Comparison of outcomes after minimally invasive versus open partial nephrectomy with respect to trainee involvement utilizing the American College of Surgeons National Surgical Quality Improvement Program

Impact of resident participation on surgical outcomes in laparoscopically assisted vaginal hysterectomy

OBJECTIVE

To compare surgical outcomes in patients with benign diseases who underwent laparoscopically assisted vaginal hysterectomy (LAVH) to determine the association between surgical outcomes and resident participation in the gynecologic field.

METHODS

A single-center retrospective study was conducted of patients diagnosed with benign gynecologic diseases who underwent LAVH between January 2010 and December 2015. Clinicopathologic characteristics and surgical outcomes were compared between the resident involvement and non-involvement groups. The primary endpoint was the 30-day postoperative morbidity. Observers were propensity matched for 17 covariates for resident involvement or non-involvement.

RESULTS

Of the 683 patients involved in the study, 165 underwent LAVH with resident involvement and 518 underwent surgery without resident involvement. After propensity score matching (157 observations), 30-day postoperative morbidity occurred in 6 (3.8%) and 4 (2.5%) patients in the resident involvement and non-involvement groups, respectively (P = 0.501). The length of hospital stay differed significantly between the two groups: 5 days in the resident involvement group and 4 days in the non-involvement group (P < 0.001). On multivariate analysis, Charlson Comorbidity Index >2 (odds ratio [OR] 8.01, 95% confidence interval [CI] 2.68-23.96; P < 0.001), operative time (OR 1.02, 95% CI 1.01-1.03; P < 0.001), and estimated blood loss (OR 1.00, 95% CI 1.00-1.00; P < 0.001) were significantly associated with 30-day morbidity, but resident involvement was not statistically significant.

CONCLUSION

There was no significant difference in the 30-day morbidity rate when residents participated in LAVH. These findings suggest that resident participation in LAVH may be a viable approach to ensure both residency education and patient safety.

Patient Safety and Quality Improvement in Minimally Invasive Surgery

Background: The journey of minimally invasive (MI) urology is one of quality improvement (QI) and patient safety. New techniques have been progressively studied for adoption and growth. As more advanced methods of data collection and analysis are developed, a review of the patterns and history of these principles in the development of MI urology can inform future urologic QI and patient safety initiatives. Objective: To perform a scoping review identifying patterns of QI and patient safety in MI urology. Methods: PubMed and the American Urological Association (AUA) journal search page were screened on December 2022 for publications using the search parameters "quality improvement" and "minimally invasive." Articles were screened according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews (PRISMA-ScR). Results: The initial literature search identified 471 articles from PubMed and 57 from the AUA journal search page. After screening, 528 articles were relevant to the topic and reviewed. Four hundred eighty-two articles were duplicates or did not meet inclusion criteria. Forty-six are included in this review. Conclusion: Urology has developed a pattern of assessing MI surgery vs the open counterpart. This includes analyzing the newest approach to understand complications, examining the factors contributing to complications, and lastly designing projects to mitigate future risk. This information, as well as advanced methods of data collection, has identified areas of improvement for new QI projects. The stage is set for a promising future with the adoption of advanced QI in daily urologic practice to improve patient safety and minimize errors.

A propensity score matching analysis: Impact of senior resident versus fellow participation on outcomes of complex surgical oncology

BACKGROUND

Teaching hospitals that train both general surgery residents and fellows in complex general surgical oncology have become more common. This study investigates whether participation of a senior resident versus a fellow has an impact on outcomes of patients undergoing complex cancer surgery.

METHODS

Patients who underwent esophagectomy, gastrectomy, hepatectomy, or pancreatectomy between 2007 and 2012 with assistance from a senior resident (post-graduate years 4-5) or a fellow (post-graduate years 6-8) were identified from the ACS NSQIP. Based on age, sex, body mass index, ASA classification, diagnosis of diabetes mellitus, and smoking status, propensity-scores were created for odds of undergoing the operation assisted by a fellow. Patients were matched 1:1 based on propensity score. Postoperative outcomes including risk of major complication were compared after matching.

RESULTS

In total, 6934 esophagectomies, 13,152 gastrectomies, 4927 hepatectomies, and 8040 pancreatectomies were performed with assistance of a senior resident or fellow. After matching, overall rates of major complications were equivalent across all four anatomic locations between cases performed with the participation of a senior resident versus a surgical fellow: esophagectomy (37.0%% vs 31.6%, p = 0.10), gastrectomy (22.6% vs 22.3%, p = 0.93), hepatectomy (15.8% v 16.0%, p = 0.91), and pancreatectomy (23.9% vs 25.2%, p = 0.48). Operative time was shorter for gastrectomy (212 vs. 232 min; p = 0.004) involving a resident compared to a fellow, but comparable for esophagectomy (330 vs. 336 min; p = 0.41), hepatectomy (217 vs. 219 min; p = 0.85), and pancreatectomy (320 vs. 330 min; p = 0.43).

CONCLUSIONS

Senior resident participation in complex cancer operations does not appear to negatively impact operative time or postoperative outcomes. Future research is needed to further assess this domain of surgical practice and education, particularly with regard to case selection and operative complexity.

The Association of Trainee Involvement in Radical Cystectomy With Perioperative and Oncologic Outcomes

OBJECTIVE

To assess the impact of trainee involvement in surgery on perioperative and oncological outcomes of patients undergoing radical cystectomy (RC).

MATERIALS AND METHODS

We reviewed the records of patients undergoing RC for urothelial carcinoma between 2000 and 2015 at our institution. Trainee level was categorized as fellow, chief, senior and junior residents. Demographic, perioperative and oncological outcomes were recorded and compared between the groups. Specifically, operative time, 30-day complications, severe complications (Clavien III-V) and oncological outcomes (overall, cancer-specific and recurrence-free survival) were assessed.

RESULTS

A total of 895 patients were included for study. On multivariable analysis, operative times were 30-40 minutes longer in procedures assisted by junior residents as compared to more senior trainees. Notably, trainee level was not associated with overall or severe complications on multivariable analyses. Similarly, trainee level was not associated with oncologic outcomes.

CONCLUSION

While cases assisted by junior residents had longer operative times, complication rates and oncological outcomes were comparable across trainee groups. Trainee level does not appear to have an impact on perioperative and oncological outcomes of RC for urothelial carcinoma.

Resident Level Involvement Affects Operative Time and Surgical Complications in Lower Extremity Fracture Care

OBJECTIVE

The purpose of this study is to evaluate the effect of resident participation on operative time and surgical complications in isolated lower extremity fracture care.

SETTING

Patients who were treated at teaching hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program database.

PARTICIPANTS

A total of 2,488 patients who underwent surgical fixation of isolated hip fractures, femoral or tibial shaft fractures, and ankle fractures.

DESIGN

Patients were stratified by surgical procedure and post-graduate year (PGY) of the resident involved. Total operative time and surgical complications were analyzed with respect to resident participation and seniority. Multivariable logistic regression analyses were used to adjust for potential confounders including case complexity, wound class, and patient comorbidity burden.

RESULTS

As PGY level increased, operative time increased for each procedure. The odds for a deep surgical site infection decreased as resident seniority increased, but the odds for wound dehiscence increased as resident seniority increased. We found no difference in the incidences of superficial infections or return to the OR with respect to PGY level. Academic quarter within the academic year did not correlate with any of the surgical complications. Furthermore, when cases performed with residents were compared to those performed without residents, there was no increased risk of superficial infections, deep infections, or return to the OR.

CONCLUSIONS

This nationally representative dataset demonstrates that operative times for lower extremity orthopedic trauma increased as resident seniority increased. Additionally, senior resident participation was associated with increased wound dehiscence, whereas junior resident participation was associated with an increased risk of deep surgical site infections. However, there was no associated "July effect" for residents at any level of training and there was no increased risk for surgical site infections or return to the OR in cases involving resident participation.

Association of the Risk of a Venous Thromboembolic Event in Emergency vs Elective General Surgery

Importance

Trauma patients have an increased risk of venous thromboembolism (VTE), partly because of greater inflammation. However, it is unknown if this association is present in patients who undergo emergency general surgery (EGS).

Objectives

To investigate whether emergency case status is independently associated with VTE compared with elective case status and to test the hypothesis that emergency cases would have a higher risk of VTE.

Design, Setting, and Participants

This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program database from January 1, 2005, to December 31, 2016, for all cholecystectomies, ventral hernia repairs (VHRs), and partial colectomies (PCs) to obtain a sample of commonly encountered emergency procedures that have elective counterparts. Emergency surgeries were then compared with elective surgeries. The dates of analysis were January 1 to 31, 2019.

Main Outcomes and Measures

The primary outcome was VTE at 30 days. A multivariable analysis controlling for age, sex, body mass index, bleeding disorder, disseminated cancer, laparoscopy approach, and surgery type was performed.

Results

There were 604 537 adults undergoing surgical procedures over 12 years (mean [SD] age, 55.3 [16.6] years; 61.4% women), including 285 847 cholecystectomies, 158 500 VHRs, and 160 190 PCs. The rate of VTE within 30 days was 1.9% for EGS and 0.8% for elective surgery, a statistically significant difference. Overall, 4607 patients (0.8%) had deep vein thrombosis, and 2648 patients (0.4%) had pulmonary embolism. A total of 6624 VTEs (1.1%) occurred in the cohort. As expected, when VTE risk was examined by surgery type, the risk increased with invasiveness (0.5% for cholecystectomy, 0.8% for VHR, and 2.4% for PC; P < .001). On multivariable analysis, EGS was independently associated with VTE (odds ratio [OR], 1.70; 95% CI, 1.61-1.79). Also associated with VTE were open surgery (OR, 3.38; 95% CI, 3.15-3.63) and PC (OR, 1.86; 95% CI, 1.73-1.99).

Conclusions and Relevance

In this cohort study, emergency surgery and increased invasiveness appeared to be independently associated with VTE compared with elective surgery. Further study on methods to improve VTE chemoprophylaxis is highly recommended for emergency and more extensive operations to reduce the risk of potentially lethal VTE.

Three Different Learning Curves Have an Independent Impact on Perioperative Outcomes After Robotic Partial Nephrectomy: A Comparative Analysis

Background

Robot-assisted partial nephrectomy (RAPN) has become widely accepted, but its different underlying types of learning curves have not been comparatively analyzed to date. This study aimed to determine and compare the impact that the learning curve of the department, the console surgeon, and the bedside assistant as well as patient-related factors has on the perioperative outcomes of RAPN.

Methods

The study retrospectively analyzed 500 consecutive transperitoneal RAPNs (2007–2018) performed in a tertiary referral center by 7 surgeons and 37 bedside assistants. Patient characteristics and surgical data were obtained. Experience (EXP) was defined as the current number of RAPNs performed by the department, the surgeon, and the assistant. As the primary outcome, the impact of EXP and patient-related factors on perioperative outcomes were analyzed and compared. As the secondary outcome, a cutoff between “experienced” and “inexperienced” was defined. Correlation and regression analysis, receiver operating characteristic curve analysis, Fisher’s exact test, and the Mann–Whitney U test were performed, with p values lower than 0.05 denoting significance.

Results

The EXP of the department, the surgeon, and the assistant each has a major influence on perioperative outcome in RAPN irrespective of patient-related factors. Perioperative outcomes improve significantly with EXP greater than 100 for the department, EXP greater than 35 for the surgeon, and EXP greater than 15 for the assistant.

Conclusions

The perioperative results of RAPN are influenced by three different types of learning curves including those for the surgical department, the console surgeon, and the assistant. The influence of the bedside assistant clearly has been underestimated to date because it has a significant impact on the perioperative outcomes of RAPN.

Electronic supplementary material

The online version of this article (10.1245/s10434-020-08856-1) contains supplementary material, which is available to authorized users.

Lower Incidence of Postoperative Acute Kidney Injury in Robot-Assisted Partial Nephrectomy Than in Open Partial Nephrectomy: A Propensity Score-Matched Study

Background: Acute kidney injury (AKI) after partial nephrectomy is attributed to parenchymal reduction and ischemia, but the extent of its effect remains unclear. This study aimed to compare the incidence of postoperative AKI among surgical modalities, robot-assisted partial nephrectomy (RAPN), laparoscopic partial nephrectomy (LPN), and open partial nephrectomy (OPN), and to evaluate the validity of RAPN by comparing it with LPN and OPN in terms of postoperative AKI, perioperative complications, and long-term renal function. Patients and Methods: Patients who underwent RAPN, LPN, and OPN for renal tumors at our institutions between 2004 and 2018 were retrospectively analyzed. RAPN and LPN were performed under warm ischemia and OPN under cold ischemia. En bloc hilar clamping was employed for LPN and OPN and arterial clamping for RAPN. AKI was defined as % decrease in estimated glomerular filtration rate (eGFR) >25% from preoperative eGFR to postoperative nadir eGFR. Multivariate regression analysis was used to test associations of AKI with perioperative factors. Then, we compared the incidence of AKI with two propensity score-matched cohorts: RAPN vs OPN and RAPN vs LPN. Results: This study included 1762 cases (RAPN: 959, LPN: 215, and OPN: 588). After matching, 147 cases each from RAPN and LPN groups and 368 cases each from RAPN and OPN groups were selected. RAPN had shorter warm ischemia time than LPN, lower incidence of AKI, and lower % decrease in eGFR after 6 months. RAPN had a shorter ischemia time and a lower incidence of AKI than OPN, although the % decrease in eGFR after 6 months did not differ significantly. Conclusions: AKI incidence was lower in RAPN than in LPN or OPN, which may be due to the shorter ischemia time or clamping of only arteries in RAPN. Although long-term renal outcomes did not differ between RAPN and OPN, RAPN can help prevent AKI. This supports the validity of RAPN for patients with chronic kidney disease.

Renal Thermal Ablation Trends of American Urologists

Objective: To define current trends in the utilization of renal thermal ablation by urologists in the United States. Material and Methods: A six-month case log data for renal procedures submitted by certifying and recertifying American urologists from 2003 to 2018 were obtained from the American Board of Urology and stratified by current procedural terminology code. The utilization of thermal ablative techniques was examined with respect to overall trends, surgeon, and practice characteristics associated with its use. Results: Six thousand two hundred eleven unique urologists performed 54,075 renal procedures, including 1916 (3.5%) thermal ablations, 630 (1.2%) renal biopsies, 17,361 (32.1%) partial nephrectomies, 20,403 (37.8%) radical nephrectomies, and 7957 (14.7%) nephroureterectomies. Eight hundred twenty-five (13.3%) unique urologists performed renal ablations, including 1344 (70.2%), 418 (21.8%), and 154 (8.0%) laparoscopic, percutaneous, and open ablation procedures, respectively. The annual volume of ablation was highest in 2008, followed by 2010 and 2009. On multivariate modeling of those performing renal interventions, the first decade of practice, self-declared endourologist, urologist who completed an endourology fellowship, urologist who practices in the Mid Atlantic, North Central, South Central, and South Eastern United States (compared with New England) were more likely to perform thermal ablation for renal masses. Urologists who perform renal biopsies and partial nephrectomies are also more likely to perform ablation of renal masses. Conclusions: Thermal ablation accounted for a small percentage of renal interventions performed by urologists in the last 1.5 decades with definable associations to practice characteristics. Renal ablation was most commonly performed laparoscopically, with declining use in recent years.

Contemporary Perioperative Morbidity and Mortality Rates of Minimally Invasive vs Open Partial Nephrectomy in Obese Patients with Kidney Cancer

Aims: To compare early postoperative morbidity and mortality rates in obese patients (body mass index ≥30 kg/m²) who underwent minimally invasive partial nephrectomy (MIPN) vs open partial nephrectomy (OPN), utilizing the National Surgical Quality Improvement Program (NSQIP) database. Materials and Methods: The NSQIP database was queried to identify obese patients who underwent either MIPN or OPN between 2008 and 2016. Patient demographics, comorbidities, operative time (OT), length of stay (LOS), and 30-day postoperative complications, readmissions, and mortality rates were recorded and compared between the two groups. Multivariable logistic regression analysis was used to determine the adjusted odds of early postoperative complications in MIPN vs OPN. Results: A total of 6041 obese MIPN patients and 3064 obese OPN patients were identified. Mean OT (minutes ± standard deviation) was longer for MIPN vs OPN (197.2 ± 71.0 vs 189.6 ± 82.4, p < 0.001), while mean LOS (3.8 ± 2.8 days vs 5.8 ± 3.5 days, p < 0.001) and 30-day complications (8.5% vs 19.8%, p < 0.001) were lower. No difference in 30-day postoperative mortality rates between MIPN (0.4%) and OPN (0.5%) was observed (p = 0.426). In the adjusted analysis, the odds of any complication within 30 days in the MIPN group were 61% lower, blood transfusion 73% lower, pneumonia 38% lower, sepsis 70% lower, acute renal failure 64% lower, superficial surgical site infection 40% lower, and reoperation 47% lower, compared with OPN patients. Conclusions: When compared with OPN in obese patients, the likelihood of 30-day postoperative morbidity was significantly lower in MIPN patients. However, the odds of 30-day mortality rates were similar between the groups.

Effect of Surgical Trainee Presence on Vaginal Hysterectomy Outcomes

STUDY OBJECTIVE

Because of the rapid decline in vaginal hysterectomy (VH) cases in recent years, there is concern regarding gynecologic surgical training and proficiency for VH. The objective of this study is to determine the effect of surgical trainee involvement on surgical outcomes in VH cases performed for benign indications.

DESIGN

Retrospective, multicenter, cohort study (Canadian Task Force classification II-2).

SETTING

Participating hospitals in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) at various international sites.

PATIENTS

Women who underwent VH for benign indication enrolled from the ACS-NSQIP from 2006 to 2012.

INTERVENTION

ACS-NSQIP database.

MEASUREMENTS AND MAIN RESULTS

Our study included 5756 patients who underwent VH, and surgical trainees were present in 2276 cases (39.5%). Patients who had a trainee present during VH were more likely to be older, nonsmoking, have comorbidities, and be classified as American Society of Anesthesiologists class III or IV. They were also more likely to be admitted as inpatients, undergo concomitant adnexal surgery, and have uterine weight greater than 250 g. Trainee presence during VH was associated with increased rates of overall complications (5.1% vs 3.19%, p < .001), urinary tract infection (5.27% vs 2.64%, p < .001), and operative time (124.25 ± 59.29 minutes vs 88.64 ± 50.9 minutes, p < .001). After controlling for baseline characteristics, trainee presence was associated with increased odds of overall complications (adjusted odds ratio, 1.63; 95% confidence interval, 1.25-2.13), urinary tract infection (adjusted odds ratio, 2.02; 95% confidence interval, 1.51-2.69), and prolonged operative time (adjusted odds ratio, 3.65; 95% confidence interval, 3.20-4.15). No differences were observed for other measures of surgical morbidity or mortality.

CONCLUSION

Despite the increased patient complexity and operative time associated with teaching cases, the involvement of surgical trainees is associated with urinary tract infection but not with any major surgical morbidity or mortality. These findings have important implications for gynecologic surgical training for VH.

Infection following penile prosthesis placement at an academic training center remains low despite involvement of surgeons-in-training

Purpose

Primary care providers harbor misconceptions regarding penile prosthetic surgery, largely overestimating the rate of infection. Rates of infection following surgery for primary placement and revision are estimated as 1% to 3% and 10% to 18%, respectively. Our objective was to determine the contemporary incidence of infection following inflatable penile prostheses surgery at an academic training center where surgeons-in-training are routinely involved.

Materials and Methods

Review of a prospectively collected single-surgeon database was performed. All cases of inflatable penile prostheses placement from January 2011 through June 2017 were reviewed. Information regarding training level of assistant surgeon(s) was collected, and follow-up data was compiled regarding postoperative infections and need for revision surgery.

Results

Three hundred nine cases meeting inclusion criteria were identified. Mean patient age was 64.2 years, and mean follow-up was 28.7 months. Distribution involved 257 (83.2%) for primary placement, 45 (14.6%) for removal/replacement, and 7 (2.3%) in setting of prior device removal. Diabetes was noted in 31.1% of men. Surgeon-in-training involvement was noted in 100% of cases. Infection was confirmed in a patient who had skin breakdown over an area of corporal reconstruction with polytetrafluoroethylene. The overall postoperative infection rate was 0.3%.

Conclusions

In this series from an academic training center, infection following penile prosthetic surgery is low, similar to other centers of excellence, even with 100% involvement of surgeons-in-training. This data should be used to better inform primary care providers and members of the general public potentially interested in restoration of sexual function.

Short Stay Thyroid Surgery: Can We Replicate the Same in Low Resource Setting?

Introduction

The concept of short stay thyroidectomy has been tested and in practice in the developed world; the same has not been replicated in countries with limited resources due to lack of organized healthcare system. So, in this study, we tried to analyze if short stay thyroid surgery can be performed in a cost-effective way in developing countries and also if the endocrine surgical trainee can deliver these services safely.

Methods

The study was conducted prospectively from January 2013 to July 2014, at Department of Endocrine Surgery, SGPGIMS, Lucknow, India. Study group included patients undergoing short stay hemithyroidectomy whereas matched patients who qualified for inclusion criteria but did not undergo short stay surgery due to various reasons constituted control group. Outcome in both the groups was compared in terms of complication rates, cost benefit, and patient satisfaction. Subgroup analysis was also done for trainee versus consultant performed short stay thyroid surgery.

Results

A total of 439 patients with surgical thyroid disorders were evaluated at our institute during the study period and out of these 110 patients (58 cases and 52 controls) fulfilled the inclusion criteria. Younger patients with low socioeconomic status who were paying out of pocket were found to be more inclined to short stay thyroid surgery. There was no significant difference between the two groups in terms of postanesthetic discharge score (PADS), complication rates, and patients satisfaction; however there was significant reduction (p <0.001) in hospital cost in short stay group. In subgroup analysis, procedure time was more in trainee performed surgeries; however there was no significant difference in terms of mean PADS and complication rates.

Conclusion

Short stay thyroidectomy can provide a better cost-effective alternative to conventional thyroidectomy in patients undergoing thyroid surgery and can be safely performed by endocrine surgical trainees even in a low resource setting.

The Impact of Teaching on Fundamental General Urologic Procedures: Do Residents Help or Hurt?

OBJECTIVE

To examine the effects of trainee involvement on fundamental urology procedures.

METHODS

Current Procedural Terminology codes were used to identify patients within the National Surgical Quality Improvement Program database who underwent a selection of fundamental general urology procedures (2005-2013). Operative time and perioperative complications (30-day) were compared between cases with and without trainee involvement.

RESULTS

29,488 patients had general urology procedures with information regarding trainee involvement, 13,251 (44.9%) with trainee involvement, and 16,237 (55.1%) without. Overall patients who underwent procedures with trainee involvement were younger and had fewer comorbidities (Table 1). Trainee involvement showed significant increase in operative time in all procedures included in the study (Table 2). On multivariate analysis trainee involvement increased the risk of complications (Odds Ratio (OR) 1.61, 95% CI 1.45-1.78, P < .001). Other factors that increased the risk of complications were: American Society of Anesthesiologists (ASA) class 3-4 (OR 2.01, 95% CI 1.46-2.77, P < .001), partially or totally dependent functional status (OR 2.22, 95% CI 1.68-2.94, P < .001), diabetes mellitus (OR 1.21, 95% CI 1.05-1.39, P = .008), heart disease (OR 1.19, 95% CI 1.02-1.38, P = .027), and respiratory disease (OR 1.33, 95% CI 1.09-1.63, P = .027).

CONCLUSION

While trainees are valuable members of the urology team at teaching hospitals and training is necessary, their involvement in urologic surgery appears to increase operative time for all procedures and complications in certain procedures. Further research needs to be done on how to mitigate these effects while preserving surgical education quality.

Perioperative Morbidity of Open Versus Minimally Invasive Partial Nephrectomy: A Contemporary Analysis of the National Surgical Quality Improvement Program

INTRODUCTION AND OBJECTIVES

In recent years, there has been a shift to minimally invasive partial nephrectomy (MIPN) with the dissemination of robot-assisted technology. However, contemporary data on the comparative morbidity of open partial nephrectomy (OPN) and MIPN are lacking. We, therefore, evaluated the perioperative morbidity of OPN and MIPN using a contemporary national cohort.

METHODS

We identified 13,658 patients aged 18 to 89 who underwent PN from 2010 to 2015 in the National Surgical Quality Improvement Program (NSQIP) database, of whom 9018 (66.0%) underwent MIPN. The associations of MIPN with 30-day morbidity were evaluated using logistic regression, adjusted for patient features.

RESULTS

Median age at surgery was 60 (interquartile range [IQR] 51, 68) years. Overall, 30-day complications occurred in 6.7% of patients. Compared with OPN, MIPN was associated with lower rates of 30-day complications (4.9% vs 10.1%, p < 0.0001), perioperative blood transfusion (3.8% vs 12.5%, p < 0.0001), prolonged hospitalization (5.6% vs 23.4%, p < 0.0001), readmission (4.4% vs 7.8%, p < 0.0001), reoperation (1.8% vs 3.2%, p < 0.0001), and 30-day mortality (0.3% vs 0.6%, p = 0.001). On multivariable analysis, MIPN was independently associated with a reduced risk of 30-day complications (odds ratio [OR] 0.46, p < 0.0001), perioperative blood transfusion (OR 0.27, p < 0.0001), prolonged hospitalization (OR 0.19, p < 0.0001), readmission (OR 0.59, p < 0.0001), and reoperation (OR 0.57, p < 0.0001). Postoperative complications occurred predominantly early after surgery, whereas hospital readmissions and reoperation occurred at a consistent rate.

CONCLUSIONS

In this contemporary national cohort, MIPN was independently associated with reduced rates of 30-day complications, perioperative blood transfusion, prolonged hospitalization, hospital readmission, and reoperation, compared with OPN.

Resident Involvement in Microsurgery: An American College of Surgeons National Surgical Quality Improvement Program Analysis

OBJECTIVE

In the current healthcare climate, there is increased focus on medical errors, patient outcomes, and the influence of resident participation on these metrics. Other studies have examined the influence of resident involvement on surgical outcomes, but the arena of microsurgery, with added complexity and learning curve, has yet to be investigated.

DESIGN

A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was performed to find patients undergoing procedures with free tissue transfer by screening for Current Procedural Terminology codes. Primary outcomes measured include flap failure, wound, infectious, and major and minor complications.

SETTING

This study was conducted at the Methodist Hospital, an academic hospital located in Houston, Texas.

PARTICIPANTS

Patients in the National Surgical Quality Improvement Program database between the years 2005 and 2012 undergoing microsurgical procedures were included in this analysis.

RESULTS

A total of 1466 patients met inclusion criteria. There was a statistically significant association of major complications with age, peripheral vascular disease, American Society of Anesthesiologists (ASA) classification of 3 or greater, total operative time, and year of operation. Multivariate analysis on minor complications demonstrated significant association with ASA class of 3 or 4. Resident involvement was not a significant factor among any outcome measures including major complications, minor complications, flap failure, wound complications, infectious complications, bleeding requiring transfusion, and unexpected reoperation rates within 30 days.

CONCLUSIONS

This study provides further evidence in support of the claim that resident involvement in microsurgery is safe and effective, with similar rates of major complications, minor complications, flap failure, and unexpected reoperation. High ASA classification and history of peripheral vascular disease were strong predictors of major complications and should be optimized preoperatively before free tissue transfer. Later years were associated with decreased major complication rates, which may be reflective of enhanced supervision standards.

The effect of training level on complications after free flap surgery of the head and neck

OBJECTIVES

Analyze postoperative complications after free flap surgery based on PGY training level.

METHODS

Data on free flap surgeries of the head and neck performed from 2005 to 2013 was collected from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Cases identifying the status of resident participation in the surgery and the PGY level were included.

RESULTS

There were 582 cases with primary surgeon data available. 63 cases were performed with a junior resident, 211 were performed with the assistance of a senior resident, 279 cases were performed with a fellow, and 29 cases were performed by an attending alone without resident involvement. The overall complication rate was 55.2%. There was no statistically significant difference in the rate of complications between groups (47.6%, 59.7%, 53.0%, 58.6%, p=0.277). After controlling for all confounding variables using multivariate analysis there was no significant difference in morbidity, mortality, readmissions, and reoperation amongst the groups. Furthermore, when comparing resident versus fellow involvement using multivariate analysis there were no significant differences in morbidity (OR=0.768[0.522-1.129]), mortality (OR=1.489[0.341-6.499]), readmissions (OR=1.018[0.458-2.262]), and reoperation (OR=0.863[0.446-1.670]).

CONCLUSION

Resident and fellow participation in microvascular reconstructive cases does not appear to increase 30-day rates of medical, surgical, or overall complications.

Resident and fellow participation in Thyroid and Parathyroid surgery: an ACS-NSQIP clinical outcomes analysis

BACKGROUND

The effect of decreased overall hours of training in surgical specialties is still being examined. Of particular interest is the safety of patients undergoing surgeries with trainee surgeons. The aim of this study was to identify if there were significant differences in outcomes of patients undergoing commonly performed thyroid and parathyroid surgeries when trainees were involved.

MATERIALS AND METHODS

Postoperative complication rates, length of stay (LOS), and total operation time (OT) data were gathered from the American College of Surgeons National Surgical Quality Improvement Project database. The cases were identified by CPT code and were divided based on the training level of the participating resident surgeon: Junior (postgraduate year [PGY] 1-2), senior (PGY 3-5), fellow (PGY >5), as well as an attending-only group where no resident was present. We compared the clinical outcomes, LOS, and OT in each trainee group to the attending-only group as the reference.

RESULTS

A total of 84,711 cases were identified of which 45.33% involved trainee participation. Odds ratios (ORs) and 95% confidence interval for overall, neurologic, and bleeding complications were calculated. No difference in the odds of overall patient complications or neurologic complications was observed. A decrease in the odds of bleedings complications when a junior or senior trainee was present was observed. Overall complications in operations including a junior trainee (PGY 1-2) had an OR of 1.04 (0.85, 1.29), a senior trainee (PGY 3-5) had an OR of 1.00 (0.89, 1.13), and a fellow had an OR of 0.98 (0.74, 1.31). Mean OT was found to be significantly different between attending only and junior and senior trainees. There was no significant difference in OT between fellows and attending only. LOS did not meaningfully differ across groups.

CONCLUSIONS

In three commonly performed thyroid and parathyroid operations, there is not an increased overall or neurologic complication odds when a surgical trainee is involved; there are decreased odds of a bleeding complication.

Does teaching of robotic partial nephrectomy affect renal function and perioperative outcomes?

PURPOSE

Partial nephrectomy (PN) represents the treatment of choice for localized renal tumor<7cm. Minimally invasive approaches are considered standard of care in many institutions. Maintaining acceptable warm ischemic time (WIT) while teaching robotic PN (RPN) remains challenging. The goal of the present study was to assess the effect of teaching RPN on WIT and renal function in patients undergoing RPN.

METHODS

Patients undergoing RPN for cT1-T2 renal tumors were included. RENAL nephrometry score was used to adjust for tumor complexity. Glomerular filtration rates (GFR) were determined preoperatively, at day 2 and at ≥3-month follow-up. Patients in whom the attending surgeon (staff) performed tumorectomy and renorraphy were compared with those in whom the fellow performed these steps. Primary outcomes were WIT and GFR decrease at follow-up visit. Morbidity and margin positivity represented secondary outcomes.

RESULTS

Overall, 69 patients (46 "staff" vs. 23 "fellow") were included. Patient׳s characteristics did not differ significantly between the 2 groups. In particular, RENAL score and preoperative GFR were similar between both groups. Mean WIT was 22±9 in the staff and 24±7 in the fellow group (P = 0.09). At follow-up, a GFR reduction of 9% was observed in the staff group vs. 13% in the fellow group (P = 0.38). Complication rates (13% vs. 17%, P = 0.63) and positive margins (9% vs. 4%, P = 0.47) did not differ significantly between staff and fellow.

CONCLUSIONS

In our experience, teaching RPN with a strict supervision and stepwise standardized procedure was oncologically and functionally safe after 3 to 6 months of follow-up.

The role of the assistant during robot-assisted partial nephrectomy: does experience matter?

The objective of this study was to evaluate surgical outcomes with respect to the experience level of the bedside assistant during robot-assisted partial nephrectomy. A retrospective review was conducted of a prospectively maintained database of 414 consecutive robot-assisted laparoscopic partial nephrectomies performed by experienced robotic surgeons at our institution from April 2011 to September 2014. A senior-level assistant was defined as a resident in his or her post-graduate year (PGY) 4 or 5, or a fellow. Junior-level assistants were considered to be PGY-2, PGY-3, or a nurse first assistant. Multivariate analyses were performed using linear, Poisson, and logistic regression models. There were 115 junior-level cases and 299 senior-level cases. On univariate analysis, the experience level of the assistant had no impact on operative time (168 for junior level vs. 163 min for senior level, p = 0.656). Likewise, there were no differences between the junior- and senior-level groups with regard to warm ischemia time (21.3 vs. 20.9 min, p = 0.843), negative margin status (111/115 (96.5 %) vs. 280/299 (93.6 %), p = 0.340), or postoperative complications (17/115 (14.8 %) vs. 35/299 (11.7 %), p = 0.408). After multivariate analysis, operative time was associated with increased body mass index and tumor size (both p < 0.001), but not with resident experience level (p = 0.051). Estimated blood loss and postoperative complications were also not associated with the PGY of the assistant (p = 0.488 and p = 0.916, respectively). Despite common concern, the PGY status of a physician trainee serving as the bedside assistant does not appear to influence the outcomes of robot-assisted partial nephrectomy at a high-volume center.

The impact of surgical trainee participation on sinus surgery outcomes

OBJECTIVES/HYPOTHESIS

To determine the effect of otolaryngology trainee participation on clinical outcomes in patients who undergo endoscopic sinus surgery (ESS) for chronic rhinosinusitis.

STUDY DESIGN

Secondary analysis of prospectively collected data.

METHODS

Patients enrolled in a sinus surgery outcomes study between May 2011 and March 2013 were stratified into two groups--those who were operated on by an attending alone and those operated on by an attending with a trainee present (resident, fellow, or both). Patients completed quality of life (QOL) surveys including the Chronic Sinusitis Survey (CSS), 22-item Sino-Nasal Outcome Test (SNOT-22), and EuroQol 5-dimension survey preoperatively and 1 year postoperatively. Operative time, estimated blood loss (EBL), complication rates, and survey scores were compared between groups.

RESULTS

The study population consisted of 452 patients. The attending alone (n = 119) and trainee (n = 333) groups were statistically comparable in terms of patient demographics, disease severity, and extent of surgery. Mean operative time was significantly shorter in the attending-alone group (80.0 vs. 90.6 minutes, P < .01). Mean EBL (105 mL attending vs. 117 mL trainee, P = .39) and complication rates (3.3% attending vs. 0.6% trainee, P = .07) were similar between groups. Observed changes in QOL measures following ESS were comparable between groups, although absolute improvement in the SNOT-22 scores (19.0 attending vs. 24.5 trainee, P = .05) did show a trend toward greater improvement in the trainee group.

CONCLUSIONS

Trainee participation in ESS is associated with prolongation in surgical time; however, such participation was not found to adversely affect patient safety or clinical outcomes.

LEVEL OF EVIDENCE

2b.

Outcomes of open partial nephrectomies performed by Australian trainees

BACKGROUND

Partial nephrectomy (PN) has become the standard of care for small renal tumours, with open partial nephrectomy (OPN) being superseded by minimally invasive PN. Advances in minimal access surgery have resulted in fewer relative contraindications, with subsequently fewer OPN being performed. Consequentially, trainees have less opportunity to gain skills and experience in open renal surgery. The aims of this study were to assess the standard of OPN performed by Australian urological trainees and to define whether OPN is a safe and suitable training opportunity.

METHOD

A retrospective review was undertaken on patients who underwent OPN performed by urology trainees from 2010 to 2014 at two training hospitals in Western Australia. Data collected included patient demographics, surgical and oncological outcomes and morbidity.

RESULTS

Sixty patients underwent OPN, with a mean age of 56 years. Most tumours were single, with mean size 31 mm. Mean operative time was 157 min, with a mean cold ischaemic time of 27 min. Mean pre- and post-operative creatinine levels were equivalent (77 μmol/L). The overall complication rate was 18%, with no documented urinary leaks, and 1.7% blood transfusion rate. Median length of stay was 4 days. There were no oncological positive margins or recurrence after a median follow-up of 2 years.

CONCLUSION

Our data support the notion that Australian urological trainees can perform the majority of OPN cases, with equivalent oncological outcomes. We would advocate that when an OPN is being performed, the supervising consultant should use the case as an adjuvant for open renal surgery training.

National Outcomes for Open Ventral Hernia Repair Techniques in Complex Abdominal Wall Reconstruction

Modern adjuncts to complex, open ventral hernia repair often include component separation (CS) and/or panniculectomy (PAN). This study examines nationwide data to determine how these techniques impact postoperative complications. The National Surgical Quality Improvement Program database was queried from 2005 to 2013 for inpatient, elective open ventral hernia repairs (OVHR). Cases were grouped by the need for and type of concomitant advancement flaps: OVHR alone (OVHRA), OVHR with CS, OVHR with panniculectomy (PAN), or both CS and PAN (BOTH). Multivariate regression to control for confounding factors was conducted. There were 58,845 OVHR: 51,494 OVHRA, 5,357 CS, 1,617 PAN, and 377 BOTH. Wound complications (OVHRA 8.2%, CS 12.8%, PAN 14.4%, BOTH 17.5%), general complications (15.2%, 24.9%, 25.2%, 31.6%), and major complications (6.9%, 11.4%, 7.2%, 13.5%) were different between groups ( P < 0.0001). There was no difference in mortality. Multivariate regression showed CS had higher odds of wound [odds ratio (OR) 1.7, 95% confidence interval (CI) 1.5–2.0], general (OR 1.5, 95% CI: 1.3–1.8), and major complications (OR 2.1, 95%, CI: 1.8–2.4), and longer length of stay by 2.3 days. PAN had higher odds of wound (OR 1.5, 95%, CI: 1.3–1.8) and general complications (OR 1.7, 95% CI: 1.5–2.0). Both CS and PAN had higher odds of wound (OR 2.2,95%, CI: 1.5–3.2), general (OR 2.5, 95%, CI: 1.8–3.4), and major complications (OR 2.2, 95%CI: 1.4–3.4), and two days longer length of stay. In conclusion, patients undergoing OVHR that require CS or PAN have a higher independent risk of complications, which increases when the procedures are combined.

Can robot-assisted radical prostatectomy be taught to chief residents and fellows without affecting operative outcomes?

Purpose

To determine whether robot-assisted radical prostatectomy (RARP) may be taught to chief residents and fellows without influencing operative outcomes.

Methods

Between August 2011 and June 2012, 388 patients underwent RARP by a single primary surgeon (DIL) at our institution. Our teaching algorithm divides RARP into five stages, and each trainee progresses through the stages in a sequential manner. Statistical analysis was conducted after grouping the cohort according to the surgeons operating the robotic console: attending only (n = 91), attending and fellow (n = 152), and attending and chief resident (n = 145). Approximately normal variables were compared utilizing one-way analysis of variance, and categorical variables were compared utilizing two-tailed χ² test; P < 0.05 was considered statistically significant.

Results

There was no difference in mean age (P = 0.590), body mass index (P = 0.339), preoperative SHIM (Sexual Health Inventory for Men) score (P = 0.084), preoperative AUASS (American Urologic Association Symptom Score) (P = 0.086), preoperative prostate-specific antigen (P = 0.258), clinical and pathological stage (P = 0.766 and P = 0.699, respectively), and preoperative and postoperative Gleason score (P = 0.775 and P = 0.870, respectively). Operative outcomes such as mean estimated blood loss (P = 0.807) and length of stay (P = 0.494) were similar. There was a difference in mean operative time (P < 0.001; attending only = 89.3 min, attending and fellow 125.4 min, and attending and chief resident 126.9 min). Functional outcomes at 3 months and 1 year postoperatively such as urinary continence rate (P = 0.977 and P = 0.720, respectively), and SHIM score (P = 0.661 and P = 0.890, respectively) were similar. The rate of positive surgical margins (P = 0.058) was similar.

Conclusions

Training chief residents and fellows to perform RARP may be associated with increased operative times, but does not compromise short-term functional and oncological outcomes.

National outcomes of laparoscopic Heller myotomy: operative complications and risk factors for adverse events

INTRODUCTION

Laparoscopic Heller myotomy (LHM) has supplanted an open approach due to decreased operative morbidity. Our goal was to quantify the incidence of peri-operative complications and identify risk factors for adverse outcomes in LHM.

METHODS

All LHM were queried from 2005 to 2011 from the National Surgical Quality Improvement Program database. Adverse outcomes were identified, and univariate and stepwise logistic regression (MVR) was then performed to quantify association.

RESULTS

There were 1,237 LHM in the study period. Patient averages were: age 51.9 ± 16.8 years, BMI 27.3 ± 6.6 kg/m(2), Charlson comorbidity index (CCI) 0.2 ± 0.6. 15.3 % had >10 % body mass loss in the preoperative 6 months. During surgery, 10.2 % underwent concomitant EGD, and mean operative time was 141.6 ± 63.4 min. There were 7(0.06 %) wound complications, 22(1.8 %) general complications, and 30(2.4 %) major complications. Average length of stay (LOS) was 2.8 ± 5.5 days. The rate of readmission and reoperation were 3.1 and 2.3 %, respectively, and there were 4(0.03 %) deaths. General and major complications were associated with alcohol use, pack-years of smoking, weight loss, history of stroke, radiation therapy, and longer operative times (p < 0.05); however, these factors did not remain significant on MVR (p > 0.05). Operative time was found to be significantly longer by 35.3 min for inpatients, 43.1 min in functionally dependent patients, 50.0 min in preoperative septic patients, and 17.2 min with concomitant EGD (p < 0.01 for all). LOS was found to be longer by 1.9 days for inpatients, 1.8 days in ASA category ≥3, and 1.2 days per one point increase in CCI (p < 0.001 for all).

CONCLUSION

LHM is being performed nationally with a low incidence of operative complications and mortality. General and major complications following LHM are associated with patient alcohol use, pack-years of smoking, weight loss, history of stroke, radiation therapy, and longer operative times. Additionally, independent predictors of longer operative time and LOS were identified.

Open vs Minimally Invasive Partial Nephrectomy: Assessing the Impact of BMI on Postoperative Outcomes in 3685 Cases from National Data

PURPOSE

Previous studies analyzing the relationship between Body Mass Index (BMI) and complications after partial nephrectomy have been underpowered. We use a national surgical database to explore the association of BMI with postoperative outcomes for Open Partial Nephrectomy (OPN) and Minimally Invasive Partial Nephrectomy (MIPN).

PATIENTS AND METHODS

Years 2005-2012 of the National Surgical Quality Improvement Program (NSQIP) were queried for OPN and MIPN. Postoperative complications were organized according to Clavien Grades and compared across normal weight (BMI kg/m(2)=18.5-<25.0), overweight (BMI=25.0-<30.0), and obese (BMI≥30.0) patients using standard descriptive statistics and multivariate regression modeling.

RESULTS

Of 1667 OPNs and 2018 MIPNs, 46.2% of patients were obese. Operative time was 16.91 minutes longer on average for obese patients (p<0.001). The overall complication rate after OPN was 17.9%, 17.2%, and 17.9% (p=0.945) for normal weight, overweight, and obese patients, respectively; while the overall complication rate after MIPN was 6.9%, 6.3%, and 8.7% (p=0.147). Multivariate regression analysis demonstrated that overweight and obese patients were not at increased risk for any complication grade after OPN and MIPN compared to normal weight patients. When comparing procedures, MIPN had a lower complication rate compared to OPN for obese (8.7% vs 17.9%, p<0.001) and morbidly obese patients (9.2% vs 22.2%, p=0.001).

CONCLUSIONS

Although surgery in obese patients is longer compared to normal weight patients, it does not appear to increase the likelihood of 30-day postoperative complications for OPN or MIPN. However, obese patients undergoing MIPN had lower complication rates than those undergoing OPN.

The impact of resident involvement in minimally-invasive urologic oncology procedures

INTRODUCTION

Robotic and laparoscopic surgical training is an integral part of resident education in urology, yet the effect of resident involvement on outcomes of minimally-invasive urologic procedures remains largely unknown. We assess the impact of resident participation on surgical outcomes using a large multi-institutional prospective database.

METHODS

Relying on the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files (2005-2011), we abstracted the 3 most frequently performed minimally-invasive urologic oncology procedures. These included radical prostatectomy, radical nephrectomy and partial nephrectomy. Multivariable logistic regression models were constructed to assess the impact of trainee involvement (PGY 1-2: junior, PGY 3-4: senior, PGY ≥5: chief) versus attending-only on operative time, length-of-stay, 30-day complication, reoperation and readmission rates.

RESULTS

A total of 5459 minimally-invasive radical prostatectomies, 1740 minimally-invasive radical nephrectomies and 786 minimally-invasive partial nephrectomies were performed during the study period, for which data on resident surgeon involvement was available. In multivariable analyses, resident involvement was not associated with increased odds of overall complications, reoperation, or readmission rates for minimally-invasive prostatectomy, radical and partial nephrectomy. However, operative time was prolonged when residents were involved irrespective of the type of procedure. Length-of-stay was decreased with senior resident involvement in minimally-invasive partial nephrectomies (odds ratio [OR] 0.49, p = 0.04) and prostatectomies (OR 0.68, p = 0.01). The major limitations of this study include its retrospective observational design, inability to adjust for the case complexity and surgeon/hospital characteristics, and the lack of information regarding the minimally-invasive approach utilized (whether robotic or laparoscopic).

CONCLUSIONS

Resident involvement is associated with increased operative time in minimally-invasive urologic oncology procedures. However, it does not adversely affect the complication, reoperation or readmission rates, as well as length-of-stay.

Resident participation in laparoscopic hysterectomy: impact of trainee involvement on operative times and surgical outcomes

OBJECTIVE

The purpose of this study was to determine the impact of resident involvement on morbidity after total laparoscopic hysterectomy for benign disease.

STUDY DESIGN

We performed a retrospective review of a National Surgical Quality Improvement Program database of total laparoscopic hysterectomy for benign disease that was performed with resident involvement vs attending alone between Jan. 1, 2008, and Dec. 31, 2011. Surgical operative times and morbidity and mortality rates were compared. Binary logistic regression was used to control for covariates that were significant on univariate analysis (P < .05).

RESULTS

A total of 3441 patients were identified as having undergone a total laparoscopic hysterectomy for benign disease. The mean age of patients was 47.4 ± 11.1 years; the mean body mass index was 30.6 ± 7.9 kg/m(2). A resident participated in 1591 of cases (46.2%); 1850 of the procedures (53.8%) were done by an attending physician alone. Cases with resident involvement had higher mean age, Charlson morbidity scoring, and American Society of Anesthesiologists classification and were more likely to be inpatient cases. With resident involvement, the mean operative time was increased (179.29 vs 135.46 minutes; P < .0001). There were no differences in the rates of experiencing at least 1 complication (6.8% for resident involvement vs 5.4% for attending alone; P = .5), composite severe morbidity (1.3% resident vs 1.0% attending alone), or 30-day mortality rate (0% resident vs 0.1% attending alone). Additionally, there were no differences between groups in the infectious, wound, neurorenal, thromboembolic, septic, and cardiopulmonary complications. Cases with resident involvement had significantly increased rates of postoperative transfusion of packed red blood cells (2% vs 0.4%; P < .0001), reoperation (2.2% vs 1.3%; P = .048), and a 30-day readmission (5.5% vs 2.9%; P = .015). In models that were adjusted for factors that differed between the 2 groups, cases with resident involvement had increased odds of receiving postoperative blood transfusion (odds ratio [OR], 4.98; 95% confidence interval [CI], 2.18-11.33), reoperation (OR, 1.7, 95% CI, 1.01-2.89) and readmission (OR, 1.93, 95% CI, 1.09-3.42).

CONCLUSION

Resident involvement in total laparoscopic hysterectomy for benign disease was associated with clinically appreciable longer surgical time and small differences in the rates of postoperative transfusions, reoperation, and readmission. However, the rates of overall complications, severe complications, and 30-day mortality rate remain comparable.

A little slower, but just as good: postgraduate year resident versus attending outcomes in laparoscopic ventral hernia repair

INTRODUCTION

The purpose of this study was to analyze the effect of residents on patient outcomes in laparoscopic ventral hernia repair (LVHR).We hypothesized that increasing postgraduate year (PGY) level would correlate with better outcomes.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2005 to 2011 for elective LVHR. Attending only cases were used as the control, and resident cases were stratified into junior (PGY 1-3), chief (4-5), and fellow (6+) cases. Standard statistical tests and multivariate regression controlling for age, body mass index, Charlson comorbidity index, smoking, functional status, and inpatient cases were performed for trainee involvement and PGY level.

RESULTS

There were 6,841 ventral hernia repairs that met inclusion criteria: 2,773 attending and 4,068 resident cases. There were 1,644 junior, 1,983 chief, and 441 fellow cases. Patients were similar between the attending and resident groups. The resident group had a higher rate of inpatient cases, general complications, longer operative time, and hospital length of stay. After controlling for confounders in multivariate analysis, only operative time was significantly different; resident cases were 17.7 min longer (CI 15.0-20.6; p < 0.001). There was no significant difference in the rate of wound or major complications, readmission, reoperation, or mortality between attending and resident cases. Demographics were not significantly different between the PGY level strata. On multivariate regression by PGY level with attending alone as the reference, only operative time was significantly different. Juniors (15.7 min, CI 12.2-19.2), chiefs (18.0 min, CI 14.7-21.3), and fellows (24.9 min, CI 19.1-30.7) had significantly longer cases than attending alone; all p < 0.001.

CONCLUSION

Trainee involvement during LVHR does not change the clinical outcomes for patients as compared to those performed by an attending only. Operative time is significantly longer with increasing PGY level, perhaps indicating the complexity of the operation or increasing trainee involvement as primary surgeon. However, patient care does not suffer, affirming the current surgical training curriculum is appropriate.