A Little Slower, But Just as Good: Resident Outcomes in Laparoscopic Ventral Hernia Repair by Post-Graduate Year (PGY)

Samuel W Ross, MD, MPH, Bindhu Oommen, MD, MPH, Joel F Bradley, MD, Mimi Kim, MD, Amanda L Walters, MS, John M Green, MD, Vedra A Augenstein, MD, Brant T Heniford, MD. Carolinas Medical Center, Dept. of Surgery, Division of Gastrointestinal and Minimally Invasive Surgery.

INTRODUCTION: The controversy of resident experience level and involvement in operations and its associated surgical outcomes have been long debated. We sought to analyze the effect of residents on patient outcomes in laparoscopic ventral hernia repair (LVHR), and hypothesized that increasing PGY level would correlate with better outcomes.

METHODS: The American College of Surgeons NSQIP database was queried from 2005-2011 for LVHR. Inclusion criteria were age >18 and resident PGY level data. All emergent cases were excluded. 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. Demographics, comorbidities, complications, and patient outcomes were compared between resident and attending as a whole and by PGY level using standard statistical tests with a significance of p≤0.05. New variables were created to group post-operative complications. Multivariate regression controlling for age, BMI, Charlson Comorbidity Index (CCI), smoking, functional status, and inpatient cases was performed.

RESULTS: There were 6,841 VHR 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: age (57.4±13.6vs56.8±13.4), male (39.7%vs41.2%), BMI (33.7±8.2vs33.4±8.3 kg/m2), CCI (0.4±0.8vs0.4±0.8), smoking (19.2%vs19.4%), independent functional status (98.9%vs98.7%); all p>0.05. In the resident group, there was a higher rate of inpatient cases (41.9%vs53.7%,p<0.001), minor complications (3.0%vs4.1%,p=0.018), longer operative time (92.2±55.3vs114.6±65.3 minutes; p<0.001) and hospital length of stay (LOS) (2.0±8.0vs2.2±4.5 days;p<0.001). However, after controlling for confounders in multivariate analysis only operative time was significantly different; resident cases were 17.7 minutes 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. Outcomes by PGY level are presented in the Table. On multivariate regression by PGY level with attending alone as the reference, only operative time was significantly different. Juniors (15.7 minutes, CI 12.2-19.2), chiefs (18.0 minutes, CI 14.7-21.3), and fellows (24.9 minutes, CI 19.1-30.7) had significantly longer cases than attendings alone; all p<0.001.

CONLUSION: After accounting for confounding variables, patients undergoing LVHR with resident involvement in their operation have equal clinical outcomes as patients with an attending alone. Interestingly, operative time is significantly longer with increasing PGY level, perhaps indicating the difficulty of the operation or increasing resident or fellow autonomy. Surgical trainee participation in LVHR does increase operative time, but patient care does not suffer.


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