Resident self-assessment of common endocrine procedures

Bridging the Gap: A Qualitative Assessment of General Surgery Resident Confidence and Knowledge Deficits in Managing Surgical Endocrinopathy

BACKGROUND

Most thyroid and parathyroid surgeries are performed by nonfellowship trained, low-volume surgeons with associated higher complication rates. Furthermore, the average number of endocrine procedures performed by general surgery residents is decreasing. While previous studies have documented a lack of general surgery resident confidence in performing these procedures, the specific knowledge gaps in endocrine surgery remain unexplored.

METHODS

We conducted semi-structured interviews with surgical residents (clinical PGY3-PGY5) at a high-volume academic center with an endocrine surgery fellowship to discuss their experience, knowledge, and deficits managing patients with surgical thyroid and parathyroid disease. Interviews were audio-recorded, de-identified, and transcribed verbatim. Content analysis was used to identify areas of confidence and knowledge deficits in all phases of care.

RESULTS

Overall, 14 trainees participated in the study (50% women, mean PGY: 3.8). Preoperatively, residents were confident with thyroid nodule and primary hyperparathyroidism work-up, but less comfortable with rare conditions. Residents were uncomfortable using ultrasound to identify suspicious lymph nodes or abnormal parathyroid glands. Residents perceived knowledge deficits in the multidisciplinary care and work-up of patients with advanced thyroid cancer. Intraoperatively, most residents were confident performing thyroidectomy and focused parathyroidectomy, but less comfortable performing 4-gland explorations or neck dissections. Several had concern with independently identifying and protecting the recurrent laryngeal nerve or locating parathyroid glands in the setting of negative localization. Residents noted a lack of autonomy in both thyroidectomy and parathyroidectomy. Postoperatively, residents felt confident in the acute management of patients, but identified deficits in long-term management of patients with thyroid cancer or chronic complications.

CONCLUSIONS

Despite confidence in managing "bread and butter" cervical endocrine surgery in all phases of care, residents perceive a lack of meaningful autonomy intraoperatively. Further educational endeavors may be required to ensure graduating residents are "practice ready" for straightforward cases they may encounter in practice as a general surgeon. A lack of exposure to complex endocrinopathy even at a high-volume center suggests that comprehensive endocrine surgery fellowship remains critical.

A comparison of robotic and laparoscopic minimally invasive adrenalectomy for adrenal malignancies

BACKGROUND

Although guidelines recommend open adrenalectomy for most resectable adrenal malignancies, minimally invasive adrenalectomies are performed. Robotic adrenalectomies have become more popular recently, but there is a paucity of literature comparing laparoscopic and robotic resections.

METHODS

Patients who underwent a planned minimally invasive adrenalectomy for adrenal malignancies (adrenocortical carcinoma, malignant pheochromocytoma, other carcinoma) were identified in the National Cancer Database. The primary outcome was the conversion rate from minimally invasive to open. Other post-operative outcomes and survival were compared.

RESULTS

416 patients (76.5%) underwent a laparoscopic adrenalectomy and 128 (23.5%) underwent a robotic operation. Demographics and clinical characteristics were similar. Approximately 19% of tumors resected by a minimally invasive approach were > 10 cm. The intra-operative conversion rate was decreased among robotic adrenalectomies relative to laparoscopic on univariate (7.8% vs. 18.3%, p = 0.005) and multivariable (odds ratio 0.39, p = 0.01) analyses. Using marginal standardization, there was a stepwise increase in the conversion rate as tumor size increased (< 5, 5-10, > 10 cm) for laparoscopic (7.5%, 18.0%, 33.2%) and robotic (3.1%, 8.3%, 17.3%) adrenalectomies. Operations which required conversion had a greater margin positivity rate, greater length of stay, and an association with poor overall survival.

CONCLUSION

In contrast to most clinical guidelines, minimally invasive adrenalectomies are being performed on large malignant tumors. A laparoscopic approach was associated with a greater conversion rate and subsequent poor outcomes. If a surgeon is not planning an open adrenalectomy, but adrenal malignancy is a possibility, robotic adrenalectomy may be the preferred approach for resectable adrenal tumors.