Resident Operative Experience in Hepatopancreatobiliary Surgery: Exposing the Divide

Hepato-pancreato-biliary and transplant surgery experience among New Zealand general surgery trainees

BACKGROUND

Subspecialty surgery experience during general surgery training in Australasia is influenced by many factors, including duration of training, training location and the introduction of post-fellowship training programmes. Experience in hepato-pancreato-biliary (HPB) and transplant surgery is part of the general surgery curriculum, although trainee experience in these subspecialties has not been quantified in this region, which is relevant to post-fellowship training programmes. Therefore, the aim of this study was to quantify the HPB and transplant operative experience of New Zealand (NZ) general surgery trainees.

METHODS

Operative logbook data were analysed for all NZ trainees from 2013 to 2017, including procedures categorized as pancreatic, biliary, hepatic and transplant surgery only. The number of cases within each category was used to model the cumulative operative experience over a 5-year training programme.

RESULTS

During the study period, 118 trainees (303 trainee years) recorded 15 662 HPB and transplant procedures. Of these, 13 838 (88.4%) were cholecystectomies (mean cumulative experience 219.3 cases). Excluding cholecystectomy, trainees had a mean cumulative experience of 5.7 biliary, 7.5 pancreatic, 8.1 liver and 4.2 transplant procedures during their training. Transplant experience was predominantly access for peritoneal dialysis (228/260, 86.7%), with cumulative transplant experience otherwise reaching 0.47 procedures over 5 years.

CONCLUSION

Exposure to HPB and transplant surgery during general surgery training in NZ is limited beyond cholecystectomy. Additional exposure during post-fellowship training is likely required for general surgeons to practice in these subspecialties.

Longitudinal Survey of Trainee Case Log Entry for Carotid Endarterectomy: Trends in Neurologic, General, and Vascular Surgery

BACKGROUND

Multiple surgical specialties perform carotid endarterectomy (CEA). As indications for CEA narrows, neurosurgery residents are less exposed to this procedure. This study aims to determine trends in CEA training among graduating trainees in neurosurgery and compare these to general and vascular surgery.

METHODS

ACGME case log reports were retrospectively reviewed from 2013 to 2019 for neurologic, general, and vascular surgery residencies and vascular surgery fellowship. These annual reports contain the mean number of logged cases for graduating trainees and their level of participation. We analyzed trends in logged cases over the study period and compared mean number of logged cases between specialties and their respective required minimum numbers.

RESULTS

Neurosurgery residents (13.5 ± 0.76) performed significantly more CEAs than their counterparts in general surgery (9.4 ± 0.34, P < 0.01) but less in integrated vascular surgery (57.7 ± 0.88) and vascular surgery fellowship (47.9 ± 0.79, both P < 0.001). The only statistically significant change over the study period was a decline in mean number of cases logged by general surgery residents at -0.4 cases/year (P < 0.001). Trainees in all specialties reported around twice as many cases as the respective Accreditation Council for Graduate Medical Education required minimum numbers. Neurosurgery residents demonstrated increasing participation as lead surgeons by 0.7 cases/year (P = 0.04) and a concurrent decline as senior surgeons by 1.4 cases/year (P < 0.01).

CONCLUSIONS

Neurosurgery residents exceeded their minimum requirements for CEA, with increasing trend in higher level of participation. But neurosurgery residents' exposure to this procedure was far less significant than their colleagues in vascular surgery, a gap that may widen over time and should be addressed proactively.

Fluorescence cholangiography enhances surgical residents’ biliary delineation skill for laparoscopic cholecystectomies

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.