Declining operative experience for junior level residents: Unintended consequence of minimally invasive surgery?

Matthew G Mullen, Elise P Salerno, Alex D Michaels, Traci L Hedrick, Min-Woong Sohn, Philip W Smith, Bruce D Schirmer, Charles M Friel. The University of Virginia Health System

Introduction: Laparoscopy increases the complexity of basic surgical procedures including appendectomy, cholecystectomy, and inguinal hernia repair.  We previously demonstrated a shift from junior to senior resident participation in cases traditionally performed by junior level residents. We hypothesized that this trend would correct over time.

Methods: A sample of essential laparoscopic and open general surgery procedures (appendectomy, inguinal herniorrhaphy, cholecystectomy, and partial colectomy) was chosen for analysis.  The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Files were queried for these procedures from 2005 through 2012.  Cases were stratified by participating resident post-graduate year [PGY] with “junior resident” defined as PGY1-3.  Logistic regression was performed to determine change in junior resident participation for each type of procedure over time.

Results: 185,335 cases were included in the study.  For three of the operations we considered, the prevalence of laparoscopic surgery increased from 2005-2012 (all p <0.001).  Cholecystectomy was an exception, which showed an unchanged proportion of cases performed laparoscopically across the study period (p=0.119).  Junior resident participation decreased by 4.5%/year (p<0.001) for laparoscopic procedures and by 6.2%/year (p<0.001) for open procedures, as shown in Figure 1.  The proportion of laparoscopic surgeries performed by junior level residents decreased for appendectomy by 2.6%/year (p<0.001) and cholecystectomy by 6.1%/year (p<0.001), whereas it was unchanged for inguinal herniorrhaphy (p=0.75) and increased for partial colectomy by 3.9%/year (p=0.003).  A decline in junior resident participation was seen for all open surgeries, with appendectomy decreasing by 9.4%/year (p<0.001), cholecystectomy by 4.1%/year (p<0.002), inguinal herniorrhaphy by 10%/year (p<0.001) and partial colectomy by 2.9%/year (p<0.004).

Conclusions: Along with the proliferation of laparoscopy for common general surgical procedures there has been a concomitant reduction in the participation of junior level residents.  Contrary to our hypothesis, familiarity with laparoscopy has not translated to redistribution of basic operations from senior to junior residents.  This trend has significant implications for general surgery resident education.

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