Getting residents in the game: an evaluation of general surgery residents' participation in pediatric laparoscopic surgery

A Survey of Current Approaches to Inguinal Hernia Repair by Pediatric General Surgeons in the United States

INTRODUCTION

Inguinal hernia repair (IHR) is a common pediatric operation performed via open or laparoscopic approaches. The objective of this survey study was to assess current approaches to IHR in a national sample of pediatric general surgeons.

METHODS

A REDCap survey was distributed to all pediatric general surgeons at 21 US institutions in 2023. Descriptive statistics were used to analyze responses.

RESULTS

The response rate was 70.0% (145/207) with median fellowship graduation year of 2011. Respondents reported they were primarily taught either an open (73.1%) or laparoscopic (6.9%) technique in fellowship, while 18.6% reported being taught both techniques equally. Overall, 60.7% of respondents reported currently performing both laparoscopic and open IHR, while 27.6% reported performing only open IHR and 11.7% reported performing only laparoscopic IHR. During unilateral open IHR, 75.8% of respondents check for and repair a contralateral inguinal hernia, most commonly by placing a laparoscope via the hernia sac (76.3%). Selective mesh use in adolescents was similar between laparoscopic and open repair approaches. For recurrent hernias, 37.2% of respondents indicated performing the approach that was not performed previously, while 38.6% and 22.8% indicated they routinely perform a laparoscopic or open approach, respectively, regardless of initial repair approach.

CONCLUSION

Over two thirds of surgeons reported incorporating laparoscopic IHR into their practice despite nearly three-quarters of respondents indicating they were primarily taught an open approach in training. Training in laparoscopic IHR has been increasing over time, and respondents reported a wide variety of laparoscopic and open repair techniques.

LEVEL OF EVIDENCE

IV.

A Contemporary Review of Surgical Approach and Outcomes in Pediatric Hypertrophic Pyloric Stenosis

INTRODUCTION

In order to define optimal resources and outcome standards for infant pyloromyotomy, we sought to perform a contemporary analysis of surgical approach (laparoscopic versus open) and outcomes.

METHODS

The National Surgical Quality Improvement Project Pediatrics Participant Use File (NSQIP PUF) was queried from 2016 to 2020. Utilization of laparoscopy was trended over time. Complication rates and length of stay were compared by operative approach.

RESULTS

9752 pyloromyotomies were included in the analysis. The utilization of laparoscopy steadily increased over the study time period (66% to 79%) and was associated with a shorter operative time. On multivariate regression, the utilization of laparoscopy was associated with a lower risk of overall complications, length of stay, and superficial surgical site infections. Overall complication rates were lower than previously reported (2.02%). The most common complication was superficial infection (1.2%).

CONCLUSIONS

In facilities reporting to pediatric National Quality Improvement Project, utilization of laparoscopy has steadily increased, and complication rates are lower than previously reported. Complication rates and length of stay were lower with the laparoscopic approach in this contemporary cohort. These results offer benchmarks for quality improvement initiatives. The laparoscopic approach should be standard in facilities performing this procedure.

Comparing pyloromyotomy outcomes across Canada

BACKGROUND

Changing patterns of referral and management of hypertrophic pyloric stenosis (HPS) in North America have recently been described. Comfort with perioperative management, anesthesia, and corrective surgery have been cited as reasons for these changes. Our primary objective was to assess pyloromyotomy outcomes between different hospital types across Canada. The secondary objective was to geospatially map all pyloromyotomies to identify regions of higher HPS incidence across Canada.

METHODS

Data of all pyloromyotomies done between 2011 and 2013 were acquired from Canadian Institute for Health Information (CIHI). Complication rates and length of hospital stay (LOS) were analyzed. Postal codes for each patient were used to geospatially map regions of higher HPS incidence.

RESULTS

A total of 1261 pyloromyotomies were assessed. There was no difference in LOS or complication rates between different hospital types or surgeon group. Open pyloromyotomies were done in 75% of the cases. Several regions of higher HPS incidence were identified across Canada.

CONCLUSION

This study found no difference in complication rate or LOS stay between hospital type and surgeon type across Canada. This may reflect a previously identified referral trend in the United States towards pediatric centers. Several regions of higher HPS incidence were identified, and may aid in identifying genetic elements causing HPS.

LEVEL OF EVIDENCE

2c.

Management of paediatric acute appendicitis in the general hospital setting: a national survey of preferred surgical technique

BACKGROUND

The advent of laparoscopic surgery has facilitated the management of acute appendicitis in the adult population. In the paediatric population (<12 years), management varies according to institution and/or consultant expertise. The aim of this study was to analyse consultant preference for laparoscopic versus open appendicectomy in the management of acute appendicitis in children under 12 years presenting to general hospitals.

METHODS

A 15-point questionnaire was distributed to 81 consultant surgeons identified from the specialist register of the Irish Medical Council and practicing as general surgeons outside of specialist paediatric centres.

RESULTS

A response rate of 83 % (67/81) was obtained. Of the 67 surgeons surveyed, 11 (16 %) had formal paediatric training. Sixty percent (40/67) of surgeons expressed a preference for the open technique. The median frequency of on-call rota was >1 in 5 (32/67) and only 3 % (2/67) claimed that the on-call commitment influenced decision-making regarding surgical approach. The average minimum age (9.3 years, range 1-14) and average minimum weight (25 kg, range 12-70) at which the operating surgeon would perform a laparoscopic appendicectomy were also recorded. Thirty percent (20/67) of consultant general surgeons had immediate access to specialist paediatric laparoscopic equipment.

DISCUSSION

This study has shown wide variability amongst consultant general surgeons when considering open versus laparoscopic appendicectomy in children under 12 years. Restricted access to specialist paediatric laparoscopic equipment, combined with declining exposure to paediatric surgical training, may continue to limit the numbers of paediatric laparoscopic appendicectomies performed in the general setting.

Should general surgery residents be taught laparoscopic pyloromyotomies? An ethical perspective

OBJECTIVES

The authors examine the ethical implications of teaching general surgery residents laparoscopic pyloromyotomy.

DESIGN/PARTICIPANTS

Using the authors' previously presented ethical framework, and examining survey data of pediatric surgeons in the United States and Canada, a rigorous ethical argument is constructed to examine the question: should general surgery residents be taught laparoscopic pyloromyotomies?

RESULTS

A survey was constructed that contained 24 multiple-choice questions. The survey included questions pertaining to surgeon demographics, if pyloromyotomy was taught to general surgery and pediatric surgery residents, and management of complications encountered during pyloromyotomy. A total of 889 members of the American Pediatric Surgical Association and Canadian Association of Paediatric Surgeons were asked to participate. The response rate was 45% (401/889). The data were analyzed within the ethical model to address the question of whether general surgery residents should be taught laparoscopic pyloromyotomies.

CONCLUSIONS

From an ethical perspective, appealing to the ethical model of a physician as a fiduciary, the answer is no.

DEFINITIONS

We previously proposed an ethical model based on 2 fundamental ethical principles: the ethical concept of the physician as a fiduciary and the contractarian model of ethics. The fiduciary physician practices medicine competently with the patient’s best interests in mind. The role of a fiduciary professional imposes ethical standards on all physicians, at the core of which is the virtue of integrity, which requires the physician to practice medicine to standards of intellectual and moral excellence. The American College of Surgeons recognizes the need for current and future surgeons to understand professionalism, which is one of the 6 core competencies specified by the Accreditation Council for Graduate Medical Education. Contracts are models of negotiation and ethically permissible compromise. Negotiated assent or consent is the core concept of contractarian bioethics. Nonnegotiable goods are goals for residency training that should never be sacrificed or negotiated away. Fiduciary responsibility to the patient, regardless of level of training, should never be compromised, because doing so violates the professional virtue of integrity. The education of the resident is paramount to afford him or her the opportunity to provide competent care without supervision to future patients. Such professional competence is the intellectual and clinical foundation of fiduciary responsibility, making achievement of educational goals during residency training another nonnegotiable good.

Laparoscopic pyloromyotomy: effect of resident training on complications

PURPOSE

The purpose of this study was to characterize the safety of laparoscopic pyloromyotomy and examine the effect of resident training on the occurrence of complications.

METHODS

Five hundred consecutive infants who underwent laparoscopic pyloromyotomy between January 1997 and December 2005 were reviewed and analyzed.

RESULTS

Laparoscopic pyloromyotomy was successfully completed in 489 patients (97.8%). Four hundred seventeen patients were boys (83%). Intraoperative complication occurred in 8 (1.6%) patients (mucosal perforation, 7; serosal injury to the duodenum, 1). All were immediately recognized and uneventfully repaired. Six patients (1.2%) required revision pyloromyotomy for persistent or recurrent gastric outlet obstruction. There were 7 wound complications (1.4%) and no deaths. Pediatric surgery residents performed 81% of the operations, whereas 16% were done by general surgery residents (postgraduate years 3-4). There was a 5.4-fold increased risk of mucosal perforation or incomplete pyloromyotomy when a general surgery resident rather than a pediatric surgery resident performed the operation (95% confidence interval, 1.8-15.8; P = .003). These effects persisted even after controlling for weight, age, and attending experience.

CONCLUSIONS

The laparoscopic pyloromyotomy has an excellent success rate with low morbidity. The occurrence of complications is increased when the operation is performed by a general surgery resident, even when directly supervised by pediatric surgical faculty.

The gap in laparoscopic colorectal experience between colon and rectal and general surgery residency training programs

PURPOSE

In this article, we review the laparoscopic experience of general surgery and colorectal residency training programs in the United States during the past 5 and 12 years, respectively. The purpose of this study was to determine whether an adequate experience was being provided, and at what level of training, to safely and effectively perform advanced laparoscopy.

METHODS

General Surgery Operative Reports from the training years 2000 to 2004 were obtained from the Accreditation Council for Graduate Medical Education. Similarly, colorectal operative performance logs from the training years 1994 to 2005 were obtained from the American Board of Colon and Rectal Surgery.

RESULTS

From 2000 to 2004, basic and advanced laparoscopic cases (as designated by the Accreditation Council for Graduate Medical Education) have increased from 10.1 to 12.2 percent and 2.1 to 3.7 percent, respectively. Within this period, the number of laparoscopic colon cases/resident/career has increased from 1.8 to 4.6. The percentage of cases performed laparoscopically increased from 3.9 to 22.5 percent from 1993-1994 to 2004-2005 training years. From 1993 to 2001, the average number of laparoscopic cases/resident increased from 6.3 to 16.1. In 2004, the average number of cases/resident increased to 45.3. Of this number, 30 were colon, 9.4 were rectal, and the remaining 5.9 were miscellaneous colorectal procedures.

CONCLUSIONS

Learning curves for laparoscopic colectomy are reported in the range of 20 to 60 cases. Based on the most recent data reviewed, colon and rectal resident experience is tending toward this threshold. Recent general surgery graduates may be lacking the appropriate volume to reach proficiency in laparoscopic colorectal surgery.

Minimally invasive pediatric surgery: Increasing implementation in daily practice and resident's training

BACKGROUND

In 1998, the one-year experience in minimally invasive abdominal surgery in children at a pediatric training center was assessed. Seven years later, we determined the current status of pediatric minimally invasive surgery in daily practice and surgical training.

METHODS

A retrospective review was undertaken of all children with intra-abdominal operations performed between 1 January 2005 and 31 December 2005.

RESULTS

The type of operations performed ranged from common interventions to demanding laparoscopic procedures. 81% of all abdominal procedures were performed laparoscopically, with a complication rate stable at 6.9%, and conversion rate decreasing from 10% to 7.4%, compared to 1998. There were six new advanced laparoscopic procedures performed in 2005 as compared to 1998. The children in the open operated group were significantly smaller and younger than in the laparoscopic group (p < 0.001 and p = 0.001, respectively). The majority (64.2%) of the laparoscopic procedures were performed by a trainee. There was no difference in the operating times of open versus laparoscopic surgery, or of procedures performed by trainees versus staff surgeons. Laparoscopy by trainees did not have a negative impact on complication or conversion rates.

CONCLUSIONS

Laparoscopy is an established approach in abdominal procedures in children, and does not hamper surgical training.