The novel picture archiving and communication system (PACS), compatible with virtual reality (VR) software, displays cross-sectional images in VR. VR magnetic resonance cholangiopancreatography (MRCP) was tested to improve the anatomical understanding and intraoperative performance of minimally invasive cholecystectomy (CHE) in surgical trainees.

Design

We used an immersive VR environment to display volumetric MRCP data (Specto VRTM). First, we evaluated the tolerability and comprehensibility of anatomy with a validated simulator sickness questionnaire (SSQ) and examined anatomical landmarks. Second, we compared conventional MRCP and VR MRCP by matching three-dimensional (3D) printed models and identifying and measuring common bile duct stones (CBDS) using VR MRCP. Third, surgical trainees prepared for CHE with either conventional MRCP or VR MRCP, and we measured perioperative parameters and surgical performance (validated GOALS score).

Setting

The study was conducted out at Clarunis, University Center for Gastrointestinal and Liver Disease, Basel, Switzerland.

Participants

For the first and second study step, doctors from all specialties and years of experience could participate. In the third study step, exclusively surgical trainees were included. Of 74 participating clinicians, 34, 27, and 13 contributed data to the first, second, and third study phases, respectively.

Results

All participants determined the relevant biliary structures with VR MRCP. The median SSQ score was 0.75 (IQR: 0, 3.5), indicating good tolerability. Participants selected the corresponding 3D printed model faster and more reliably when previously studying VR MRCP compared to conventional MRCP: We obtained a median of 90 s (IQR: 55, 150) and 72.7% correct answers with VR MRCP versus 150 s (IQR: 100, 208) and 49.6% correct answers with conventional MRCP, respectively (p &lt; 0.001). CBDS was correctly identified in 90.5% of VR MRCP cases. The median GOALS score was higher after preparation with VR MRCP than with conventional MRCP for CHE: 16 (IQR: 13, 22) and 11 (IQR: 11, 18), respectively (p = 0.27).

Conclusions

VR MRCP allows for a faster, more accurate understanding of displayed anatomy than conventional MRCP and potentially leads to improved surgical performance in CHE in surgical trainees.

Resident Involvement in Inguinal Hernia Repair is Safe but Associated With Increased Operative Time

INTRODUCTION

Understanding how resident participation in surgery affects outcomes is critical for academic surgeons. The purpose of this study was to evaluate if resident participation was associated with adverse outcomes for inguinal hernia repair.

METHODS

We used the Veterans Affairs Surgical Quality Improvement Program to look at 61,737 patients aged ≥18 y who had open inguinal hernia repairs from 1998 to 2018. Propensity weighting was used to compare postoperative complications and operative time for patients having surgery performed by an attending alone versus attending with a postgraduate year (PGY) 1, 3, or 5 residents.

RESULTS

There were 29,806 hernias (48%) repaired by an attending, 12,024 (19%) by an intern, 9008 (15%) by a PGY-3 resident, and 10,898 (18%) by a PGY-5 resident. After propensity weighting, there was a 0.13% (95% CI -0.11% to 0.38%, P = 0.29) increase in complications with PGY-1 participation compared to cases performed by attendings alone, a 0.3% increase (95% CI 0.01% to 0.59%, P = 0.04) for PGY-3 residents, and a 0.4% increase (95% CI 0.11% to 0.69%, P = 0.007) for PGY-5 residents. There was also an increase in operative time of 26 min (95% CI 25 to 27, P < 0.001) with PGY-1 participation, 19 min (95% CI 18 to 20, P < 0.001) with PGY-3 participation, and 23 min (95% CI 22 to 24, P < 0.001) with PGY-5 participation.

CONCLUSIONS

Resident involvement in inguinal hernia surgery was associated with a significant increase in operative time but had a minimal impact on postoperative complications. Although resident participation in hernia surgery is safe, surgical programs should focus on enhancing operative efficiency for residents.

Endoscopic Sphincterotomy for Cholecysto-Choledocholithiasis Complicates Subsequent Laparoscopic Cholecystectomy: A Retrospective Report From Sri Lanka

Objective: Published literature so far has supported the fact that patients who underwent endoscopic retrograde cholangio-pancreatography and sphincterotomy (ERCPS) had a difficult perioperative course after subsequent laparoscopic cholecystectomy. Through a retrospective study, this original report mentions statistics in a Southeast Asian population comparing the effect on conversion to open surgery in patients undergoing laparoscopic cholecystectomy after ERCPS in a university hospital in Sri Lanka.

Methods: The results of 205 patients who underwent laparoscopic cholecystectomy and 85 patients who were converted to open surgery between 2016 and 2018 were analyzed to find out whether ERCPS is a risk factor for conversion or subsequent perioperative morbidity.

Results: Demographics like age, gender and previous abdominal surgeries were comparable between the two groups. Cholecysto-choledocholithiasis and undergoing ERCPS for it were significant factors associated with conversion to open cholecystectomy.

Conclusion: Performing laparoscopic cholecystectomy after ERCPS for cholecysto-choledocholithiasis is a significant challenge and preferably should be often handled by a more experienced surgeon.

Use of the self-reported critical view of safety in laparoscopic cholecystectomy during residency

BACKGROUND

Even though the goal of safely performing cholecystectomy is already a priority in general surgical training programs, we aimed to study how many residents and attendings reached the critical view of safety (CVS) in laparoscopic cholecystectomy.

MATERIALS AND METHODS

Retrospective review of prospectively collected data of all patients with biliary surgical conditions, which underwent laparoscopic cholecystectomy and their corresponding postoperative notes with self-reported CVS from May 2019 to May 2020 in an academic hospital. Comparisons of operative variables between postgraduate year and attendings were made.

RESULTS

Laparoscopic cholecystectomy was performed in 126 elective cases (62.6%) and 75 (37.3%) emergency cases. On 105 (83.3%) of the elective cases and on 54 (66.7%) emergency cases, a CVS was successfully performed. PGY3 and PGY5 had higher odds of achieving CVS compared to attendings OR 6.09 (95% CI 2.05 to 8.07) and 4.51 (95% CI 1.0 to 10.20), respectively. Overall, attendings had decreased odds ratio of achieving CVS of 0.488 when compared to all residents. Elective procedures had increased odds ratios of achieving CVS of 3.44 (95% CI 1.52 to 7.74). On elective cases, attendings performed significantly faster procedures when compared to PGY2-4, but not PGY5. No differences were seen between operative speeds between PGY. Third-year residents were identified as having the highest frequency of CVS; however, these differences were not statistically significant. In emergency cases, blood loss, operative time, CVS, and bile duct injuries revealed non-significant differences between operators.

CONCLUSION

CVS was reached significantly more often in elective than in emergency surgeries. There is still a lack of residents and attending surgeons who still failed to complete CVS during LC, highlighting the need for further education. Future studies should be attempted to repeat this study with a larger sample size and multiple coaching sessions to determine long-term efficacy.

Laparoscopic cholecystectomy performed by general surgery residents. Is it safe? How much does it cost?

OBJECTIVE

to evaluate the effectiveness and safety of laparoscopic cholecystectomies performed by residents of the first and second-year of a general surgery residency program. We studied the primary total cost of treatment and complication rates as primary outcomes, comparing the groups operated by senior and resident surgeons.

METHODS

this was a retrospective cohort study of patients who underwent laparoscopic cholecystectomy performed in a training hospital of large surgical volume in Brazil, in the period between June 1, 2018 and May 31, 2019. The study population comprised patients who underwent elective cholecystectomy due to uncomplicated chronic calculous cholecystitis or to the presence of gallbladder polyps with surgical indication. We divided the cases into three groups, based on the graduation of the main surgeon at the time of the procedure: first-year residents (R1), second-year residents (R2), and trained general surgeons (GS).

RESULTS

during the study period, 1,052 laparoscopic cholecystectomies were performed, of which 1,035 procedures met the inclusion criteria, with 78 (7.5%) patients operated on with the participation of first-year residents (R1), 500 (48.3%) patients with the participation of second-year residents (R2), and 457 (44.2%) with the participation of senior surgeons only. There was no difference in conversion rates, complications, and reporting of adverse events between groups. We observed a significant difference regarding hospitalization costs (p = 0.003), with a higher mean for the patients operated with the participation of R1, of US$ 2,671.13, versus US$ 2,414.60 and US$ 2,396.24 for the procedures performed by senior surgeons and R2, respectively.

CONCLUSIONS

laparoscopic cholecystectomy with the participation of residents is safe, even in their first years of training. There is an additional cost of about 10% in the treatment of patient operated with the participation of first-year residents. There was no significant difference in the cost of the group operated by second-year residents.

Emergency General Surgery and the Gallbladder: The Affordable Care Act's Impact on Practice Patterns

BACKGROUND

Gallbladder disease frequently requires emergency general surgery (EGS). The Affordable Care Act (ACA) mandated health insurance coverage for all with the intent to improve access to care and decrease morbidity, mortality, and costs. We hypothesize that after the ACA open-enrollment in 2014 the number of EGS cholecystectomies decreased as access to care improved with a shift in EGS cholecystectomies to teaching institutions.

METHODS

A retrospective review of the National Inpatient Sample Database from 2012 to quarter 3 of 2015 was performed. Patients age 18-64, with a nonelective admission for gallbladder disease based on ICD-9 codes, were collected. Outcomes measured included cholecystectomy, complications, mortality, and wage index-adjusted costs. The effect of the ACA was determined by comparing preACA to postACA years.

RESULTS

189,023 patients were identified. In the postACA period the payer distribution for admissions decreased for Self-pay (19.3% to 13.6%, P < 0.001), Medicaid increased (26.3% to 34.0%, P < 0.001) and Private insurance was unchanged (48.6% to 48.7%, P = 0.946). PostACA, admissions to teaching hospitals increased across all payer types, EGS cholecystectomies decreased, while complications increased, and mortality was unchanged. Median costs increased significantly for Medicaid and Private insurance while Self-pay was unchanged. Based on adjusted DID analyses for Insured compared to Self-pay patients, EGS cholecystectomies decreased (-2.7% versus -1.21%, P = 0.033) and median cost increased more rapidly (+$625 versus +$166, P = 0.017).

CONCLUSIONS

The ACA has changed EGS, shifting the majority of patients to teaching institutions despite insurance type and decreasing the need for EGS cholecystectomy. The trend toward higher complication rate with increased overall cost requires attention.

Trainee surgeons and patient outcomes in carotid endarterectomy: a retrospective cohort study

BACKGROUND

In Australia and New Zealand, more than 2000 carotid endarterectomies are performed annually. The major morbidities arising from this procedure are post-operative stroke, cranial nerve injury and death. Carotid endarterectomy surgery is a key component of the vascular surgical training programme. We assessed the impact of having a surgical trainee perform a major component of this procedure on the post-operative rates of stroke, cranial nerve injury and mortality.

METHODS

We performed a retrospective cohort study of vascular surgical patients undergoing carotid endarterectomy, with data obtained from the Australasian Vascular Audit database between January 2010 and December 2014. The dataset comprised of 6528 carotid endarterectomies performed during this time. The collected data were stratified into two categories - consultant-led cases, and those in which trainee surgeons performed at least a major component of the surgery under consultant supervision. The results were analysed for differences in post-operative stroke, cranial nerve injury and inpatient mortality. Differences between groups were assessed using multivariate analysis, adjusting for potentially confounding covariables.

RESULTS

On multivariate analysis, there was no statistically significant difference in the rates of post-operative stroke (odds ratio (OR) 0.88, 95% confidence interval (CI) 0.57-1.36, P = 0.55), cranial nerve injury (OR 0.68, 95% CI 0.39-1.21, P = 0.19) or inpatient mortality (OR 0.78, 95% CI 0.29-2.13, P = 0.63) between the two cohorts.

CONCLUSION

Having surgical trainees perform components of carotid endarterectomies under supervision is not associated with an increased rate of post-operative stroke, cranial nerve injury or mortality.

Fluorescence cholangiography enhances surgical residents’ biliary delineation skill for laparoscopic cholecystectomies

BACKGROUND

Laparoscopic cholecystectomy (LC) is a minimally invasive procedure, often performed by surgical residents (SRs). Fluorescence cholangiography (FC) enables real-time identification of biliary anatomy.

AIM

To investigate the benefit of FC for enhancing SRs’ identification skills.

METHODS

Prospective data was collected from January 2018 to June 2018 at our hospital. The study cohorts were the SRs (study group, n = 15) and the surgical staff (SS; control group, n = 9). Participants were assigned to watch videos of LCs with FC from five different patients who had gallbladder disease, and identify structures in the video clips (including cystic duct, common bile duct, common hepatic duct, and cystic artery), first without FC, and then with FC.

RESULTS

In the without-FC phase, the overall misidentification rate by SRs (21.7%) was greater than that of the SS (11.8%; P = 0.018), However, in the FC phase, the two groups did not significantly differ in misidentification rates (23.3% vs 23.3%, P = 0.99). Paired-structure analysis of the without-FC and with-FC phases for the SR group found a significantly higher misidentification rate in the without-FC phase than the with-FC phase (21.9% vs 10.9%; P < 0.01). However, misidentification rates in the with-FC phase did not significantly differ between SRs and SS.

CONCLUSION

FC enhanced identification skills of inexperienced surgeons during LC compared with conventional training. Combined with simulation-based video training, FC is a promising tool for enhancing technical and decision skills of trainees and inexperienced surgeons.

Evaluating the impact of resident involvement during the laparoscopic nephrectomy

Introduction

Laparoscopic nephrectomy (LN) is the most performed laparoscopic procedure by urologic residents (Res). A large amount of data exists on laparoscopic nephrectomies in terms of safety and surgical outcomes, but only a little is known about the influence of residents. The purpose of this study was to evaluate this influence on the clinical outcome of a laparoscopic nephrectomy.

Material and methods

Retrospectively, patients who had undergone a LN between 2010 and 2018 were assessed. Data included patient demographics, date of surgery, pre- and postoperative results and complications. The patients who had undergone a LN were divided into two groups: one where residents were involved and another group where only a staff surgeon (Sur) performed the operation. All training residents had a questionnaire sent to them to evaluate their role during the LN.

Results

A total of 229 patients met the study criteria, of which 78 patients were operated together with a resident and 151 by a staff surgeon alone. Both groups were homogeneous in terms of age, comorbidities, left/right sided LN and tumor-stage. Between these two groups, no significant differences were observed in median estimated blood loss (Res 87 ml vs. Sur 100 ml), intraoperative adverse events (Res 10.3% vs. Sur 6% p = 0.24), conversion to open surgery (Res 6.4% vs. Sur 6%) and high-grade postoperative complications (Res 3.9% vs. Sur 4.6%). However, when a resident participated, the LN lasted on average 20 minutes longer (Res mean 130 min vs. Sur 110 min p ≤0.001).

Conclusions

Our data shows that involvement of a resident in laparoscopic nephrectomy has no effect on the clinical outcome. Therefore, it is safe to perform a laparoscopic nephrectomy together with a resident, but it is important to take the additional surgical time into account.

Experiencia y curva de aprendizaje de apendicectomía y colecistectomía laparoscópica de los residentes de cirugía general en un hospital latinoamericano

Introducción: La cirugía laparoscópica ha revolucionado el manejo quirúrgico de los pacientes y ha generado una necesidad de capacitación en el área. El rendimiento en la vida real es lo que permite una determinación global de las competencias en un procedimiento y establece un método de formación. El objetivo de este estudio es describir la evolución en la experiencia quirúrgica de un grupo de residentes de cirugía general. Metodología: Estudio observacional analítico de cohorte retrospectiva en el Hospital Universitario San Ignacio. Incluyó 4191 procedimientos realizados, divididos en 1045 apendicectomías laparoscópicas (AL) y 3146 colecistectomías laparoscópicas (CL), realizadas por un total de 52 residentes entre enero de 2008 y diciembre de 2014. Resultados: Tanto en AL como en CL se observó un aumento en el número de procedimientos anuales. Al comparar los tiempos promedios de AL por año de residencia, se observó una tendencia a la disminución en la mediana a medida que el residente era mayor. Las complicaciones intraoperatorias fueron del 0,77 % para AL y del 1,9 % para CL. La complicación postoperatoria más frecuente fue infección del sitio operatorio con una mortalidad menor al 0,5 %. Conclusión: Los resultados evocan la necesidad de continuar con programas de residencia que proporcionen preparación adecuada en el abordaje laparoscópico, posiblemente con exposición cada vez más temprana a procedimientos mínimamente invasivos.

The Presence of an Advanced Gastrointestinal (GI)/Minimally Invasive Surgery (MIS) Fellowship Program Does Not Impact Short-Term Patient Outcomes Following Fundoplication or Esophagomyotomy

INTRODUCTION

The current surgical landscape reflects a continual trend towards sub-specialization, evidenced by an increasing number of US surgeons who pursue fellowship training after residency. Despite this growing trend, however, the effect of advanced gastrointestinal (GI)/minimally invasive surgery (MIS) fellowship programs on patient outcomes following foregut/esophageal operations remains unclear. This study looks at two representative foregut surgeries (laparoscopic fundoplication and esophagomyotomy) performed in New York State (NYS), comparing hospitals which do and do not possess a GI/MIS fellowship program, to examine the effect of such a program on perioperative outcomes. We also aimed to identify any patient or hospital factors which might influence perioperative outcomes.

METHODS

The SPARCS database was examined for all patients who underwent a foregut procedure (specifically, either an esophagomyotomy or a laparoscopic fundoplication) between 2012 and 2014. We compared the following outcomes between institutions with and without a GI/MIS fellowship program: 30-day readmission, hospital length of stay (LOS), and development of any major complication.

RESULTS

There were 3175 foregut procedures recorded from 2012 to 2014. Just below one third (n = 1041; 32.8%) were performed in hospitals possessing a GI/MIS fellowship program. Among our entire included study population, 154 patients (4.85%) had a single 30-day readmission, with no observed difference in readmission between hospitals with and without a GI/MIS fellowship program, even after controlling for potential confounding factors (p = 0.6406 and p = 0.2511, respectively). Additionally, when controlling for potential confounders, the presence/absence of a GI/MIS fellowship program was found to have no association with risk of having a major complication (p = 0.1163) or LOS (p = 0.7562). Our study revealed that postoperative outcomes were significantly influenced by patient race and payment method. Asians and Medicare patients had the highest risk of suffering a severe complication (10.00 and 7.44%; p = 0.0311 and p = 0.0036, respectively)-with race retaining significance even after adjusting for potential confounders (p = 0.0276). Asians and uninsured patients demonstrated the highest readmission rates (15.00 and 12.50%; p = 0.0129 and p = 0.0012, respectively)-with both race and payment method retaining significance after adjustment (p = 0.0362 and p = 0.0257, respectively). Lastly, payment method was significantly associated with postoperative LOS (p < 0.0001), with Medicaid patients experiencing the longest LOS (mean 3.99 days) and those with commercial insurance experiencing the shortest (mean 1.66 days), a relationship which retained significance even after adjusting for potential confounders (p < 0.0001).

CONCLUSION

The presence of a GI/MIS fellowship program does not impact short-term patient outcomes following laparoscopic fundoplication or esophagomyotomy (two representative foregut procedures). Presence of such a fellowship should not play a role in choosing a surgeon. Additionally, in these foregut procedures, patient race (particularly Asian race) and payment method were found to be independently associated with postoperative outcomes, including postoperative LOS.

Impact of surgical proficiency levels on postoperative morbidity: a single centre analysis of 558 ileostomy reversals

PURPOSE

Defunctioning ileostomies reduce the consequences of distal anastomotic leakage following bowel resections. Ileostomy reversal in itself, however, is associated with appreciable morbidity (3-40%) and mortality (0-4%). Despite being a common teaching procedure, there is limited information on the impact of surgical proficiency levels on postoperative outcome.

METHODS

Adult patients undergoing closure of a defunctioning ileostomy between September 2008 and January 2017 were identified from a surgical administrative database that was collected prospectively (n = 558). Baseline characteristics (age, ASA score, BMI, health care insurance coverage) and closure techniques were recorded. Operation time, rate of bowel resection, postoperative complications ranked by Clavien-Dindo classification and length of stay were analysed with respect to proficiency levels (residents vs. consultants).

RESULTS

Two hundred three ileostomy reversals were performed by residents; 355 ileostomies were closed by consultants. Operation time was considerably shorter in the consultant group (p < 0.001). Major postoperative complication rates however were not different among the groups when adjusted for possible confounders (p = 0.948). The rate of anastomotic leakage was 3% and the overall major morbidity rate was 11%.

CONCLUSION

Operation time rather than surgical outcome and overall morbidity were affected by surgical proficiency levels. Therefore, ileostomy reversal can be considered an appropriate teaching operation for young general surgery trainees.

Involvement of Residents Does Not Increase Postoperative Complications After Open Reduction Internal Fixation of Ankle Fractures: An Analysis of 3251 Cases

Ankle fractures are common injuries frequently treated by foot and ankle surgeons. Therefore, it has become a core competency for orthopedic residency training. Surgical educators must balance the task of training residents with optimizing patient outcomes and minimizing morbidity and mortality. The present study aimed to determine the effect of resident involvement on the 30-day postoperative complication rates after open reduction and internal fixation of ankle fractures. A second objective of the present study was to determine the independent risk factors for complications after this procedure. We identified patients in the American College of Surgeons National Surgical Quality Improvement Program database who had undergone open reduction internal fixation for ankle fractures from 2005 to 2012. Propensity score matching was used to help account for a potential selection bias. We performed univariate and multivariate analyses to identify the independent risk factors associated with short-term postoperative complications. A total of 3251 open reduction internal fixation procedures for ankle fractures were identified, of which 959 (29.4%) had resident involvement. Univariate (2.82% versus 4.54%; p = .024) and multivariate (odds ratio 0.71; p = .75) analyses demonstrated that resident involvement did not increase short-term complication rates. The independent risk factors for complications after open reduction internal fixation of ankle fractures included insulin-dependent diabetes, increasing age, higher American Society of Anesthesiologists score, and longer operative times.

Laparoscopic cholecystectomy: a prospective cohort study assessing the impact of grade of operating surgeon on operative time and 30-day morbidity

Introduction There is an increasing trend towards day case surgery for uncomplicated gallstone disease. The challenges of maximising training opportunities are well recognised by surgical trainees and the need to demonstrate timely progression of competencies is essential. Laparoscopic cholecystectomy provides the potential for excellent trainee learning opportunities. Our study builds upon previous work by assessing whether measures of outcome are still affected when cases are stratified based on procedural difficulty. Material and methods A prospective cohort study of all laparoscopic cholecystectomies conducted at a district general hospital between 2009 and 2014, performed under the care of a single consultant. The operative difficulty was determined using the Cuschieri classification. The primary endpoint was duration of operation. Secondary endpoints included length of hospital stay, delayed discharge rate and 30-day morbidity. Results A total of 266 laparoscopic cholecystectomies were performed during the study period. Mean operative time for all consultant-led cases was 52.5 minutes compared with 51.4 minutes for trainees (P = 0.67 unpaired t-test). When cases were stratified for difficulty, consultant-led cases were on average 5 minutes faster. Median duration of hospital stay was equivalent in both groups and there was no statistical difference in re-attendance (12.9% vs. 15.3% P = 0.59) or re-admission rates (3.2% vs. 8.1% P = 0.10) at 30 days. Conclusions Our study provides evidence that laparoscopic cholecystectomy provides a good training opportunity for surgical trainees without being detrimental to patient outcome. We recommend that, in selected patients, under consultant supervision, laparoscopic cholecystectomy can be performed primarily by the surgical trainee without impacting on patient outcome or theatre scheduling.

Impact of Fellow Versus Resident Assistance on Outcomes Following Pancreatoduodenectomy

BACKGROUND

Participation by surgical trainees in complex procedures is key to their development as future practicing surgeons. The impact of surgical fellows versus general surgery resident assistance on outcomes in pancreatoduodenectomy (PD) has not been well studied. The purpose of this study was to determine differences in patient outcomes based on level of surgical trainee.

METHODS

Consecutive cases of PD (n = 254) were reviewed at a single high-volume institution over a 2-year period (July 2013-June 2015). Thirty-day outcomes were monitored through the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) and Quality In-Training Initiative. Patient outcomes were compared between PD assisted by general surgery residents versus hepatopancreatobiliary fellows.

RESULTS

The hepatopancreatobiliary surgery fellows and general surgery residents participated in 109 and 145 PDs, respectively. The incidence of each individual postoperative complication (renal, infectious, pancreatectomy-specific, and cardiopulmonary), total morbidity, mortality, and failure to rescue were the same between groups.

CONCLUSIONS

Patient operative outcomes were the same between fellow- and resident-assisted PD. These results suggest that hepatopancreatobiliary surgery fellows and general surgery residents should be offered the same opportunities to participate in complex general surgery procedures.

Transumbilical laparoscopic appendectomy performed by residents is safe and feasible

INTRODUCTION

The aim of this study was to compare the clinical outcomes of single-incision transumbilical laparoscopy-assisted appendectomy performed by surgical residents and attending surgeons.

METHODS

We reviewed the clinical outcomes of 131 transumbilical laparoscopy-assisted appendectomies performed from January 2011 to June 2014. During the study period, 13 residents and 6 board-certified attending surgeons performed the procedures. For all operations performed by residents and attending surgeons, we reviewed and compared gender, age, BMI, body temperature, white blood cell count, C-reactive protein serum level, and the presence of a fecalith or abscess. Clinical outcomes including operative time, estimated blood loss, need for additional ports, conversion to open surgery, intraoperative complications, postoperative complications, and postoperative hospital stay were compared between the two groups.

RESULTS

The mean preoperative white blood cell count in the resident-operated group was significantly higher than in the attending-operated group (14.0 vs 10.8 ×10³ /mm³ , P = 0.007). There were no other significant differences in clinical variables between the two groups. Outcomes show that estimated blood loss was significantly higher (23.4 vs 9.8 mL, P = 0.031) and operative time tended to be longer (86.0 vs 72.0 min, P = 0.056) in the resident-operated group. No other significant differences were observed.

CONCLUSION

Transumbilical laparoscopy-assisted appendectomy performed by residents is feasible and safe. It is an acceptable as a part of routine surgical training.

Fluorescent incisionless cholangiography as a teaching tool for identification of Calot's triangle

BACKGROUND

Intraoperative incisionless fluorescent cholangiogram (IOIFC) has been demonstrated to be a useful tool to increase the visualization of Calot's triangle. This study evaluates the identification of extrahepatic biliary structures with IOIFC by medical students and surgery residents.

METHODS

Two pictures were taken, one with xenon light and one with near-infrared (NIR) light, at the same stage during dissection of Calot's triangle in ten different cases of laparoscopic cholecystectomy (LC). All twenty pictures were organized in a random fashion to remove any imagery bias. Twenty students and twenty residents were asked to identify the biliary anatomy.

RESULTS

Medical students were able to accurately identify the cystic duct on an average 33.8 % under the xenon light versus 86 % under NIR light (p = 0.0001), the common hepatic duct (CHD) on an average 19 % under the xenon light versus 88.5 % under NIR light (p = 0.0001), and the junction on an average 24 % under xenon light versus 80.5 % under NIR light (p = 0.0001). Surgery residents were able to accurately identify the cystic duct on an average 40 % under the xenon light versus 99 % under NIR light (p = 0.0001), the CHD on an average 35 % under the xenon light versus 96 % under NIR light (p = 0.0001), and the junction on an average 24 % under the xenon light versus 95.5 % under NIR light (p = 0.0001).

CONCLUSIONS

IOIFC increases the visualization of Calot's triangle structures when compared to xenon light. IOIFC may be a useful teaching tool in residency programs to teach LC.

Clinical strategies to aim an adequate safety profile for patients and effective training for surgical residents: The laparoscopic cholecystectomy model

Background

Training programs for resident surgeons represent a challenge for the mentoring activity. The aim of the present study is to investigate the impact of our training program for laparoscopic cholecystectomy on patient's safety and on the modulation of the residents' exposure to clinical scenario with different grades of complexity.

Material and methods

This is a retrospective study based on a clinical series of laparoscopic cholecystectomy performed in a teaching hospital. Study population was grouped according to the expertise of the attending primary operator among resident surgeons. Four groups were identified: consultant (C), senior resident (SR); intermediate level resident (IR); junior resident (JR). The intraoperative and postoperative outcomes were confronted to evaluate the patient's safety profile.

Results

447 patients were submitted to LC: 96 cases were operated by a C, 200 by SR, 112 by IR and 39 by JR. The mean operative time was the longest for the JR group. A statistically higher rate of conversion to open approach was registered in C and IR groups in comparison to JR and SR groups. However, in C and IR groups, patients had worse ASA score, higher BMI and more frequent past history of previous abdominal surgery, cholecystitis or pancreatitis. Overall, it was not registered any statistically significant difference among the groups in terms of length of hospital stay and prevalence of major postoperative complications.

Conclusion

Applying an educational model based on both graduated levels of responsibility and modulated grade of clinical complexity can guarantee an high safety profile.

•

Practical training is an essential part in postgraduate programs for Residents.

•

Laparoscopy represents a challenging procedure in terms of mentoring.

•

Our Program seems to be economically sustainable and clinically feasible.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

The costs of operative complications for ankle fractures: a case control study

As our healthcare system moves towards bundling payments, it is vital to understand the potential financial implications associated with treatment of surgical complications. Considering that surgical treatment of ankle fractures is common, there remains minimal data relating costs to postsurgical intervention. We aimed to identify costs associated with ankle fracture complications through case-control analysis. Using retrospective analysis at a level I trauma center, 28 patients with isolated ankle fractures who developed complications (cases) were matched with 28 isolated ankle fracture patients without complications (controls) based on ASA score, age, surgery type, and fracture type. Patient charts were reviewed for demographics and complications leading to readmission/reoperation and costs were obtained from the financial department. Wilcoxon tests measured differences in the costs between the cases and controls. 28 out of 439 patients (6.4%) developed complications. Length of stay and median costs were significantly higher for cases than controls. Specifically, differences in total costs existed for infection and hardware-related pain. This is the first study to highlight the considerable costs associated with the treatment of complications due to isolated ankle fractures. Physicians must therefore emphasize methods to control surgical and nonsurgical factors that may impact postoperative complications, especially under a global payment system.

Resident involvement does not influence complication after total hip arthroplasty: an analysis of 13,109 cases

Our study aimed to determine the impact of resident involvement on the 30-day postoperative complication rates following primary total hip arthroplasty (THA). Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, 13,109 primary THAs were identified, of which 3462 (26.4%) had resident involvement. Neither univariate (4.45% vs 4.52%, P = 0.86) nor multivariate (OR 1.04, P = 0.75) analyses demonstrated an increased complication rate with resident involvement following THA. We did find, however, that increased operative time, comorbidities, age, obesity, prior history of stroke and/or cardiac surgery were all independent risk factors for short-term complication. Our findings suggest that resident involvement does not increase 30-day complication rates following primary THA.

Does resident involvement impact post-operative complications following primary total knee arthroplasty? An analysis of 24,529 cases

Little is known about the impact of resident involvement on complication rates following total knee arthroplasty (TKA). The goal of our study was to determine the impact of resident involvement on complications following primary TKA. Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2005-2012) we identified 24,529 patients who underwent primary TKA. Of these, 5960 (24.3%) had a resident involved in a primary TKA. Using a multivariate logistic regression which incorporated propensity score adjustment, no differences were seen in morbidity and mortality following those cases with resident involvement (OR: 1.15, P = 0.129). In the first large scale, comprehensive analysis of resident impact on short-term morbidity and mortality, no increase in complications was observed with resident involvement in primary TKA.

Post-endoscopic retrograde cholangiography laparoscopic cholecystectomy: challenging but safe

Interval laparoscopic cholecystectomy was found to be safe and associated with a low rate of perioperative complications.

Background and Objectives:

Up to 19% of patients undergoing laparoscopic cholecystectomy (LC) have common bile duct stones and may require endoscopic retrograde cholangiography (ERCP) before LC. The risk of complications of LC after ERCP is higher, and the optimal interval between ERCP and LC is disputed. In our unit, LC is performed approximately 6 weeks after ERCP. This study aims to compare outcomes between subsets of patients undergoing LC with or without prior ERCP.

Methods:

All patients undergoing ERCP and elective laparoscopic cholecystectomy (ELC) over a 1-year period were included. Outcome measures included ERCP outcomes, duration of surgery, intraoperative findings, and postoperative outcomes. Two groups of patients were compared: LC after ERCP and ELC.

Results:

The study included 190 ELC patients and 43 patients with LC after ERCP (ERCP-LC) (December 2008 to December 2009). At ERCP, 25 patients (58%) had ductal stones. The post-ERCP complication rate was 5%. The median time to LC was 42 days, and 6 patients (14%) were readmitted before LC. There were more severe adhesions and longer median operating times in the ERCP-LC group (75 minutes for ELC vs 110 minutes for ERCP-LC, P = .013). We found no significant differences in rates of conversion to open surgery, postoperative complications, lengths of stay, and readmission rates.

Conclusion:

Interval LC after ERCP is a more technically challenging procedure but is associated with a low rate of complications. Although there is emerging evidence that early LC after ERCP is feasible, our study shows that our current practice of delaying LC by approximately 6 weeks is safe.

Additional surgical procedure is a risk factor for surgical site infections after laparoscopic cholecystectomy

PURPOSE

Surgical site infections (SSI) are associated with increased costs and length of hospital stay, readmission rates, and mortality. The aim of this study was to identify risk factors for SSI in patients undergoing laparoscopic cholecystectomy.

METHODS

Analysis of 35,432 laparoscopic cholecystectomies of a prospective multicenter database was performed. Risk factors for SSI were identified among demographic data, preoperative patients' history, and operative data using multivariate analysis.

RESULTS

SSIs after laparoscopic cholecystectomy were seen in 0.8 % (n = 291) of the patients. Multivariate analysis identified the following parameters as risk factors for SSI: additional surgical procedure (odds ratio [OR] 4.0, 95 % confidence interval [CI] 2.2-7.5), age over 55 years (OR 2.4 [1.8-3.2]), conversion to open procedure (OR 2.6 [1.9-3.6]), postoperative hematoma (OR 1.9 [1.2-3.1]), duration of operation >60 min (OR 2.5 [1.7-3.6], cystic stump insufficiency (OR 12.5 [4.2-37.2]), gallbladder perforation (OR 6.2 [2.4-16.1]), gallbladder empyema (OR 1.7 [1.1-2.7]), and surgical revision (OR 15.7 [10.4-23.7]. SSIs were associated with a significantly prolonged hospital stay (p < 0.001), higher postoperative mortality (p < 0.001), and increased rate of surgical revision (p < 0.001).

CONCLUSIONS

Additional surgical procedure was identified as a strong risk factor for SSI after laparoscopic cholecystectomy. Furthermore, operation time >60 min, age >55 years, conversion to open procedure, cystic stump insufficiency, postoperative hematoma, gallbladder perforation, gallbladder empyema, or surgical revision were identified as specific risk factors for SSI after laparoscopic cholecystectomy.

The impact of resident involvement on post-operative morbidity and mortality following orthopaedic procedures: a study of 43,343 cases

BACKGROUND

Few studies have addressed the role of residents' participation in morbidity and mortality after orthopaedic surgery. The present study utilized the 2005-2010 National Surgical Quality Improvement Program (NSQIP) dataset to assess the risk of 30-day post-operative complications and mortality associated with resident participation in orthopaedic procedures.

METHODS

The NSQIP dataset was queried using codes for 12 common orthopaedic procedures. Patients identified as having received one of the procedures had their records abstracted to obtain demographic data, medical history, operative time, and resident involvement in their surgical care. Thirty-day post-operative outcomes, including complications and mortality, were assessed for all patients. A step-wise multivariate logistic regression model was constructed to evaluate the impact of resident participation on mortality- and complication-risk while controlling for other factors in the model. Primary analyses were performed comparing cases where the attending surgeon operated alone to all other case designations, while a subsequent sensitivity analysis limited inclusion to cases where resident participation was reported by post-graduate year.

RESULTS

In the NSQIP dataset, 43,343 patients had received one of the 12 orthopaedic procedures queried. Thirty-five percent of cases were performed with resident participation. The mortality rate, overall, was 2.5 and 10 % sustained one or more complications. Multivariate analysis demonstrated a significant association between resident participation and the risk of one or more complications [OR 1.3 (95 % CI 1.1, 1.4); p < 0.001] as well as major systemic complications [OR 1.6 (95 % CI 1.3, 2.0); p < 0.001] for primary joint arthroplasty procedures only. These findings persisted even after sensitivity testing.

CONCLUSIONS

A mild to moderate risk for complications was noted following resident involvement in joint arthroplasty procedures. No significant risk of post-operative morbidity or mortality was appreciated for the other orthopaedic procedures studied.

LEVEL OF EVIDENCE

II (Prognostic).

Safety of surgical resident training

The current structure of residency training allows for safe participation of residents in the care of surgical patients. In part, this is likely due to the ability of attending-level surgeons and educators to adequately select and provide the supervision needed for different levels of residents. Nonetheless, efforts have to be made to ensure the optimal safety of patients in several settings of modern health care. For laparoscopic surgery, training and simulation are highly advisable in preparing residents to perform well in the early stage of their learning curves. Attention has to be given to safe and complete hand-offs, especially with the increased focus on restricting work hours and the increased number of changing shifts. Measures to ensure optimal preparation of surgical residents to perform well in stressful situations should also be taken, because such situations are an intrinsic part of this specialty. It is only by focusing on all these aspects that we can ensure the safety for our patients and provide the best possible training for the next generation of surgeons.