- Email: [email protected]
Laparoscopic appendectomy — Outcomes of senior trainees operating without supervision versus experienced pediatric surgeons
Journal of Pediatric Surgery 54 (2019) 276–279
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Laparoscopic appendectomy — Outcomes of senior trainees operating without supervision versus experienced pediatric surgeons Heron D. Baumgarten, Erin G. Brown, Kathryn W. Russell, N. Scott Adzick, Pablo Laje ⁎ Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
a r t i c l e
i n f o
Article history: Received 18 October 2018 Accepted 30 October 2018 Key words: Laparoscopic appendectomy Fellowship training Trainee autonomy Surgical independence
a b s t r a c t Aim of the study: Pediatric surgery trainees at our program are allowed to perform unsupervised laparoscopic appendectomies during their last year of training to promote independent operative decision-making skills. We reviewed the outcomes of laparoscopic appendectomies done by senior trainees without supervision and compared them to experienced pediatric surgeons. Methods: We reviewed 500 laparoscopic appendectomies performed without supervision by the last 10 pediatric surgery trainees during their last year of training (first 50 cases of each trainee). We compared the outcomes of those 500 cases to the outcomes of 200 laparoscopic appendectomies performed by eight experienced pediatric surgeons (last 25 cases of each surgeon). Data are expressed as mean (SD), unless otherwise indicated. A P value of ≤0.05 was regarded as significant. Main results: Median age in the “trainees” and “surgeons” groups was 11 (range 2–22) and 12 (2–20) years, respectively (P = 0.35). The proportion of perforated appendicitis was similar: 98/500 (19.6%) in the trainees group and 42/200 (21%) in the surgeons group, respectively (P = 0.75). Mean operative time was 41 (SD 14.5) min in the trainees group vs. 39 (SD 16.1) min in the surgeons group (P = 0.05). Minor intraoperative complications occurred in 3/500 (0.6%) cases in the trainees group vs. 1/200 (0.5%) in the surgeons group (P = 0.69). No major complications occurred in either group. Mean hospital stay was 2 (range 0.5–26) and 2.3 (range 0.5–18) days in the trainees and surgeons groups, respectively (P = 0.25). There were 13/500 vs. 5/200 readmissions (P = 0.92), and 1/500 vs. 1/200 reoperations in the trainees and surgeons groups, respectively (P = 0.91). Conclusion: Allowing senior pediatric surgery trainees to perform laparoscopic appendectomies without supervision to stimulate surgical autonomy is safe and does not compromise patient outcomes. Level of evidence: III. © 2018 Elsevier Inc. All rights reserved.
Surgical trainee autonomy is a topic of extensive discussion among surgical societies, training program directors, and trainees themselves, as training work hour restrictions and the increasingly litigious nature of medical care are resulting in the graduation of surgical trainees who are not confident in their ability to truly operate independently [1–3]. While subspecialty training may partially help with this issue, opportunities for true autonomy in surgical training programs are exceedingly rare, at least in the United States [2–6]. Despite all this, surgical trainees in all specialties are still expected to operate independently with complete confidence the day after they complete their residency or fellowship, without being given the opportunity to do so while they are still in training. The question of how to safely promote autonomy in surgical trainees is a highly relevant one at the present time, since surgical education is under more scrutiny than ever before. At our training program, ⁎ Corresponding author at: Department of Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Wood Building, Suite 5100, Philadelphia, PA 19104. Tel.: + 1 215 590 5905. E-mail address: [email protected] (P. Laje). https://doi.org/10.1016/j.jpedsurg.2018.10.092 0022-3468/© 2018 Elsevier Inc. All rights reserved.
the pediatric surgery fellows are allowed, and encouraged, to perform unsupervised laparoscopic appendectomies during their last year of training as a way to promote independent patient management and autonomous operative decision-making skills. This study aims to evaluate the safety of this educational strategy by comparing the outcomes of patients operated on by senior fellows versus those of patients operated on by experienced pediatric surgeons. 1. Materials and methods After obtaining Institutional Review Board approval (IRB 17-014551) we did a retrospective chart review of 700 laparoscopic appendectomy performed between 2011 and 2017. Those 700 included the first 50 consecutive cases performed without supervision by our most recent 10 pediatric surgery fellows (“trainees” group, n = 500) and the last 25 consecutive cases performed by each of the eight attending pediatric surgeons in our division (“surgeons” group, n = 200). The attending pediatric surgeons had between 7 and 22 years of postfellowship experience. The patients' clinical condition was not a factor in determining who
H.D. Baumgarten et al. / Journal of Pediatric Surgery 54 (2019) 276–279
did the operation. Interval and incidental appendectomies were excluded. Perforated appendicitis was defined as pus in the peritoneal cavity and/or a visible hole in the appendix. Demographic and surgical outcome data including operative time, intraoperative and postoperative complications, length of stay, readmission, postoperative abscess, and reoperation were compared between groups. Statistical significance was determined by t-test and chi-square test for means and proportions, respectively. A P value b 0.05 was considered statistically significant. 2. Results
group and 11.8% of the cases in the trainees group) (P = 0.42) [7]. There were no conversions to open appendectomy in either group. Mean operative time for all cases was 41.5 (SD: 14.5) min in the trainees group and 39.1 (SD: 16.1) min in the surgeons group (P = 0.05). The mean operative time of the cases of perforated appendicitis was 51.7 (SD: 16.9) min in the trainees group and 52.7 (SD: 17.7) min in the surgeons group (P = 0.76). Lastly, the mean operative time of the cases of nonperforated appendicitis was 39 (SD: 12.7) min in the trainees group and 35.5 (SD: 13.5) min in the surgeons group, which was statistically significant (P = 0.003). 2.3. Complications
2.1. Patient demographics The median patient age in the “trainees” and the “surgeons” groups was 11 (range 2–22) and 12 (2–20) years, respectively (P = 0.35) (Table 1). The proportion of cases of perforated appendicitis was similar in both groups: 98/500 (19.6%) in the trainees and 42/200 (21%) in the surgeons group, respectively (P = 0.75). 2.2. Diagnosis and intraoperative management The most common imaging modality for diagnosis was ultrasound, which was equally used in both groups: 76.5% (382/500) and 75.4% (151/200) of cases (trainees and surgeons groups, respectively [P = 0.84]). Magnetic resonance imaging was used in cases with an inconclusive ultrasound, although at different rates between groups: 5% versus 11.5% in the trainees and surgeons groups, respectively (P b 0.01). A similar proportion of patients in each group was transferred from other hospitals with an already performed CT-scan: 35% and 35.2% (P N 0.99). Most operations were done with the standard three-port laparoscopic technique, and occasionally with the transumbilical extracorporeal laparoscopic-assisted technique (9.5% of the cases in the surgeons
Table 1 Demographic and outcome data of patients with acute appendicitis who underwent laparoscopic appendectomy by senior pediatric surgery trainees or by experienced attending surgeons. OP: operative time. LOS: length of hospital stay. PO: postoperative. SD: standard deviation. “Trainees” Group
“Surgeons” Group
P value
There were 3 minor intraoperative complications in the trainees group (3/500, 0.6%): 1 appendiceal artery bleeding controlled with several hemostatic maneuvers and 2 partial cecectomies (stapling across the cecum) owing to a perforation at the base of the appendix. There was one minor intraoperative complication in the surgeons group (1/200, 0.5%): an omental hematoma secondary to a Veress needle injury (P = 0.69). Within the subgroup of perforated appendicitis, there were 8 postoperative abscesses out of 98 cases in the trainees group (8.2%) and 13 postoperative abscesses out of 42 cases in the surgeons group (31%) (P b 0.001). However, the incidence of postoperative abscesses requiring an intervention (needle aspiration and/or a percutaneous drain) was statistically similar between groups: 6/98 cases in the trainees group and 5/42 cases in the surgeons group (P = 0.24). 2.4. Postoperative care There was one reoperation in the trainees group (1/500, 0.2%; negative exploratory laparoscopy for abdominal pain during the original admission), and one reoperation in the surgeons group (1/200, 0.5%; lysis of adhesions for small bowel obstruction; after the initial hospital discharge) (P = 0.91). The mean hospital stay was 2 (range 0.5–26) and 2.3 (range 0.5–18) days in the trainees and surgeons groups, respectively (P = 0.25). There were 13 readmissions in the trainees group (13/500, 2.6%; abdominal pain [n = 4], constipation [n = 3], dehydration [n = 1], umbilical abscess [n = 2], postoperative abscess [n = 2] and gastroenteritis [n = 1]), and there were 5 re-admissions in the surgeons group (5/200, 2.5%; postoperative abscess [n = 2], diarrhea [n = 2] and abdominal pain [n = 1]) (P = 0.92). 3. Discussion
All cases
N = 500
N = 200
-
Age (median & range in years) OP time (mean & SD in minutes) Complications LOS (mean & SD in days) Readmissions Reoperations
11 (2 to 22) 41.5 (14.5) 3/500 2 (2.4) 13/500 1/500
12 (2 to 20) 39.1 (16.1) 1/200 2.3 (2.9) 5/200 1/200
0.35 0.05 0.69 0.25 0.92 0.91
Perforated Appendicitis Age (median & range in years) OP time (mean & SD in minutes) Complications PO abscess PO Abscesses requiring intervention LOS (mean & SD in days) Readmissions Reoperations
98 of 500 (19.6%) 10 (2 to 17) 51.7 (16.9) 2 of 98 8 of 98
42 of 200 (21%) 10 (2 to 17) 52.7 (17.7) 0/42 13/42
0.75 0.91 0.75 0.87 b0.01
6 of 98
5 of 42
0.41
5.1 (2.9) 8 of 98 0 of 98
6.8 (3.6) 5 of 42 1 of 42
b0.01 0.70 0.66
402/500 = 80.4% 11 (2 to 22) 39 (12.7) 1/402 1.3 (1.5) 5 of 402 1 of 402
158/200 = 79% 12 (3 to 20) 35.5 (13.5) 1/158 1.1 (0.7) 0 of 158 0 of 158
0.75 0.16 b0.01 0.91 0.09 0.35 0.62
Nonperforated appendicitis Age (median & range in years) OP time (mean & SD in minutes) Complications LOS (mean & SD in days) Readmissions Reoperations
277
In our current stage of surgical education with work hour restrictions that put a strict limit to what trainees are exposed to, there is increasing concern among program directors and educational councils about the preparedness of surgical trainees to operate independently with full confidence at the end of their training. Not only are trainees graduating with a smaller number of cases, but there are virtually no opportunities for surgical trainees to operate independently without the oversight of an attending surgeon, a fact that is mostly driven by medicolegal concerns and the ever-growing culture of patient safety. Numerous articles in the literature have shown that all these deficits in surgical education are real, and most importantly, that many surgical trainees do not feel ready to practice independently at the end of their training [1,4,8–10]. Several studies have evaluated the outcomes of patients treated within education environments, analyzing the effect of resident involvement in care [11]. In particular, the laparoscopic appendectomy has been identified as an important training case, and the impact of trainee participation in the OR has been reported with favorable results [12–14]. With the support of these studies, we decided to take the issue one step forward: at our training program we allow pediatric surgery fellows during their last year of training to take on the management of
278
H.D. Baumgarten et al. / Journal of Pediatric Surgery 54 (2019) 276–279
patients with acute appendicitis in a completely independent way, from diagnosis, to surgery, to postoperative care, to the postdischarge visit in the outpatient clinic. The goal of this approach is to promote autonomy at every level of surgical care and to allow the trainees to gain confidence while they are still under the umbrella of the training program. Some important technical aspects of this approach need to be clarified. First: while the attending surgeons are not involved upfront in the management of patients cared for by the trainees, they are immediately available for advice and assistance, before, during, and after the operation. Second: the senior trainees who are entitled to operate independently in our program have medical malpractice insurance and have the full support of the institution. Third: the pediatric surgery trainees in our program have completed five years of general surgery residency and are American Board of Surgery-certified General Surgeons qualified to perform a variety of pediatric surgery operations such as laparoscopic appendectomies, inguinal hernia repairs, and umbilical hernia repairs, among others. Additionally, senior trainees have completed a full year of pediatric surgery fellowship before being allowed to operate independently. In order to validate our approach from a patient safety perspective, we collected the outcome data of 10 senior pediatric surgery fellows over an 8-year period. A group of 10 fellows should be large enough to eliminate interpersonal differences and should allow obtaining generalizable data. We exclusively evaluated the first 50 cases of each fellow in order to focus on the early stages of the learning curve, since beyond 40 to 50 cases it is likely that the learning curve of managing acute appendicitis independently has reached a plateau. We compared the outcomes of patients operated on by senior trainees versus patients operated on by experienced attending surgeons and found no clinically relevant differences in any of the commonly assessed surgical outcome parameters. From a patient safety perspective, the most important finding of the study was that there were no statistically significant differences in the incidence of complications during or after the operation, in the number of reoperations, or in the need for readmission between groups. Our study demonstrated that allowing senior pediatric surgery trainees to manage and operate children with acute appendicitis without supervision is safe, with a remarkably low complication rate and outcomes that are comparable to those of experienced surgeons. But what if the study showed that the outcomes were different in those cases operated on by senior trainees? As long as the outcomes for trainees meet the same surgical standards expected for experienced surgeons, minor differences (e.g. a slightly longer operative time) should be acceptable in a training program that wants to truly prepare their trainees to operate independently. In contrast, training programs that do not allow trainees to operate independently generate trainees that are less experienced and possibly less safe at the end of their training, a cost that is paid by the trainees' first posttraining patients. It could be argued that the first patients of an independent surgeon will have a higher risk of complications either way: during the training (with our approach), or after the training (with the standard approach). But from the perspective of a trainee, it is probably better to start developing an autonomous practice while still under the protection of the training program. The idea of letting trainees do operations independently is not new. There are a number of publications in the literature that report acceptable outcome from pilot programs in which trainees take autonomous surgical care of patients, with universally positive opinions from the participating trainees [15,16]. In the reported settings, however, the attending surgeon of record supervised the case in some capacity, at least by discussing the surgical plan before and after the procedure. In our program, in contrast, the senior trainees play 100% the role of an attending surgeon since the actual attending surgeon on call is not aware of the cases being managed by the trainees (unless, as described before, the input of the attending surgeon is requested by the trainee).
It is very clear to us that the experience of managing acute appendicitis independently cannot be translated to the readiness to autonomously perform more complex cases. Surgical training is a never-ending process, and true readiness requires good judgment and experience that exceed residency and fellowship. That being said, we believe that our approach has a strong educational value. Surgical training is changing, mostly in ways that negatively impact the operative experience of trainees [17]. It is critical that surgical training programs find ways to reverse the trend created by “well-intended-but-not-applicable” policies that are detrimental to a proper surgical training [18]. A limitation of this study is the inability to conclude that our senior trainees increased their self-confidence by operating independently simply because there is no quantitative way to objectively measure confidence [19]. However, all our trainees take up the opportunity and responsibility of managing patients independently, and consistently regard this as a uniquely positive educational experience. In conclusion, allowing senior pediatric surgery trainees to manage and operate on patients with acute appendicitis without the intervention of an attending surgeon is safe and does not compromise patient outcomes. While there are no quantitative data to prove it, we believe that this approach has educational value when it comes to preparing trainees for posttraining independent practice, and that is how our trainees perceive it. CRediT authorship contribution statement Heron D. Baumgarten: Conceptualization, Investigation, Formal analysis, Writing - review & editing. Erin G. Brown: Conceptualization, Investigation, Formal analysis, Writing - original draft, Writing - review & editing. Kathryn W. Russell: Formal analysis, Writing - review & editing. N. Scott Adzick: Formal analysis, Writing - review & editing. Pablo Laje: Conceptualization, Investigation, Formal analysis, Writing - original draft, Writing - review & editing. Appendix A. Discussion Presenter - Heron Baumgarten Q: Andrew Holland, Sydney, Australia • I very much support the concept of trainees operating independently but I was a little concerned when you mentioned that potentially a patient could be in the operating theatre with a trainee performing surgery without the attending consultant even being aware. On the other side of the fence it is much easier to help someone out with an unexpected finding if you at least know about the case beforehand. A (Heron Baumgarten CHOP, Philadelphia) • I think the purpose of this is to truly have an independent and autonomous operative experience. Additionally I would say that senior fellows are board certified in general surgery so they would potentially be performing these cases in practice already if they had not pursued paediatric surgery fellowship and just gone straight into the community and further there is always an attending consultant on call who is ready to come in for other cases or bigger cases so there is always someone readily available to help. Q: Andrew Holland, Sydney, Australia • I appreciate someone is available, but it's a lot easier to offer or provide help if you at least know about the patient.
References [1] Fonseca AL, Reddy V, Longo WE, et al. Graduating general surgery resident operative confidence: perspective from a national survey. J Surg Res 2014;190:419–28. [2] Malangoni MA, Biester TW, Jones AT, et al. Operative experience of surgery residents: trends and challenges. J Surg Educ 2013;70:783–8.
H.D. Baumgarten et al. / Journal of Pediatric Surgery 54 (2019) 276–279 [3] Mattar SG, Alseidi AA, Jones DB, et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg 2013;258:440–9. [4] Chen XP, Sullivan AM, Alseidi A, et al. Assessing residents' readiness for or autonomy: a qualitative descriptive study of expert surgical teachers' best practices. J Surg Educ 2017;74:e15–21. [5] Klingensmith ME, Cogbill TH, Luchette F, et al. Factors influencing the decision of surgery residency graduates to pursue general surgery practice versus fellowship. Ann Surg 2015;262:449–55. [6] Meyerson SL, Teitelbaum EN, George BC, et al. Defining the autonomy gap: when expectations do not meet reality in the operating room. J Surg Educ 2014;71:e64–72. [7] Perea L, Peranteau WH, Laje P. Transumbilical extracorporeal laparoscopic-assisted appendectomy. J Pediatr Surg 2018;53:256–9. [8] Picarella EA, Simmons JD, Borman KR, et al. "Do one, teach one" the new paradigm in general surgery residency training. J Surg Educ 2011;68:126–9. [9] Kairys JC, McGuire K, Crawford AG, et al. Cumulative operative experience is decreasing during general surgery residency: a worrisome trend for surgical trainees? J Am Coll Surg 2008;206:804–11 [discussion 811-3]. [10] Bell Jr RH. Why Johnny cannot operate. Surgery 2009;146:533–42. [11] Davis Jr SS, Husain FA, Lin E, et al. Resident participation in index laparoscopic general surgical cases: impact of the learning environment on surgical outcomes. J Am Coll Surg 2013;216:96–104.
279
[12] Naiditch JA, Lautz TB, Raval MV, et al. Effect of resident postgraduate year on outcomes after laparoscopic appendectomy for appendicitis in children. J Laparoendosc Adv Surg Tech A 2012;22:715–9. [13] Perry ZH, Netz U, Mizrahi S, et al. Laparoscopic appendectomy as an initial step in independent laparoscopic surgery by surgical residents. J Laparoendosc Adv Surg Tech A 2010;20:447–50. [14] Singh P, Turner EJ, Cornish J, et al. Safety assessment of resident grade and supervision level during emergency appendectomy: analysis of a multicenter, prospective study. Surgery 2014;156:28–38. [15] Wojcik BM, Fong ZV, Patel MS, et al. The resident-run minor surgery clinic: a pilot study to safely increase operative autonomy. J Surg Educ 2016;73: e142–9. [16] Day KM, Scott JK, Gao L, et al. Progressive surgical autonomy in a plastic surgery resident clinic. Plast Reconstr Surg Glob Open 2017;5(5):e1318. [17] Hirschl RB. The making of a surgeon: 10,000 hours? J Pediatr Surg 2015;50(5): 699–706. [18] Philibert I, Nasca T, Brigham T, et al. Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships? Annu Rev Med 2013;64:467–83. [19] Elfenbein DM. Confidence crisis among general surgery residents: a systematic review and qualitative discourse analysis. JAMA Surg 2016;151: 1166–75.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Laparoscopic appendectomy — Outcomes of senior trainees operating without supervision versus experienced pediatric surgeons Heron D. Baumgarten, Erin G. Brown, Kathryn W. Russell, N. Scott Adzick, Pablo Laje ⁎ Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
a r t i c l e
i n f o
Article history: Received 18 October 2018 Accepted 30 October 2018 Key words: Laparoscopic appendectomy Fellowship training Trainee autonomy Surgical independence
a b s t r a c t Aim of the study: Pediatric surgery trainees at our program are allowed to perform unsupervised laparoscopic appendectomies during their last year of training to promote independent operative decision-making skills. We reviewed the outcomes of laparoscopic appendectomies done by senior trainees without supervision and compared them to experienced pediatric surgeons. Methods: We reviewed 500 laparoscopic appendectomies performed without supervision by the last 10 pediatric surgery trainees during their last year of training (first 50 cases of each trainee). We compared the outcomes of those 500 cases to the outcomes of 200 laparoscopic appendectomies performed by eight experienced pediatric surgeons (last 25 cases of each surgeon). Data are expressed as mean (SD), unless otherwise indicated. A P value of ≤0.05 was regarded as significant. Main results: Median age in the “trainees” and “surgeons” groups was 11 (range 2–22) and 12 (2–20) years, respectively (P = 0.35). The proportion of perforated appendicitis was similar: 98/500 (19.6%) in the trainees group and 42/200 (21%) in the surgeons group, respectively (P = 0.75). Mean operative time was 41 (SD 14.5) min in the trainees group vs. 39 (SD 16.1) min in the surgeons group (P = 0.05). Minor intraoperative complications occurred in 3/500 (0.6%) cases in the trainees group vs. 1/200 (0.5%) in the surgeons group (P = 0.69). No major complications occurred in either group. Mean hospital stay was 2 (range 0.5–26) and 2.3 (range 0.5–18) days in the trainees and surgeons groups, respectively (P = 0.25). There were 13/500 vs. 5/200 readmissions (P = 0.92), and 1/500 vs. 1/200 reoperations in the trainees and surgeons groups, respectively (P = 0.91). Conclusion: Allowing senior pediatric surgery trainees to perform laparoscopic appendectomies without supervision to stimulate surgical autonomy is safe and does not compromise patient outcomes. Level of evidence: III. © 2018 Elsevier Inc. All rights reserved.
Surgical trainee autonomy is a topic of extensive discussion among surgical societies, training program directors, and trainees themselves, as training work hour restrictions and the increasingly litigious nature of medical care are resulting in the graduation of surgical trainees who are not confident in their ability to truly operate independently [1–3]. While subspecialty training may partially help with this issue, opportunities for true autonomy in surgical training programs are exceedingly rare, at least in the United States [2–6]. Despite all this, surgical trainees in all specialties are still expected to operate independently with complete confidence the day after they complete their residency or fellowship, without being given the opportunity to do so while they are still in training. The question of how to safely promote autonomy in surgical trainees is a highly relevant one at the present time, since surgical education is under more scrutiny than ever before. At our training program, ⁎ Corresponding author at: Department of Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Wood Building, Suite 5100, Philadelphia, PA 19104. Tel.: + 1 215 590 5905. E-mail address: [email protected] (P. Laje). https://doi.org/10.1016/j.jpedsurg.2018.10.092 0022-3468/© 2018 Elsevier Inc. All rights reserved.
the pediatric surgery fellows are allowed, and encouraged, to perform unsupervised laparoscopic appendectomies during their last year of training as a way to promote independent patient management and autonomous operative decision-making skills. This study aims to evaluate the safety of this educational strategy by comparing the outcomes of patients operated on by senior fellows versus those of patients operated on by experienced pediatric surgeons. 1. Materials and methods After obtaining Institutional Review Board approval (IRB 17-014551) we did a retrospective chart review of 700 laparoscopic appendectomy performed between 2011 and 2017. Those 700 included the first 50 consecutive cases performed without supervision by our most recent 10 pediatric surgery fellows (“trainees” group, n = 500) and the last 25 consecutive cases performed by each of the eight attending pediatric surgeons in our division (“surgeons” group, n = 200). The attending pediatric surgeons had between 7 and 22 years of postfellowship experience. The patients' clinical condition was not a factor in determining who
H.D. Baumgarten et al. / Journal of Pediatric Surgery 54 (2019) 276–279
did the operation. Interval and incidental appendectomies were excluded. Perforated appendicitis was defined as pus in the peritoneal cavity and/or a visible hole in the appendix. Demographic and surgical outcome data including operative time, intraoperative and postoperative complications, length of stay, readmission, postoperative abscess, and reoperation were compared between groups. Statistical significance was determined by t-test and chi-square test for means and proportions, respectively. A P value b 0.05 was considered statistically significant. 2. Results
group and 11.8% of the cases in the trainees group) (P = 0.42) [7]. There were no conversions to open appendectomy in either group. Mean operative time for all cases was 41.5 (SD: 14.5) min in the trainees group and 39.1 (SD: 16.1) min in the surgeons group (P = 0.05). The mean operative time of the cases of perforated appendicitis was 51.7 (SD: 16.9) min in the trainees group and 52.7 (SD: 17.7) min in the surgeons group (P = 0.76). Lastly, the mean operative time of the cases of nonperforated appendicitis was 39 (SD: 12.7) min in the trainees group and 35.5 (SD: 13.5) min in the surgeons group, which was statistically significant (P = 0.003). 2.3. Complications
2.1. Patient demographics The median patient age in the “trainees” and the “surgeons” groups was 11 (range 2–22) and 12 (2–20) years, respectively (P = 0.35) (Table 1). The proportion of cases of perforated appendicitis was similar in both groups: 98/500 (19.6%) in the trainees and 42/200 (21%) in the surgeons group, respectively (P = 0.75). 2.2. Diagnosis and intraoperative management The most common imaging modality for diagnosis was ultrasound, which was equally used in both groups: 76.5% (382/500) and 75.4% (151/200) of cases (trainees and surgeons groups, respectively [P = 0.84]). Magnetic resonance imaging was used in cases with an inconclusive ultrasound, although at different rates between groups: 5% versus 11.5% in the trainees and surgeons groups, respectively (P b 0.01). A similar proportion of patients in each group was transferred from other hospitals with an already performed CT-scan: 35% and 35.2% (P N 0.99). Most operations were done with the standard three-port laparoscopic technique, and occasionally with the transumbilical extracorporeal laparoscopic-assisted technique (9.5% of the cases in the surgeons
Table 1 Demographic and outcome data of patients with acute appendicitis who underwent laparoscopic appendectomy by senior pediatric surgery trainees or by experienced attending surgeons. OP: operative time. LOS: length of hospital stay. PO: postoperative. SD: standard deviation. “Trainees” Group
“Surgeons” Group
P value
There were 3 minor intraoperative complications in the trainees group (3/500, 0.6%): 1 appendiceal artery bleeding controlled with several hemostatic maneuvers and 2 partial cecectomies (stapling across the cecum) owing to a perforation at the base of the appendix. There was one minor intraoperative complication in the surgeons group (1/200, 0.5%): an omental hematoma secondary to a Veress needle injury (P = 0.69). Within the subgroup of perforated appendicitis, there were 8 postoperative abscesses out of 98 cases in the trainees group (8.2%) and 13 postoperative abscesses out of 42 cases in the surgeons group (31%) (P b 0.001). However, the incidence of postoperative abscesses requiring an intervention (needle aspiration and/or a percutaneous drain) was statistically similar between groups: 6/98 cases in the trainees group and 5/42 cases in the surgeons group (P = 0.24). 2.4. Postoperative care There was one reoperation in the trainees group (1/500, 0.2%; negative exploratory laparoscopy for abdominal pain during the original admission), and one reoperation in the surgeons group (1/200, 0.5%; lysis of adhesions for small bowel obstruction; after the initial hospital discharge) (P = 0.91). The mean hospital stay was 2 (range 0.5–26) and 2.3 (range 0.5–18) days in the trainees and surgeons groups, respectively (P = 0.25). There were 13 readmissions in the trainees group (13/500, 2.6%; abdominal pain [n = 4], constipation [n = 3], dehydration [n = 1], umbilical abscess [n = 2], postoperative abscess [n = 2] and gastroenteritis [n = 1]), and there were 5 re-admissions in the surgeons group (5/200, 2.5%; postoperative abscess [n = 2], diarrhea [n = 2] and abdominal pain [n = 1]) (P = 0.92). 3. Discussion
All cases
N = 500
N = 200
-
Age (median & range in years) OP time (mean & SD in minutes) Complications LOS (mean & SD in days) Readmissions Reoperations
11 (2 to 22) 41.5 (14.5) 3/500 2 (2.4) 13/500 1/500
12 (2 to 20) 39.1 (16.1) 1/200 2.3 (2.9) 5/200 1/200
0.35 0.05 0.69 0.25 0.92 0.91
Perforated Appendicitis Age (median & range in years) OP time (mean & SD in minutes) Complications PO abscess PO Abscesses requiring intervention LOS (mean & SD in days) Readmissions Reoperations
98 of 500 (19.6%) 10 (2 to 17) 51.7 (16.9) 2 of 98 8 of 98
42 of 200 (21%) 10 (2 to 17) 52.7 (17.7) 0/42 13/42
0.75 0.91 0.75 0.87 b0.01
6 of 98
5 of 42
0.41
5.1 (2.9) 8 of 98 0 of 98
6.8 (3.6) 5 of 42 1 of 42
b0.01 0.70 0.66
402/500 = 80.4% 11 (2 to 22) 39 (12.7) 1/402 1.3 (1.5) 5 of 402 1 of 402
158/200 = 79% 12 (3 to 20) 35.5 (13.5) 1/158 1.1 (0.7) 0 of 158 0 of 158
0.75 0.16 b0.01 0.91 0.09 0.35 0.62
Nonperforated appendicitis Age (median & range in years) OP time (mean & SD in minutes) Complications LOS (mean & SD in days) Readmissions Reoperations
277
In our current stage of surgical education with work hour restrictions that put a strict limit to what trainees are exposed to, there is increasing concern among program directors and educational councils about the preparedness of surgical trainees to operate independently with full confidence at the end of their training. Not only are trainees graduating with a smaller number of cases, but there are virtually no opportunities for surgical trainees to operate independently without the oversight of an attending surgeon, a fact that is mostly driven by medicolegal concerns and the ever-growing culture of patient safety. Numerous articles in the literature have shown that all these deficits in surgical education are real, and most importantly, that many surgical trainees do not feel ready to practice independently at the end of their training [1,4,8–10]. Several studies have evaluated the outcomes of patients treated within education environments, analyzing the effect of resident involvement in care [11]. In particular, the laparoscopic appendectomy has been identified as an important training case, and the impact of trainee participation in the OR has been reported with favorable results [12–14]. With the support of these studies, we decided to take the issue one step forward: at our training program we allow pediatric surgery fellows during their last year of training to take on the management of
278
H.D. Baumgarten et al. / Journal of Pediatric Surgery 54 (2019) 276–279
patients with acute appendicitis in a completely independent way, from diagnosis, to surgery, to postoperative care, to the postdischarge visit in the outpatient clinic. The goal of this approach is to promote autonomy at every level of surgical care and to allow the trainees to gain confidence while they are still under the umbrella of the training program. Some important technical aspects of this approach need to be clarified. First: while the attending surgeons are not involved upfront in the management of patients cared for by the trainees, they are immediately available for advice and assistance, before, during, and after the operation. Second: the senior trainees who are entitled to operate independently in our program have medical malpractice insurance and have the full support of the institution. Third: the pediatric surgery trainees in our program have completed five years of general surgery residency and are American Board of Surgery-certified General Surgeons qualified to perform a variety of pediatric surgery operations such as laparoscopic appendectomies, inguinal hernia repairs, and umbilical hernia repairs, among others. Additionally, senior trainees have completed a full year of pediatric surgery fellowship before being allowed to operate independently. In order to validate our approach from a patient safety perspective, we collected the outcome data of 10 senior pediatric surgery fellows over an 8-year period. A group of 10 fellows should be large enough to eliminate interpersonal differences and should allow obtaining generalizable data. We exclusively evaluated the first 50 cases of each fellow in order to focus on the early stages of the learning curve, since beyond 40 to 50 cases it is likely that the learning curve of managing acute appendicitis independently has reached a plateau. We compared the outcomes of patients operated on by senior trainees versus patients operated on by experienced attending surgeons and found no clinically relevant differences in any of the commonly assessed surgical outcome parameters. From a patient safety perspective, the most important finding of the study was that there were no statistically significant differences in the incidence of complications during or after the operation, in the number of reoperations, or in the need for readmission between groups. Our study demonstrated that allowing senior pediatric surgery trainees to manage and operate children with acute appendicitis without supervision is safe, with a remarkably low complication rate and outcomes that are comparable to those of experienced surgeons. But what if the study showed that the outcomes were different in those cases operated on by senior trainees? As long as the outcomes for trainees meet the same surgical standards expected for experienced surgeons, minor differences (e.g. a slightly longer operative time) should be acceptable in a training program that wants to truly prepare their trainees to operate independently. In contrast, training programs that do not allow trainees to operate independently generate trainees that are less experienced and possibly less safe at the end of their training, a cost that is paid by the trainees' first posttraining patients. It could be argued that the first patients of an independent surgeon will have a higher risk of complications either way: during the training (with our approach), or after the training (with the standard approach). But from the perspective of a trainee, it is probably better to start developing an autonomous practice while still under the protection of the training program. The idea of letting trainees do operations independently is not new. There are a number of publications in the literature that report acceptable outcome from pilot programs in which trainees take autonomous surgical care of patients, with universally positive opinions from the participating trainees [15,16]. In the reported settings, however, the attending surgeon of record supervised the case in some capacity, at least by discussing the surgical plan before and after the procedure. In our program, in contrast, the senior trainees play 100% the role of an attending surgeon since the actual attending surgeon on call is not aware of the cases being managed by the trainees (unless, as described before, the input of the attending surgeon is requested by the trainee).
It is very clear to us that the experience of managing acute appendicitis independently cannot be translated to the readiness to autonomously perform more complex cases. Surgical training is a never-ending process, and true readiness requires good judgment and experience that exceed residency and fellowship. That being said, we believe that our approach has a strong educational value. Surgical training is changing, mostly in ways that negatively impact the operative experience of trainees [17]. It is critical that surgical training programs find ways to reverse the trend created by “well-intended-but-not-applicable” policies that are detrimental to a proper surgical training [18]. A limitation of this study is the inability to conclude that our senior trainees increased their self-confidence by operating independently simply because there is no quantitative way to objectively measure confidence [19]. However, all our trainees take up the opportunity and responsibility of managing patients independently, and consistently regard this as a uniquely positive educational experience. In conclusion, allowing senior pediatric surgery trainees to manage and operate on patients with acute appendicitis without the intervention of an attending surgeon is safe and does not compromise patient outcomes. While there are no quantitative data to prove it, we believe that this approach has educational value when it comes to preparing trainees for posttraining independent practice, and that is how our trainees perceive it. CRediT authorship contribution statement Heron D. Baumgarten: Conceptualization, Investigation, Formal analysis, Writing - review & editing. Erin G. Brown: Conceptualization, Investigation, Formal analysis, Writing - original draft, Writing - review & editing. Kathryn W. Russell: Formal analysis, Writing - review & editing. N. Scott Adzick: Formal analysis, Writing - review & editing. Pablo Laje: Conceptualization, Investigation, Formal analysis, Writing - original draft, Writing - review & editing. Appendix A. Discussion Presenter - Heron Baumgarten Q: Andrew Holland, Sydney, Australia • I very much support the concept of trainees operating independently but I was a little concerned when you mentioned that potentially a patient could be in the operating theatre with a trainee performing surgery without the attending consultant even being aware. On the other side of the fence it is much easier to help someone out with an unexpected finding if you at least know about the case beforehand. A (Heron Baumgarten CHOP, Philadelphia) • I think the purpose of this is to truly have an independent and autonomous operative experience. Additionally I would say that senior fellows are board certified in general surgery so they would potentially be performing these cases in practice already if they had not pursued paediatric surgery fellowship and just gone straight into the community and further there is always an attending consultant on call who is ready to come in for other cases or bigger cases so there is always someone readily available to help. Q: Andrew Holland, Sydney, Australia • I appreciate someone is available, but it's a lot easier to offer or provide help if you at least know about the patient.
References [1] Fonseca AL, Reddy V, Longo WE, et al. Graduating general surgery resident operative confidence: perspective from a national survey. J Surg Res 2014;190:419–28. [2] Malangoni MA, Biester TW, Jones AT, et al. Operative experience of surgery residents: trends and challenges. J Surg Educ 2013;70:783–8.
H.D. Baumgarten et al. / Journal of Pediatric Surgery 54 (2019) 276–279 [3] Mattar SG, Alseidi AA, Jones DB, et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg 2013;258:440–9. [4] Chen XP, Sullivan AM, Alseidi A, et al. Assessing residents' readiness for or autonomy: a qualitative descriptive study of expert surgical teachers' best practices. J Surg Educ 2017;74:e15–21. [5] Klingensmith ME, Cogbill TH, Luchette F, et al. Factors influencing the decision of surgery residency graduates to pursue general surgery practice versus fellowship. Ann Surg 2015;262:449–55. [6] Meyerson SL, Teitelbaum EN, George BC, et al. Defining the autonomy gap: when expectations do not meet reality in the operating room. J Surg Educ 2014;71:e64–72. [7] Perea L, Peranteau WH, Laje P. Transumbilical extracorporeal laparoscopic-assisted appendectomy. J Pediatr Surg 2018;53:256–9. [8] Picarella EA, Simmons JD, Borman KR, et al. "Do one, teach one" the new paradigm in general surgery residency training. J Surg Educ 2011;68:126–9. [9] Kairys JC, McGuire K, Crawford AG, et al. Cumulative operative experience is decreasing during general surgery residency: a worrisome trend for surgical trainees? J Am Coll Surg 2008;206:804–11 [discussion 811-3]. [10] Bell Jr RH. Why Johnny cannot operate. Surgery 2009;146:533–42. [11] Davis Jr SS, Husain FA, Lin E, et al. Resident participation in index laparoscopic general surgical cases: impact of the learning environment on surgical outcomes. J Am Coll Surg 2013;216:96–104.
279
[12] Naiditch JA, Lautz TB, Raval MV, et al. Effect of resident postgraduate year on outcomes after laparoscopic appendectomy for appendicitis in children. J Laparoendosc Adv Surg Tech A 2012;22:715–9. [13] Perry ZH, Netz U, Mizrahi S, et al. Laparoscopic appendectomy as an initial step in independent laparoscopic surgery by surgical residents. J Laparoendosc Adv Surg Tech A 2010;20:447–50. [14] Singh P, Turner EJ, Cornish J, et al. Safety assessment of resident grade and supervision level during emergency appendectomy: analysis of a multicenter, prospective study. Surgery 2014;156:28–38. [15] Wojcik BM, Fong ZV, Patel MS, et al. The resident-run minor surgery clinic: a pilot study to safely increase operative autonomy. J Surg Educ 2016;73: e142–9. [16] Day KM, Scott JK, Gao L, et al. Progressive surgical autonomy in a plastic surgery resident clinic. Plast Reconstr Surg Glob Open 2017;5(5):e1318. [17] Hirschl RB. The making of a surgeon: 10,000 hours? J Pediatr Surg 2015;50(5): 699–706. [18] Philibert I, Nasca T, Brigham T, et al. Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships? Annu Rev Med 2013;64:467–83. [19] Elfenbein DM. Confidence crisis among general surgery residents: a systematic review and qualitative discourse analysis. JAMA Surg 2016;151: 1166–75.