Unsupervised laparoscopic appendicectomy by surgical trainees is safe and time-effective

Does the Experience Level of Surgeons and Assistants Influence the Rate of Complications Following Appendicectomy?

Background Appendicectomies are the most frequently performed acute general surgery. The risk of complications depends on several factors, including patient age, American Society of Anesthesiologists (ASA), duration of symptoms, serum inflammatory markers, and the grade of inflammation. Prior research failed to demonstrate a relationship between the rate of complications and the surgeon's level of experience. It is unclear if the assistant's level of experience influences complication rates. Methods We conducted a retrospective cohort study to investigate the relationship between the surgeon's and assistant's position and the rate of complications following appendicectomy. We also explored whether more experienced staff were involved in higher-risk cases and their relationship with resource utilization. Results There was no significant difference in total complication rates based on the surgeon's and assistant's position (p = 0.48 and p = 0.99, respectively). Post-operative bleeding was the only complication that correlated with the assistant's level of experience (p = 0.002). More experienced surgeons performed faster appendicectomies (p =0.002), while the assistant's position had no influence (p = 0.47). There was no statistically significant relationship between the surgeon's and assistant's position, and post-operative length of admission, or risk factors for complications as measured by age, days of abdominal pain, white blood cell count (WCC), C-reactive protein (CRP), ASA, radiographic and intra-operative American Association for the Surgery of Trauma (AAST). Conclusion Experienced surgeons performed faster appendicectomies. There was a trend toward higher rates of post-operative bleeding with less experienced assistants. Otherwise, there was no relationship between the surgeon's experience level and post-appendicectomy complication rates, length of post-operative stay, or patient risk factors for complications.

How does the number of training years in pediatric surgery affect appendectomy outcomes?

INTRODUCTION

Appendectomy has traditionally been considered as a training operation for junior pediatric surgeons during their training period. However, with the increase of laparoscopic appendectomy, there has been a growing concern about the performance of this procedure by junior trainees. Our aim is to analyze intra-/postoperative appendectomy outcomes according to the number of training years during Pediatric Surgical residency training program.

METHODS

A retrospective study was performed in patients who underwent appendectomy between 2018 and 2021 in our institution, who were divided into 5 groups according to the number of training years of the junior surgeon who performed the intervention (Y1-Y5). Demographics, complicated appendicitis rate, operation time, and postoperative complications were compared. A stratified analysis according to the technique performed (open/laparoscopic) was performed.

RESULTS

A total of 1274 appendectomized patients were analyzed, of which 1257 (98.7%) were operated on by junior trainees (81 in Y1; 407 in Y2; 337 in Y3; 261 in Y4; and 171 in Y5) without demographic differences between groups. As the year of training increased, an elevation in complicated appendicitis rate was observed, although without statistically significant differences. However, laparoscopic/open appendectomies ratio increased with increasing year of training (p < 0.001). Operative time decreased significantly with increasing year of training (p < 0.001), both in open and laparoscopic appendectomies. There were no significant differences in postoperative complications, nor in the stratified analysis according to surgical technique.

CONCLUSION

Appendectomy performed by junior pediatric surgery trainees can be considered a safe procedure from the first year of training, regardless of the technique used.

Systematic review and meta-analysis comparing perioperative outcomes of emergency appendectomy performed by trainee vs trained surgeon

BACKGROUND

Appendectomy is a benchmark operation for trainee progression, but this should be weighed against patient safety and perioperative outcomes.

METHODS

Systematic literature review and meta-analysis comparing outcomes of appendectomy performed by trainees versus trained surgeons.

RESULTS

Of 2086 articles screened, 29 studies reporting on 135,358 participants were analyzed. There was no difference in mortality (Odds ratio [OR] 1.08, P = 0.830), overall complications (OR 0.93, P = 0.51), or major complications (OR 0.56, P = 0.16). There was no difference in conversion from laparoscopic to open surgery (OR 0.81, P = 0.12) and in intraoperative blood loss (Mean Difference [MD] 5.58 mL, P = 0.25). Trainees had longer operating time (MD 7.61 min, P < 0.0001). Appendectomy by trainees resulted in shorter duration of hospital stay (MD 0.16 days, P = 0.005) and decreased reoperation rate (OR 0.78, P = 0.05).

CONCLUSIONS

Appendectomy performed by trainees does not compromise patient safety. Due to statistical heterogeneity, further randomized controlled trials, with standardized reported outcomes, are required.

Laparoscopic appendectomy as an index procedure for surgical trainees: clinical outcomes and learning curve

Surgical training is essential to maintain safety standards in healthcare. The aim of this study is to evaluate learning curves and short-term postoperative outcomes of laparoscopic appendectomy (LA) performed by trainees (TRN) and attendings (ATT). The present study included the medical records of patients with acute appendicitis who underwent a fully LA in our department between January 2013 and December 2018. Cases were divided into trainees (TRN and ATT groups based on the experience of the operating surgeon. The primary outcome measures were 30-day morbidity and mortality. Preoperative patients' clinical characteristics, intraoperative findings, operative times, and postoperative hospitalization were compared. Operative times were used to extrapolate learning curves and evaluate the effects of changes in faculty using CUSUM charts. A propensity score matching analysis was performed to reduce differences between cohorts regarding both preoperative characteristics and intraoperative findings. A total of 1173 patients undergoing LA for acute appendicitis were included, of whom 521 (45%) in the TRN group and 652 (55%) in the ATT group. No significant differences were found between the two groups in terms of complication rates, operative times and length of hospital stay. However, CUSUM chart analysis showed decreased operating times in the TRN group. Operative times improved more quickly for advanced cases. The results of this study indicate that LA can be performed by trainees without detrimental effects on clinical outcomes, procedural safety, and operative times. However, the learning curve is longer than previously acknowledged.

Safety assessment of open appendectomies for complicated acute appendicitis in children: a comparison of trainees and specialists

PURPOSE

The aim of this study was to compare the outcome of children with complicated acute appendicitis (CAA) who underwent open appendectomy (OA) performed either by trainees under the direct supervision of an SPS, or an SPS.

METHODS

Two hundred thirty eight patients with CAA were reviewed operated on either by a junior trainee (JT) or a senior trainee (ST) under the direct supervision of an SPS or by an SPS. The outcome measures were the overall rate of complications, operative time (OT), length of hospital stay (LHS) and 30-day readmission rate.

RESULTS

No statistical differences were observed between the three groups regarding the overall complication rates and 30-day readmission rate. Although, no statistical differences were observed in the mean OT between the three groups, the mean OT for perforated appendicitis (PA) performed by JTs was significantly longer than when performed by SPSs (p 0.012). Furthermore, there was a statistically significant difference between JTs and SPSs in terms of LHS for patients with PA (p 0.028).

CONCLUSION

This study suggests that no statistical differences were observed between the supervised trainees and SPSs regarding the overall complication rate and 30-readmission rate when they performed OA for GA or PA except of a longer OT and LHS for PA performed by JTs.

Montgomery in, Bolam out: are trainee surgeons 'material risks' when taking consent for cataract surgery?

Trainee involvement in cataract surgery is vital to allow proper training of the next generation of ophthalmic surgeons. However, recent changes in the UK Law, coupled with open publication of National Cataract Dataset results, lead us to conclude that the status of being a trainee is itself a material risk that now needs to be divulged to patients during the consent process. The opinions of current trainee surgeons in the UK were sampled via questionnaire and clinical negligence counsel was involved in the authorship of the paper in order to analyse the legal issues at stake. Attitudes towards consent regarding trainee involvement in UK cataract surgery need to change.

Does time of surgery influence the rate of false-negative appendectomies? A retrospective observational study of 274 patients

Background

Multiple disciplines have described an “after-hours effect” relating to worsened mortality and morbidity outside regular working hours. This retrospective observational study aimed to evaluate whether diagnostic accuracy of a common surgical condition worsened after regular hours.

Methods

Electronic operative records for all non-infant patients (age > 4 years) operated on at a single centre for presumed acute appendicitis were retrospectively reviewed over a 56-month period (06/17/2012–02/01/2017). The primary outcome measure of unknown diagnosis was compared between those performed in regular hours (08:00–17:00) or off hours (17:01–07:59). Pre-clinical biochemistry and pre-morbid status were recorded to determine case heterogeneity between the two groups, along with secondary outcomes of length of stay and complication rate.

Results

Out of 289 procedures, 274 cases were deemed eligible for inclusion. Of the 133 performed in regular hours, 79% were appendicitis, compared to 74% of the 141 procedures performed off hours. The percentage of patients with an unknown diagnosis was 6% in regular hours compared to 15% off hours (RR 2.48; 95% CI 1.14–5.39). This was accompanied by increased numbers of registrars (residents in training) leading procedures off hours (37% compared to 24% in regular hours). Pre-morbid status, biochemistry, length of stay and post-operative complication rate showed no significant difference.

Conclusions

This retrospective study suggests that the rate of unknown diagnoses for acute appendicitis increases overnight, potentially reflecting increased numbers of unnecessary procedures being performed off hours due to poorer diagnostic accuracy. Reduced levels of staffing, availability of diagnostic modalities and changes to workforce training may explain this, but further prospective work is required. Potential solutions may include protocolizing the management of common acute surgical conditions and making more use of non-resident on call senior colleagues.

Securing the Appendiceal Stump During Emergency Appendicectomy: Options and Influencing Factors in Current UK Surgical Practice

INTRODUCTION

The aim of our study was to identify the most commonly employed methods and influencing factors for securing the appendiceal stump in current NHS practice.

METHODS

An electronic survey of the Scottish Surgical Research Group network, invitation extended to the UK National Research Collaborative.

RESULTS

A total of 111 responses were received from 32 surgical centers; 28 (25.2%) consultants, 66 (59.5%) specialty trainees and 12 (10.8%) core trainees. Endoscopic ligatures were the preferred method in 96 (86.5%) with no difference in those with the greatest operative experience (P=0.79), 12 (10.8%) preferred polymeric clips. Ease of application (70.3%) and severity of stump inflammation (65.8%) had the greatest influence on the method chosen. Cost was a factor in 36.0%.

CONCLUSIONS

The preferred method for securing the appendiceal stump in UK practice is endoscopic ligatures regardless of operative experience. Factors with the greatest influence on the method employed include the ease of application and severity of stump inflammation. Our findings are likely to be representative of current NHS practice in Scotland.

Safety and feasibility of single-port laparoscopic appendectomy as a training procedure for surgical residents

Background:

Single-port laparoscopic appendectomy (SPLA) is one of the most commonly performed single-port surgeries worldwide. This study aimed to determine whether the performance of SPLA by residents without sufficient experience as operators of conventional LA (CLA) is safe and feasible.

Patients and Methods:

Records of patients who underwent LA between March 2017 and February 2018 at a hospital in Korea were retrospectively analysed. Patients aged <18 years or >80 years were excluded from the study. SPLA and CLA were performed by two 2^nd-year residents (junior group) and three 3^rd-year residents (senior group). Demographic data, perioperative variables and surgical outcomes were compared.

Results:

During the study period, 154 patients underwent LA (104 SPLA and 50 CLA) performed by surgical residents. No differences were found between the SPLA and CLA groups in demographic data or perioperative variables, except for the drain insertion rate. The SPLA group had significantly shorter mean operation times than did the CLA group. No significant difference was observed between the junior and senior groups in the mean operation time for LA. Perioperative outcomes were not significantly different between groups. Fewer women underwent SPLA performed by 2^nd-year residents compared with SPLA performed by 3^rd-year residents. However, there were no differences in other general characteristics or perioperative outcomes.

Conclusions:

SPLA was safe and feasible when performed by junior residents. Surgical residents with sufficient experience as assistants during laparoscopic appendectomies could perform SPLA safely. Furthermore, SPLA could serve as a teaching procedure for surgical residents.

Comparison of Appendectomy Outcomes Between Senior General Surgeons and General Surgery Residents

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.

Safety assessment of resident grade and supervision level during emergency appendectomy: analysis of a multicenter, prospective study

BACKGROUND

Resident surgeons have been identified as a risk factor for worse outcome after appendectomy. The context of grade of resident and impact of supervision require further investigation. The objective of this study was to determine whether grade and supervision level of resident-performed appendectomy affects patient outcome.

METHODS

A multicenter, prospective cohort study was performed for consecutive patients undergoing appendectomy during May and June 2013. The primary endpoint for this analysis was the 30-day adverse event rate. Supervision was defined as resident-performed appendectomy with an attending scrubbed. Multivariable binary logistic regression was used to take into account case mix and produce adjusted odds ratios (OR).

RESULTS

From 2,867 appendectomies, 87% were performed by residents, and 72% were performed unsupervised. Residents operated on significantly younger patients with lower American Society of Anesthesiologists scores. Although wound infection rates were similar between attendings, and senior and junior residents (4.1%, 3.8%, 3.4% respectively; P = .486), pelvic abscess rate was greater for attendings (5.2%, 2.7%, 2.4%; P = .045). In adjusted models, supervised senior, supervised junior, and unsupervised junior residents showed no difference in 30-day adverse event rates compared with attendings (OR, 1.07 [P = .834], 0.93 [P = .773], and 0.83 [P = .264] respectively); unsupervised senior residents had a lesser rate of adverse events (OR, 0.71; P = .045). All resident groups showed no difference for rates of histopathologically normal appendectomy compared with attendings.

CONCLUSION

Resident-performed appendectomy does not worsen patient outcomes. These findings support independent resident operating rights for selected cases. The system relies on mutual credentialing of competency between residents and supervising attendings.

Causes and costs of a decade of litigation following emergency appendectomy in England

BACKGROUND

There has been recent interest in the delayed and nonoperative management of appendicitis. The present study assessed the causes and costs of litigation against surgeons following emergency appendectomy, with an emphasis on claims relating to preoperative management.

MATERIALS AND METHODS

Data were obtained from the English NHS Litigation Authority for claims relevant to appendectomy between 2002 and 2011. Two authors independently extracted data and classified it against predetermined criteria.

RESULTS

Successful litigation occurred in 66 % of closed cases (147/223) with a total payout of £8.1 million. There were 24 claims against organizational operating room delays (9 % of total) and 27 against delayed diagnosis (10 %), with respective success rates of 70 and 68 %. From 21 claims relating to damage to fertility, nine were due to either delayed diagnosis or organizational operating room delays. Misdiagnosis was the second most common cause for litigation (16 %), but it had the lowest likelihood of success (49 %). Faulty surgical technique was the most common reason for litigation (39 %), with a 70 % likelihood of success. Of eight claims related to fatality, one was due to unacceptable preoperative delay leading to preventable perforated appendicitis. The overall highest median payouts were for claims of damage to fertility (£52,384), operating list delays (£44,716), and delayed diagnosis (£42,292).

CONCLUSIONS

There were significant medicolegal risks surrounding delays related to access to operating lists and diagnosis. Whereas future evidence regarding the safety of delayed appendectomy may provide scientific defense against these claims, the present study provides evidence of the current medicolegal risk to surgeons following delayed treatment of appendicitis.

Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES)

BACKGROUND

In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases.

METHODS

Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011.

RESULTS

A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer).

CONCLUSIONS

Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.

Appendectomy by residents is safe and not associated with a higher incidence of complications: a retrospective cohort study

OBJECTIVE

The purpose of this retrospective cohort study was to investigate whether current practice where residents perform appendectomies affects quality of care. Therefore, we investigated whether there was a difference in incidence of complications and mortality in appendectomies performed by surgeons (S), supervised residents (SR), or unsupervised residents (UR).

BACKGROUND

Appendicitis is among the most frequent conditions requiring urgent surgery. Admittance and surgery are often managed by residents. Recent studies have shown that laparoscopic appendectomy can be safely performed by residents. It is not known whether these results are applicable on appendectomies in general.

METHODS

All patients undergoing appendectomy in our hospital between January 1, 2000, and December 31, 2009, were included in the analysis. Patients undergoing appendectomy by surgeons, supervised residents, and unsupervised residents were compared. Primary endpoints were complications and mortality.

RESULTS

During the study period, 1538 patients were operated. The risk of complications (S: 20% vs SR: 17% vs UR: 16%; P = 0.209, S vs SR; P = 0.149, S vs UR; and P = 0.872, SR vs UR) and mortality (S: 0.3% vs SR: 0.2% vs UR: 0.4%, P = 1.000 for all comparisons) were similar in all groups. In the multivariate model, the odds ratio for complications in the group operated by supervised residents was 0.84 (95% CI: 0.58-1.22, P = 0.357) versus 0.81 (95% CI: 0.55-1.18, P = 0.265) in the unsupervised residents' group.

CONCLUSIONS

Current practice where residents perform appendectomies either unsupervised or supervised by an experienced surgeon should not be discouraged. We found that it is safe and does not lead to more complications or negatively affect quality of care.

A systematic review of the effects of residency training on patient outcomes

BACKGROUND

Residents are vital to the clinical workforce of today and tomorrow. Although in training to become specialists, they also provide much of the daily patient care. Residency training aims to prepare residents to provide a high quality of care. It is essential to assess the patient outcome aspects of residency training, to evaluate the effect or impact of global investments made in training programs. Therefore, we conducted a systematic review to evaluate the effects of relevant aspects of residency training on patient outcomes.

METHODS

The literature was searched from December 2004 to February 2011 using MEDLINE, Cochrane, Embase and the Education Resources Information Center databases with terms related to residency training and (post) graduate medical education and patient outcomes, including mortality, morbidity, complications, length of stay and patient satisfaction. Included studies evaluated the impact of residency training on patient outcomes.

RESULTS

Ninety-seven articles were included from 182 full-text articles of the initial 2,001 hits. All studies were of average or good quality and the majority had an observational study design. Ninety-six studies provided insight into the effect of 'the level of experience of residents' on patient outcomes during residency training. Within these studies, the start of the academic year was not without risk (five out of 19 studies), but individual progression of residents (seven studies) as well as progression through residency training (nine out of 10 studies) had a positive effect on patient outcomes. Compared with faculty, residents' care resulted mostly in similar patient outcomes when dedicated supervision and additional operation time were arranged for (34 out of 43 studies). After new, modified or improved training programs, patient outcomes remained unchanged or improved (16 out of 17 studies). Only one study focused on physicians' prior training site when assessing the quality of patient care. In this study, training programs were ranked by complication rates of their graduates, thus linking patient outcomes back to where physicians were trained.

CONCLUSIONS

The majority of studies included in this systematic review drew attention to the fact that patient care appears safe and of equal quality when delivered by residents. A minority of results pointed to some negative patient outcomes from the involvement of residents. Adequate supervision, room for extra operation time, and evaluation of and attention to the individual competence of residents throughout residency training could positively serve patient outcomes. Limited evidence is available on the effect of residency training on later practice. Both qualitative and quantitative research designs are needed to clarify which aspects of residency training best prepare doctors to deliver high quality care.

Surgical trainee participation during infrainguinal bypass grafting procedures is associated with increased early postoperative graft failure

OBJECTIVE

This study was conducted to determine the potential effect of surgical trainee participation during infrainguinal bypass procedures on postoperative graft patency rates.

METHODS

Data from the National Surgical Quality Improvement Program (NSQIP) Participant User Files from 2005 through 2009 were retrospectively reviewed, using propensity score matching, to identify all patients undergoing infrainguinal bypass grafting procedures, excluding those who had prior operation ≤30 days of the index procedure. A separate analysis was performed on a subset of procedures from the entire NSQIP sample that was matched on propensity for intraoperative surgical trainee participation. The primary predictor variable was intraoperative surgical trainee participation. The main outcome measure was the 30-day postoperative graft failure rate.

RESULTS

For the entire sample of 14,723 NSQIP patients undergoing infrainguinal bypass grafting, 30-day graft failure rates were significantly higher when a surgical trainee participated (5.8%) vs without participation (3.9%; P < .0001). For the cohort of 9234 patients matched on their propensity for intraoperative trainee participation, this difference in graft failure rate remained significant (5.0% with participation vs 4.0% without participation; P = .02).

CONCLUSIONS

Surgical trainee participation is an independent risk factor for technical failure after infrainguinal bypass grafting. Prospective evaluation is needed to determine the cause of this increase in graft failure rates for procedures that involve surgical trainees.

Laparoscopic appendectomy by residents: evaluating outcomes and learning curve

BACKGROUND

Laparoscopic appendectomy is being performed increasingly, worldwide. To the resident, it provides a valuable opportunity to master basic laparoscopic skills. Studies have shown that laparoscopic appendectomy performed by residents is safe. However, to date, there is no clear evidence for the minimum number of these operations required to achieving proficiency and safety. The aim of this study is to assess the outcome of laparoscopic appendectomies performed by surgical residents and to evaluate the effect of learning curve on patient outcome.

METHODS

All patients undergoing laparoscopic appendectomies performed by six residents during the study period were reviewed. Data on patient demographics,clinical and histological diagnosis, and outcome variables including operative duration, conversion to open surgery, complications, and length of stay were analyzed. We evaluated the effect of the learning curve by dividing patients into two groups: a first group consisting of the initial 20 patients and a second group consisting of the next 20 patients operated upon independently by each resident. Variables were analyzed to determine any difference between the two groups.

RESULTS

Three hundred six patients with the clinical diagnosis of acute appendicitis underwent laparoscopic appendectomy by residents. Mean operative time was 83.8 min. Of patients, 14.6% required conversion to open surgery. Mean length of hospitalization was 2.82 days. Operative duration and complication rate were significantly reduced with increasing experience of residents. The length of hospital stay and conversion rate to open surgery remained unchanged.

CONCLUSION

Operative duration and complications can be reduced with increasing experience of a resident.