Minimally Invasive Surgery Adoption Into an Established Surgical Practice:

Edward P Dominguez, MD, Cory D Barrat, MD, Ryan Gruner, BS, Donald Whisler, BS, Lynn Shaffer, PhD. Riverside Methodist Hospital, Minimally Invasive Surgery, Columbus, OH

Introduction:
We compared the rate of adoption of laparoscopic techniques by general surgeons before and after the introduction of a MIS fellowship trained colleague to an established practice. The advancement of minimally invasive surgery techniques has changed the practice of general surgery. Practicing general surgeons actively adopt new techniques often without the benefit of established training resources. Training opportunities such as weekend courses, video libraries, hands-on conferences, and traveling proctors have been used with varying success. None of these methods allow for comprehensive teaching and follow-through during the surgeon’s learning curve. Integrating a fellowship trained surgeon into an established practice may optimize the safe and efficient adoption of MIS by the other colleagues. Our secondary objective explored the barriers and drivers behind adopting these new MIS techniques.

Methods and Procedures:
A retrospective review of operative reports from July 2004 through June 2008 obtained the number of laparoscopic and open appendectomies, colectomies, ventral/incisional hernias, and inguinal hernias performed by the five surgeons of Riverside Surgical Associates. All operations were performed at Riverside Methodist Hospital and Knightsbridge Surgery Center in Columbus, OH. Three time intervals were formed: (A) 18 months before arrival of the MIS trained surgeon, (B) the 12 month “transition period,” representing 6 months before and 6 months after arrival of the MIS trained surgeon, and (C) 18 months following the transition period. The proportion of total cases classified as laparoscopic was calculated by procedure type and time period. Only cases performed by the five partners, and not by the MIS trained surgeon, were included in the analysis. In addition, a survey elicited the opinions of the five surgeons on various aspects of the transition, including barriers to adopting MIS techniques and effectiveness of different methods for learning MIS techniques.

Results:
A total of 4,016 cases were reviewed (1693 in period A, 964 in period B, and 1359 in period C). The percentage of total cases performed laparoscopically increased across time periods, from 12.1% in period A, 27.5% in period B, to 48.3% in period C. Laparoscopic appendectomies (LA) significantly increased across time periods from 19% in period A to 80% in period C (p<0.0001). Adoption of laparoscopic ventral/incisional and inguinal hernias accelerated after the transition period compared to before: increase in laparoscopic ventral/incision procedures before transition was 4.8% vs. 20.1% after (p=0.0322); comparable figures for inguinal hernias are 0.6% before transition vs. 31.1% after (p<0.0001). Finally, laparoscopic colectomies significantly increased from 25% in period A to 52% in period C (p<.0001). Survey responses indicated that “mentoring by a colleague with MIS training” was superior to other methods for learning MIS procedures (p=0.0327 to p=0.0516).

Conclusions:
The integration of a fellowship-trained MIS colleague into a general surgery practice resulted in a 300% increase in the proportion of appendectomies, ventral hernias, inguinal hernias, and colectomies performed laparoscopically by the other members of the practice. When surveyed, the surgeons felt that mentoring by a colleague with MIS training was the most effective method for adopting MIS procedures into their practice.

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