Laparoscopic appendectomy - Outcomes of senior trainees operating without supervision versus experienced pediatric surgeons

Trend of minimally invasive and open surgery experience of general surgery residents: Accreditation Council for Graduate Medical Education general surgery case log in Thailand

Purpose

Minimally invasive surgery (MIS) offers patients several benefits, such as smaller incisions, and fast recovery times. General surgery residents should be trained in both open and MIS. We aimed to examine the trends of minimally invasive and open procedures performed by general surgery residents in Thailand.

Methods

A retrospective review of the Royal College of Surgeons of Thailand and Accreditation Council for Graduate Medical Education general surgery case logs from 2007 to 2018 was performed for common open and laparoscopic general surgery operations. The data were grouped by three time periods, which were 2007-2010, 2011-2014, and 2015-2018, and analyzed to explore changes in the operative trends.

Results

For Thai residents, the mean number of laparoscopic operations per person per year increased from 5.97 to 9.36 (56.78% increase) and open increased from 20.02 to 27.16 (35.67% increase). There was a significant increase in the average number of minimally invasive procedures performed among cholecystectomy (5.83, 6.57, 8.10; p < 0.001) and inguinal hernia repair (0.33, 0.35, 0.66; p < 0.001). Compared to general surgery residents in the United States, Thai residents had more experience with open appendectomy, but significantly less experience with all other operations/procedures.

Conclusion

The number of open and minimally invasive procedures performed or assisted by Thai general surgery residents has slowly increased, but generally lags behind residents in the United States. The Thai education program must be updated to improve residents' technical skills in open and laparoscopic surgery to remain competitive with their global partners.

Systematic review and meta-analysis comparing perioperative outcomes of pediatric emergency appendicectomy performed by trainee vs trained surgeon

Appendicectomy is a common pediatric surgical procedure performed by trainees and surgeons with varying reported outcomes. It is a benchmark procedure for trainee progression and training benefits should be weighed against patient safety and perioperative outcomes. This systematic review and meta-analysis investigated any differential perioperative outcomes dependent on the grade of the operating surgeon. A systematic literature review and meta-analysis were performed comparing outcomes of pediatric appendicectomy performed by trainees versus trained surgeons. Of 2,086 articles screened, 5 retrospective non-randomized comparative studies reporting on 10,019 participants were analyzed. There was no difference in overall complications (OR 0.92; 95% CI 0.76, 1.12; P = 0.42), major complications [Clavien-Dindo (CD) III/IV] (OR 1.18; 95% CI 0.71, 1.97; P = 0.52), minor complications (CD I/II) (OR 1.13; 95% CI 0.57, 2.27; P = 0.72), post-op ileus (OR 0.74; 95% CI 0.10, 5.26; P = 0.76), wound infections (OR 0.87; 95% CI 0.62, 1.21; P = 0.41), abscess formation (OR 0.58; 95% CI 0.28, 1.22; P = 0.15), operation times [Mean Difference (MD) 2.31 min; 95% CI - 4.94, 9.56; P = 0.53] and reoperation rate (OR 1.22; 95% CI 0.23, 6.42; P = 0.81). Trainees had fewer conversions to open appendicectomy (OR 0.14; 95% CI 0.02, 0.88; P = 0.04). Appendicectomy performed on pediatric patients by trainees did not compromise patient safety. LEVEL OF EVIDENCE: III.

Postoperative recovery assessment after appendectomy in children - laparoscopic versus open technique

Introduction/Objective. Surgery is a ?gold standard? in treating the acute appendicitis in pediatric patients. The aim of the study was to determine the effect of open and laparoscopic appendectomy on postoperative recovery, return to everyday activities and quality of life in patients operated for the acute appendicitis. Methods. This prospective study was performed at the Institute for Children and Youth Healthcare of Vojvodina, during a period of ten months. This study was approved by Ethic committee of the Institute. All patients treated for the acute appendicitis by surgery were divided into two basic groups: open or laparoscopic appendectomy and into three subgroups, depending on the degree of appendicitis. We analyzed length of surgery, oral intake, establishing peristalsis, hospital stay, return to everyday activities and quality of life after surgery. Results. Laparoscopic technique was performed in 60 patients (48%), and the open method in 65 (52%). In laparoscopically treated patients (66.7%), peristalsis occurred earlier (p < 0.001), length of hospital stay was shorter (5.95 ? 1.21 days) (Z = -3.054; p = 0.002), the total score of daily activities showed a statistically significantly better score (Z = -7.667; p = 0.000), and they achieved a high level of quality of life significantly earlier (t = 2.773; p = 0.007). Conclusion. The advantage of minimally invasive surgery in the treatment of acute appendicitis in children is reflected in the faster re-establishment of every day functioning, faster recovery, and a good quality of life.

Laparoscopic pyloromyotomy can be performed safely by senior pediatric surgery trainees without supervision at high volume centers

AIM OF THE STUDY

Pediatric surgery trainees at our institution perform 15 to 20 supervised laparoscopic pyloromyotomies during their junior year, and are allowed to perform the operation independently without supervision during their senior year. We reviewed the outcomes of laparoscopic pyloromyotomies performed by senior trainees operating without supervision and compared them to experienced pediatric surgeons.

METHOD

We did a retrospective reviewed of all unsupervised laparoscopic pyloromyotomies (n = 90) performed by the last 12 pediatric surgery fellows (2012-2018) during their senior year, and the most recent 90 consecutive laparoscopic pyloromyotomies performed by 9 experienced pediatric surgeons. Statistical significance was determined by T-test and Fisher's exact test. Data is expressed as mean (SD) or median (range). A p value of ≤0.05 was considered significant.

RESULTS

Mean age at surgery was 4.7 (SD: 1.6) and 5 (SD: 2.3) weeks in the trainees and surgeons group, respectively (p = 0.38). Mean operative time was 28 (SD: 13) minutes in the trainees group vs. 25 (SD: 10) minutes in the surgeons group (p = 0.09). Intraoperative complications occurred in 3 of 90 (2.7%) cases in the trainees group (three mucosal perforations, all detected during the operation, one repaired laparoscopically, two repaired open), and none in the surgeons group (p = 0.11). One postoperative complication requiring reoperation occurred in the trainees group (omentum eviscerated through an incision site), while none occurred in the surgeons group (p = 0.36). No incomplete pyloromyotomies occurred in either group. The median length of postoperative hospital stay was 1 (1 to 10) and 1 (1 to 6) days in the trainees and surgeons group, respectively (p = 0.63).

CONCLUSION

Senior trainees at high-volume training programs can perform unsupervised laparoscopic pyloromyotomies safely as a mean to promote surgical autonomy without compromising patient outcomes.

LEVEL OF EVIDENCE

III.

Single-incision laparoscopic appendectomy is a safe procedure for beginners to perform: experience from 1948 cases

BACKGROUND

Single-incision laparoscopic appendectomy (SIL-A) has recently become an option for treating appendicitis. The aim of this study was to evaluate the safety, feasibility, and surgical outcomes of SIL-A by residents and surgeons during the learning period.

METHODS

A total of 1948 consecutive patients who underwent SIL-A from May 2008 to November 2014 were studied retrospectively. Surgeries were performed by residents and eight surgeons. Prior to the first case, surgeons and residents had been trained in a training protocol during the learning period. Three initial cases of SIL-A were performed under the supervision of experienced surgeons. Patients were divided into two groups: group 1 (learning period, n = 483), the first 40 cases by each surgeon and resident; and group 2 (experienced period, n = 1465), cases after the 40th procedure performed by each surgeon. Surgical results were compared between the two groups by performing propensity score matching analysis.

RESULTS

After propensity score matching, there was no significant difference in patient demographics and characteristics of appendicitis between the two groups. The operating time was longer in group 1 than in group 2 (45.3 ± 18.0 vs. 33.9 ± 16.1 min, p < 0.001). The morbidity rate (7.0% vs. 6.5%, p = 0.795) was similar between the two groups. Readmission rate (2.1% vs. 1.3%, p = 0.414) and reoperation rate (0.8% vs. 0.8%, p = 0.348) were also similar between the two groups. However, the rate of incisional hernia occurrence (0.6% vs. 0%, p = 0.066) tended to be larger in group 1 than in group 2 without showing a significant difference.

CONCLUSION

SIL-A is a technically feasible and safe procedure when it is performed by residents and surgeons during learning period under an appropriate training protocol. However, residents and surgeons in the learning period should perform it carefully to prevent incisional hernias.