Jennifer Jolley, MD, Daniel Lomelin, MPH, Anton Simorov, MD, Carl Tadaki, MD, Dmitry Oleynikov, MD. University of Nebraska Medical Center (UNMC/UNO)
INTRODUCTION: Laparoscopic surgery is widely recognized as requiring superior skill and experience for optimization of patient outcomes. In the literature, surgical procedures are associated with a learning curve regarding the number of cases required for a surgeon to become proficient in these operations. Consequently, involvement of less experienced resident surgeons may impact patients directly and the healthcare system overall. This study examines basic and advanced laparoscopic procedures performed between 2010 and 2011 in order to evaluate the clinical effect of resident surgeon participation.
METHODS: The surgery records from basic laparoscopic procedures, appendectomy (LA) and cholecystectomy (LC), and advanced, Nissen fundoplication (LN), were queried from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database to investigate consequences of resident involvement. Cases were identified using Current Procedural Terminology codes and included those where resident involvement was discernable. Analyses were performed using IBM SPSS Statistics v.22, all tests’ α-level were 0.05. Multiple logistic regression was used to evaluate resident involvement while accounting for age, race, gender, admission status, wound classification, and ASA classification.
RESULTS: Overall 71,819 surgeries were reviewed, 66,327 basic (37,636 LC and 28,691 LA) and 5,492 advanced (LN). In basic laparoscopy, median age was 48 years (IQR: 35-61) and 37 years (IQR: 26-50) in LC and LA respectively. Where sex was available, 72.2% (N=26,996) of LC and 49.5% (N=14,089) of LA patients were female. In advanced laparoscopy, median age was 59 years (IQR: 48-69) and 67.7% (N=3,691) of patients were female.
Logistic regression analysis showed that in basic laparoscopy, resident involvement was not significantly associated with mortality, morbidity, and return to the OR in LA. The same was true of LC, with the addition that readmission was also not significantly related to resident involvement. In LA, resident involved surgeries had increased odds of readmission (OR: 1.54. 95% CI: 1.23-1.94, p<0.001) and OR time >60 minutes (OR: 2.77, 95% CI: 2.60-2.95, p<0.001), but decreased odds of LOS >2 days (OR: 0.92, 95% CI: 0.85-0.99, p=.018). In LC, resident involvement was associated with an increased odds of a LOS >2 days (OR: 1.16, CI: 1.09-1.23, p<0.001), while OR time was also more likely to be >60 minutes (OR: 3.52, CI: 3.36-3.69, p<0.001).
In advanced laparoscopy, resident involvement was not a significant factor in the odds of mortality, morbidity, return to OR, or readmission. Surgeries involving residents had increased odds of having LOS >2 days (OR: 1.65, CI: 1.46-1.86, p<0.001), and of the surgery lasting >60 minutes (OR: 6.29, CI: 4.92-8.04, p<0.001).
CONCLUSIONS: For residents to become competent in laparoscopic surgery, hands-on learning is critical. Our study demonstrates that resident involvement is safe and does not result in poorer patient outcomes . However, operative times were lengthier in all surgeries, and readmissions or LOS were also increased only in some basic laparoscopic procedures. Thus, while it is important for surgical trainees to get in the operating room and is generally safe, it does appear to have some real consequences for patients which may also impact the healthcare system financially.