Outcomes Following Cholecystectomy on a Service Designed to Maximize Chief Resident Entrustment

Comparison of Surgical Outcomes of Emergent Laparoscopic Cholecystectomy for Acute Cholecystitis Between Attending Surgeons and Residents: A Retrospective Study in Single Medical Center

Background: With improvements in skills and evidence of safety, emergent laparoscopic cholecystectomy is routinely performed for acute cholecystitis, if indicated, at our hospital. However, resident operations are concerned with the dilemmas of training programs and patient safety. Hence, our aim was to clarify the safety and feasibility of emergency laparoscopic cholecystectomy performed by attending surgeons and residents. Materials and Methods: Our study was a retrospective review of 923 patients, who underwent laparoscopic cholecystectomy between January 2021 and June 2022 at our hospital. We excluded combined surgery, single-port methods, laparoscopic common bile duct exploration, elective surgery, and patients with Mirizzi symptoms. Of the 191 patients who underwent emergency laparoscopic cholecystectomy, 118 were operated on by residents, and 73 were operated on by attending surgeons. Patient demographics, surgical and postoperative outcomes, and length of hospital stay were compared between the groups. Results: No significant differences were observed in sex, age, body mass index (BMI), or surgical history. Older age (60 versus 52 years) and higher BMI (26.29 versus 25.46) were observed in the attending group, and the severity was greater than that in the resident group. No significant differences were observed in the operative results, including mortality (both groups, n = 0), morbidity, blood loss, or length of stay. However, the operation time was significantly shorter in the attending group obviously (86.41 versus 117.89 minutes, P < .0001) significantly. Conclusion: Emergent laparoscopic cholecystectomy for acute cholecystectomy performed by a resident under supervision appears feasible and safe. The resident operator was associated with increased operative times, however, not complications. This study confirms that residents can also finish surgery in precisely selected cases, and the more important concept is knowing the limits of asking for help.

Inguinal Hernia Repairs on the Chief's Service: A Safe Educational Model in Resident Entrustment

OBJECTIVE

We hypothesized that a Chief Resident Service educational model provides safe care for patients compared to that received on standard academic services where rotating residents adopt the practices and preferences of their attending.

DESIGN

We retrospectively identified patients undergoing inguinal hernia repairs from July 2016 through June 2019 and matched Chief's service patients to standard academic service patients 1:1 on CPT, sex and age. We compared patient characteristics, recurrence rates, outcomes and complications.

SETTING

Tertiary care center, single institution.

PARTICIPANTS

Overall, 77 patients undergoing inguinal hernia repairs (66% open and 34% laparoscopic) on the Chief's service matched successfully to 77 standard academic service patients during the study period.

RESULTS

Age, BMI and ASA were similar between the services, but Chief's service patients were less likely to be current smokers (1.3% vs. 24.7%) and more likely to be former smokers (59.7% vs. 26.0%) than standard academic service patients (p < 0.01). Patients presenting with incarcerated hernias (5.2% vs. 9.1%), recurrent (10.4% vs. 5.2%) and bilateral hernias (19.5% vs. 10.4%) were similar between the Chief's service and standard academic services, respectively (all p > 0.05). Operative times were longer for the Chief's service for open (123 min vs. 67, p < 0.01) and laparoscopic (112 min vs. 79, p = 0.02) repairs. Recurrence rates (6.5% vs. 3.9%, p = 0.47) and complications including infection, seroma or hematoma requiring evacuation and need for reoperation were similarly low (p > 0.05) between the Chief's and standard academic services, respectively. Despite low complication rates, Chief's service patients were more likely to present to the ED post-op (14.3% vs. 1.3%; p = 0.001), but readmission rates were similarly low (2.6% vs. 0%, p = 0.09).

CONCLUSIONS

Providing general surgery chief residents with a supervised opportunity to direct, plan and provide surgical care in clinic and the operating room, as a transition to independent practice following graduation, is safe for patients presenting with inguinal hernias. Concerns about patient safety should not be a barrier to maximizing entrustment for the evaluation and operative management of select core general surgery diagnoses and operations.