Article

A National Review of the Frequency of Minimally Invasive Surgery Among General Surgery Residents Assessment of ACGME Case Logs During 2 Decades of General Surgery Resident Training

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Abstract

Minimally invasive surgery (MIS) has created a shift in how many surgical diseases are treated. Examining the effect on resident operative experience provides valuable insight into trends that may be useful for restructuring the requirements of resident training. To evaluate changes in general surgery resident operative experience regarding MIS. Retrospective review of the frequency of MIS relative to open operations among general surgery residents using the Accreditation Council for Graduate Medical Education case logs for academic years 1993-1994 through 2011-2012. General surgery residency training among accredited programs in the United States. We analyzed the difference in the mean number of MIS techniques and corresponding open procedures across training periods using 2-tailed t tests with statistical significance set at P < .05. Of 6 467 708 operations with the option of MIS, 2 393 030 (37.0%) were performed with the MIS approach. Of all MIS operations performed, the 5 most common were cholecystectomy (48.5%), appendectomy (16.2%), groin hernia repair (10.0%), abdominal exploration (nontrauma) (4.4%), and antireflux procedures (3.6%). During the study period, there was a transition from a predominantly open to MIS approach for appendectomy, antireflux procedures, thoracic wedge resection, and partial gastric resection. Cholecystectomy is the only procedure for which MIS was more common than the open technique throughout the study period (P < .001). The open approach is more common for all other procedures, including splenectomy (0.7% MIS), common bile duct exploration (24.9% MIS), gastrostomy (25.9% MIS), abdominal exploration (33.1% MIS), hernia (20.3% MIS), lung resection (22.3% MIS), partial or total colectomy (39.1%), enterolysis (19.0% MIS), ileostomy (9.0% MIS), enterectomy (5.2% MIS), vagotomy (1.8% MIS), and pediatric antireflux procedures (35.9% MIS); P < .001. Minimally invasive surgery has an increasingly prominent role in contemporary surgical therapy for many common diseases. The open approach, however, still predominates in all but 5 procedures. Residents today must become efficient at performing multiple techniques for a single procedure, which demands a broader skill set than in the past.

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... Respecto a los procedimientos más frecuentemente realizados, los resultados son similares a los encontrados en algunos estudios locales en los que la mayoría corresponden a urgencias médicas abdominales en cerca del 50% de los casos, principalmente colecistectomía y apendicectomía 25,26 . Estos resultados son similares a los reportados en otros países 24,27,28 . Sin embargo, a diferencia de los más comunes que se realizan en Colombia, ingresan en la lista la cirugía de obesidad, la tiroidectomía, la resección de melanoma y la cirugía antirreflujo 24,27 . ...
... Estos resultados son similares a los reportados en otros países 24,27,28 . Sin embargo, a diferencia de los más comunes que se realizan en Colombia, ingresan en la lista la cirugía de obesidad, la tiroidectomía, la resección de melanoma y la cirugía antirreflujo 24,27 . Igualmente, los resultados muestran predominio de los procedimientos mínimamente invasivos en relación con los abiertos 27,28 . ...
... Sin embargo, a diferencia de los más comunes que se realizan en Colombia, ingresan en la lista la cirugía de obesidad, la tiroidectomía, la resección de melanoma y la cirugía antirreflujo 24,27 . Igualmente, los resultados muestran predominio de los procedimientos mínimamente invasivos en relación con los abiertos 27,28 . ...
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Resumen: Introducción: La supervisión efectiva y la autonomía gradual del residente de cirugía son importantes recursos educativos para su futura práctica independiente y segura. El objetivo de este estudio es el de comparar las percepciones sobre la supervisión y autonomía que tienen los residentes y profesores en el quirófano, con referencia a los estándares definidos en el currículo. Métodos: Se realizó una medición de las percepciones de residentes y profesores mediante la Escala de Zwisch. Se identificaron los 10 procedimientos más frecuentemente realizados. Para cada uno de los procedimientos se calculó la media y la desviación estándar de la escala. Se comparó la percepción de los residentes, profesores con respecto a los niveles de competencia descritos en el currículo mediante el cálculo de ANOVA independiente (p
... The field of general surgery has been more proactive in performing self-evaluations of the shifts occurring in surgical technique education over time. In a large analyses spanning over two decades (1993-2012), Richards et al. [6] assessed the trends of minimally invasive surgery (MIS) versus open procedures performed by general surgery residents. Through using Current Procedural Terminology (CPT) codes, the group was able to separate ACGME resident logged cases performed in a minimally invasive fashion (robotic + laparoscopic) from open. ...
... In doing so, they learned there was a noteworthy overall increase of 10.7% in utilizing MIS as compared to the open technique when training residents. Some procedures, such as appendectomy, antirefulux, thoracic wedge, and partial gastric resection, were even found to have predominantly shifted from originally being open to now an MIS dominated approach [6]. Unfortunately, Richards et al. [6] were not able to delineate how much of this MIS shift was accountable to robotics. ...
... Some procedures, such as appendectomy, antirefulux, thoracic wedge, and partial gastric resection, were even found to have predominantly shifted from originally being open to now an MIS dominated approach [6]. Unfortunately, Richards et al. [6] were not able to delineate how much of this MIS shift was accountable to robotics. CPT codes, even to this day, in many cases, lack the specificity to define a procedure as being purely laparoscopic vs. robotically assisted, further impeding our understanding of the evolution of robotics into surgery. ...
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Purpose of Review To review the integration of robotics in urology residency programs and evaluate how it has impacted a graduates’ level of surgical competence. Recent Findings Surgical technique training has shown a dramatic shift towards robotics with the most profound occurring in oncology. However, integration of robotics is not uniform across programs nor even among residents themselves. Robotics require graduates to garner a broader skill set within the same prescribed training time. Unfortunately, in this modern era, graduates are feeling more ill-equipped to start independent practice and show an increased need to pursue fellowship training to achieve technical proficiency. Summary The dissemination of robotics in residency programs has gone unchecked. Modulating existing training structures through (1) development of procedure- and surgical technique-specific target metrics for graduation and (2) integration of a formalized robotic curriculum may improve the overall quality and outcome of the educational experience.
... Keywords Robotic surgery · Training curriculum · Open · Laparoscopic General surgery robotic procedures have significantly increased over the past several years [1,2]. The adoption of robotic surgery was initially driven by the fields of urology and gynecology, but over time, its use has become more widespread in general surgery [3]. ...
... For residency programs that have been able to incorporate robotic surgery training into their curriculum, there are concerns about the impact that robotic surgery will have on resident operative case distribution, specifically laparoscopic and open cases [2,5]. Previous studies have shown that at some institutions, as the volume of robotic cases increased, the number of laparoscopic or open cases steadily decreased [5,6]. ...
... As minimally invasive approaches are being adopted for many general surgery procedures and robotic surgery is increasing in popularity, many training institutions are moving toward earlier exposure to robotic surgery in residency training [7]. However, concerns exist that the increase in robotic cases performed by residents during their training would have detrimental effects on their open and laparoscopic case volume distributions [2,5]. The 80-h work week restrictions imposed by the ACGME in 2003 further exacerbate these concerns as residents have less time to operate [7]. ...
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Background Robotic-assisted general surgery procedures are becoming commonplace, requiring more residency programs to establish training curricula for residents. Concerns exist regarding the impact this will have on surgical residents’ operative case distribution in laparoscopic and open surgery. This study aimed to analyze the impact of a growing robotic operative case volume and established robotic surgery training curriculum on the general surgery resident operative experience.Methods The robotic surgery training curriculum at the Medical College of Wisconsin was established in 2017. ACGME operative case logs of residents from 2014 to 2020 were analyzed to determine resident participation in open, laparoscopic, and robotic cases. Case categories included alimentary tract, abdomen, endocrine, thoracic, pediatric, and trauma. A one-way analysis of variance (ANOVA) was used to analyze overall cases, as well as participation by case type, post-graduate year (PGY) level, resident role, and institution type. Statistical significance was defined as a p value < 0.05.ResultsOperative case logs from 77 residents were analyzed with a total of 34,757 cases: 59.3% open, 39.6% laparoscopic, and 1.1% robotic. There was no significant change in open or laparoscopic case volumes. However, there was a 3.4% increase in robotic cases, from 2014 to 2020 (p = 0.01), specifically in foregut (4.0%, p = 0.01), intestinal (1.6%, p = 0.03), and hernia (8.3%, p = 0.003) procedures. Academic (2.8%, p = 0.01) and veterans’ hospital (2.0%, p = 0.01) institutions saw a significant increase in their residents’ robotic cases. The only resident role with a significant increase in robotic cases was first assistant (8.0%, p = 0.004). There was no significant difference across PGY levels by surgical approach.Conclusions This study highlights that the growth of robotic cases has not had a detrimental effect on the resident experience with open and laparoscopic cases. As robotic cases continually increase, the impact on laparoscopic and open case volumes must be monitored to ensure a well-balanced training experience.
... First, the operative time and conversion rates of SILAs performed by resident doctors were comparable to those in procedures performed by staff surgeons. A number of studies have reported that operative times tend to be longer with the participation of residents, which is contrary to the results of this study [8]. The conversion rate for surgeries performed by the residents was 4%, which is comparable to that reported in previous literature (Table 3) [1e5]. ...
... In general, surgical training begins with simple open procedures, such as appendectomy, hernioplasty and cholecystectomy, and progresses to more complex procedures. However, many simple open procedures have now been replaced by laparoscopic procedures, including SILS, because of their minimal invasiveness and good cosmesis [8]. This raises two issues in surgical education: (i) reduced opportunity for training in open surgical skills; and (ii) lack of a standardized approach to laparoscopic surgical training for some procedures. ...
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Introduction To confirm the safety and feasibility of single-incision laparoscopically assisted appendectomy (SILA) performed by resident doctors. Materials and methods We retrospectively analyzed 86 consecutive patients who underwent SILA between August 2010 and August 2016 at Kinki Central Hospital. During this period, 9 residents and 6 board-certified attending surgeons performed SILA. Data on the patients' characteristics and perioperative complications were collected from their medical records. Results Resident doctors operated on 55% (47/86) of patients undergoing SILA. There were no significant differences between the groups with regard to patient characteristics. Mean operative time in the resident and staff surgeon groups was 74 min and 71 min, respectively (p = 0.5). Median blood loss in both the resident and staff surgeon groups was 0 mL (p = 0.3). The rate of conversion to a different operative procedure was 4% (2/47) in the resident group and 3% (1/39) in the staff surgeon group (p = 1). All three above-mentioned procedures, two (4%, 2/47) in the resident group and one (3%, 1/39) in the staff surgeon group, were converted to multi-port laparoscopic appendectomy. The mean postoperative hospital stay was 5 days for both the resident and staff surgeon groups (p = 0.7). Perioperative complications developed in 9% (4/47) of the patients in the resident group and 21% (8/39) of the patients in the staff surgeon group (p = 0.1). Conclusions SILA performed by residents under the guidance of a staff surgeon is safe and feasible.
... Based on the RACUSUM model, high intraoperative time is mitigated after 28 procedures, incidence of intraoperative complications tends to diminish after 24 procedures, and improvement in estimated blood loss did not remain consistent. TSFs exhibit a tipping point in LDN performance by 24-28 cases and proficiency by [35][36][37][38] cases. ...
... Our study is the first report published in a generation of TSFs who were exposed to extensive laparoscopic surgery during their training. In fact, the American Board of Surgery (ABS) now requires "Fundamentals of Laparoscopic Surgery" training as a general surgery residency graduation requirement (34), and a recent national review found that nearly 40% of cases logged by general surgery residents are done laparoscopically (35). Consequently, our estimate of 24-28 cases as the tipping point for the LDN LC seems reasonable because formal and sequentially more complex laparoscopic training is now routine during surgical residency training. ...
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UNOS recommends that fellowship-trained surgeons participate in 15 LDN to be considered proficient. ASTS mandates 12 LDN during abdominal transplant surgery fellowship (ATSF). We performed a retrospective intraoperative case analysis to create a risk-adjusted cumulative summation (RACUSUM) model to assess the learning curve (LC) of novice TSF (nTSF). Between January 2000 and December 2014, 30 nTSF rotated on the Organ Procurement Rotation (OPR) of our ASTS-approved ATSF. Measures of surgical performance included: 1) intraoperative time (ORT), 2) estimated blood loss (EBL), and 3) incidence of intraoperative complications (IOC). Performance of senior TSF (sTSF) was used to benchmark nTSF performance. Scores were tabulated in a learning curve model (LCM), adjusting for case complexity and prior TSF case volume. Rates of adverse surgical events (ASE) were significantly higher for nTSF than for sTSF. Univariable analysis correlated multiple renal arteries, high BMI, prior abdominal surgery, male donors, and nephrolithiasis with a higher incidence of ASE. Based on the RACUSUM LCM, high ORT is mitigated after 28 procedures; IOC tend to diminish after 24 procedures; and improvement in EBL did not remain consistent. TSF exhibit a tipping point in LDN performance by 24-28 cases and proficiency by 35-38 cases. This article is protected by copyright. All rights reserved.
... Non-elective repairs were more frequently repaired by a MIS approach. This is consistent with a review of resident ACGME case logs which showed an increase in the percentage of laparoscopic adult anti-reflux procedures performed by surgical residents-from 30% in 1993 to 80% in 2011 [14]. Antireflux procedures are among the top 5 most frequent laparoscopic procedures performed in resident training, in addition to cholecystectomy, appendectomy, inguinal hernia repair, and diagnostic laparoscopy [14]. ...
... This is consistent with a review of resident ACGME case logs which showed an increase in the percentage of laparoscopic adult anti-reflux procedures performed by surgical residents-from 30% in 1993 to 80% in 2011 [14]. Antireflux procedures are among the top 5 most frequent laparoscopic procedures performed in resident training, in addition to cholecystectomy, appendectomy, inguinal hernia repair, and diagnostic laparoscopy [14]. This increase in MIS PEH repair exposure in residency training and increasing amount of MIS fellowships likely translates into the increase of MIS PEH repairs in daily practice as graduates are more comfortable with the approach. ...
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Background The majority of laparoscopic paraesophageal hernia (PEH) repairs are performed electively. We aimed to investigate the frequency of non-elective laparoscopic (MIS) PEH repair and compare 30-day outcomes to elective MIS repairs and non-elective open repairs. We hypothesized that an increasing percentage of non-elective PEH repairs would be performed laparoscopically and that this population would have improved outcomes compared to non-elective open PEH counterparts.Methods The 2011–2016 NSQIP PUFs were used to identify patients who underwent PEH repair. Case status was classified as open vs. MIS and elective versus non-elective. Preoperative patient characteristics, operative details, discharge destination, and 30-day postoperative complication rates were compared. Logistic regression was used to examine the impact of case status on 30-day mortality.ResultsWe identified 20,010 patients who underwent PEH. There were an increasing number of MIS PEH repairs in NSQIP between 2011 and 2016. Non-elective repairs were performed in 2,173 patients and 73.4% of these were completed laparoscopically. Elective MIS patients were younger, had a higher BMI, and were more likely to be functionally independent (p < 0.01) than their non-elective counterparts. Non-elective MIS patients had a higher wound class and ASA class compared to their elective counterparts. Compared to elective MIS cases, non-elective MIS PEH repair was associated with increased odds of mortality, even after controlling for patient characteristics (OR = 1.76, p = 0.02). There was no statistically significant difference in mortality for non-elective MIS vs. non-elective open PEH repair. There is an increase in non-elective PEH repairs recorded in NSQIP over time studied.Conclusions The population undergoing non-elective MIS PEH repairs is different from their elective MIS counterparts and experience a higher postoperative mortality rate. While the observed increased utilization of MIS techniques in non-elective PEH repairs likely provides benefits for the patient, there remain differences in outcomes for these patients compared to elective PEH repairs.
... There has been a growing trend in adopting minimally invasive surgeries (MIS) in aesthetic surgery due to better scar cosmesis and plastic surgeon opinion is that the future of plastic surgery will include endoscopic procedures [15]. However, MIS training can be difficult to incorporate into the resident curriculum as it creates a challenging environment for educators who must provide experience in two unique skills sets for the same operations [23,24]. This once again emphasizes the importance of extending the teaching curriculum beyond the "one-size-fits-all" model to allow graduates the opportunity to practice cosmetic procedures outside the ACGME recommended core curriculum. ...
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Background: As the demand for cosmetic surgery continues to rise, plastic surgery programs and the training core curriculum have evolved to reflect these changes. This study aims to evaluate the perceived quality of current cosmetic surgery training in terms of case exposure and educational methods. Methods: A 16-question survey was sent to graduates who completed their training at a U.S. plastic surgery training program in 2017. The survey assessed graduates' exposure to cosmetic surgery, teaching modalities employed and their overall perceived competence. Case complexity was characterized by the minimum number of cases needed by the graduate to feel confident in performing the procedure. Results: There was a 25% response rate. The majority of respondents were residents (83%, n=92) and the remaining were fellows (17%, n=18). Almost three quarters of respondents were satisfied with their cosmetic training. Respondents rated virtual training as the most effective learning modality and observing attendings' patients/cases as least effective. Perceived competence was more closely aligned with core curriculum status than case complexity, i.e. graduates feel more prepared for core cosmetic procedures despite being more technically difficult than non-core procedures. Conclusions: Despite the variability in cosmetic exposure during training, most plastic surgery graduates are satisfied with their aesthetic training. Incorporation of teaching modalities, such as virtual training, can increase case exposure and allow trainees more autonomy. The recommended core curriculum is adequately training plastic surgery graduates for common procedures and more specialized procedures should be consigned to aesthetic fellowship training.
... The shift away from open surgery towards minimally invasive surgery (MIS) worldwide has dramatically increased over the last decade. During this same time, these changes have been reflected in general surgery residency training as well, resulting in a larger percentage of laparoscopic case volumes for graduating general surgery residents [1]. In its infancy, MIS was considered its own unique specialty but is now pervasive in almost every surgical discipline. ...
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Background The aim of our study is to determine minimally invasive trainee motivation and expectations for their respective fellowship. Minimally Invasive Surgery (MIS) is one of the largest non-ACGME post-residency training pathways though little is known concerning the process of residents choosing MIS as a fellowship focus. As general surgery evolves, it is important to understand resident motivation in order to better prepare them for a surgical career. Methods A survey invitation was sent to current trainees in the Minimally Invasive and related pathways through the Fellowship Council. The participants were asked to complete a web-based questionnaire detailing demographics, experiences preparing for fellowship, motivation in choosing an MIS fellowship, and expectations for surgical practice after fellowship. Results Sixty-seven MIS trainees responded to the survey out of 151 invitations (44%). The Fellowship Council website, mentors, and other fellows were cited as the most helpful source of information when applying for fellowship. Trainees were active in surgical societies as residents, with 78% having membership in the ACS and 60% in SAGES. When deciding to pursue MIS as a fellowship, the desire to increase laparoscopic training was the most important factor. The least important reasons cited were lack of laparoendoscopic training in residency and desire to learn robotic surgery. The majority of trainees believed their laparoscopic skill set was above that of their residency cohort (81%). The most desired post-fellowship employment model is hospital employee (46%) followed by private practice (27%). Most fellows plan on marketing themselves as MIS surgeons (90%) or General Surgeons (78%) when in practice. Conclusions Residents who choose MIS as a fellowship have a strong exposure to laparoscopy and want to become specialists in their field. Mentors and surgical societies including ACS and SAGES play a vital role in preparing residents for fellowship and practice.
... Using these surgical techniques the visual feedback to the surgeon is only possible through the camera inserted into the body; furthermore direct palpation of organs is not possible. Minimally invasive surgery (MIS), such as laparoscopy or endoscopy, a promising technique that has changed the way surgery is practiced is nowadays widely accepted and adopted as a valid alternative to classical procedures (Ulmer 2010;Sanger et al. 2014;Richards et al. 2015). ...
Article
In medicine, the augmented reality technology allows surgeons to have a sort of ‘X-ray’ vision of the patient’s body and can help them during the surgical procedures. This paper describes an application of augmented reality that could be used as a support for a more accurate preoperative surgical planning and also for an image-guided procedure. Augmented reality can support the surgeon during the needle insertion in the treatment of liver tumours with the radiofrequency ablation in order to guide the needle and to have an accurate placement of the surgical instrument within the lesion. The augmented visualisation can prevent as much as possible damages to the healthy cells of the liver.
... IOIFC may be a useful teaching tool in residency programs to teach LC. Laparoscopic cholecystectomy (LC) remains the most commonly performed procedure by a general surgery resident [1,2]. Despite the fact that LC has proven to be a safe procedure, the rate of common bile duct (CBD) injury still remains unacceptably high at between 0.2 and 0.4 % even in the hands of minimally invasive trained surgeons [3]. ...
Article
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Background: Intraoperative incisionless fluorescent cholangiogram (IOIFC) has been demonstrated to be a useful tool to increase the visualization of Calot's triangle. This study evaluates the identification of extrahepatic biliary structures with IOIFC by medical students and surgery residents. Methods: Two pictures were taken, one with xenon light and one with near-infrared (NIR) light, at the same stage during dissection of Calot's triangle in ten different cases of laparoscopic cholecystectomy (LC). All twenty pictures were organized in a random fashion to remove any imagery bias. Twenty students and twenty residents were asked to identify the biliary anatomy. Results: Medical students were able to accurately identify the cystic duct on an average 33.8 % under the xenon light versus 86 % under NIR light (p = 0.0001), the common hepatic duct (CHD) on an average 19 % under the xenon light versus 88.5 % under NIR light (p = 0.0001), and the junction on an average 24 % under xenon light versus 80.5 % under NIR light (p = 0.0001). Surgery residents were able to accurately identify the cystic duct on an average 40 % under the xenon light versus 99 % under NIR light (p = 0.0001), the CHD on an average 35 % under the xenon light versus 96 % under NIR light (p = 0.0001), and the junction on an average 24 % under the xenon light versus 95.5 % under NIR light (p = 0.0001). Conclusions: IOIFC increases the visualization of Calot's triangle structures when compared to xenon light. IOIFC may be a useful teaching tool in residency programs to teach LC.
... [1][2][3][4] All these advantages have led laparoscopic skills to become a minimal competence requisite for general surgery programs. 5 Advanced laparoscopic surgery involves long learning curves, where residents and fellows must acquire technically demanding minimally invasive skills, such as intracorporeal suturing and knot tying. 4,6 Restrictions in working hours, less exposure to patients, and ethical concerns make the optimal learning of these advanced surgical skills even more difficult. ...
Article
Introduction: Simulated laparoscopy training is limited by its low-quality image. A high-definition (HD) laparoscopic training box was developed under the present necessity of simulating advanced surgery. Objective: To describe and test a new HD laparoscopic training box for advanced simulation training. Methods: We describe the features and image quality of the new training box. The simulator was tested and then evaluated by a group of 76 expert surgeons using a 4-item questionnaire. To assess the effectiveness of training using this simulation box, 15 general surgery residents were trained to perform a laparoscopic jejuno-jejunostomy in a validated simulation program. They were assessed with objective rating scales before and after the training program, and their results were compared with that of experts. Results: The training box was assembled using high-density fiberglass shaped as an insufflated abdomen. It has an adapted full-HD camera with a LED-based illumination system. A manually self-regulated monopod attached to the camera enables training without assistance. Of the expert surgeons who answered the questionnaire, 91% said that the simulation box had a high-quality image and that it was very similar to real laparoscopy. All residents trained improved their rating scores significantly when comparing their initial versus final assessment ( P < .001). Their performance after completing the training in the box was similar to that of experts ( P > .2). Conclusions: This novel laparoscopic training box presents a high-resolution image and allows training different types of advanced laparoscopic procedures. The simulator box was positively assessed by experts and demonstrated to be effective for laparoscopy training in resident surgeons.
... 12e14 Conversely, one previous study of ACGME case logs from 1994 to 2012 found that the open approach was more common than the laparoscopic approach during this more limited time frame. 15 Similarly, our analysis of the 4 index general surgery operations, inguinal and femoral hernia repair and colectomy or proctectomy were more likely to be performed open, although cholecystectomy and appendectomy were predominantly performed laparoscopically. This suggests that for certain operations, residents may be more comfortable with the open rather than the laparoscopic approach at graduation. ...
Article
Background: The operative experience of today's surgery residents is different than years past. Although overall volume remains stable, the composition is changing. As such, trends in open versus laparoscopic surgery for general surgery residents were examined. Methods: The Accreditation Council for Graduate Medical Education national operative log reports from 1994 to 2018 were analyzed for the 15 operations recorded as both open and laparoscopic. Operative volume was examined for total major, surgeon chief, and surgeon junior cases. Results: From 1994 to 2018, 26,258 residents graduated with 955.2 ± 31.7 total major cases. The 15 identified operations comprised 38.4% of this volume. During the 25-year study period, laparoscopic volume increased (+9.67 cases per year), whereas open volume decreased (-3.25 cases per year, P < .0001 for each). Similar trends were seen for both chief and surgeon junior cases (P < .05 for both). For 2 of the 4 core general surgery operations examined (hernia and proctocolectomy), the open approach was still the dominant approach, providing residents an opportunity to perform open surgery in an era of increasing minimally invasive approaches. Conclusion: For select procedures, the frequency of laparoscopy has surpassed open surgery for general surgery residents. These trends raise the concern that when necessary, general surgery graduates may not have adequate experience converting to open.
... In the management of small bowel obstruction and peptic ulcer disease, MIS has yet to surpass open techniques as the most common approach, and specifically regarding peptic ulcer disease, has only been described as appropriate "if conducted by expert operators on properly selected patients." [16][17][18] Surgery residents are graduating with increasing laparoscopic experience [19,20] and an increasing number of residents are going on to complete MIS fellowships [21]. This likely resulted in an overall larger proportion of surgeons who feel prepared to perform advanced laparoscopic procedures with each year as more surgeons with advanced laparoscopic and robotic skillsets matriculate. ...
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Background Minimally invasive surgery (MIS) has demonstrated superior outcomes in many elective procedures. However, its use in emergency general surgery (EGS) procedures is not well characterized. The purpose of this study was to examine the trends in utilization and outcomes of MIS techniques in EGS over the past decade. Methods The 2007–2016 ACS-NSQIP database was utilized to identify patients undergoing emergency surgery for four common EGS diagnoses: appendicitis, cholecystitis/cholangitis, peptic ulcer disease, and small bowel obstruction. Trends over time were described. Preoperative risk factors, operative characteristics, outcomes, morbidity, and trends were compared between MIS and open approaches using univariate and multivariate analysis. Results During the 10-year study period, 190,264 patients were identified. The appendicitis group was the largest (166,559 patients) followed by gallbladder disease (9994), bowel obstruction (6256), and peptic ulcer disease (366). Utilization of MIS increased over time in all groups (p < 0.001). There was a concurrent decrease in mean days of hospitalization in each group: appendectomy (2.4 to 2.0), cholecystectomy (5.7 to 3.2), peptic ulcer disease (20.3 to 11.7), and bowel obstruction (12.9 to 10.5); p < 0.001 for all. On multivariate analysis, use of MIS techniques was associated with decreased odds of 30-day mortality, surgical site infection, and length of hospital stay in all groups (p < 0.001). Conclusions Use of MIS techniques in these four EGS diagnoses has increased in frequency over the past 10 years. When adjusted for preoperative risk factors, use of MIS was associated with decreased odds of wound infection, death, and length of stay. Further studies are needed to determine if increased access to MIS techniques among EGS patients may improve outcomes.
... Moreover, up to one-third of patients with intra-abdominal adhesions require a second operation for the release of existing adhesions, which can further increase the risk 3,4 . ...
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Peritoneal adhesions are fibrous tissues that tether organs to one another or to the peritoneal wall and represent the major cause of postsurgical morbidity. Enterolysis at repeat surgeries induces adhesion reformation that is more difficult to prevent than primary adhesion. Here we studied the preventive effects of different approaches of berberine treatment for primary adhesion, and its effects on adhesion reformation compared to Interceed. We found the primary adhesion was remarkably prevented by berberine through intraperitoneal injection 30 min before abrasive surgery (pre-berberine) or direct addition into injured cecum immediately after the surgery (inter-berberine). Rats with adhesion reformation had a more deteriorative collagen accumulation and tissue injury in abrasive sites than rats with primary adhesion. The dysregulated TIMP-1/MMP balance was observed in patients after surgery, as well as adhesion tissues from primary adhesion or adhesion reformation rats. Inter-berberine treatment had a better effect for adhesion reformation prevention than Interceed. Berberine promoted the activation of MMP-3 and MMP-8 by directly blocking TIMP-1 activation core, which was reversed by TIMP-1 overexpression in fibroblasts. In conclusion, this study suggests berberine as a reasonable approach for preventing primary adhesion formation and adhesion reformation.
... The adoption of minimally invasive surgery has significantly affected training of surgical residents (SRs). Laparoscopic cholecystectomy (LC) is an minimally invasive surgery procedure that is performed by SRs in nearly 50% of cases [1] . According to the Accreditation Council of Graduated Medical Education, LC is a core-level surgery, of which a graduate should possess significant knowledge and procedural competency [2] . ...
Article
Background: Laparoscopic cholecystectomy (LC) is a minimally invasive procedure, often performed by surgical residents (SRs). Fluorescence cholangiography (FC) enables real-time identification of biliary anatomy. Aim: To investigate the benefit of FC for enhancing SRs' identification skills. Methods: Prospective data was collected from January 2018 to June 2018 at our hospital. The study cohorts were the SRs (study group, n = 15) and the surgical staff (SS; control group, n = 9). Participants were assigned to watch videos of LCs with FC from five different patients who had gallbladder disease, and identify structures in the video clips (including cystic duct, common bile duct, common hepatic duct, and cystic artery), first without FC, and then with FC. Results: In the without-FC phase, the overall misidentification rate by SRs (21.7%) was greater than that of the SS (11.8%; P = 0.018), However, in the FC phase, the two groups did not significantly differ in misidentification rates (23.3% vs 23.3%, P = 0.99). Paired-structure analysis of the without-FC and with-FC phases for the SR group found a significantly higher misidentification rate in the without-FC phase than the with-FC phase (21.9% vs 10.9%; P < 0.01). However, misidentification rates in the with-FC phase did not significantly differ between SRs and SS. Conclusion: FC enhanced identification skills of inexperienced surgeons during LC compared with conventional training. Combined with simulation-based video training, FC is a promising tool for enhancing technical and decision skills of trainees and inexperienced surgeons.
... 23 Case logs have been studied in great detail and trends have shown a gradual shift in case numbers from year to year. [24][25][26][27] Shifts can be reflective of not only general trends in neurosurgery but also changes in institutional practice and residency training models. [27][28][29][30][31][32][33] These distinctions, however, can be difficult, if not impossible to tease out through national graduating averages alone. ...
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BACKGROUND Neurological surgery resident applicants seek out certain aspects of training, including case volume. While graduating Accreditation Council for Graduate Medical Education (ACGME) summary data are available yearly, they are not program specific and drawing conclusions is difficult. OBJECTIVE To model general benchmarks for resident case volume across US programs to increase transparency and allow comparison of programs. METHODS ACGME neurosurgical resident national reports from 2017 to 2019 were downloaded. Averages, standard deviations, and medians were recorded from each of the 27 procedural categories. Monte Carlo simulations were performed. Each distribution was run independently 1 to 4 times to represent the number of residents in a given program per year. Cases were divided into different categories: endovascular, open vascular, tumor, spine, and pediatrics. RESULTS Average derived graduating case volumes were 1558 cases in 2017, 1599 cases in 2018, and 1618 cases in 2019. Programs with 3 residents per year averaged 4755 cases per year, with 90th percentile of 5401 cases per year. After removing endovascular cases, radiosurgery cases, and critical care procedures, the average was 3794 cases, with 90th percentile of 4197 cases per year. Categorically, the 90th percentile was 241 for open vascular, 373 for endovascular, 1600 for spine, 769 for tumor, and 352 for pediatrics. CONCLUSION Case volume is an important part of neurosurgical training and a major factor in determining applicant residency program ranking. Through Monte Carlo simulation, the average case volume for programs with 3 residents per year was determined. Metrics and benchmarking remain an important part of applicant and program growth.
... Laparoscopic procedures in emergency surgery in the past have not always been recommended due to concerns regarding patient physiology, lack of overall laparoscopic training, and/or experience with laparoscopic emergencies [22]. However, uptake of laparoscopic skills has increased with newly trained general and acute care surgeons [23,24], and it is clear from our data that this trend is continuing in the USA both in Level I trauma centers and non-trauma centers. In fact, our data show that non-trauma centers perform the majority of these minimally invasive procedures. ...
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Background The aim of this study was to evaluate the use of laparoscopic surgery for common emergency general surgery (EGS) procedures within an integrated Acute Care Surgery (ACS) network. We hypothesized that laparoscopy would be associated with improved outcomes. Methods Our integrated health care system’s EGS registry created from AAST EGS ICD-9 codes was queried from January 2013 to October 2015. Procedures were grouped as laparoscopic or open. Standard descriptive and univariate tests were performed, and a multivariable logistic regression controlling for open status, age, BMI, Charlson Comorbidity Index (CCI), trauma tier, and resuscitation diagnosis was performed. Laparoscopic procedures converted to open were identified and analyzed using concurrent procedure billing codes across episodes of care. Results Of 60,604 EGS patients identified over the 33-month period, 7280 (12.0%) had an operation and 6914 (11.4%) included AAST-defined EGS procedures. There were 4813 (69.6%) surgeries performed laparoscopically. Patients undergoing a laparoscopic procedure tended to be younger (45.7 ± 18.0 years vs. 57.2 ± 17.6, p < 0.001) with similar BMI (29.7 ± 9.0 kg/m² vs. 28.8 ± 8.3, p < 0.001). Patients in the laparoscopic group had lower mean CCI score (1.6 ± 2.3 vs. 3.4 ± 3.2, p ≤ 0.0001). On multivariable analysis, open surgery had the highest association with inpatient mortality (OR 8.67, 4.23–17.75, p < 0.0001) and at all time points (30-, 90-day, 1-, 3-year). At all time points, conversion to open was found to be a statistically significant protective factor. Conclusion Use of laparoscopy in EGS is common and associated with a decreased risk of all-cause mortality at all time points compared to open procedures. Conversion to open was protective at all time points compared to open procedures.
... Studies across specialties demonstrate that domain-specific knowledge and general problem solving skills are necessary for clinical competence [5], and across specialties variety of cases and quality of supervision may influence acumen [6]. Although case logs requiring a broad clinical exposure are de riguer for surgical residency training [7], little has been published on the role of breadth of exposure for non-surgical specialties, and its impact on clinical acumen. ...
Article
This study examined how volume in certain patient case types and breadth across patient case types in the outpatient clinic setting are related to Neurology Clerkship student performance. Case logs from the outpatient clinic experience of 486 students from The University of Chicago Pritzker School of Medicine, USA, participating in the 4 week Neurology Clerkship from July 2008 to June 2013 were reviewed. A total of 12,381 patient encounters were logged and then classified into 13 diagnostic categories. How volume of cases within categories and the breadth of cases across categories relate to the National Board of Medical Examiners Clinical Subject Examination for Neurology and a Neurology Clerkship Objective Structured Clinical Examination was analyzed. Volume of cases was significantly correlated with the National Board of Medical Examiners Clinical Subject Examination for Neurology (r = .290, p < .001), the Objective Structured Clinical Examination physical examination (r = .236, p = .011), and the Objective Structured Clinical Examination patient note (r = .238, p = .010). Breadth of cases was significantly correlated with the National Board of Medical Examiners Clinical Subject Examination for Neurology (r = .231, p = .017), however was not significantly correlated with any component of the Objective Structured Clinical Examination. Volume of cases correlated with higher performance on measures of specialty knowledge and clinical skill. Fewer relationships emerged correlating breadth of cases and performance on the same measures. This study provides guidance to educators who must decide how much emphasis to place on volume versus breadth of cases in outpatient clinic learning experiences.
... We particularly focused on chief residents (postgraduate year [PGY]-5) and fellows (PGY-6, -7, -8). We limited our evaluation to MIS operations for several reasons: first, laparoscopic skills are essential for resident training as these operations are becoming more prominent in treatment of surgical diseases [13]; second, attendings have less control over the flow of the operation when the resident or fellow is in the surgeon position; and third, MIS fellowships are ever increasing in number, which likely impacts residents' MIS operative experience. We hypothesized that when comparing operations in which either chief residents or fellows participated, there would be no difference in major surgical outcomes. ...
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IntroductionAs fellowship training after general surgery residency has become increasingly common, the impact on resident education must be considered. Patient safety and procedure outcomes are often used as justification by attendings who favor fellows over residents in certain minimally invasive surgery (MIS) operations. The aim of the present study was to compare the impact of trainee level on the outcomes of selected MIS operations to determine if giving preference to fellows on grounds of outcomes is warranted.Methods Patients who underwent elective laparoscopic hiatal hernia repair (LHHR), laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic splenectomy (LS), laparoscopic cholecystectomy (LC), or laparoscopic ventral hernia repair (LVHR) with assistance of a general surgery chief resident or fellow were identified from the American College of Surgeon’s National Surgical Quality Improvement Program database (2007–2012). Patients were matched 1:1 based on propensity score for the odds of undergoing operations assisted by a fellow.Results5145 patients underwent LHHR, 1396 LSG, 9656 LRYGB, 863 LS, 13,434 LC, and 3069 LVHR. Fellows assisted in 41.7% of LHHR, 49.2% of LSG, 56.4% of LRYGB, 25.7% of LS, 17.1% of LC, and 27.0% of LVHR cases. After matching, overall and severe complication rates were comparable between cases performed with assistance of a fellow or chief resident. Median operative time was longer for LSG, LRYGB, and LC when a fellow assisted.Conclusions Surgical outcomes were similar between fellow and chief resident assistance in MIS operations, arguing that increased resident participation in basic and complex laparoscopic operations is appropriate without compromising patient safety.
... In addition, there has been an expansion of laparoscopy in surgical practice, along with an increased case minimum in laparoscopy by the ACGME, leading to residents needing to perform more operations with a technique that we are using more often. 14 The appendectomy has been a principal case to learn the fundamentals of laparoscopy. 15 Our results show an explosive rise in laparoscopic appendectomy and the progressive replacement of the open appendectomy. ...
Article
Objective: The expansion of Minimally Invasive Surgery (MIS) has been exponential since the introduction of laparoscopic surgery in the late 1980s. This shift in operative technique has led many to believe that surgery residents are not developing the skills needed to adequately perform open operations. Methods: We performed a retrospective review of the Accreditation Council for Graduating Medical Education national operative case log database of general surgery residents from January 2003 to December 2019. We compared the open vs. laparoscopic case numbers for six different operations, including cholecystectomy, appendectomy, inguinal hernia repair, colectomy, gastrectomy, and Nissen fundoplication. The Cochran-Armitage test was used to assess the linear trend in the procedures performed. Results: Total average residency case volumes for the procedures studied have increased from 270 to 368 (36%) over the 16-year period with MIS steadily representing a greater proportion of these cases. From 2003 to 2018, MIS representation increased in all studied procedures: cholecystectomy (88% to 94%, p = 0.048), inguinal hernia repair (20% to 47%, p ≤ 0.001), appendectomy (38% to 93%, p ≤ 0.001), colectomy (8% to 43%, p ≤ 0.001), gastrectomy (43% to 84%, p = 0.048), and Nissen (71% to 91%, p = 0.21). Conclusion: While the overall operative volume has increased nationally for surgical residents, the representation of open cases has steadily declined since the advent of MIS. The experience needed in open surgery during resident training is still to be determined and may be necessary now that laparoscopy is progressively replacing open operations.
... 5 A recent national review found that 37% of cases logged by general surgery residents are done laparoscopically, when there is an option to perform the case open or laparoscopic. 6 In 2008, our group had shown the rise in laparoscopic surgery to be accompanied by a reduction in junior resident participation in what, as open operations, previously would have been junior level cases. 7 The general response from the surgical community has been that this issue would correct over time, and the distribution of cases to junior residents would normalize. ...
Article
Introduction: Our group has previously demonstrated an upward shift from junior to senior resident participation in common general surgery operations, traditionally performed by junior-level residents. The objective of this study was to evaluate if this trend would correct over time. We hypothesized that junior resident case volume would improve. 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 Participant Use Files were queried for these procedures between 2005 and 2012. Cases were stratified by participating resident post-graduate year with "junior resident" defined as post-graduate year1-3. Logistic regression was performed to determine change in junior resident participation for each type of procedure over time. Results: A total of 185,335 cases were included in the study. For 3 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%/y (p < 0.001) for laparoscopic procedures and by 6.2%/y (p < 0.001) for open procedures. The proportion of laparoscopic surgeries performed by junior-level residents decreased for appendectomy by 2.6%/y (p < 0.001) and cholecystectomy by 6.1%/y (p < 0.001), whereas it was unchanged for inguinal herniorrhaphy (p = 0.75) and increased for partial colectomy by 3.9%/y (p = 0.003). A decline in junior resident participation was seen for all open surgeries, with appendectomy decreasing by 9.4%/y (p < 0.001), cholecystectomy by 4.1%/y (p < 0.002), inguinal herniorrhaphy by 10%/y (p < 0.001) and partial colectomy by 2.9%/y (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. As previously thought, 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.
... Despite these measures, there is still concern that the currently available training in MIS may be problematic for residents, particularly those entering practice immediately following graduation from residency [26]. There may simply not be enough traditional clinical opportunities to reach technical competence, let alone expertise, in all necessary laparoscopic skills. ...
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Introduction The benefits of minimally invasive surgery are numerous; however, considerable variability exists in its application and there is a lack of standardized training for important advanced skills. Our goal was to determine whether participation in an advanced laparoscopic curriculum (ALC) results in improved laparoscopic suturing skills. Methods and procedures Study design was a prospective, randomized controlled trial. Surgery novices and trainees underwent baseline FLS training and were pre-tested on bench models. Participants were stratified by pre-test score and randomized to undergo either further FLS training (control group) or ALC training (intervention group). All were post-tested on the same bench model. Tests for differences between post-test scores of cohorts were performed using least squared means. Multivariable regression identified predictors of post-test score, and Wilcoxon rank sum test assessed for differences in confidence improvement in laparoscopic suturing ability between groups. Results Between November 2018 and May 2019, 25 participants completed the study (16 females; 9 males). After adjustment for relevant variables, participants randomized to the ALC group had significantly higher post-test scores than those undergoing FLS training alone (mean score 90.50 versus 82.99, p = 0.001). The only demographic or other variables found to predict post-test score include level of training (p = 0.049) and reported years of video gaming (p = 0.034). There was no difference in confidence improvement between groups. Conclusions Training using the ALC as opposed to basic laparoscopic skills training only is associated with superior advanced laparoscopic suturing performance without affecting improvement in reported confidence levels. Performance on advanced laparoscopic suturing tasks may be predicted by lifetime cumulative video gaming history and year of training but does not appear to be associated with other factors previously studied in relation to basic laparoscopic skills, such as surgical career aspiration or musical ability.
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Background: The ACGME instituted duty hour restrictions in 2003. This presents a challenge for surgical residents who must acquire a medical and technical knowledge base during their training. Although the effect of work hour limitations on operative volume has been examined, no study has examined whether duty hour reform has had an effect on operative volume variability. Study design: The ACGME operative log data of graduating general surgery residents from 1992 to 2015 were examined. Residents with the most and fewest total major cases were identified and case logs, learning styles, and evaluations were analyzed. Statistical analysis was performed using linear regression analysis, chi-square test, Student's t-test, and Wilcoxon rank sum test. Significance was defined as p < 0.05. Results: One hundred and thirty-five residents graduated from 1992 to 2015. No change in overall operative volume was seen after the 2003 duty hour reform, however, there was an increase in operative variability. In addition, there was an increase in the variability of total major cases between the resident completing the most and fewest cases per class (183.3; p = 0.02) after the start of work hour restrictions. The residents who graduated with the highest operative volume were more likely to be action-based learners (odds ratio = 6.81; 95% CI, 2.84-16.34; p < 0.001) and received superior evaluation scores. Conclusions: After the implementation of the 80-hour workweek, we found a significant increase in operative variability. This might suggest a growing disparity in the operative experience among surgical residents and, consequently, a varying quality of graduating residents. Programs should therefore consider using learning styles and developing competency-based training curricula to ensure equitable training among all trainees.
Article
Introduction: Acute Care Surgery (ACS), Trauma and Surgical Critical Care (SCC) fellowships graduate fellows deemed qualified to perform complex cases immediately upon graduation. We hypothesize international fellow rotations (IFR) can be a resource to supplement operative case exposure METHODS: A survey was sent to all program directors of ACS and SCC fellowships via email. Data was captured and analyzed using the Research Electronic Data Capture (REDCap) tool. Results: The survey was sent to 113 program directors (PDs) with a response rate of 42%. Most fellows performed < 150 operative cases (59.5%). The majority of PDs thought the operative exposure could either be improved or was not enough to ensure expertise in trauma and emergent general surgery. Only a minority of the PDs found their case load exceptional (Can be improved: 43%, Not enough :30% Exceptional: 27%). Most PDs thought an international experience could supplement the breath of cases, provide research opportunities, and improve understanding of trauma systems (70%). Ten sites offered international rotations (70%). Most fellowships would be willing to provide reciprocity to the host institution (90%). Conclusions: The majority of PDs for ACS, trauma, and SCC programs perceive a need for increased quality and quantity of operative cases. The majority recognize IFR as a valuable tool to supplement fellows' education. Level of evidence: VI survey.
Article
Importance In some centers, the presence of a senior general surgeon (SGS) is obligatory in every procedure, including appendectomy, while in others it is not. There is a relative paucity in the literature of reports comparing the outcomes of appendectomies performed by unsupervised general surgery residents (GSRs) with those performed in the presence of an SGS. Objective To compare the outcomes of appendectomies performed by SGSs with those performed by GSRs. Design, Setting, and Participants A retrospective analysis was performed of all patients 16 years or older operated on for assumed acute appendicitis between January 1, 2008, and December 31, 2015. The cohort study compared appendectomies performed by SGSs and GSRs in the general surgical department of a teaching hospital. Main Outcomes and Measures The primary outcome measured was the postoperative early and late complication rates. Secondary outcomes included time from emergency department to operating room, length of surgery, surgical technique (open or laparoscopic), use of laparoscopic staplers, and overall duration of postoperative antibiotic treatment. Results Among 1649 appendectomy procedures (mean [SD] patient age, 33.7 [13.3] years; 612 female [37.1%]), 1101 were performed by SGSs and 548 by GSRs. Analysis demonstrated no significant difference between the SGS group and the GSR group in overall postoperative early and late complication rates, the use of imaging techniques, time from emergency department to operating room, percentage of complicated appendicitis, postoperative length of hospital stay, and overall duration of postoperative antibiotic treatment. However, length of surgery was significantly shorter in the SGS group than in the GSR group (mean [SD], 39.9 [20.9] vs 48.6 [20.2] minutes; P < .001). Conclusions and Relevance This study demonstrates that unsupervised surgical residents may safely perform appendectomies, with no difference in postoperative early and late complication rates compared with those performed in the presence of an SGS.
Article
Introduction: The aim of this study was to compare the clinical outcomes of single-incision transumbilical laparoscopy-assisted appendectomy performed by surgical residents and attending surgeons. Methods: We reviewed the clinical outcomes of 131 transumbilical laparoscopy-assisted appendectomies performed from January 2011 to June 2014. During the study period, 13 residents and 6 board-certified attending surgeons performed the procedures. For all operations performed by residents and attending surgeons, we reviewed and compared gender, age, BMI, body temperature, white blood cell count, C-reactive protein serum level, and the presence of a fecalith or abscess. Clinical outcomes including operative time, estimated blood loss, need for additional ports, conversion to open surgery, intraoperative complications, postoperative complications, and postoperative hospital stay were compared between the two groups. Results: The mean preoperative white blood cell count in the resident-operated group was significantly higher than in the attending-operated group (14.0 vs 10.8 ×10(3) /mm(3) , P = 0.007). There were no other significant differences in clinical variables between the two groups. Outcomes show that estimated blood loss was significantly higher (23.4 vs 9.8 mL, P = 0.031) and operative time tended to be longer (86.0 vs 72.0 min, P = 0.056) in the resident-operated group. No other significant differences were observed. Conclusion: Transumbilical laparoscopy-assisted appendectomy performed by residents is feasible and safe. It is an acceptable as a part of routine surgical training.
Article
Study objective: To describe secular trends in operative experience for surgical trainees across an extended period using the most comprehensive data available, the Accreditation Council for Graduate Medical Education (ACGME) case logs. Background: Some experts have expressed concern that current trainees are inadequately prepared for independent practice. One frequently mentioned factor is whether duty hours' restrictions (DHR) implemented in 2003 and 2004 contributed by reducing time spent in the operating room. Methods: A dataset was generated from annual ACGME reports. Operative volume for total major cases (TMC), defined categories, and four index laparoscopic procedures was evaluated. Results: TMC dropped after implementation of DHR but rebounded after a transition period (949 vs 946 cases, P = nonsignificance). Abdominal cases increased from 22% of overall cases to 31%. Alimentary cases increased from 21% to 26%. Trauma and vascular surgery substantially decreased. For trauma, this drop took place well before DHR. The decrease in vascular surgery also began before DHR but continued afterward as well: 148 cases/resident in the late 1990s to 107 currently. Conclusions: Although total operative volume rebounded after implementation of DHR, diversity of operative experienced narrowed. The combined increase in alimentary and abdominal cases is nearly 13%, over a half-year's worth of operating in 5-year training programs. Bedrock general surgery cases-trauma, vascular, pediatrics, and breast-decreased. Laparoscopic operations have steadily increased. If the competence of current graduates has, in fact, diminished. Our analysis suggests that operative volume is not the problem. Rather, changing disease processes, subspecialization, reductions in resident autonomy, and technical innovation challenge how today's general surgeons are trained.
Article
Background: Common bile duct exploration (CBDE) is one of the available options in the management of choledocholithiasis. We aim to analyze outcomes comparing the laparoscopic and open approach to CBDE using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Study design: This is a retrospective cohort study of patients undergoing CBDE from year 2008 to 2013 using ACS NSQIP database. The cohort was split into 2 groups and compared based on the operative approach, laparoscopic versus open CBDE. Results: 2,635 patients underwent CBDE during the study period. 52% underwent an open approach. After adjusting for all confounding variables, open CBDE was associated with a statistically significant increase in mortality [adjusted odd ration (aOR) 2.95 (CI 1.18 - 7.41; P value = 0.02), composite morbidity aOR 2.19 (CI 1.56 - 3.07; P value <0.0001), bleeding aOR 1.86 (CI 1.11 - 3.12; P value= 0.02), return to the operation room aOR 1.90 (CI 1.16 - 3.12; P value= 0.01), and readmission related to first operation aOR 1.55 (CI 1.00 - 2.39; P value = 0.05). On the other hand, retained CBD stones were 2.8 times more likely to occur in laparoscopic group. The mean operative time was longer by 73 minutes for patients who underwent open CBDE. Conclusions: Patients undergoing open CBDE suffer from a statistically significant higher rate of mortality and overall complications compared to the laparoscopic approach. Laparoscopic CBDE should be considered as the preferred procedure for common bile duct exploration whenever possible.
Chapter
Significant advances in minimally invasive surgery and endoscopic techniques have redefined the management of common bile duct stones. Disease processes, which would keep patients hospitalized for protracted periods of time, have migrated to outpatient or overnight stays. Despite this, it is important in the management of these issues that special consideration be lent to resource management, physiologic considerations, previous and current anatomic issues, and ultimately specific surgical planning should operative intervention be required. While the move to minimally invasive and endoscopic techniques has lessened the need for operative intervention, it has not diminished its importance and the vital role it serves in the care of these patients. It is in this vein that we must consider the experience young surgeons emerging from training have and their comfort operating in this anatomic area.
Article
Surgery can only maintain its role in a highly competitive environment if results are continuously improved, accompanied by further reduction of the interventional trauma for patients and with justifiable costs. Significant impulse to achieve this goal was expected from minimally invasive surgery and, in particular, robotic surgery; however, a real breakthrough has not yet been achieved. Accordingly, the new strategic approach of cognitive surgery is required to optimize the provision of surgical treatment. A full scale integration of all modules utilized in the operating room (OR) into a comprehensive network and the development of systems with technical cognition are needed to upgrade the current technical environment passively controlled by the surgeon into an active collaborative support system (surgery 4.0). Only then can the true potential of minimally invasive surgery and robotic surgery be exploited.
Article
Background Hiatal hernia repair is commonly performed by both general and thoracic surgeons. The present study examined differences in approach, setting, and outcomes by specialty for hiatal hernia repair. Methods Adults undergoing hiatal hernia repair were identified in the 2012–2019 American College of Surgeons National Surgical Quality Improvement Program. Patients were grouped by specialty of the operating surgeon (thoracic surgery vs general surgery). Generalized linear models were used to evaluate the effect of specialty on mortality, major morbidity, and 30-day readmission. Results Among 46,739 patients, 5.0% were operated on by thoracic surgery. General surgery operated on younger patients (44.7 years vs 47.0, P < .001) with lesser systemic illness (American Society of Anesthesiologists class ≥3 50.4% vs 54.8%, P < .001) compared to thoracic surgery. General surgery more commonly used laparoscopy (95.0% vs 82.6%) and less commonly used thoracic approaches than thoracic surgery (0.6% vs 8.5%, P < .001). From 2012 to 2019, the proportion of cases performed as an outpatient by general surgery increased (28.1% to 46.4%, P < .001), but it remained stable for thoracic surgery (0.1% to 0.7%, P = .10). After risk adjustment, thoracic surgery specialty was not associated with mortality (odds ratio 0.9, 95% confidence interval 0.5–1.5), major morbidity (0.9, 95% confidence interval 0.7–1.1), or readmission (0.9, 95% confidence interval 0.8–1.1). Rather, factors including surgical approach (laparotomy 1.6, 95% confidence interval 1.4–1.9; thoracoscopy/thoracotomy 2.0, 95% confidence interval 1.5–2.7), inpatient case status (2.4, 95% confidence interval 2.2–2.7), increasing ASA class, and functional status more strongly influenced major morbidity. Conclusion Operative factors, surgical approach, and patient comorbidities more strongly influence outcomes of hiatal hernia repair than does surgeon specialty, suggesting continued safety of hiatal hernia repair by both thoracic and general surgeons.
Article
Background: Minimally invasive pediatric surgery has increased in breadth and complexity over the past several decades, with little data on minimally invasive surgery (MIS) training in US and Canadian pediatric surgery fellowship programs. Methods: We performed a time series analysis of Accreditation Council for Graduate Medical Education pediatric surgery fellow case logs from 2003 to 2016. Proportions of cases performed in an MIS fashion as well as per-fellow MIS case averages were recorded over time. Results: There was a 30.9% increase in average number of MIS cases per fellow over the study time period. Twenty-three recorded procedures included MIS and open options (17 abdominal, three thoracic, and three genitourinary). The proportion of cases performed using a minimally invasive approach increased by an average of 29.0%, 14.6%, and 47.0% for each of these categories, respectively. Significant variability was observed in specific cases such as laparoscopic and open inguinal hernias, ranging from 0 to 85 and nine to 152 per trainee, respectively, in the final year of data collection. When examining pyloromyotomy, a high-volume procedure with a known increase in the MIS approach, the proportion of cases performed MIS increased by 83.3%. The minimum and maximum number of cases per fellow recorded ranged from 0 to 114 during the eight years in which MIS pyloromyotomy was recorded. Conclusions: MIS case exposure among graduating US and Canadian pediatric survey fellows increased substantially during the study period. More granular data, however, are needed to better define the current operative experience and criteria for determination of competency in advanced MIS.
Article
Background Minimally invasive (MI) gastrectomy has become increasingly common as a resection technique for gastric cancer; however, data are limited regarding peri-operative morbidity, oncologic outcomes and long-term survival, particularly in the Western patient population. Study design The 2010–2012 National Cancer Data Base was queried for adult patients who underwent gastrectomy for localized, intestinal-type gastric adenocarcinoma. Patients were classified by surgical approach (MI vs. open gastrectomy) on an intent-to-treat basis. Groups were propensity score matched using a 1:1 nearest neighbor algorithm, and outcomes were compared. Survival was estimated using the Kaplan-Meier method. Results Among 5420 patients, 1423 (26%) underwent MI gastrectomy. Following adjustment with propensity matching, all baseline characteristics were highly similar between 1175 patients in each treatment group. Between propensity-matched groups, MI gastrectomy patients had similar rates of margin-negative resections (91 vs. 90%, p = 0.447), median lymph node harvest (16 vs. 15, p = 0.104), and utilization of adjuvant therapies (28 vs. 28%, p = 0.748). MI gastrectomy was associated with shorter hospital stay (8 vs. 9 days, p < 0.001) without an increase in unplanned readmissions (7 vs. 6%, p = 0.456) or 30-day mortality (2 vs. 3%, p = 0.655). There was no difference in 3-year overall survival (50 vs. 55%, p = 0.359). Conclusions On a national level, MI gastrectomy for gastric cancer appears to be associated with similar perioperative and long-term outcomes compared to the traditional open approach. While prospective studies remain essential, these data provide greater equipoise for ongoing trials and institutional efforts to further implement and evaluate this technique.
Article
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Surgical adhesives are an attractive alternative to traditional mechanical tissue fixation methods of sutures and staples. Ease of application, biocompatibility, enhanced functionality (drug delivery) are known advantages but weak adhesion strength in the wet environment and lack of tissue compliant behavior still pose a challenge. In order to address these issues, non-aqueous bioadhesive based on blends of polyamidoamine (PAMAM) dendrimer, conjugated with 4-[3-(trifluoromethyl)-3H-diazirin-3-yl] benzyl bromide (PAMAM-g-diazirine) and liquid polyethylene glycol (PEG 400) has been developed. PEG 400 biocompatible solvent reduces the viscosity of PAMAM-g-diazirine dendrimer without incorporating aqueous solvents or plasticizers, allowing application by syringe or spray. Upon UV activation, diazirine-generated reactive intermediates lead to intermolecular dendrimer crosslinking. The properties of the crosslinked matrix are tissue compliant, with anisotropic material properties dependent on the PEG 400 wt%, UV dose, pressure and uncured adhesive thickness. The hygroscopic PAMAM-g-diazirine/PEG 400 blend was hypothesized to absorb water at the tissue interface, leading to high interfacial adhesion, however porous matrices led to cohesive failure. The hydrophilic nature of the polyether backbone (PEG 400) shielded cationic PAMAM dendrimers with cured bioadhesive film displaying significantly less platelet activation than neat PAMAM-g-diazirine or PLGA thin films.
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Open procedures represent the dominant form of surgery worldwide. Artificial intelligence (AI) has the potential to optimize surgical practice and improve patient outcomes, but efforts have focused primarily on minimally invasive techniques. Our work overcomes existing data limitations for training AI models by curating, from YouTube, the largest dataset of open surgical videos to date: 1997 videos from 23 surgical procedures uploaded from 50 countries. Using this dataset, we developed a multi-task AI model capable of real-time understanding of surgical behaviors, hands, and tools—the building blocks of procedural flow and surgeon skill—across both space and time. We show that our model generalizes across diverse surgery types and environments. Illustrating this generalizability, we directly applied our YouTube-trained model to analyze open surgeries prospectively collected at an academic medical center and identified kinematic descriptors of surgical skill related to efficiency of hand motion. Our Annotated Videos of Open Surgery (AVOS) dataset and trained model will be made available for further development of surgical AI.
Article
Background Various minimally invasive surgery (MIS) procedures are used for gastric submucosal tumors (SMTs), and their technical difficulties vary. Preoperative understanding of difficulties is crucial; however, objective indicators are lacking. Methods Gastric SMTs requiring MIS (n = 36) were retrospectively analyzed. Preoperative factors were evaluated using a multivariate linear regression analysis. A scoring system was then constructed, and its feasibility was evaluated. Results Three factors were identified and scored based on the weighted contribution for predicting surgical time: tumor location (cardia, score of “2”; posterior wall of fundus, “1”); tumor size (greater than 4 cm, “1”); and tumor growth appearance (intraluminal, “1”). The summed scores could stratify the surgical time stepwise in each score, and patients who scored higher than 3 had larger intraoperative blood loss and a longer hospital stay. Conclusion Our scoring system predicted surgical difficulties and may, therefore, be useful in selecting appropriate surgical approaches for gastric SMTs.
Article
PurposeThere is no standard program for laparoscopic surgery training in Japan, and competency in these procedures does not require the acquisition of board certification. The purpose of this survey was to investigate the current status of laparoscopic surgery training in Japan.MethodsA questionnaire survey was mailed to 2296 members of the Japan Society for Endoscopic Surgery who were between postgraduate year 3 and 10. The questionnaire inquired about laparoscopic surgical training conditions, operation case numbers, and autonomy in eight laparoscopic procedures.ResultsThe total response rate was 28.1%. The number of cases required to perform procedures independently was demonstrated. Most participants felt confident in performing laparoscopic appendectomy and cholecystectomy; however, they felt less confident about performing laparoscopic colectomy and gastrectomy.Conclusions The information from this survey may be useful for surgical educators, surgical societies, and the board certification council for rebuilding the surgical training system in Japan.
Article
Objective Minimally invasive surgery (MIS) is an integral component of General Surgery training and practice. Yet, little is known about how much autonomy General Surgery residents achieve in MIS procedures, and whether that amount is sufficient. This study aims to establish a contemporary benchmark for trainee autonomy in MIS procedures. We hypothesize that trainees achieve progressive autonomy, but fail to achieve meaningful autonomy in a substantial percentage of MIS procedures prior to graduation. Setting/Participants Fifty General Surgery residency programs in the United States, from September 1, 2015 to March 19, 2020. All Categorical General Surgery Residents and Attending Surgeons within these programs were eligible. Design Data were collected prospectively from attending surgeons and categorical General Surgery residents. Trainee autonomy was assessed using the 4-level Zwisch scale (Show and Tell, Active Help, Passive Help, and Supervision Only) on a smartphone application (SIMPL). MIS procedures included all laparoscopic, thoracoscopic, endoscopic, and endovascular/percutaneous procedures performed by residents during the study. Primary outcomes of interest were “meaningful autonomy” rates (i.e., scores in the top 2 categories of the Zwisch scale) by postgraduate year (PGY), and “progressive autonomy” (i.e., differences in autonomy between PGYs) in MIS procedures, as rated by attending surgeons. Primary outcomes were determined with descriptive statistics, one-way analysis of variance (ANOVA) and Z-tests. Secondary analyses compared (i) progressive autonomy between common MIS procedures, and (ii) progressive autonomy in MIS vs. non-MIS procedures. Results A total of 106,054 evaluations were performed across 50 General Surgery residency programs, of which 38,985 (37%) were for MIS procedures. Attendings performed 44,842 (42%) of all evaluations, including 16,840 (43%) of MIS evaluations, while residents performed the rest. Overall, meaningful autonomy in MIS procedures increased from 14.1% (PGY1s) to 75.9% (PGY5s), with significant (p < 0.001) increases between each PGY level. Meaningful autonomy rates were higher in the MIS vs. non-MIS group [57.2% vs. 48.0%, p < 0.001], and progressed more rapidly in MIS vs. non-MIS, (p < 0.05). The 7 most common MIS procedures accounted for 83.5% (n = 14,058) of all MIS evaluations. Among PGY5s performing these procedures, meaningful autonomy rates (%) were: laparoscopic appendectomy (95%); laparoscopic cholecystectomy (93%); diagnostic laparoscopy (87%); upper/lower endoscopy (85%); laparoscopic hernia repair (72%); laparoscopic partial colectomy (58%); and laparoscopic sleeve gastrectomy (45%). Conclusions US General Surgery residents receive progressive autonomy in MIS procedures, and appear to progress more rapidly in MIS versus non-MIS procedures. However, residents fail to achieve meaningful autonomy in nearly 25% of MIS cases in their final year of residency, with higher rates of meaningful autonomy only achieved in a small subset of basic MIS procedures.
Article
Introducción: La colecistectomía por videolaparoscopía es el procedimiento estándar para la colelitiasis sintomática, sin embargo, existen casos en los que se debe proceder a la conversión a cirugíaabierta. El objetivo fue identificar las causas de conversión de colecistectomías laparoscópicas en el Hospital de Clínicas. Materiales y métodos: Estudiodescriptivo, de corte transversal, muestreo noprobabilístico. Se analizaron 509 fichas clínicas de laSegunda Cátedra de Clínica Quirúrgica y el servicio de Urgencias de Adultos del Hospital de Clínicas (2015-2018), incluyendo variables como conversión de la cirugía laparoscópica a abierta, causa de conversión, tiempo quirúrgico, cirugía programada o de urgencia, diagnóstico pre y postoperatorio, complicaciones y comorbilidades. Resultados: El 72,9% era de sexo femenino. El principal motivo de consulta fue dolor en hipocondrio derecho (52,65%). El 7,1% de las cirugías fueron convertidas y la principal causa fue debido a adherencias (44,44%). El tiempo quirúrgico medio fue de 97,65± 45,41 minutos. La principal complicación fue la hemorragia del lecho vesicular (1,2%). Conclusión: Las causas más comunes de conversión fueron adherencias, hemorragia en el lecho vesicular, fallas técnicas y dificultad para el reconocimiento de elementos anatómicos.
Article
Background: The objective of this study was to evaluate the impact of resident involvement on surgical outcomes in laparoscopic compared to open procedures. Methods: The American College of Surgeons National Surgical Quality Improvement Program 2007-2012 was queried for open and laparoscopic ventral hernia repair (VHR), inguinal hernia repair (IHR), splenectomy, colectomy, or cholecystectomy (CCY). Multivariable regression analyses were performed to assess the impact of resident involvement on surgical outcomes. Results: In total, 88,337 VHR, 20,586 IHR, 59,254 colectomies, 3301 splenectomies, and 95,900 CCY were identified. Resident involvement was predictive for major complication during open VHR (AOR, 1.29; p < 0.001), but not during any other procedure. Resident participation significantly prolonged operative time for open, as well as laparoscopic VHR, IHR, colectomy, splenectomy, and CCY (all p < 0.01). Conclusions: The results of this study suggest that resident participation has a similar impact on surgical outcomes during laparoscopic and open surgery, and is generally safe.
Article
Background: Surgical training is under scrutiny for the effect increased resident autonomy may have on patient outcomes. We hypothesize that as laparoscopic cholecystectomy (LC) difficulty increases, there will be increased involvement by senior residents and attending physicians with no differences in complications. Methods: Ten acute care surgeons were asked to fill out a postoperative questionnaire regarding surgical difficulty after every LC between 11/9/2016 and 3/30/2017. Either the Jonckheere-Terpstra test, Mantel-Haenzel chi square test, or ANOVA was used to test for the association between perioperative data and surgical difficulty. Results: A total of 190 LCs were analyzed. PGY level, percent of surgery time with attending surgeon involvement, partial cholecystectomy rate, and length of operation all significantly rose with increasing level of difficulty (p < 0.001) with no significant differences in 60-day emergency room bounce-backs, readmission, or complication rates. Conclusions: We found that as LC difficulty increases, so does attending surgeon and/or senior resident involvement, without increased morbidity.
Article
Background: To determine whether minimally invasive surgery (MIS) training improves outcomes in laparoscopic appendectomy, a procedure that is commonly performed in general surgery training. Methods: Retrospective review was conducted of all patients undergoing laparoscopic appendectomy for suspected acute appendicitis between 2014 and 2015 at a single-center, tertiary-care academic institution. Patients operated on by MIS-trained surgeons (MIS group) were compared to those operated on by general surgeons (GS group). Single-incision and multiport laparoscopic appendectomies were included; open approach, known malignancy, and interval appendectomies were excluded. Results: A total of 507 patients were included in the study: 181 patients in the MIS group and 326 in the GS group. There were no differences in patient demographics or medical comorbidities between groups and most patients were ASA class 1 or 2. Patients operated on by MIS-trained surgeons had significantly shorter operative time (43 min, IQR 32-60 vs. 58 min, IQR 44-81; p < 0.001) and fewer intra-operative adverse events (0/181 vs. 8/326, 2.5%; p = 0.03). There was no difference in number of postoperative adverse events between groups (6/181, 3.3% vs. 21/326, 6.4%; p = 0.13). In the MIS group, subgroup analysis of single-incision versus multiport appendectomy showed no differences in intra-operative or postoperative adverse events. On multivariable linear regression, lack of MIS training and traditional multiport approach had the greatest effects on prolonging operative time (11.2 and 12.8 min, respectively; p = 0.001). Conclusions: MIS fellowship improves operative metrics and patient outcomes even in basic laparoscopy.
Article
The surgical oncologist of the future requires training in minimally invasive techniques. Increasing constraints on time and resources have led to a new emphasis on finding innovative ways to teach these surgical skills inside and outside the operating room. The goal of producing technically gifted minimally invasive surgical (MIS) oncologists requires robust, educationally sound training curricula. This article describes how MIS oncology training occurs at present with an outline of educational ideals training programs can strive for, provides two examples of successful MIS oncology programs to highlight effective strategies for moving forward, and introduces three new developments on the horizon.
Article
Background: The Parkland Grading Scale for Cholecystitis (PGS) was developed as an intraoperative grading scale to stratify gallbladder (GB) disease severity during laparoscopic cholecystectomy (LC). We aimed to prospectively validate this scale as a measure of LC outcomes. Methods: Eleven surgeons took pictures of and prospectively graded the initial view of 317 GBs using PGS while performing LC (LIVE) between 9/2016 and 3/2017. Three independent surgeon raters retrospectively graded these saved GB images (STORED). The Intraclass Correlation Coefficient (ICC) statistic assessed rater reliability. Fisher's Exact, Jonckheere-Terpstra, or ANOVA tested association between peri-operative data and gallbladder grade. Results: ICC between LIVE and STORED PGS grades demonstrated excellent reliability (ICC = 0.8210). Diagnosis of acute cholecystitis, difficulty of surgery, incidence of partial and open cholecystectomy rates, pre-op WBC, length of operation, and bile leak rates all significantly increased with increasing grade. Conclusions: PGS is a highly reliable, simple, operative based scale that can accurately predict outcomes after LC. TABLE OF CONTENTS SUMMARY: The Parkland Grading Scale for Cholecystitis was found to be a reliable and accurate predictor of laparoscopic cholecystectomy outcomes. Diagnosis of acute cholecystitis, surgical difficulty, incidence of partial and open cholecystectomy rates, pre-op WBC, operation length, and bile leak rates all significantly increased with increasing grade.
Article
Question: What are the clinical outcomes of early versus delayed laparoscopic cholecystectomy (LC) in acute cholecystitis with more than 72 hours of symptoms? Design: A randomized controlled trial. Setting: Single center at the University Hospital of Lausanne, Switzerland. Patients: Eighty-six patients were enrolled in the study that had symptoms of acute cholecystitis lasting more than 72 hours before admission. Intervention: Patients were randomly assigned to early LC or delayed LC. Main outcome: Primary outcome was overall morbidity following initial diagnosis. Secondary outcomes included total length of stay, duration of antibiotic used, cost, and surgical outcome. Results: Overall morbidity was lower in early laparoscopic cholecystectomy (ELC) [6 (14%) vs 17 (39%) patients, P = 0.015]. Median total length of stay (4 vs 7 days, P < 0.001) and duration of antibiotic therapy (2 vs 10 days, P < 0.001) were shorter in the ELC group. Total hospital costs were lower in ELC (9349&OV0556; vs 12,361&OV0556;, P = 0.018). Operative time and postoperative complications were similar (91 vs 88 minutes; P = 0.910) and (15% vs 17%; P = 1.000), respectively. Conclusions: ELC for acute cholecystitis even beyond 72 hours of symptoms is safe and associated with less overall morbidity, shorter total hospital stay, and duration of antibiotic therapy, as well as reduced cost compared with delayed cholecystectomy.
Article
Objective: To determine if visuospatial perception (VSP) testing is correlated to simulated or intraoperative surgical performance as rated by the American College of Graduate Medical Education (ACGME) milestones. Design: Classification II-2 SETTING: Two academic training institutions PARTICIPANTS: 41 residents, including 19 Brigham and Women's Hospital and 22 Mayo Clinic residents from three different specialties (OBGYN, general surgery, urology). Intervention: Participants underwent three different tests: visuospatial perception testing (VSP), Fundamentals of Laparoscopic Surgery (FLS®) peg transfer, and DaVinci robotic simulation peg transfer. Surgical grading from the ACGME milestones tool was obtained for each participant. Demographic and subject background information was also collected including specialty, year of training, prior experience with simulated skills, and surgical interest. Standard statistical analysis using Student's t test were performed, and correlations were determined using adjusted linear regression models. Measurements and main results: In univariate analysis, BWH and Mayo training programs differed in both times and overall scores for both FLS® peg transfer and DaVinci robotic simulation peg transfer (p<0.05 for all). Additionally, type of residency training impacted time and overall score on robotic peg transfer. Familiarity with tasks correlated with higher score and faster task completion (p= 0.05 for all except VSP score). There was no difference in VSP scores by program, specialty, or year of training. In adjusted linear regression modeling, VSP testing was correlated only to robotic peg transfer skills (average time p=0.006, overall score p=0.001). Milestones did not correlate to either VSP or surgical simulation testing. Conclusions: VSP score was correlated with robotic simulation skills but not with FLS skills or ACGME milestones. This suggests that the ability of VSP score to predict competence differs between tasks. Therefore, further investigation is required into aptitude testing, especially prior to its integration as an entry examination into a surgical subspecialty.
Article
To identify background characteristics and cognitive tests that may predict surgical trainees' future technical performance, and therefore be used to supplement existing surgical residency selection criteria. Assessment of technical skills is not commonly incorporated as part of the selection process for surgical trainees in North America. Emerging evidence, however, suggests that not all trainees are capable of reaching technical competence. Therefore, incorporating technical aptitude into selection processes may prove useful. A systematic search was carried out of the MEDLINE, PsycINFO, and Embase online databases to identify all studies that assessed associations between surrogate markers of innate technical abilities in surgical trainees, and whether these abilities correlate with technical performance. The quality of each study was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation system. A total of 8035 records were identified. After screening by title, abstract, and full text, 52 studies were included. Very few surrogate markers were found to predict technical performance. Significant associations with technical performance were seen for 1 of 23 participant-reported surrogate markers, 2 of 25 visual spatial tests, and 2 of 19 dexterity tests. The assessment of trainee Basic Performance Resources predicted technical performance in 62% and 75% of participants. To date, no single test has been shown to reliably predict the technical performance of surgical trainees. Strategies that rely on assessing multiple innate abilities, their interaction, and their relationship with technical skill may ultimately be more likely to serve as reliable predictors of future surgical performance.
Article
Full-text available
Laparoscopic surgery has been an essential component of surgical education for the last two decades. The Accreditation Council for Graduate Medical Education (ACGME) changed the requirements for laparoscopic cases beginning with graduates in 2008, and the Fundamentals of Laparoscopic Surgery program was introduced over a decade ago as a method of measuring competency with laparoscopic techniques. The purpose of this study was to determine what changes have been made to meet these requirements and how these changes have impacted general surgery residents in their preparation to perform both basic and complex laparoscopic procedures upon completion of residency. A 23-question survey was distributed electronically to all fourth- and fifth-year residents of United States general surgery residency programs. Respondents were queried about demographics, perception of surgical education, and their level of preparedness to perform laparoscopic cases upon graduation. The survey was completed by a total of 321 residents (174 fourth-year and 147 fifth-year). Nineteen percent of respondents indicated that they anticipated problems meeting the new ACGME guidelines and 18.7% of all respondents indicated that changes had been made to their program to meet those new requirements. The majority of residents felt they had adequate laparoscopic training upon graduation, but there was a disparity between program types. Despite this finding, more than one-third of respondents believed that it would be necessary to seek additional laparoscopic training post-residency graduation. Residency training programs have had to keep pace with evolving technology while preparing future surgeons to perform with confidence upon completion of residency training. The majority of residents feel their training has been adequate, but there are also a great number who believe they will need to continue their education in laparoscopic surgery to keep pace with this ever-evolving field.
Article
Full-text available
The field of postgraduate minimally invasive surgery training has undergone substantial growth and change. A survey was sent to all program directors in surgery. Minimally invasive training patterns, facilities, their views, and performance of residents were examined. Ninety-five directors (38%) responded to the questionnaire. Of these, 51 per cent (n = 48) had a program size of three to four residents and 33 per cent (n = 31) had a program size of five to six residents. In 3 per cent of programs (n = 3), residents could not achieve the minimum Accreditation Council for Graduate Medical Education required numbers for advanced laparoscopic cases. Only 47 per cent of programs (n = 45) had dedicated rotations in minimally invasive surgery, ranging from 2 to 11 months. Up to 10 per cent (n = 9) of program directors felt that the current training in minimally invasive surgery was insufficient. Fifty-five per cent (n = 52) felt that laparoscopic adhesiolysis was an advanced laparoscopic procedure, and 33 per cent (n = 31) felt that there should be a separate minimum requirement for each of the commonly performed basic and advanced laparoscopic cases by Accreditation Council for Graduate Medical Education. Fifty-six per cent (n = 53) of programs were performing robotic surgery. Minimally invasive surgery training for surgical residents needs to increase opportunities so that they are able to perform laparoscopic procedures with confidence. There should be specific number requirements in each category of individual basic and advanced laparoscopic procedures.
Article
To evaluate trends in operative experience and to determine the effect of establishing the Surgical Council on Resident Education (SCORE) operative classification system on changes in operative volume among graduating surgery residents. The general surgery operative logs of graduating surgery residents from 2005 were retrospectively compared with residents who completed training in 2010 and 2011. Nonparametric statistical analyses were used (Mann-Whitney and median test) with significance set at p<0.01. A total of 1022 residents completing residency in 2005 were compared with 1923 residents completing training in 2010-2011. Total operations reported increased from a median of 1023 to 1238 (21%) between 2005 and 2010-2011 (p<0.001). Cases increased in most SCORE categories. The median numbers of total, basic, and complex laparoscopic operations increased by 49%, 37%, and 82%, respectively, over the 5-year interval (p<0.001). Open cavitary (thoracic + abdominal) operations decreased by 5%, whereas other major operations increased by 35% (both p<0.001). The frequency of discrete operations done at least 10 times during residency did not change. The median number of SCORE essential-common operations performed ranged from 1 to 107, whereas essential-uncommon operations ranged from 0 to 4. Twenty-three of 67 SCORE essential-common operations (34%) had a median of less than 5 and 4 had a median of 0. The operative volume of graduating surgical residents has increased by 21% since 2005; however, the number of operations done 10 times or greater has not changed. Although open cavitary procedures continue to decline, there has been a large increase in endoscopy, complex laparoscopic, and other major operations. Some essential-common operations continue to be performed infrequently. These results suggest that education in the operating room must improve and alternate methods for teaching infrequently performed procedures are needed.
Article
To assess readiness of general surgery graduate trainees entering accredited surgical subspecialty fellowships in North America. A multidomain, global assessment survey designed by the Fellowship Council research committee was electronically sent to all subspecialty program directors. Respondents spanned minimally invasive surgery, bariatric, colorectal, hepatobiliary, and thoracic specialties. There were 46 quantitative questions distributed across 5 domains and 1 or more reflective qualitative questions/domains. There was a 63% response rate (n = 91/145). Of respondent program directors, 21% felt that new fellows arrived unprepared for the operating room, 38% demonstrated lack of patient ownership, 30% could not independently perform a laparoscopic cholecystectomy, and 66% were deemed unable to operate for 30 unsupervised minutes of a major procedure. With regard to laparoscopic skills, 30% could not atraumatically manipulate tissue, 26% could not recognize anatomical planes, and 56% could not suture. Furthermore, 28% of fellows were not familiar with therapeutic options and 24% were unable to recognize early signs of complications. Finally, it was felt that the majority of new fellows were unable to conceive, design, and conduct research/academic projects. Thematic clustering of qualitative data revealed deficits in domains of operative autonomy, progressive responsibility, longitudinal follow-up, and scholarly focus after general surgery education.
Article
Importance The chief resident (CR) year is a pivotal experience in surgical training. Changes in case volume and diversity may impact the educational quality of this important year.Objective To evaluate changes in operative experience for general surgery CRs.Design, Setting, and Participants Review of Accreditation Council for Graduate Medical Education case logs from 1989-1990 through 2011-2012 divided into 5 periods. Graduates in period 3 were the last to train with unrestricted work hours; those in period 4 were part of a transition period and trained under both systems; and those in period 5 trained fully under the 80-hour work week. Diversity of cases was assessed based on Accreditation Council for Graduate Medical Education defined categories.Main Outcomes and Measures Total cases and defined categories were evaluated for changes over time.Results The average total CR case numbers have fallen (271 in period 1 vs 242 in period 5, P < .001). Total CR cases dropped to their lowest following implementation of the 80-hour work week (236 cases), but rebounded in period 5. The percentage of residents’ 5-year operative experience performed as CRs has decreased (30% in period 1 vs 25.6% in period 5, P < .001). Regarding case mix: thoracic, trauma, and vascular cases declined steadily, while alimentary and intra-abdominal operations increased. Recent graduates averaged 80 alimentary and 78 intra-abdominal procedures during their CR years. Compared with period 1, in which these 2 categories represented 47.1% of CR experience, in period 5, they represented 65.2% (P < .001). Endocrine experience has been relatively unchanged.Conclusions and Relevance Total CR cases declined especially acutely following implementation of the 80-hour work week but have since rebounded. Chief resident cases contribute less to overall experience, although this proportion stabilized before the 80-hour work week. Case mix has narrowed, with significant increases in alimentary and intra-abdominal cases. Broad-based general surgery training may be jeopardized by reduced case diversity. Chief resident cases are crucial in surgical training and educators should consider these findings as surgical training evolves.
Article
Importance: The 80-hour work-week limit for all residents was instituted in 2003 and studies looking at its effect have been mixed. Since the advent of the 16-hour mandate for postgraduate year 1 residents in July 2011, no data have been published regarding the effect of this additional work-hour restriction. Objective: To determine whether the 16-hour intern work limit, implemented in July 2011, has adversely affected operative experience. Design, setting, and participants: A retrospective review of categorical postgraduate year 1 Accreditation Council for Graduate Medical Education case logs from the intern class (N = 52) (with 16-hour work limit) compared with the 4 preceding years (2007-2010; N = 197) (without 16-hour work limit). A total of 249 categorical general surgery interns from 10 general surgery residency programs in the western United States were included. Main outcomes and measures: Total, major, first-assistant, and defined-category case totals. Results: As compared with the preceding 4 years, the 2011-2012 interns recorded a 25.8% decrease in total operative cases (65.9 vs 88.8, P = .005), a 31.8% decrease in major cases (54.9 vs 80.5, P < .001), and a 46.3% decrease in first-assistant cases (11.1 vs 20.7, P = .008). There were statistically significant decreases in cases within the defined categories of abdomen, endocrine, head and neck, basic laparoscopy, complex laparoscopy, pediatrics, thoracic, and soft tissue/breast surgery in the 16-hour shift intern era, whereas there was no decrease in trauma, vascular, alimentary, endoscopy, liver, and pancreas cases. Conclusions and relevance: The 16-hour work limit for interns, implemented in July 2011, is associated with a significant decrease in categorical intern operative experience. If the 16-hour shift were to be extended to all postgraduate year levels, one can anticipate that additional years of training will be needed to maintain the same operative volume.
Article
Background: The NSQIP database enables measurement of postoperative outcomes across a spectrum of practice settings. This allows for observations about potential effects of resident participation in surgical care during training. Study design: We queried the NSQIP database for 6 index laparoscopic surgical procedures performed during 2005-2008. Selected procedures require varying skill level (eg, appendectomy, cholecystectomy, gastric bypass, fundoplication, colectomy, and inguinal hernia), and 79,720 cases were identified. Preoperative, operative, and postoperative outcomes for each procedure were tabulated. Operative and postoperative outcomes assessed included operative time, hospital length of stay, mortality, morbidity, and return to the operating room. Initial analysis compared cases done with a resident present with cases done without residents. Subset analysis was done to determine possible differences in outcomes based on the level of resident participating, divided into Junior (PGY1-2), Senior (PGY3-5), or Fellow (PGY>5). Groups were scrutinized for both clinical and statistical differences. Results: Preoperative characteristics were similar between groups. Operative times were 20% to 47% longer with resident participation, with bigger differences seen in more basic procedures. Mortality and return to the operating room were not clinically different between the groups. Morbidity rates were higher in all procedures with resident participation. More senior residents were associated with longer operative times, without adverse impact on outcomes. Conclusions: Resident participation increases operative times for laparoscopic surgery considerably. Morbidity is statistically higher with resident participation but differences are unlikely to be clinically significant. Resident participation is a surrogate for the learning environment. These findings provide impetus for additional development of training techniques that occur outside the operating room.
Article
Background: Realizing the trends toward minimally invasive procedures, the Accreditation Council for Graduate Medical Education (ACGME) increased the requirements for laparoscopic procedures effective 2007 to 2008. Our purpose was to analyze the trend of laparoscopic versus open cases. Methods: We analyzed national ACGME general surgery operative log program data for basic and advanced open and laparoscopic procedures performed by graduating surgical residents between academic years 1996 to 1997 and 2009 to 2010. Results: From 1997 to 2010, the average number of procedures performed by graduating residents increased for appendectomies (36.5 to 59.3), cholecystectomies (90.9 to 112), hernia repairs (58.9 to 67.4), and colectomies (40.1 to 60.2). These increases have been accompanied by decreases in the percentage of open procedures for appendectomies (84% to 30%), cholecystectomies (24% to 9%), hernia repairs (90% to 70%), and colectomies (97% to 71%), which have resulted primarily from a decrease in open procedures (basic) or an increase in laparoscopic procedures (advanced). Conclusions: The rising number of laparoscopic procedures performed by surgical residents is associated with a drastic decrease in the number of basic open procedures. Although the number of open procedures is sufficient to meet ACGME requirements for now, this is an area of concern for the adequacy of training in the future.
Article
The time it takes to complete an operation is important. Operating room (OR) time is costly and directly associated with infectious complications and length of stay. Intuitively, procedures take longer when a surgical resident is operating. How much extra time should we take to train residents? We examined the relationship between laparoscopic inguinal hernia repair (IHR) procedure duration and resident participation and its impact on the development of complications and hospital stay. Data from patients undergoing laparoscopic IHR in participating institutions of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2007 to 2009 were retrospectively reviewed. Patients with current procedural terminology (CPT) codes 49650 and 49651 (laparoscopic initial and recurrent IHR) comprised our patient cohort. Participation of staff surgeon and resident postgraduate year level (PGY) were used as the main predictors for operative outcomes. A total of 6223 patients underwent laparoscopic IHR as their main procedure with no additional or concurrent procedures; 92% were men, 21% of the repairs were bilateral. In total, there were 98 patients with at least 1 complication (1.6%). Resident involvement was present in 3565 cases (57%) broken down by PGY1: 12%, PGY2: 12%, PGY3: 21%, PGY4: 19%, PGY5 or above: 36%. Median operative time was 45 minutes for staff surgeons alone and 64 minutes when there was a resident present (p < 0.001). PGY level predicted operative duration: higher PGY levels correlated with greater operative times (PGY1 median time 58 min vs PGY ≥ 5 = 67 min, p < 0.001). Resident participation was not a significant predictor for the development of complications (p = 0.30). Laparoscopic IHR is performed faster by staff surgeons without residents. There was no difference in the complication rate when residents were involved. Teaching and mentoring residents in the OR for laparoscopic IHR is safe and laudable.
Article
Simulation training may be an invaluable tool in training and assessing surgeons. Questions remain regarding its true impact on acquisition of laparoscopic skills and their transferability to the operating room. Twenty general surgery residents completed 5 exercises: bean drop/rope drill, foam cutting/endoloop, checkerboard, endostitch, and suturing/intracorporeal knot. After baseline scoring, residents had 3 weeks to practice before re-testing. Statistical analysis of objective and subjective scores included the signed rank test or paired t-test, the Kruskal-Walis test, the McNemar test, and the Global Operative Assessment of Laparoscopic Skills (GOALS). P < .05 was considered significant. Five postgraduate year (PGY) 4 and 15 PGY 1-3 residents completed the curriculum. When compared with baseline, overall scores improved (P < .05) in all categories except for the bean drop/rope drill, which improved on objectively measured tasks only (dropped beads and beads threaded). The foam cutting/endoloop task was mastered by a majority of trainees at baseline leaving no room for improvement. The results of this study reinforce that simulation leads to improvement in laparoscopic skills and that our curriculum is a valid educational tool. Further studies are needed to validate whether this results in improved skills in the operating room.
Article
Objective: : To develop and validate an ex vivo comprehensive curriculum for a basic laparoscopic procedure. Background: : Although simulators have been well validated as tools to teach technical skills, their integration into comprehensive curricula is lacking. Moreover, neither the effect of ex vivo training on learning curves in the operating room (OR), nor the effect on nontechnical proficiency has been investigated. Methods: : This randomized single-blinded prospective trial allocated 20 surgical trainees to a structured training and assessment curriculum (STAC) group or conventional residency training. The STAC consisted of case-based learning, proficiency-based virtual reality training, laparoscopic box training, and OR participation. After completion of the intervention, all participants performed 5 sequential laparoscopic cholecystectomies in the OR. The primary outcome measure was the difference in technical performance between the 2 groups during the first laparoscopic cholecystectomy. Secondary outcome measures included differences with respect to learning curves in the OR, technical proficiency of each sequential laparoscopic cholecystectomy, and nontechnical skills. Results: : Residents in the STAC group outperformed residents in the conventional group in the first (P = 0.004), second (P = 0.036), third (P = 0.021), and fourth (P = 0.023) laparoscopic cholecystectomies. The conventional group demonstrated a significant learning curve in the OR (P = 0.015) in contrast to the STAC group (P = 0.032). Residents in the STAC group also had significantly higher nontechnical skills (P = 0.027). Conclusions: : Participating in the STAC shifted the learning curve for a basic laparoscopic procedure from the operating room into the simulation laboratory. STAC-trained residents had superior technical proficiency in the OR and nontechnical skills compared with conventionally trained residents. (The study registration ID is NCT01560494.).
Article
Structured training on box trainers in laparoscopic skills in the initial years of residency has been used and found to be effective. Although there are studies that confirm immediate improvement after training, there is a lack of well-designed trials addressing the crucial issue of retention of these skills over time. The purpose of this study is to assess improvement in laparoscopic skills of surgical trainees after structured training on box trainers, compared with traditional training (observing and assisting laparoscopic procedures in the operation rooms) immediately and after 5 months. Forty surgical residents in their first 2 months of residency training were randomized to either structured training on box trainers, in addition to traditional training, or to traditional training alone. Groups were equivalent with regards to demographics, previous operative experience, and baseline skills. Structured training consisted of 4 sessions with 6 tasks on box trainers under supervision and self practice. Task-based objective structured practical examinations (OSPE) were completed before and after each task. At the end of the training, residents were assessed by a blinded faculty member with the global operative assessment of laparoscopic skills (GOALS) rating scale. Residents also completed a satisfaction questionnaire. Focus group discussions were conducted for both groups. The GOALS were repeated for both the groups at the end of 5 months to assess retention of skills. The mean GOALS score was significantly higher for the structured training group (mean/SD 20.35 + 0.74) compared with the traditional training group (mean/SD 16.35 + 1.75, p < 0.01) at the end of 5 months. The mean global rating scale (GRS) score was significantly higher (Pre 7.55 + 0.99 vs. Post 16.4 + 0.68, p < 0.01) for the structured training group at the end of course. Residents in the structured training group had significantly improved skills immediately after the training and had better retention of skills at the end of five months. Structured training on box trainers, in addition to traditional training, compared with traditional training alone, leads to better skills and improved confidence of residents. There is significant retention of skills at the end of 5 months. These results provide support for incorporation of structured training with box trainers for laparoscopic skills into surgical training programs.
Article
Purpose: The purpose of this study was to determine if the postgraduate level of resident in the operating room correlates with outcomes for pediatric patients undergoing laparoscopic appendectomy. Subjects and methods: The charts of all children who underwent laparoscopic appendectomy for appendicitis from 2007 to 2011 at a free-standing children's hospital were reviewed. Outcomes of interest were compared between patient groups based on postgraduate level of the junior-most surgeon in the operating room: (1) junior resident (postgraduate year [PGY]-1, -2, and -3); (2) senior resident (PGY-4 or -5); (3) fellow (PGY-6 or -7); or (4) attending surgeon only. Results: Junior resident (n=327), senior resident (n=129), fellow (n=246), and attending (n=73) groups were similar in terms of age (P=.69), gender distribution (P=.51), race (P=.08), and perforation status (P=.30). Operative time was shorter for senior residents (P=.002), fellows (P<.001), and attending surgeons operating without a resident (P<.001) compared with cases with junior residents. The rate of conversion to an open operation was similar among groups (P=.46). Resident level was not predictive of complications, which occurred in 26 junior resident cases (8.0%; referent), 17 senior resident cases (13.2%; odds ratio [OR] 1.73; P=.11), 33 fellow cases (13.4%; OR 1.71; P=.06), and 8 attending cases (11.0%; OR 1.62; P=.27). Fellow involvement was associated with an increased rate of postoperative percutaneous abscess drainage or re-operation for abscess or bowel obstruction (9.8%; OR 2.31; P=.020). Conclusions: Involvement of junior residents in pediatric laparoscopic appendectomy is associated with increased operative time but no higher rate of complications.
Article
Duration of surgery is a main cost factor of surgical training. The purpose of this analysis of operative times for laparoscopic cholecystectomies (LC) was to quantify the extra time and related costs in regards to the surgeons' experience in the operating room (OR). All LC performed between January 01, 2005 and December 31, 2008 in 46 hospitals reporting to the database of the Swiss Association for Quality Management in Surgery (AQC) were analyzed (n = 10,010). Four levels of seniority were specified: resident (R), junior consultant (JC), senior consultant (SC), and attending surgeon (AS). The differences in operative time according to seniority were investigated in a multivariable log-linear and median regression analysis controlling for possible confounders. The OR costs were calculated by using a full cost rate in a teaching hospital. A total of 9,208 LC were available for analysis; 802 had to be excluded due to missing data (n = 212) or secondary major operations (n = 590). Twenty-eight percent of the LC were performed by R as teaching operations (n = 2,591). Compared with R, the multivariable analysis of operative time showed a median difference of -2.5 min (-9.0; 4.8) for JC and -18 min (-25; -11) for SC and -28 min (-35; -10) for AS, respectively. The OR minute costs were 17.57, resulting in incremental costs of 492 (159; 615) per operation in case of tutorial assistance. The proportion of LC performed as tutorial assistance for R remains low. Surgical training in the OR causes relevant case-related extra time and therefore costs.
Article
The Accreditation Council for Graduate Medical Education (ACGME) modified the designation of major (index) operative cases to include those previously considered "minor." This study assessed the potential effect of these changes on resident operative experience. With Institutional Review Board approval, we analyzed National Surgical Quality Improvement Program participant use files for 2005-2008 for general and vascular surgery cases. Primary CPT case coding was mapped to the ACGME major case category using both the old and new classification schemes. The variables were analyzed using χ(2) analysis in SPSS IBM 19 (IBM, Armonk, New York). A total of 576,019 cases were reviewed. Major cases as defined by the new classification represented an increasing proportion of the cases each year, rising from 88.3% in 2005 to 95% by 2008 (p < 0.001). Major cases as defined by the old scheme decreased from 71% in 2005 to 62% by 2008 (p < 0.001). The cases covered by a resident dropped from 82% in 2005 to 61% in 2008 (p < 0.001). When comparing the new to the old scheme, 364,366 (63.3%) cases were considered major and 30,587 (5.3%) were minor by both standards; 7089 (1.2%) cases previously classified as major were changed to minor, whereas 173,977 (30.2%) (p < 0.001) previously classified as minor were now major. This latter group showed top procedures to include excision of breast lesion (22,175 [12.7%]), laparoscopic gastric bypass (18,825 [10.8%]), ventral hernia repair (14,732 [8.5%]), and appendectomy (10,190 [5.9%]). Of these newly designated major cases, the proportion not covered by residents increased from 22% in 2005 to 44% in 2007 and 2008 (p < 0.001). Although some operative cases newly classified as major are technically advanced procedures (eg, Roux-en-Y gastric bypass), other cases are not (eg, breast lesion excision), which raises the issue as to whether the major case category has been diluted by less demanding case types. The implications of these findings may suggest preservation of case volumes at the expense of case quality.
Article
Exposure to laparoscopic surgery during medical school has increased over recent years. The Fundamentals of Laparoscopic Surgery (FLS) simulator allows for objective assessment of laparoscopic skills. This study aimed to determine whether the fundamental laparoscopic skills of incoming surgery residents have improved. The initial FLS performance of first-year residents between 2003 and 2008 was identified from a prospective database. Linear regression was used to determine the effect of incoming year on performance of the five FLS simulator tasks (peg transfer, pattern cut, endoloop placement, suture with an extracorporeal knot [EC], suture with an intracorporeal knot [IC]) and the total score. Statistical significance was defined as a p value less than 0.05. A total of 63 first-year residents were identified from the database. The total FLS scores improved over time (r = 0.39; p = 0.001). The scores for peg transfer did not change significantly, but the scores for pattern cutting (r = 0.37; p = 0.002), endoloop placement (r = 0.36; p = 0.004), suture with EC (r = 0.32; p = 0.02), and suture with IC (r = 0.26; p = 0.03) all improved significantly over the 5 years. The baseline fundamental laparoscopic skills of incoming surgery residents appear to have improved over time. This may be due to increased clinical laparoscopic exposure and availability of laparoscopic simulation in medical school.
Article
The efficacy of laparoscopy simulators remains controversial. This was a comparative prospective study that evaluated the impact of simulator training on technical competence during a real surgical procedure. Residents were divided into 3 groups: the Mcgill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) group, training on a simple simulator; LAP Mentor group, training on a virtual simulator; and control group. An initial evaluation was made by a validated score during a laparoscopic cholecystectomy. Each resident was then trained for 1 month. A second evaluation was then performed. Before/after scores were significantly improved in the MISTELS (P = .042) and LAP Mentor (P = .026) groups. It was not the case in the control group. There was a better progression in the MISTELS (P = .026) and LAP Mentor (P = .007) groups than in the control group. There was no significant difference between the MISTELS and LAP Mentor groups. Simulator training provides a more rapid acquisition of competence in surgical technique.
Article
General surgery trainees' perceptions regarding their own laparoscopic training remain poorly defined. The objective of this survey was to identify and evaluate learner experiences with laparoscopic procedures in general surgery programs on a national level. Two hundred eighty-four residents were identified and contacted at English-speaking general surgery programs across Canada. Each was asked to complete a web- or paper-based survey regarding their demographics, experiences with basic and advanced minimally invasive surgery (MIS) procedures, and perceived barriers to training. Two hundred fifty-two of 284 (89%) surveyed residents responded. Eighty-seven percent of the residents had access to a skills lab that taught MIS techniques; however, standardized MIS curricula were implemented 53% of the time. Eighty percent of residents felt that skills lab training translated to improved performance in the OR. Although 90% of residents felt that they would be comfortable performing basic laparoscopic procedures, only 8% stated they would be comfortable performing advanced procedures at the end of their training. Moreover, 90% of general surgery residents felt that it was the academic surgical department's responsibility to teach both basic and advanced procedures, and 35% of respondents felt their surgical program was meeting this requirement. Half of the residents felt they had limited opportunity to be a primary surgeon because an MIS fellow was present. There exists a wide disparity between the expectations of residents and their actual experience. The majority of residents are concerned that they will not acquire sufficient laparoscopic skills during their training to perform advanced cases in practice. Additionally, the balance between resident and fellow-level cases needs to be more clearly defined as the majority of respondents identified the presence of a MIS fellow as a negative learning influence. Finally, although most centers had a surgical skills lab, 47% of respondents felt that the curriculum was not standardized and this also needs to be addressed.
Article
Virtual reality simulators contribute to basic laparoscopic skill acquisition. These trainers have not yet been shown to contribute to the acquisition of more advanced laparoscopic skills as measured by the Fundamentals of Laparoscopic Surgery (FLS). We have customized novel basic and advanced curricula for the LapSim trainer (Surgical Science, Göteborg, Sweden). Successful completion of these programs is required of our residents. We hypothesize that the successful completion of our advanced curriculum will result in the significant improvement of our residents' advanced laparoscopic skills as measured by the FLS skills scores. In all, 23 surgical residents (PGY 1-4), who had already passed our basic skills curriculum, completed our advanced LapSim curriculum. All individuals underwent FLS skills testing before and after completing the training. Laparoscopic case experience during the training period was documented for all trainees. FLS scores were analyzed by t test and controlled for case experience. Posttraining FLS scores demonstrate a significant increase for all residents from a mean of 57-66 (p < 0.02), especially for seniors (PGY 3-4): 56-68 (p < 0.01). The operative laparoscopic case volume ranged from 1-90 (mean, 30) for juniors (PGY 1-2) and 12-76 (mean 50) for seniors during the training period. Junior resident FLS improvement was dependent on case volume during the period of training; residents with less than 30 cases had a mean improvement of 0, whereas those with at least 30 cases had a 15 point improvement (p < 0.01). Senior resident FLS score improvement was independent of case numbers during the training period. Completion of our advanced LapSim curriculum results in improved advanced laparoscopic skills in senior residents as measured by FLS scores. This skill improvement is independent of laparoscopic case experience. Continuing to mandate the use of this skills curriculum should improve our residents' performance in advanced laparoscopic surgical procedures.
Article
The purpose of this study was to evaluate the impact of laparoscopy on the volume of open cases in general surgery residency training over the past 10 years. The Accreditation Council for Graduate Medical Education (ACGME) database (1999-2008), which records all cases (by Current Procedural Terminology code) performed by graduating general surgery trainees, was retrospectively analyzed. ACGME database (1999-2008). Trends were compared regarding the average number of the most common laparoscopic and open procedures (colectomy, hernia, and appendectomy) performed by graduating general surgery trainees during the reporting period. Across all procedures, an increase was noted in laparoscopic approaches with a reciprocal decrease in open cases. The number of open appendectomies decreased by 29% (30.7 to 21.7), whereas the number of laparoscopic appendectomies increased by 278% (8.5 to 32.1). Similarly, open inguinal hernia cases decreased by 12.5% (51.9 to 45.4) and open colectomy cases decreased by 10.4% (48 to 43). Conversely, laparoscopic hernia repair and laparoscopic colectomy increased by 87.5% (7.6 to 15.8) and 550% (2 to 13), respectively. In addition to the limitations placed on residency training by other factors (including work hour restrictions), changing practice patterns within the field of general surgery have a significant impact on the exposure of residents to open surgery cases. This trend might have far-reaching implications with regard to the overall competency of graduating residents and raises concerns for the future direction of surgical education.
Article
With the advent of laparoscopy, many traditional junior-level cases now require advanced laparoscopic skill. We sought to ascertain the implications of laparoscopy on residency training through the use of a large national database. American College of Surgeons National Surgical Quality Improvement Program data were gathered for patients undergoing elective open and laparoscopic inguinal herniorrhaphy, appendectomy, and partial colectomy during 2005 and 2006. Cases were stratified by resident level and compared using univariate analysis. A total of 14,729 cases were performed during the study period. For inguinal hernia repair, 72% of open repairs were performed by postgraduate year 3 residents or below versus 41% of laparoscopic repairs (P < .0001). Similarly, 61% of open appendectomies were performed by postgraduate year 3 residents or below compared with 48% of laparoscopic appendectomies (P < .0001). Forty-six percent of open colectomies were performed by postgraduate year 3 and postgraduate year 4 residents versus 33% of laparoscopic resections (P < .0001). These data show an upward shift in cases traditionally performed by junior-level residents. The implications of this shift are unknown but may lead to decreased surgical experience during the early years of training.
Article
The purpose of this study was to determine the impact of laparoscopic cholecystectomy (LC) on resident training. We reviewed our experience over an 11-year period, from academic years 1982 to 1992, with 3,046 patients who underwent elective open cholecystectomy (OC) and 640 patients who underwent LC. Prior to LC, junior residents performed 80% of all cholecystectomies, with a morbidity and mortality rate of 4% and 0.04%, respectively, compared with 11% and 0.3%, respectively, for senior residents who operated on higher-risk patients. Since the introduction of the technique, there has been a 25% increase in cholecystectomies per year, and a reduction in junior resident OC experience by 67%. Currently, 72% of all cholecystectomies are performed laparoscopically by senior residents. The replacement of OC by LC has produced a qualitative change in the operative experience of our junior residents and a delay in acquisition of operative skills. The reduction in OC experience by residents may jeopardize their ability to perform the difficult open cases.
Article
Laparoscopic cholecystectomy (LC) has replaced open cholecystectomy (OC) as the most common operation for gallbladder disease. Our goal was to determine the effect of this phenomenon on resident training in biliary surgery. The numbers of all cholecystectomies (ACs), OCs, LCs, and advanced procedures (common bile duct exploration and choledochoscopy, (CBDE) performed by residents during academic years 1989 to 1994 were examined. Trends for the residency as a whole and for each cohort of residents completing the program were studied. The number of LCs performed by the residency as a whole per academic year over the 1989 to 1994 period has increased, whereas the number of OCs decreased. The net effect of these trends was an increase in the number of ACs. Although the percentage of LCs performed by postgraduate year 1, 2, and 3 residents (juniors) increased over the study period, the proportion of OCs and ACs performed by this group decreased. For each cohort of residents completing training in the years 1989 through 1994, the number of ACs and LCs performed increased, whereas the number of OCs decreased. Experience in CBDE for the residency as a whole and for the cohort was stable. In conclusion, experience in ACs and LCs has increased, and experience in OCs has decreased. Also, experience in biliary surgery has shifted to the senior level.
Article
Patient preference has driven the adoption of minimally invasive surgery (MIS) techniques and altered surgical practice. MIS training in surgical residency programs must teach new skill sets with steep learning curves to enable residents to master key procedures. Because no nationally recognized MIS curriculum exists, this study asked experts in MIS which laparoscopic procedures should be taught and how many cases are required for competency. Expert recommendations were compared to the number of cases actually performed by residents (Residency Review Committee [RRC] data). A detailed survey was sent nationwide to all surgical residency programs (academic and private) known to offer training in MIS and/or have a leader in the field. The response rate was approximately 52%. RRC data were obtained from the resident statistics summary report for 1998-1999. Experts identified core procedures for MIS training and consistently voiced the opinion that to become competent, residents need to perform these procedures many more times than the RRC data indicate they currently do. At present, American surgical residency programs do not meet the suggested MIS case range or volume required for competency. Residency programs need to be restructured to incorporate sufficient exposure to core MIS procedures. More expert faculty must be recruited to train residents to meet the increasing demand for laparoscopy.
Article
Although laparoscopic surgery has become widespread during the past decade, no systematic study of the training needs exists. To obtain guidance for planning, we analyzed the national resident operative experience during the past 8 years. The laparoscopic experiences of all surgical residents graduating between 1994 and 2001 were subjected to regression analysis. The laparoscopic volume of each trainee and change in ratio of laparoscopic/open operation over time were used to estimate the growth of individual laparoscopic operations in training programs. Laparoscopic surgery constituted only 5.7% of a trainee's total surgical experience in 1994, but comprised 13% by 2001. A resident completing training in 1994 performed 53 laparoscopic operations, of which 79% (42) were cholecystectomies. By 2001, a graduate performed 126 laparoscopic operations, of which 68% (86) were cholecystectomies. During the interim, most laparoscopic operations exhibited growth. Trainee experience in some newer operations has also increased steadily but at a much slower rate. This descriptive statistical survey of training experience yields a comprehensive picture of the laparoscopic capability of the young surgeon. The growth potential of some newer operations has also been measured. Using these data, guidelines can be drawn as to which operation programs should focus resources on training residents. Since competence depends on exposure, residency training alone may not provide sufficient depth to allow recent graduates to perform the newer operations independently.
Article
The field of postgraduate minimally invasive surgery/gastrointestinal surgery (MIS/GIS) training has undergone substantial growth and change. To determine whether fellowships are meeting a strategic need in training, we conducted a survey to assess the current status and trends of change in MIS/GIS fellowships. A survey was distributed to fellows currently in MIS/GIS programs in the United States and Canada in 2003 and 2006. Fellows were asked to describe demographics as well as their experience both during fellowship and residency. We compared this with aggregate data of resident experience through the Accreditation Council for Graduate Medical Education (ACGME) case logs, data tracked by industry, and program data from the Fellowship Council (FC) web site. There were 54 responses to the 75 surveys distributed in 2006 (72% response rate). MIS fellows performed more laparoscopic cases during their residency than the average graduating chief resident, but did not feel competent to perform advanced laparoscopic surgery. However, combining fellowship numbers with residency numbers does suggest that the total experience provides competency in a wide variety of procedures. It seems that the MIS/GIS Fellowship is meeting a real need among graduating surgical residents; fellows felt unprepared for clinical practice at the completion of residency. It is encouraging to note the improvements in fellowship structure, standards, and overall experience, brought by the efforts of the FC. It is hoped that this report of the state of MIS fellowship with a comprehensive review of current data will aid in further evaluation and improvement.
Article
As laparoscopy continues to permeate general surgery, there is an increased need for residents to acquire advanced laparoscopic skills during a surgical training program. To underscore its importance, the Accreditation Council of Graduate Medical Education (ACGME) recently increased the requirements for laparoscopy from 34 to 60 basic cases and from 0 to 25 advanced cases. With this in mind, the purpose of this study is to assess the impact of an organized minimally invasive surgical service on the volume of advanced laparoscopic cases of a general surgery residency program. In July 2005 an independent minimally invasive surgical service, consisting of a fellowship-trained laparoscopic surgeon and 3 general surgery residents was instituted in an otherwise stable academic general surgery residency program. A retrospective review of the general resident's operative database was performed from 2001 to 2006 to assess the impact of this service on the volume of advanced laparoscopic cases of graduating chief residents. In the 4 years before the initiation of the minimally invasive service, the operative volume remained flat despite a stable training program and steady population growth. In the year after the formation of the dedicated service, the mean number of advanced cases performed by the graduating chief residents more than doubled, from 17.7 cases in each of the 2 years before, to 35.6 cases, fulfilling the ACGME requirements. The number of advanced laparoscopic cases per resident in this otherwise stable general surgery residency program substantially increased with the incorporation of a dedicated minimally invasive service led by a fellowship-trained laparoscopic surgeon. These data suggest that the volume increases needed to satisfy ACGME requirements may only be possible by creation of such a training experience dedicated to advanced laparoscopy.