Postgraduate year does not influence operating time in laparoscopic cholecystectomy

Automated analysis of intraoperative phase in laparoscopic cholecystectomy: A comparison of one attending surgeon and their residents

OBJECTIVE

This study compares the intraoperative phase times in laparoscopic cholecystectomy performed by an attending surgeon and supervised residents over 10-years to assess operative times as a marker of performance and any impact of case severity on times.

DESIGN

Laparoscopic cholecystectomy videos were uploaded to Touch Surgery™ Enterprise, a combined software and hardware solution for securely recording, storing, and analysing surgical videos, which provide analytics of intraoperative phase times. Case severity and visualisation of the critical view of safety (CVS) were manually assessed using modified 10-point intraoperative gallbladder scoring system (mG10) and CVS scores, respectively. Attending and residents' times were compared unmatched and matched by mG10.

SETTING

Secondary analysis of anonymized laparoscopic cholecystectomy video, recorded as standard of care.

PARTICIPANTS

Adult patients who underwent elective laparoscopic cholecystectomy a single UK hospital. Cases were performed by one attending and their residents.

RESULTS

159 (attending=96, resident=63) laparoscopic cholecystectomy videos and intraoperative phase times were reviewed on Touch Surgery™ Enterprise and analyzed. Attending cases were more challenging (p=0.037). Residents achieved higher CVS scores (p=0.034) and showed longer dissection of hepatocystic triangle (HCT) times (p=0.012) in more challenging cases. Residents' total operative time (p=0.001) and dissection of HCT (p=0.002) times exceeded the attending's in low-severity matched cases (mG10=1). Residents' total operative times (p<0.001), port insertion/gallbladder exposure (p=0.032), and dissection of HCT (p<0.001) exceeded the attending's in matched cases (mG10=2). Residents' total operative (p<0.001), dissection of HCT (p<0.001), and gallbladder dissection (p=0.010) times exceeded the attendings in unmatched cases.

CONCLUSIONS

Residents' total operative and dissection of HCT times significantly exceeded the attending's unmatched cases and low-severity matched cases which could suggest training need, however, also reflects an expected assessment of competence, and validates time as a marker of performance.

Comparison of surgical outcomes of emergent laparoscopic cholecystectomy for acute cholecystitis between attending surgeons and senior residents: A propensity-matched analysis

INTRODUCTION

Emergent laparoscopic cholecystectomy (LC) is routinely performed for acute cholecystitis (AC) at our institution. This study was conducted to investigate the feasibility and safety of emergent LC for AC performed by senior residents.

MATERIALS AND METHODS

Data from 362 patients with AC who underwent emergent LC between January 2012 and June 2020 were retrospectively reviewed. Of these patients, 328 were operated on by senior residents (SR), and 34 were operated on by the attending surgeon (AS). Clinical characteristics and surgical and postoperative outcomes were compared between the SR and AS groups. Propensity score matching was used to minimize selection bias. When the operator was an SR, the LC was assisted by the AS.

RESULTS

Before matching, in the SR group, more patients had a history of abdominal surgery, and C-reactive protein and white blood cell counts were significantly higher. In the image findings, the minor axis of the gallbladder (GB) was longer, and the wall of the GB was thicker in the SR group. After propensity score matching, 28 pairs were identified. There were no significant differences in operative time (83 vs 88 minutes, P = .92), the amount of blood loss (25 vs 10 mL, P = .13), conversion to open surgery (3.6% vs 3.6%, P = 1), postoperative complications (7.2% vs 0%, P = .74), and postoperative hospital stay (4 vs 4 days, P = .87).

CONCLUSION

Emergent LC for AC performed by SR under supervision appears to be feasible and safe.

The impact of virtual reality simulation training on operative performance in laparoscopic cholecystectomy: meta-analysis of randomized clinical trials

Background

Simulation training can improve the learning curve of surgical trainees. This research aimed to systematically review randomized clinical trials (RCT) evaluating the performance of junior surgical trainees following virtual reality training (VRT) and other training methods in laparoscopic cholecystectomy.

Methods

MEDLINE (PubMed), Embase (Ovid SP), Web of Science, Scopus and LILACS were searched for trials randomizing participants to VRT or no additional training (NAT) or simulation training (ST). Outcomes of interest were the reported performance using global rating scores (GRS), the Objective Structured Assessment of Technical Skill (OSATS) and Global Operative Assessment of Laparoscopic Skills (GOALS), error counts and time to completion of task during laparoscopic cholecystectomy on either porcine models or humans. Study quality was assessed using the Cochrane Risk of Bias Tool. PROSPERO ID: CRD42020208499.

Results

A total of 351 titles/abstracts were screened and 96 full texts were reviewed. Eighteen RCT were included and 15 manuscripts had data available for meta-analysis. Thirteen studies compared VRT and NAT, and 4 studies compared VRT and ST. One study compared VRT with NAT and ST and reported GRS only. Meta-analysis showed OSATS score (mean difference (MD) 6.22, 95%CI 3.81 to 8.36, P < 0.001) and time to completion of task (MD −8.35 min, 95%CI 13.10 to 3.60, P = <0.001) significantly improved after VRT compared with NAT. No significant difference was found in GOALS score. No significant differences were found between VRT and ST groups. Intraoperative errors were reported as reduced in VRT groups compared with NAT but were not suitable for meta-analysis.

Conclusion

Meta-analysis suggests that performance measured by OSATS and time to completion of task is improved with VRT compared with NAT for junior trainee in laparoscopic cholecystectomy. However, conclusions are limited by methodological heterogeneity and more research is needed to quantify the potential benefit to surgical training.

Elective Laparoscopic Cholecystectomy as an Entrustable Professional Activity (EPA) for General Surgical Trainees in Australia

INTRODUCTION

To evaluate the operation time and surgical outcomes of elective laparoscopic cholecystectomy performed by surgical trainees at different levels of training at Eastern health and hence, to establish the efficacy and safety of elective laparoscopic cholecystectomy as an Entrustable Professional Activity for surgical trainees in general surgery.

OBJECTIVE

Elective laparoscopic cholecystectomies performed at our institution between January 2018 and January 2019 were included. Analyses were divided among three groups - consultants (C), fellows (F) and registrars (R). Standard technique with critical view of safety was used.

RESULTS

A total of 592 patients was included, with a mean age of 54 ± 63 years old. The average operation time was 84 ± 51 minutes. Surgical education and training (SET) 2 trainees took significantly longer when compared to their SET3 and above counterparts as a primary operator (SET2: 131 ± 32 min, Reference; SET3: 78 ± 21 min, p = 0.003; SET4: 80 ± 33 min, p = 0.004; SET5: 77 ± 28 min, p = 0.003; F: 93 ± 77 min, p = 0.036; C: 85 ± 59 min; p = 0.007). Consultant primary operators took an average of 15 minutes longer to complete the operation when assisted by a SET trainee compared to the non-SET registrars (p = 0.03). The overall complication rate was 3.2% and was not significantly different among all three groups (p = 0.17). No death was recorded during the study period. The readmission and return to theatre rates were 7.8% and 0.8% respectively and were not significantly different among the groups (p-values = 0.61 and 0.69). All conversion to open were performed by the consultant primary operator.

CONCLUSIONS

Elective laparoscopic cholecystectomy can be safely performed by surgical trainees at all SET levels when under appropriate supervision, although junior surgical trainees that is SET 2 took longer to complete the procedure. This operation seems to have a steep, but relatively short, learning curve and it may be broken down into various components. These components, with the addition of time, may be suitable as an Entrustable Professional Activity tool for assessing the competency of early SET trainees.

Intraoperative Measures to Reduce the Risk of COVID-19 Transmission During Minimally Invasive Procedures: A Systematic Review and Critical Appraisal of Societies' Recommendations

BACKGROUND

The coronavirus 2019 pandemic and the hypothetical risk of virus transmission through aerosolized CO2 or surgical smoke produced during minimally invasive surgery (MIS) procedures have prompted societies to issue recommendations on measures to reduce this risk. The aim of this systematic review is to identify, summarize and critically appraise recommendations from surgical societies on intraoperative measures to reduce the risk of severe acute respiratory syndrome coronavirus 2 transmission to the operative room (OR) staff during MIS.

METHODS

Medline, Embase, and Google Scholar databases were searched using a search strategy or free terms. The search was supplemented with searches of additional relevant records on coronavirus 2019 resource websites from Surgical Associations and Societies. Recommendations published by surgical societies that reported on the intraoperative methods to reduce the risk of severe acute respiratory syndrome coronavirus 2 transmission to the OR staff during MIS were also reviewed for inclusion. Expert opinion articles were excluded. A preliminary synthesis was performed of the extracted data to categorize and itemize the different types of recommendations. The results were then summarized in a narrative synthesis.

RESULTS

Thirty-three recommendation were included in the study. Most recommendations were targeted to general surgery (13) and gynecology (8). Areas covered by the documents were recommendations on performance of laparoscopic/robotic surgery versus open approach (28 documents), selection of surgical staff (13), management of pneumoperitoneum (33), use of energy devices (20), and management of surgical smoke and pneumoperitoneum desufflation (33) with varying degree of consensus on the specific recommendations among the documents.

CONCLUSIONS

While some of the early recommendations advised against the use of MIS, they were not strictly based on the available scientific evidence. After further consideration of the literature and of the well-known benefits of laparoscopy to the patient, later recommendations shifted to encouraging the use of MIS as long as adequate precautions could be taken to protect the safety of the OR staff. The release and implementation of recommendations should be based on evidence-based practices that allows health care systems to provide safe surgical and medical assistance.

Laparoscopic cholecystectomy performed by general surgery residents. Is it safe? How much does it cost?

OBJECTIVE

to evaluate the effectiveness and safety of laparoscopic cholecystectomies performed by residents of the first and second-year of a general surgery residency program. We studied the primary total cost of treatment and complication rates as primary outcomes, comparing the groups operated by senior and resident surgeons.

METHODS

this was a retrospective cohort study of patients who underwent laparoscopic cholecystectomy performed in a training hospital of large surgical volume in Brazil, in the period between June 1, 2018 and May 31, 2019. The study population comprised patients who underwent elective cholecystectomy due to uncomplicated chronic calculous cholecystitis or to the presence of gallbladder polyps with surgical indication. We divided the cases into three groups, based on the graduation of the main surgeon at the time of the procedure: first-year residents (R1), second-year residents (R2), and trained general surgeons (GS).

RESULTS

during the study period, 1,052 laparoscopic cholecystectomies were performed, of which 1,035 procedures met the inclusion criteria, with 78 (7.5%) patients operated on with the participation of first-year residents (R1), 500 (48.3%) patients with the participation of second-year residents (R2), and 457 (44.2%) with the participation of senior surgeons only. There was no difference in conversion rates, complications, and reporting of adverse events between groups. We observed a significant difference regarding hospitalization costs (p = 0.003), with a higher mean for the patients operated with the participation of R1, of US$ 2,671.13, versus US$ 2,414.60 and US$ 2,396.24 for the procedures performed by senior surgeons and R2, respectively.

CONCLUSIONS

laparoscopic cholecystectomy with the participation of residents is safe, even in their first years of training. There is an additional cost of about 10% in the treatment of patient operated with the participation of first-year residents. There was no significant difference in the cost of the group operated by second-year residents.

Effect of Resident Involvement on Operative Time and Operating Room Staffing Costs

OBJECTIVE

The operating room (OR) is a major driver of hospital costs; therefore, operative time is an expensive resource. The training of surgical residents must include time spent in the OR, but that experience comes with a cost to the surgeon and hospital. The objective of this article is to determine the effect of surgical resident involvement in the OR on operative time and subsequent hospital labor costs.

DESIGN

The Kruskal-Wallis statistical test is used to determine whether or not there is a difference in operative times between 2 groups of cases (with residents and without residents). This difference leads to an increased cost in associated hospital labor costs for the group with the longer operative time.

SETTING

Cases were performed at Greenville Memorial Hospital. Greenville Memorial Hospital is part of the larger healthcare system, Greenville Health System, located in Greenville, SC and is a level 1 trauma center with up to 33 staffed ORs.

PARTICIPANTS

A total of 84,997 cases were performed at the partnering hospital between January 1st, 2011 and July 31st, 2015. Cases were only chosen for analysis if there was only one CPT code associated with the case and there were more than 5 observations for each group being studied. This article presents a comprehensive retrospective analysis of 29,134 cases covering 246 procedures.

RESULTS

The analysis shows that 45 procedures took significantly longer with a resident present in the room. The average increase in operative time was 4.8 minutes and the cost per minute of extra operative time was determined to be $9.57 per minute. OR labor costs at the partnering hospital was found to be $2,257,433, or $492,889 per year.

CONCLUSIONS

Knowing the affect on operative time and OR costs allows managers to make smart decisions when considering alternative educational and training techniques. In addition, knowing the connection between residents in the room and surgical duration could help provide better estimates of surgical time in the future and increase the predictability of procedure duration.

Effect of Residents on Operative Time and Complications: Focus on Laparoscopic Cholecystectomy in the Community

OBJECTIVE

To better understand important aspects of resident education in the perioperative setting, given that there are conflicting data regarding resident training and outcomes (e.g., operative times and complications). To study continuity of care in a resident-run outpatient hospital clinic.

DESIGN

Retrospective analysis of 2 databases.

SETTING

The study was set up in a community teaching hospital.

RESULTS

Of 4603 cases in a cholecystectomy database, 3302 (72%) were assisted by residents, with operative times ranging from 19 to 383 minutes, and 1576 (22.9%) were assisted by nonresidents. The average times were 93 and 77 minutes for resident- and non-resident-assisted cases, respectively. Complications were almost 3 times more likely for urgent vs. elective but were similar for resident-assisted vs. non-resident-assisted cases. The operative time was similar across PGY levels. Of 149 cases in a resident-run outpatient clinic, 100 (67%) of the residents participated in preoperative, intraoperative, and postoperative phases of case, but in only 4% of cases was it the same resident.

CONCLUSION

Resident assistance increased operative times but not complications. Counterbalanced effects of increasing skill and increasing participation may explain this time stability across PGY levels. Continuity of care is preserved in the era of the 80-hour workweek, but not to a patient-specific degree.

Patient and Procedural Factors That Influence Anesthetized, Nonoperative Time in Spine Surgery

STUDY DESIGN

Retrospective study.

OBJECTIVE

Efficient use of operating room time is important, as delays during induction or recovery increase time not spent operating while in the operating room. We identified factors that increase anesthetized, nonoperative time by utilizing a database of over 5,000 consecutive neurosurgical spine cases.

METHODS

Surgical records were searched to identify all spine surgeries performed between January 2010 and July 2012. Anesthetized, nonoperative time was calculated from the anesthesia record and compared with both patient and procedure characteristics to determine any significant relationships.

RESULTS

There were 5,515 surgical cases with a mean age of 60.5 and mean body mass index (BMI) of 29.7; 3,226 (58%) were male subjects. There were 1,176 (21%) fusion cases, and level of pathology was predominantly lumbar (4,010 cases, 73%). Fusion cases had a significantly longer total anesthetized, nonoperative time (fusion: 98 minutes, nonfusion: 76 minutes, mean difference: 22 minutes, p < 0.0001). Significant factors affecting anesthetized, nonoperative time in nonfusion cases include age greater than 65 years (mean difference 5 minutes, p < 0.0001), American Society of Anesthesiologists (ASA) grade, and BMI (BMI < 25: 72 ± 1.2 minutes, BMI 25 to 29: 74 ± 0.6 minutes, BMI 30 to 39: 79 ± 0.6 minutes, BMI 40 + : 87 ± 1.8 minutes, p < 0.0001). Similarly, for fusion operations, age > 65 years significantly increased nonoperative time (mean difference 6 minutes, p < 0.01), as did increasing ASA (mean difference 9 minutes, p < 0.0001) and increasing BMI.

CONCLUSION

Patient and surgical factors, including ASA grade, BMI, level of pathology, and surgical approach, have noticeable effects on anesthetized, nonoperative times in spine surgery.

[Not Available]

OBJECTIVES

Database review to analyse age and sex differences in complication and conversion rates and influence on return to normal daily activities and work after laparoscopic cholecystectomy (LC).

METHODS

658 patients had a laparoscopic cholecystectomy for proven gallstones between 9/4/2001 and 15/2/2006 under the care of one surgeon (F. H.) at Benenden hospital, Kent, UK.

RESULTS

We had a 65.5% response rate with 431 replies at a mean follow up of 22.4 months (2.3-52.8). There was a male to female ratio of 5:23 with a mean age of 54.2 years (22-83). Using linear regression we found no significant correlation with operative time and variables of age and sex (df = 2, 251, R (2) = 0.03, F = 0.574, p < 0.564). No significant correlation with number of complications and age or sex (df = 2, 334, R (2) = 0.004, F = 1.615, p < 0.200). Age (Exp(B) = 1.040, p < 0.51) and sex (Exp(B) = 0.863, p < 0.855) had no effect on conversion. No difference was found in relation to age and sex with return to normal daily activities (df = 2, 307, F = 0.904, p < 0.406). Age was a non-significant predictor of return to work (Beta = 0.040, p < 0.572) however men return to work significantly sooner (Beta = 0.191, p < 0.007).

CONCLUSIONS

Operative time, number of complications, conversion to open and return to normal daily activities may not be affected by age or sex of patients. Hospital stay may be longer in older patients. Men appear to return to work sooner. Further analysis with validated questionnaires are required.

Impact of seniority on operative time and short-term outcome in laparoscopic cholecystectomy: Experience of an academic Surgical Department in a developing country

INTRODUCTION:

Resident participation in laparoscopic cholecystectomy (LC) is one of the first steps of laparoscopic training. The impact of this training is not well-defined, especially in developing countries. However, this training is of critical importance to monitor surgical teaching programmes.

OBJECTIVE:

The aim of this study was to determine the impact of seniority on operative time and short-term outcome of LC.

DESIGNS AND SETTINGS:

We performed a retrospective study of all consecutive laparoscopic cholecystectomies for gallbladder lithiasis performed over 2 academic years in an academic Surgical Department in Morocco.

PARTICIPANTS:

These operations were performed by junior residents (post-graduate year [PGY] 4–5) or senior residents (PGY 6), or attending surgeons assisted by junior residents, none of whom had any advanced training in laparoscopy. All data concerning demographics (American Society of Anesthesiologists, body mass index and indications), surgeons, operative time (from skin incision to closure), conversion rate and operative complications (Clavien–Dindo classification) were recorded and analysed. One-way analysis of variance, Student's t-test and Chi-square tests were used as appropriate with statistical significance attributed to P < 0.05.

RESULTS:

One hundred thirty-eight LC were performed. No differences were found on univariate analysis between groups in demographics or diagnosis category. The overall rate of operative complications or conversions and hospital stay were not significantly different between the three groups. However, mean operative time was significantly longer for junior residents (n = 27; 115 ± 24 min) compared to senior residents (n = 37; 77 ± 35 min) and attending surgeons (n = 66; 55 ± 17 min) (P < 0.001).

CONCLUSION:

LC performed by residents appears to be safe without a significant difference in complication rate; however, seniority influences operative time. This information supports early resident involvement in laparoscopic procedures and also the need to develop cost-effective laboratory training programmes.

The effect of residents as teaching assistants on operative time in laparoscopic cholecystectomy

BACKGROUND

We examined the effect of primary surgeon (PS) and teaching assistant (TA) seniority on operative time and outcomes for residents performing laparoscopic cholecystectomy (LC).

METHODS

This was a retrospective analysis of urgent LC at a county teaching hospital. Relevant data included postgraduate year (PGY) of the PS and TA and markers of disease severity. Primary outcome was operative time. Secondary outcomes were conversion to open cholecystectomy and complications.

RESULTS

There were 1,202 LCs; 415 included an intraoperative cholangiogram. On multivariable analysis, every PGY increase of PS decreased operative time by 3.2 minutes (P = .02). For every PGY increase of TA, operative time decreased 10.8 minutes (P < .001). Acute or gangrenous pathology increased conversion to open surgery (P < .001). Seniority of PS and TA was not associated with increases in conversion or complication rates.

CONCLUSIONS

Residents' operative time improves as experience with LC increases. These improvements become more profound after adjusting for the seniority of the TA.

Post-endoscopic retrograde cholangiography laparoscopic cholecystectomy: challenging but safe

Interval laparoscopic cholecystectomy was found to be safe and associated with a low rate of perioperative complications.

Background and Objectives:

Up to 19% of patients undergoing laparoscopic cholecystectomy (LC) have common bile duct stones and may require endoscopic retrograde cholangiography (ERCP) before LC. The risk of complications of LC after ERCP is higher, and the optimal interval between ERCP and LC is disputed. In our unit, LC is performed approximately 6 weeks after ERCP. This study aims to compare outcomes between subsets of patients undergoing LC with or without prior ERCP.

Methods:

All patients undergoing ERCP and elective laparoscopic cholecystectomy (ELC) over a 1-year period were included. Outcome measures included ERCP outcomes, duration of surgery, intraoperative findings, and postoperative outcomes. Two groups of patients were compared: LC after ERCP and ELC.

Results:

The study included 190 ELC patients and 43 patients with LC after ERCP (ERCP-LC) (December 2008 to December 2009). At ERCP, 25 patients (58%) had ductal stones. The post-ERCP complication rate was 5%. The median time to LC was 42 days, and 6 patients (14%) were readmitted before LC. There were more severe adhesions and longer median operating times in the ERCP-LC group (75 minutes for ELC vs 110 minutes for ERCP-LC, P = .013). We found no significant differences in rates of conversion to open surgery, postoperative complications, lengths of stay, and readmission rates.

Conclusion:

Interval LC after ERCP is a more technically challenging procedure but is associated with a low rate of complications. Although there is emerging evidence that early LC after ERCP is feasible, our study shows that our current practice of delaying LC by approximately 6 weeks is safe.

Operative Time and Cost of Resident Surgical Experience

Objective

Describe the procedure length difference between surgeries performed by an attending surgeon alone compared with the resident surgeon supervised by the same attending surgeon.

Study Design

Case series with chart review.

Setting

Tertiary care center and residency program.

Subjects and Methods

Six common otolaryngologic procedures performed between August 1994 and May 2012 were divided into 2 cohorts: attending surgeon alone or resident surgeon. This division coincided with our July 2006 initiation of an otolaryngology–head and neck surgery residency program. Operative duration was compared between cohorts with confounding factors controlled. In addition, the direct result of increased surgical length on operating room cost was calculated and applied to departmental and published resident case log report data.

Results

Five of the 6 procedures evaluated showed a statistically significant increase in surgery length with resident involvement. Operative time increased 6.8 minutes for a cricopharyngeal myotomy ( P = .0097), 11.3 minutes for a tonsillectomy ( P < .0001), 27.4 minutes for a parotidectomy ( P = .028), 38.3 minutes for a septoplasty ( P < .0001), and 51 minutes for tympanomastoidectomy ( P < .0021). Thyroidectomy showed no operative time difference. Cost of increased surgical time was calculated per surgery and ranged from $286 (cricopharyngeal myotomy) to $2142 (mastoidectomy). When applied to reported national case log averages for graduating residents, this resulted in a significant increase of direct training-related costs.

Conclusion

Resident participation in the operating room results in increased surgical length and additional system cost. Although residency is a necessary part of surgical training, associated costs need to be acknowledged.

Anesthesia preparation time is not affected by the experience level of the resident involved during his/her first month of adult cardiac surgery

OBJECTIVE

This study was designed to answer the question of whether the experience level of the resident on his/her first month of adult cardiothoracic anesthesiology has an impact on operating room efficiency in a large academic medical center. Traditionally, the resident's 1st month of cardiac anesthesia had been reserved for the clinical anesthesia (CA)-2 year of training. This study analyzed the impact on operating room efficiency of moving the 1st month of cardiac anesthesia into the CA-1 year. The authors hypothesized that there would be no difference in anesthesia preparation times (defined as the interval between "in-room" and "anesthesia-ready" times) between CA-1 and CA-2 residents on their 1st month of cardiac anesthesia.

DESIGN

This study was retrospective and used an electronic anesthesia information management system database.

SETTING

This study was conducted on care provided at a single 450-bed academic medical center.

PARTICIPANTS

This study included 12 residents in their 1st month of cardiac anesthesia.

INTERVENTIONS

The anesthesia preparation time (defined as the interval between "in-room" and "anesthesia-ready" times) was measured for cases involving residents on their first month of cardiac anesthesia.

MEASUREMENTS AND MAIN RESULTS

Anesthesia preparation times for 6 CA-1 resident months and 6 CA-2 resident months (100 adult cardiac procedures in total) were analyzed (49 for the CA-1 residents and 51 for the CA-2s). There were no differences in preparation time between CA-1 and CA-2 residents as a group (p = 0.8169). The CA-1 residents had an unadjusted mean (±standard error) of 51.1 ± 3.18 minutes, whereas the CA-2 residents' unadjusted mean was 50.2 ± 2.41 minutes. Adjusting for case mix (valves v coronary artery bypass graft surgery), the CA-1 mean was 49.1 ± 5.22 minutes, whereas the CA-2 mean was 49.1 ± 4.54 minutes.

CONCLUSIONS

These findings suggest that operating room efficiency as measured by the anesthesia preparation time may not be affected by the level of the resident on his/her 1st month of adult cardiac anesthesia.

Single-incision laparoscopic cholecystectomy: initial evaluation of a large series of patients

BACKGROUND

Findings have shown that single-incision laparoscopic cholecystectomy (SILC) is feasible and reproducible. The authors have pioneered a two-trocar SILC technique at the University of Texas Southwestern. Their results for 100 patients are presented.

METHODS

From January 2008 to March 2009, 100 patients with symptomatic gallbladder disease underwent SILC through a 1.5- to 2-cm umbilical incision using a two-port (5-mm) technique. For nearly all the patients, a 30 degrees angled scope was used. The gallbladder was retracted, with two or three sutures placed along the gallbladder. These sutures were either fixated internally or placed through the abdominal wall to obtain a critical view of Calot's triangle. The SILC procedure was performed using standard technique with 5-mm reticulating or conventional laparoscopic instruments. The cystic duct and artery were well visualized, clipped, and divided. Cholecystectomy was completed with electrocautery, and the specimen was retrieved through the umbilical incision.

RESULTS

In this series, 80 women (85%) and 15 men (15%) with an average age of 33.8 years (range, 17-66 years) underwent SILC. Their mean BMI was 29.8 kg/m(2) (range, 17-42.5 kg/m(2)), and 39% of these patients had undergone previous abdominal surgery. The mean operative time was 50.8 min (range, 23-120 min). The mean estimated blood loss was 22.3 ml (range, 5-125 ml), and 5% of the patients had an intraoperative cholangiogram. There were no conversions of the SILC technique. A two-trocar technique was feasible for 87% of the patients. For the remaining patients, either a three-channel port or three individual trocars were required. A SILC technique was used for 5% of the patients to manage acute cholecystitis or gallstone pancreatitis.

CONCLUSION

The SILC technique with a two-trocar technique is safe, feasible, and reproducible. The operating times are reasonable and can be lessened with experience. Even complex cases can be managed with this technique. Excellent exposure of the critical view was obtained in all cases. The SILC procedure is becoming the standard of care for most of the authors' elective patients with gallbladder disease. Clinical trials are warranted before the SILC technique is adopted universally.

Impact of established skills in open surgery on the proficiency gain process for laparoscopic surgery

BACKGROUND

Laparoscopic training traditionally follows open surgical training. This study aimed to investigate the impact of experience in open surgery on the laparoscopic proficiency gain process.

METHODS

A survey form investigating the importance of open experience before the start of laparoscopic training was sent to surgical experts and trainees in the United Kingdom. A separate experimental study objectively assessed the effects of open experience on laparoscopic skill acquisition using a virtual reality simulator. In the study, 11 medical students with no prior surgical experience (group A) and 14 surgical trainees with open but no laparoscopic experience in (group B) performed 250 simulated laparoscopic cholecystectomies. Psychomotor skills were evaluated by motion analysis and video-based global rating scores. Before the first and after the fifth and tenth operation, knowledge of laparoscopic techniques was assessed by a written test and by self-reported confidence levels indicated on a questionnaire.

RESULTS

The 80 experts and 282 trainees who responded to the survey believed prior open experience aids confidence levels, knowledge, and skills acquisition. In the simulation study, no intergroup difference was found for any parameter after the first procedure. Group B scored significantly higher in the laparoscopic knowledge test before training began (42.7% vs. 64.3%; p = 0.002), but no significant difference was found after five operations. The two groups did not differ significantly in terms of confidence. Group B had a significantly shorter total operation time only at the first operation (2,305.6 s vs. 1,884.6 s; p = 0.037). No significant intergroup difference in path length, number of movements, or video-based global rating scores was observed.

CONCLUSIONS

Prior open experience does not aid the laparoscopic learning process, as demonstrated in a simulated setting. Given the wealth of evidence demonstrating translation of virtual skills to the operating theater, we propose that the safe and effective introduction of well-supervised laparoscopic training may be possible at the beginning of a surgical training curriculum.

The costs and quality of operative training for residents in tympanoplasty type I

CONCLUSION

A teaching hospital would incur more operation room costs on training surgical residents.

OBJECTIVE

To evaluate the increased operation time and the increased operation room costs of operations performed by surgical residents. As a model we used a very common surgical otology procedure -- tympanoplasty type I.

SUBJECTS AND METHODS

From January 1, 2004 to December 31, 2004, we included in this study 100 patients who received tympanoplasty type I in Taipei Veterans General Hospital. Fifty-six procedures were performed by a single board-certified surgeon and 44 procedures were performed by residents. We analyzed the operation time and surgical outcomes in these two groups of patients. The operation room cost per minute was obtained by dividing the total operation room expenses by total operation time in the year 2004.

RESULTS

The average operation time of residents was 116.47 min, which was significantly longer (p<0.0001) than that of the board-certified surgeon (average 81.07 min). It cost USD $40.36 more for each operation performed by residents in terms of operation room costs. The surgical success rate of residents was 81.82%, which was significantly lower (p=0.016) than that of the board-certified surgeon (96.43%).

Influence of resident training on anaesthesia induction times

BACKGROUND

The effect of resident training in anaesthesiology on operating room (OR) economics is an issue of debate. Comparisons of anaesthesia process times between residents and consultants might be systematically skewed by interactions of anaesthesia technique and patient factors.

METHODS

In this prospective, observational study, we analysed anaesthesia process times in 599 cases performed for four different surgical services in a University hospital. The following factors were recorded for each case and used in multivariate analyses of process times: age, American Society of Anesthesiologist (ASA) status, BMI, emergency status, the educational level of the anaesthetist, and the anaesthesia technique.

RESULTS

In the non-adjusted comparison, only for two of seven anaesthetic techniques did resident cases have statistically significant longer induction times than consultant cases: general anaesthesia with placement of a central venous catheter [mean (sd) anaesthesia time for resident cases 38.2 (17.0) vs 22.3 (10.0) min for consultant cases, P=0.001] and general anaesthesia with a laryngeal mask airway [resident cases 11.3 (5.5) vs consultant cases 7.3 (5.0) min, P=0.003]. Anaesthetic technique had the greatest effect on anaesthesia induction time. Educational level of the anaesthetist and age of the patients had small, but significant effects.

CONCLUSIONS

Anaesthesia cases performed by residents have in some, but not in all, anaesthesia techniques increased process times compared with cases performed by consultants. This limits a possible negative impact on OR economics by resident education. Patient-based factors including ASA status, BMI, and emergency status have minimal or no effect on anaesthesia process times.

Laparoscopic pyloromyotomy: effect of resident training on complications

PURPOSE

The purpose of this study was to characterize the safety of laparoscopic pyloromyotomy and examine the effect of resident training on the occurrence of complications.

METHODS

Five hundred consecutive infants who underwent laparoscopic pyloromyotomy between January 1997 and December 2005 were reviewed and analyzed.

RESULTS

Laparoscopic pyloromyotomy was successfully completed in 489 patients (97.8%). Four hundred seventeen patients were boys (83%). Intraoperative complication occurred in 8 (1.6%) patients (mucosal perforation, 7; serosal injury to the duodenum, 1). All were immediately recognized and uneventfully repaired. Six patients (1.2%) required revision pyloromyotomy for persistent or recurrent gastric outlet obstruction. There were 7 wound complications (1.4%) and no deaths. Pediatric surgery residents performed 81% of the operations, whereas 16% were done by general surgery residents (postgraduate years 3-4). There was a 5.4-fold increased risk of mucosal perforation or incomplete pyloromyotomy when a general surgery resident rather than a pediatric surgery resident performed the operation (95% confidence interval, 1.8-15.8; P = .003). These effects persisted even after controlling for weight, age, and attending experience.

CONCLUSIONS

The laparoscopic pyloromyotomy has an excellent success rate with low morbidity. The occurrence of complications is increased when the operation is performed by a general surgery resident, even when directly supervised by pediatric surgical faculty.

Influence of resident and attending surgeon seniority on operative performance in laparoscopic cholecystectomy

BACKGROUND

Resident participation in laparoscopic cholecystectomy (LC) is important for education but increases the time of operation. This time cost in training programs is not well-defined, and available data show no decrease in operative time as residents progress in training. We undertook this study to determine the effect of the resident and attending surgeon seniority on the operative performance of LC.

PATIENTS AND METHODS

We undertook a retrospective review of LCs performed for all indications over two academic years in our training program. Operations were performed by junior (PGY 1-3) or senior (PGY 4-5) residents, assisted by junior (trained after 1994) or senior attending surgeons, none of whom had fellowship training in advanced laparoscopy. Demographics, surgeon, assistant, operative time, and operative complications were recorded. Operative diagnoses were defined as noninflammatory (biliary colic, dyskinesia, or polyps) or inflammatory (cholecystitis, pancreatitis). The primary outcome was time in minutes from skin incision to closure; secondary outcomes were complications and conversions to laparotomy. ANOVA, Student's t-test, and chi2 tests were used as appropriate with statistical significance attributed to P < 0.05.

RESULTS

Three hundred fifteen LCs were performed. Two hundred seventy were without conversion to laparotomy or intraoperative cholangiography and were included in time and complication analysis. Junior attendings averaged 4 and senior attendings averaged 21 postresidency years. No differences were found on univariate analysis between groups in demographics or diagnosis category. Operative times were longer for junior residents irrespective of attending seniority: Jr Res/Jr Staff (n = 65): 86 +/- 32 min; Jr/Sr (n = 78): 88 +/- 38 min; Sr/Jr (n = 52): 73 +/- 27 min; Sr/Sr (n = 75): 67 +/- 24 min (P < 0.05). The overall rate of operative complications was higher in junior than senior resident cases (5.6% versus 0.78%, P < 0.05). The most common complication was cystic duct leak, of which 4/5 occurred in junior resident cases. Senior attendings had a trend toward increased conversions (8.4% versus 3.7%, P = 0.09).

CONCLUSION

Resident, but not attending surgeon, seniority influences operative time and complication rate in LC. This information may help surgical educators maximize both resident learning and operative efficiency and safety.

Getting residents in the game: an evaluation of general surgery residents' participation in pediatric laparoscopic surgery

PURPOSE

In a large children's hospital, the authors evaluated general surgery residents' experience with pediatric laparoscopic procedures and the impact of their participation on patient outcome.

METHODS

The records of all children who underwent laparoscopic appendectomy, splenectomy, fundoplication, or pyloromyotomy were reviewed. The level of participation by general surgery residents in each of these operations was determined. Outcome was assessed for these procedures in terms of intraoperative and postoperative complications.

RESULTS

A resident was the operating surgeon in 164 of 174 laparoscopic appendectomies (94%), 37 of 38 laparoscopic splenectomies (97%), 78 of 104 laparoscopic fundoplications (75%), and 72 of 97 laparoscopic pyloromyotomies (74%). Adverse outcomes in the cases in which a resident was surgeon were limited to 4 postappendectomy infectious complications, 3 cases of recurrent reflux after fundoplication, and one incomplete myotomy and one mucosal injury after laparoscopic pyloromyotomy.

CONCLUSIONS

The authors have shown that well-supervised general surgery residents can perform common, pediatric laparoscopic operations with excellent results. Although it is essential for established pediatric surgeons and fellows in pediatric surgery to acquire expertise in minimally invasive surgery, once they have confidence in their own skills they may safely permit qualified general surgery residents to perform laparoscopic procedures in children.