Paul N Montero, MD, Neal Agee, MD, Kent Kercher, MD, William Hope, MD, Amy E Lincourt, PhD, Dimitrios Stefanidis, MD PhD, B Todd Heniford, MD. Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center
Introduction: Poorer patient outcomes at the beginning of the academic year have been reported as a result of trainee inexperience (“July Phenomenon”). Our aim was to investigate if this phenomenon exists during the transition of general surgery residents to a minimally invasive surgery (MIS) fellowship with an apprenticeship model.
Methods: Outcomes related to advanced laparoscopic procedures including adrenalectomy, colectomy, para-esophageal herniorraphy (PEH), Heller myotomy, nephrectomy, gastric bypass, and gastric band cases performed by supervised fellows from 1999-2009 were analyzed. Patient demographics, OR time, EBL, length of stay, lymph nodes resected, and complications were recorded. Cases performed during the first 3 months of fellowship were compared to those during the last 3 months.
Results: 506 MIS cases were performed in the first 3 months and 458 in the last 3 months of fellowship training. There were no differences in patient age, BMI, ASA, or case specific OR times, EBL, transfusions, length of stay, lymph nodes resected or complications. For gastric bypass performed in the last 3 months of training, there was a decreased EBL and OR time despite a higher ASA. For gastric bands, the later cases had a shorter OR time but longer length of stay despite a lower age (see Table).
Conclusions: A “July Phenomenon” could not be demonstrated for MIS fellowship training. Complex laparoscopic surgeries can be taught and performed early during fellowship training using an apprenticeship model without compromise to the quality and safety of the operation.
Early versus late case demographics and outcomes in an MIS program (bold denotes significance).
| Age | BMI | ASA | LOS | OR Time | EBL | Intra-Op Complications | |
| Adrenalectomy | |||||||
| Early (n=39) | 52.4 | 31.2 | 2.64 | 3.67 | 156.3 | 81.7 | 0.000 |
| Late (n=32) | 55.0 | 30.9 | 2.83 | 6.03 | 172.8 | 57.0 | 0.031 |
| p | 0.43 | 0.86 | 0.58 | 0.21 | 0.33 | 0.18 | 0.27 |
| Colectomy | |||||||
| Early (n=123) | 59.5 | 27.7 | 2.46 | 5.98 | 185.3 | 114.8 | 0.033 |
| Late (n=117) | 59.6 | 28.2 | 2.31 | 5.89 | 184.8 | 119.3 | 0.017 |
| p | 0.97 | 0.47 | 0.18 | 0.86 | 0.96 | 0.81 | 0.45 |
| Heller | |||||||
| Early (n=32) | 47.8 | 25.4 | 2.13 | 3.13 | 175.9 | 53.3 | 0.000 |
| Late (n=25) | 47.1 | 28.9 | 2.13 | 2.12 | 208.5 | 50.0 | 0.000 |
| p | 0.86 | 0.09 | 0.96 | 0.25 | 0.06 | 0.66 | 1.00 |
| PEH | |||||||
| Early (n=34) | 63.7 | 29.3 | 2.56 | 5.50 | 206.6 | 90.3 | 0.000 |
| Late (n=31) | 65.0 | 28.9 | 2.39 | 4.52 | 209.8 | 61.8 | 0.065 |
| p | 0.67 | 0.78 | 0.50 | 0.55 | 0.86 | 0.42 | 0.30 |
| Nephrectomy | |||||||
| Early (n=10) | 45.0 | 30.1 | 1.50 | 4.40 | 186.8 | 55.0 | 0.000 |
| Late (n=9) | 52.0 | 27.7 | 2.00 | 5.33 | 186.1 | 72.2 | 0.000 |
| p | 0.28 | 0.39 | 0.02 | 0.34 | 0.98 | 0.29 | 1.00 |
| Gastric Bypass | |||||||
| Early (n=175) | 41.5 | 44.6 | 2.67 | 2.27 | 163.2 | 72.4 | 0.023 |
| Late (n=92) | 42.7 | 45.3 | 2.78 | 2.24 | 144.8 | 60.7 | 0.033 |
| p | 0.29 | 0.28 | 0.04 | 0.80 | <0.01 | 0.01 | 0.58 |
| Gastric Band | |||||||
| Early (n=93) | 43.5 | 43.8 | 2.62 | 0.81 | 76.3 | 35.4 | 0.000 |
| Late (n=92) | 43.3 | 41.9 | 2.54 | 1.01 | 68.2 | 35.9 | 0.000 |
| p | 0.88 | 0.01 | 0.22 | <0.01 | 0.02 | 0.91 | 1.00 |
| All Surgeries | |||||||
| Early (n=506) | 49.1 | 37.0 | 2.54 | 3.32 | 156.1 | 71.4 | 0.016 |
| Late (n=458) | 49.9 | 36.9 | 2.54 | 3.40 | 150.5 | 63.5 | 0.022 |
| p | 0.37 | 0.99 | 0.94 | 0.76 | 0.20 | 0.08 | 0.51 |
Session: Resident/Fellow
Program Number: S120