Assisting Skills in Advanced Laparoscopic Surgery Among Different Level of Surgical Residents in a Program with Early Introduction of Laparoscopic Training

Iswanto Sucandy, MD, Gintaras Antanavicius, MD FACS. Abington Memorial Hospital

Introduction : Resident participation in advanced laparoscopic operations requiring significant learning curve has become commonplace during early phase of surgical training. Previous study on laparoscopic cholecystectomy has reported that junior residents with less technical experience contribute to longer operative time, higher blood loss and increased perioperative complications. The aim of this study was to determine the effect of resident seniority in assisting advanced laparoscopic bariatric operations which is a common practice in many academic centers across the United States.

Patients and Methods : A retrospective review was conducted in all patients undergoing robotically assisted laparoscopic biliopancreatic diversion with duodenal switch (R-LBPD/DS) between December 2008 and March 2010. Patients demographic, training level of residents, operative time, conversion rate, estimated blood loss, operative complication and length of stay were recorded. Variables were compared based on the assistant training level (PGY-4 (group A), PGY-3 (group B), PGY-2 (group C), and bariatric physician assistant (group D)).

Results : A total of fifty consecutive cases (F:M=37:13) were included with no significant differences in age, body mass index (BMI) and number of comorbidity among the four groups (all p>0.05). Among assistants of various training level, no statistically significant differences were found in the mean operative time (A=320, B=340, C=309, D=291 minutes; p=0.16), estimated blood loss, and length of stay (A=3.44, B=3.30, C=3.36, D=3.30 days; p=0.46). All cases were successfully completed using minimally invasive approach. There were no intraoperative or 30-day major complications (ie; anastomotic leak, hemorrhage, intestinal obstruction, inadvertent organ injury, and thromboembolic event) seen. A single patient experienced port site infection (Group A) and another developed carpal tunnel syndrome exacerbation postoperatively (Group C). No complication related re-operation or mortality occurred in this series.

Conclusions : Our initial results suggested that different assistant training levels beyond internship do not significantly influence efficiency and outcomes primarily reflected by duration of the operation, blood loss, complications, conversion rates and length of stay. Junior level residents in a program with early introduction of laparoscopic training appear to demonstrate adequate assisting skills to participate in advanced laparoscopic operations. Physician extender is a highly valuable member of bariatric surgery service.