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Resident participation in laparoscopic hysterectomy: impact of trainee involvement on operative times and surgical outcomes
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GYNECOLOGY
Resident participation in laparoscopic hysterectomy: impact of trainee involvement on operative times and surgical outcomes Elena Igwe, MD; Enrique Hernandez, MD; Stephen Rose, MD; Shitanshu Uppal, MD OBJECTIVE: The purpose of this study was to determine the impact of resident involvement on morbidity after total laparoscopic hysterectomy for benign disease. STUDY DESIGN: We performed a retrospective review of a National
Surgical Quality Improvement Program database of total laparoscopic hysterectomy for benign disease that was performed with resident involvement vs attending alone between Jan. 1, 2008, and Dec. 31, 2011. Surgical operative times and morbidity and mortality rates were compared. Binary logistic regression was used to control for covariates that were significant on univariate analysis (P < .05). RESULTS: A total of 3441 patients were identified as having undergone
a total laparoscopic hysterectomy for benign disease. The mean age of patients was 47.4 11.1 years; the mean body mass index was 30.6 7.9 kg/m2. A resident participated in 1591 of cases (46.2%); 1850 of the procedures (53.8%) were done by an attending physician alone. Cases with resident involvement had higher mean age, Charlson morbidity scoring, and American Society of Anesthesiologists classification and were more likely to be inpatient cases. With resident involvement, the mean operative time was increased (179.29 vs 135.46 minutes; P < .0001). There were no differences in the rates of experiencing at least 1 complication (6.8% for resident involvement vs
5.4% for attending alone; P ¼ .5), composite severe morbidity (1.3% resident vs 1.0% attending alone), or 30-day mortality rate (0% resident vs 0.1% attending alone). Additionally, there were no differences between groups in the infectious, wound, neurorenal, thromboembolic, septic, and cardiopulmonary complications. Cases with resident involvement had significantly increased rates of postoperative transfusion of packed red blood cells (2% vs 0.4%; P < .0001), reoperation (2.2% vs 1.3%; P ¼ .048), and a 30-day readmission (5.5% vs 2.9%; P ¼ .015). In models that were adjusted for factors that differed between the 2 groups, cases with resident involvement had increased odds of receiving postoperative blood transfusion (odds ratio [OR], 4.98; 95% confidence interval [CI], 2.18e11.33), reoperation (OR, 1.7, 95% CI, 1.01e2.89) and readmission (OR, 1.93, 95% CI, 1.09e3.42). CONCLUSION: Resident involvement in total laparoscopic hysterectomy for benign disease was associated with clinically appreciable longer surgical time and small differences in the rates of postoperative transfusions, reoperation, and readmission. However, the rates of overall complications, severe complications, and 30-day mortality rate remain comparable.
Key words: laparoscopic hysterectomy, NSQIP, resident involvement, surgical outcome
Cite this article as: Igwe E, Hernandez E, Rose S, et al. Resident participation in laparoscopic hysterectomy: impact of trainee involvement on operative times and surgical outcomes. Am J Obstet Gynecol 2014;211:484.e1-7.
T
he Halstedian theory of residency and fellow training, based on a continuing learning process with gradual increases in responsibility, is currently the basis of all US training
programs.1 In an era of enhanced emphasis on patient safety, it is of paramount importance to understand how trainee involvement affects surgical outcomes. This concern has been well
studied in the vascular, orthopedic, and general surgery fields. Most researchers have come to a similar conclusion that trainee involvement leads to increased surgical times along with clinically
From the Department of Obstetrics and Gynecology, Temple University Hospital, Philadelphia, PA (Drs Igwe and Hernandez), and Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI (Drs Rose and Uppal). Received April 1, 2014; revised May 30, 2014; accepted June 11, 2014. The authors report no conflict of interest. The American College of Surgeons (ACS) intermittently audits the data to ensure its integrity. The ACS National Surgical Quality Improvement Program and the hospitals participating in the ACS National Surgical Quality Improvement Program are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. Presented as Oral Plenary at the 40th Annual Scientific Meeting of the Society of Gynecologic Surgeons, Scottsdale, AZ, March 24-26, 2014. Corresponding author: Shitanshu Uppal, MD. [email protected] 0002-9378/$36.00 ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.06.024
See related editorial, page 444
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ajog.org insignificant increases in minor morbidities. However, no appreciable effect on mortality rate has been reported.2-8 Among reproductive-aged women, hysterectomy is the second most frequent surgical procedure. With the growth of minimally invasive procedures, of the approximately 600,000 hysterectomies performed each year in the United States, 12% are being performed laparoscopically.9,10 The laparoscopic hysterectomy has been shown consistently to decrease postoperative pain, reduce postoperative morbidity, and decrease hospital stay.11-13 The obvious advantages of this desirable approach make it imperative that obstetrics and gynecology residents receive adequate exposure and experience to this technique. To find a balance between patient safety and resident education, the direct effects of resident participation in the operating room must be scrutinized by evaluation of postoperative outcomes. This current study aimed to investigate the effect of resident involvement in benign laparoscopic hysterectomies on the postoperative surgical outcomes.
M ATERIALS
AND
M ETHODS
Data sources and patient population The National Surgical Quality Improvement Program (NSQIP) database was analyzed for this study. NSQIP is an American College of Surgeons (ACS) initiative that allows for the collection of risk-adjusted data to facilitate the assessment of outcome measures after surgery. A trained surgical clinical reviewer prospectively collects the NSQIP data. Validated data from patients’ medical charts allows quantification of 30-day, risk-adjusted surgical outcomes, which includes after discharge at which time approximately 50% of complications occur. The NSQIP dataset includes data for patients who underwent a total laparoscopic hysterectomy for a benign disease from Jan. 1, 2008 to Dec. 31, 2011. Patients who underwent supracervical or laparoscopic-assisted vaginal hysterectomy were excluded from the analysis. The human subjects committee at the University of Wisconsin policy on publicly available datasets with deidentified
patient information makes this study exempt from institutional review board review.
Data collection and analysis From the NSQIP database, we abstracted the details of patients’ preoperative laboratory values, comorbidities, details of the procedure, postoperative complications, and death. The Charlson Index, a measure of comorbidity, was derived from recorded medical history in our cohort. Medical comorbidities were assigned a score (Charlson score) according to the method described by Charlson et al14,15 and the Deyo et al16 modification for use with administrative databases.16 The Charlson Index has been previously studied in a gynecologic population.17,18 Postoperative complications were then classified into the following categories; vascular (bleeding that requires reoperation, deep vein thrombosis), cardiopulmonary (pneumonia, pulmonary embolism, reintubation, prolonged intubation, myocardial infarction, and cardiac arrest), wound (superficial or deep surgical site infections or wound dehiscence), infectious (superficial, deep and organ space surgical site infections, urinary tract infection, pneumonia, systemic sepsis, and septic shock), neurorenal (acute renal failure, progressive renal insufficiency, urinary tract infections, cardiovascular accident/stroke, coma >24 hours, peripheral nerve injury), thromboembolic (pulmonary embolism and deep vein thrombosis), and transfusion (any units of blood transfused). The complexity of surgery was determined by the total relative value units assigned to the procedure. Additionally, the database was queried for Current Procedural Terminology codes 44180 and 58660, which are used in circumstances of extensive lysis of adhesions. Cases with these additional procedural codes were labeled as requiring “extensive lysis of adhesions.” Readmission data were available only for the year 2011. Three separate variables were created to quantify the number of postoperative complications that were experienced by the patients. These 3 variables were 1 complications (patients who experienced at least 1 complication in any domain),
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3 complications (patients who experienced 3 complications in any domain), and severe morbidity (patients who experienced 1 of the following complications: organ space surgical site infection, wound dehiscence, cerebrovascular accident with coma lasting >24 hours, pulmonary embolism, ventilator support for >48 hours, progressive renal insufficiency that required dialysis, or septic shock).
Analysis of the level of training NSQIP variable “Level of Residency Supervision” was used to determine the role of the residents in the surgery. The dataset provides information on the highest level of supervision provided by the attending staff surgeon for the case. For the cases with resident involvement, NSQIP variable “Highest Level of Resident Surgeon” was used to determine the postgraduate year of training. Trainees in the first 2 years of training were categorized as “junior residents” and all other postgraduate-year trainees were categorized as “senior residents.” Statistical analysis Mean and median values were used to describe continuous data, with discrete variables displayed as totals and frequencies. For univariate analyses, 2-tailed t tests and Mann-Whitney U tests were used to compare continuous data; the Fisher exact and c2 tests were used for categoric variables, as appropriate. Binary logistic regression was used to control for covariates that were noted to be significant on univariate analysis (P < .05). Point estimates are expressed as odds ratios (ORs) and 95% confidence intervals (95% CI) are provided.
R ESULTS A total of 5478 patients were identified as having undergone laparoscopic hysterectomy with/without bilateral salpingooophorectomy. After the exclusion of 1910 cases in which the data for the resident/attending involvement was not available and 127 cases with discrepant information, a total of 3441 patients were considered for analysis. From these, 480 cases did not have details of the postgraduate year level and were not
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FIGURE 1
Total number of cases by resident involvement
Igwe. Resident participation in laparoscopic hysterectomy. Am J Obstet Gynecol 2014.
considered in the subgroup analysis and during the logistic regression modeling at which time postgraduate-year level was considered a confounding factor. Figure 1 provides the distribution of trainees with regard to the year of training. The details of the breakdown of the Current Procedural Terminology codes that were retrieved from the NSQIP database are summarized in Table 1.
Patient demographics and baseline comorbidity characteristics The mean age of the patients in this cohort was 47.43 11.06 years, and the mean body mass index was 30.62 7.92 kg/m2. Data for the preoperative comorbidities and demographics are listed in Table 2. Cases with resident involvement had statistically significantly higher mean
age, Charlson morbidity scoring, percentage of patients who underwent inpatient surgery, and higher American Society of Anesthesiologists classification. The minimal difference in the mean Charlson score (022 vs 069), however, is not clinically relevant. However, no difference was noted in the body mass index, percentage of cases done as emergency, weight loss of >10% in last 6 months, patients who underwent surgery in the last 30 days, and various preoperative laboratory parameters that included hematocrit, albumin, and platelet levels. Surgical complexity, as determined by the billed total relative value units for the procedures, was noted marginally higher in resident group (0.68 units), which is unlikely to be clinically relevant. The number of cases that required extensive lysis of adhesions was similar in the 2 groups: attending alone 81 cases (4.4 %) vs resident involved 63 cases (4%); P ¼ .55.
Operative times The mean operative time in the group with resident involvement was 43.83 minutes longer than the cases with no resident involvement (179.29 vs 135.46 minutes; P < .0001), and the total duration of anesthesia was 56.97 minutes longer in the resident group (240.47 vs 183.50 minutes; P < .0001). Subanalysis of operative times between the junior resident and senior resident groups demonstrated no difference in the operative time (178 vs 181 minutes; P ¼ .87), and each group had statistically higher operative time
compared with attending-alone group (Figure 2).
Reoperation rates The overall rate of reoperation was 1.7%; 59 patients underwent reoperation from the entire cohort. The cases with resident involvement had higher reoperation rate (2.2% vs 1.3%; P ¼ .048). On subgroup analysis, the readmission rate was noted to be 1.6% for junior resident, 2.3% for senior resident, and 1.3% for the attending-alone groups (P ¼ .097). Readmission rates Readmission rates were calculated on 2011 data. Cases with resident involvement had a higher rate of readmission (5.5% vs 2.9%; P ¼ .015). On subgroup analysis, the readmission rate was noted to be 4.2% for junior resident, 5.6% for senior resident, and 2.9% for the attending-alone groups (P ¼ .078). Complications The overall rate of experiencing at least 1 complication in this cohort was 5.4% for the attending-alone and 6.8% for the resident-involved groups (P ¼ .52). There was no difference in the infectious, wound, neurorenal, thromboembolic, septic, and cardiopulmonary complications. However, a higher incidence of patients in the resident-involved group underwent postoperative transfusion of packed red blood cells (2% vs 0.4%). Additionally, the overall composite variable for severe morbidity was similar between the 2 groups (1% vs 1.3%; P ¼ .26; Table 3). Comparison of the complications between the junior
TABLE 1
Benign laparoscopic hysterectomy Current Procedural Terminology codes from the National Surgical Quality Improvement Program Current Procedural Terminology code: laparoscopic hysterectomy
Total cases in the National Surgical Quality Improvement Program (n [ 5478), n
Cases with available resident participation data (n [ 3441), n
Resident participation, %
58570 (<250 g)
1613
1119
37.2
58571 (<250 g with ovaries)
3013
1732
50.3
58572 (>250 g)
531
373
52.3
58573 (>250 g with ovaries)
321
210
50.0
Igwe. Resident participation in laparoscopic hysterectomy. Am J Obstet Gynecol 2014.
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ajog.org resident and senior resident groups did not demonstrate any difference in the rate of complications (Table 4).
Multivariate regression model On binary logistic regression modeling, after being controlled for factors significantly different between the 2 groups at significance level of 0.1 (age, Charlson score, and complexity of surgery), resident involvement remained the significant factor with approximately 5 times higher risk of receiving postoperative blood transfusion (OR, 4.98; 95% CI, 2.18e11.33; P < .0001). A second regression model was constructed for reoperation and readmission rates. Resident involvement remained significant, with nearly twice the reoperation risk (OR, 1.7; 95% CI, 1.01e2.89) and readmission risk (OR, 1.93; 95% CI, 1.09e3.42; P ¼ .025).
TABLE 2
Baseline preoperative parameters between the 2 groups Attending alone (n [ 1850)
Variable
Resident involved (n [ 1591)
P value
Patient demographics 45.61 10.61
Age, ya Inpatient, n (%) Emergency, n (%)
48.70 10.99
< .001
919 (49.7)
878 (55.2)
.01
2 (0.1)
5 (0.3)
.169
459 (24.8%)
300 (18.9%)
Comorbidities and risk factors Smoker, % Charlson score
0.22 0.79
a
Body mass index, kg/m
2a
30.56 7.56
0.69 1.37
< .001 < .001
30.7 8.34
.59 < .01
American Society of Anesthesiologists class, n (%)
C OMMENT The apprenticeship model of training demands that the attending surgeon trains residents with the goal of the resident becoming autonomous. Although this goal has not changed over the past century, stricter patient safety measures have led to heightened concern in outcomes in procedures that involve trainees. We studied these concerns in the field of benign gynecology, by analyzing laparoscopic hysterectomy cases with resident involvement vs attending alone. In the current study of the data from 3441 patients that were considered for analysis from NSQIP, mean operative times were increased statistically significantly by nearly 45 minutes in cases with resident involvement. In addition, the total duration of anesthesia was nearly 1 hour longer on an average. Analysis of the outcomes indicated that the laparoscopic hysterectomies with resident involvement are just as safe as those performed by an attending alone. However, cases with resident involvement had a greater incidence of postoperative transfusion of packed red blood cells, increased reoperation rate, and increased readmission rates. Other studies in the field of general surgery have evaluated operative times
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1
242 (13.1)
161 (10.1)
2
1313 (71.1)
1061 (66.7)
3
285 (15.45)
357 (22.4)
4
6 (0.3)
12 (0.8)
Surgery in last 30 days, n (%)
5 (0.3)
10 (0.6)
Weight loss >10% in last 6 mo, n (%)
4 (0.2)
6 (0.4)
.09
Preoperative laboratory profilea 38.79 3.81
38.54 4.02
.07
278.55 73.49
273.03 72.38
.03
4.13 0.39
4.13 0.42
.84
Creatinine, mg/dL
0.78 0.46
0.79 0.41
.45
International normalized ratio
1.04 0.48
1.02 0.16
.49
Hematocrit, % Platelets, 10 /L 9
Albumin, g/L
Surgical complexity
a
Extensive lysis of adhesions, n (%)
81 (4.4)
63 (4)
.55
Relative value unitsa
21.25 8.35
21.93 8.29
.02
Data are given as mean SD.
Igwe. Resident participation in laparoscopic hysterectomy. Am J Obstet Gynecol 2014.
in cases with resident involvement and reported similar findings. HernandezIrizarry et al5 examined mean operative times with resident involvement for 6223 laparoscopic hernia repairs from the ACS-NSQIP from 2007-2009. Operative times were increased significantly from 45-64 minutes when residents were involved. Another group used the ACSNSQIP database for 3 general surgery procedures (laparoscopic appendectomy, cholecystectomy, and open inguinal
hernia repairs) that were performed from 2005-2008.6 There was a significant increase in operative times with resident involvement, on average, 16.6 minutes longer. These findings are in line with our current study of average increase in time of 43.83 minutes in laparoscopic hysterectomies. Although the increase in times in our study is numerically higher, the percentage increase of 25% in time is comparable with the general surgery studies described. This increase in
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FIGURE 2
Operative time by resident involvement
Igwe. Resident participation in laparoscopic hysterectomy. Am J Obstet Gynecol 2014.
operating room time may be a reflection of the training environment, which involves surgical residents, anesthesia residents, medical students, and surgical tech students in the operating room. The financial implications of the increased operative time can be significant. One
group calculated that the estimated financial costs of a 13-minute increase in operative time with resident involvement (when extrapolated to all general surgery residents across the country who graduate with approximately 1000 cases) nears $53 million annually.19 Although the precise reasons could not be ascertained from NSQIP database, our study highlights the importance of further research to find out the causes of the operating room time increases with trainee involvement. Advani et al8 looked at laparoscopic appendectomy in uncomplicated appendicitis with regard to resident involvement. They found an increase in serious morbidity (1.8% vs 1.3%; P ¼.01) and an increase in overall morbidity (3.7% vs 2.8%; P ¼ .004). Although these numbers were statistically significant, they were deemed not clinically significant. Another study that included general surgical and vascular operations found that resident involvement was associated with statistically higher morbidity rates (OR, 1.07; 95% CI, 1.02e1.10) but
decreased mortality rates (OR, 0.97; 95% CI, 0.9e1.05) in all procedures, with no true associated clinical significance.7 In our study, the only complications that we found to be increased significantly with resident involvement was transfusion of packed red blood cells (OR, 4.98), reoperation rate (OR, 1.8) and 30-day readmission rates (OR, 1.9). No other difference was identified in morbidity or mortality rate. The subanalysis based on resident training level did not change these findings. Literature with the involvement of residents during gynecologic surgery is sparse. Akingba et al20 retrospectively reviewed 424 cases of women who underwent benign hysterectomies and found no significant difference in postoperative complications other than seroma formation in the attending-only group. This study was not powered adequately to evaluate laparoscopic cases, because only 8.25% of hysterectomies were laparoscopic. In addition, they reported that the degree of
TABLE 3
Complications, morbidity, and death with attending alone vs resident involvement Complication
Attending alone (n [ 1850), n (%)
Resident involved (n [ 1591), n (%)
100 (5.4)
108 (6.8)
P value
Unadjusted odds ratio (95% confidence interval)
No. of complications 1 3 Severe morbidity Death at 30 d
0 18 (1) 1 (0.1)
5 (0.3) 20 (1.3) 0
.052 NA .26 NA
NS NA NA NA
Type of complication Wound Cardiopulmonary
14 (0.8)
21 (1.3)
.07
NS
9 (0.5)
11 (0.7)
.29
NS
86 (4.6)
67 (4.2)
.29
NS
4 (0.2)
8 (0.5)
.12
NS
58 (3.1)
39 (2.5)
.13
NS
Transfusion >4 units packed red blood cells
7 (0.4)
32 (2.0)
< .0001
Septic
8 (0.4)
7 (0.4)
.59
NS
Reoperation
24 (1.3)
35 (2.2)
.048
1.7 (1.01e2.89)
Readmission (n ¼ 1213)
19 (2.9)
34 (5.5)
.015
1.94 (1.09e3.44)
Infectious Thromboembolic Neurorenal
NA, not available; NS, not significant. Igwe. Resident participation in laparoscopic hysterectomy. Am J Obstet Gynecol 2014.
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TABLE 4
Complications, morbidity, and death with junior vs senior resident involvement Complication
Attending alone (n [ 1850), n (%)
Junior resident involved (n [ 255), n (%)
Senior resident involved (n [ 1252), n (%)
P value
No. of complications
100 (5.4)
17 (6.7)
86 (6.9)
.22
5 (0.4)
NS
17 (1.4)
.33
1
0
3
18 (1)
0 1 (0.4)
Severe morbidity
1 (0.1)
Death at 30 d
14 (0.8)
6 (2.4)
15 (1.2)
.05
9 (0.5)
1 (0.4)
10 (0.8)
.491
86 (4.6)
11 (4.3)
52 (4.2)
.80
8 (0.6)
.09
Type of complication Wound Cardiopulmonary Infectious
4 (0.2)
0
0
0
.67
58 (3.1)
3 (1.2)
34 (2.7)
.20
Thromboembolic
7 (0.4)
7 (2.7)
24 (1.9)
.001
Neurorenal
8 (0.4)
0
7 (0.6)
.47
26 (5.6)
.078
Readmission (n ¼ 1157)
19 (2.9)
4 (4.2)
Igwe. Resident participation in laparoscopic hysterectomy. Am J Obstet Gynecol 2014.
attending experience correlated with shorter operative times. Although this study does not compare well with ours, because we solely investigated laparoscopic hysterectomies and used a much larger database, the morbidity and mortality results are in line with the findings of others. Our study has significant limitations that are largely the limitations of the NSQIP database. First, the NSQIP database does not capture intraoperative complications; therefore, any conclusions of intraoperative complications that cause increased bleeding and increased transfusion are purely speculative. However, increased reoperation rate in cases that involved with residents and a longer operative time do point towards increased intraoperative complications as a potential cause. Nevertheless, the overall rates of reoperation and readmission are so low (in the range of 2%) that this does not alter the overall conclusion of our study. In addition, NSQIP data does not provide the reason for reoperation or readmission; therefore, it is difficult to assess the exact reasons of reoperation or readmission, which may or may not be associated with resident involvement. Moreover, we did not have the ability to stratify residents by
program characteristics, most notably teaching vs nonteaching, to control for attending surgeon experience or presence/absence of additional trainees in the operating room, and to determine the degree of resident involvement, such as by holding the laparoscope vs being the primary surgeon. One of the most concerning limitations of NSQIP data is the lack of statistics on the rate of conversion of laparoscopic cases to open. Lack of this information could significantly change the outcomes of our study. The type of total laparoscopic hysterectomy performed (robotic vs conventional laparoscopy) also could not be assessed. A higher robotic hysterectomy proportion in either group could have resulted in increased operative time related to robotic docking. Although these limitations of the NSQIP database leave further questions to be answered in future studies, strengths of our study include the use of standardized definitions for patient characteristics, clinical outcomes, and the ability to risk adjust for patient comorbidities and to grant equal comparison between groups. This current study is the first in the benign gynecologic field to use this database to examine outcomes with resident involvement.
In conclusion, as far as the overall safety to resident involvement is concerned, our study highlights that this can be done safely in gynecologic training. Although laparoscopic hysterectomy may take longer to accomplish with a resident involved, the safety profile is largely unchanged. It is paramount that further studies are carried out to ascertain the role of adjuncts to training, such as simulation laboratories, video learning to assist in training and skills assessment, and presurgery debriefing to reduce the total operating room time. REFERENCES 1. Cameron JL. William Stewart Halsted: our surgical heritage. Ann Surg 1997;225:445-58. 2. Kern SQ, Lustik MB, McMann LP, Thibault GP, Sterbis JR. Comparison of outcomes after minimally invasive versus open partial nephrectomy with respect to trainee involvement utilizing the American College of Surgeons National Surgical Quality Improvement Program. J Endourol 2014;28:40-7. 3. Schoenfeld AJ, Serrano JA, Waterman BR, Bader JO, Belmont PJ Jr. The impact of resident involvement on post-operative morbidity and mortality following orthopaedic procedures: a study of 43,343 cases. Arch Orthop Trauma Surg 2013;133:1483-91. 4. Castleberry AW, Clary BM, Migaly J, et al. Resident education in the era of patient safety: a
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nationwide analysis of outcomes and complications in resident-assisted oncologic surgery. Ann Surg Oncol 2013;20:3715-24. 5. Hernandez-Irizarry R, Zendejas B, Ali SM, Lohse CM, Farley DR. Impact of resident participation on laparoscopic inguinal hernia repairs: are residents slowing us down? J Surg Educ 2012;69:746-52. 6. Papandria D, Rhee D, Ortega G, et al. Assessing trainee impact on operative time for common general surgical procedures in ACSNSQIP. J Surg Educ 2012;69:149-55. 7. Raval MV, Wang X, Cohen ME, et al. The influence of resident involvement on surgical outcomes. J Am Coll Surg 2011;212:889-98. 8. Advani V, Ahad S, Gonczy C, Markwell S, Hassan I. Does resident involvement effect surgical times and complication rates during laparoscopic appendectomy for uncomplicated appendicitis? An analysis of 16,849 cases from the ACS-NSQIP. Am J Surg 2012;203:347-52. 9. Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient hysterectomy surveillance in the United States, 2000-2004. Am J Obstet Gynecol 2008;198:34.e1-7.
ajog.org 10. Jacoby VL, Autry A, Jacobson G, Domush R, Nakagawa S, Jacoby A. Nationwide use of laparoscopic hysterectomy compared with abdominal and vaginal approaches. Obstet Gynecol 2009;114:1041-8. 11. Nieboer TE, Johnson N, Lethaby A, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2009:CD003677. 12. Gendy R, Walsh CA, Walsh SR, Karantanis E. Vaginal hysterectomy versus total laparoscopic hysterectomy for benign disease: a metaanalysis of randomized controlled trials. Am J Obstet Gynecol 2011;204:388. e1-8. 13. American College of Obstetricians and Gynecologists. Choosing the route of hysterectomy for benign disease. ACOG Committee Opinion no. 444. Obstet Gynecol 2009;114: 1156-8. 14. Charlson M, Peterson J, Szatrowski TP, MacKenzie R, Gold J. Long-term prognosis after peri-operative cardiac complications. J Clin Epidemiol 1994;47:1389-400. 15. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying
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prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373-83. 16. Deyo RA, Cherkin DC, Ciol MA. Adapting a Clinical Comorbidity Index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992;45:613-9. 17. Frumovitz M, Sun CC, Jhingran A, et al. Radical hysterectomy in obese and morbidly obese women with cervical cancer. Obstet Gynecol 2008;112:899-905. 18. Sperling C, Noer MC, Christensen IJ, Nielsen ML, Lidegaard O, Hogdall C. Comorbidity is an independent prognostic factor for the survival of ovarian cancer: a Danish registerbased cohort study from a clinical database. Gynecol Oncol 2013;129:97-102. 19. Bridges M, Diamond DL. The financial impact of teaching surgical residents in the operating room. Am J Surg 1999;177:28-32. 20. Akingba DH, Deniseiko-Sanses TV, Melick CF, Ellerkmann RM, Matsuo K. Outcomes of hysterectomies performed by supervised residents vs those performed by attendings alone. Am J Obstet Gynecol 2008;199:673.e1-6.
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GYNECOLOGY
Resident participation in laparoscopic hysterectomy: impact of trainee involvement on operative times and surgical outcomes Elena Igwe, MD; Enrique Hernandez, MD; Stephen Rose, MD; Shitanshu Uppal, MD OBJECTIVE: The purpose of this study was to determine the impact of resident involvement on morbidity after total laparoscopic hysterectomy for benign disease. STUDY DESIGN: We performed a retrospective review of a National
Surgical Quality Improvement Program database of total laparoscopic hysterectomy for benign disease that was performed with resident involvement vs attending alone between Jan. 1, 2008, and Dec. 31, 2011. Surgical operative times and morbidity and mortality rates were compared. Binary logistic regression was used to control for covariates that were significant on univariate analysis (P < .05). RESULTS: A total of 3441 patients were identified as having undergone
a total laparoscopic hysterectomy for benign disease. The mean age of patients was 47.4 11.1 years; the mean body mass index was 30.6 7.9 kg/m2. A resident participated in 1591 of cases (46.2%); 1850 of the procedures (53.8%) were done by an attending physician alone. Cases with resident involvement had higher mean age, Charlson morbidity scoring, and American Society of Anesthesiologists classification and were more likely to be inpatient cases. With resident involvement, the mean operative time was increased (179.29 vs 135.46 minutes; P < .0001). There were no differences in the rates of experiencing at least 1 complication (6.8% for resident involvement vs
5.4% for attending alone; P ¼ .5), composite severe morbidity (1.3% resident vs 1.0% attending alone), or 30-day mortality rate (0% resident vs 0.1% attending alone). Additionally, there were no differences between groups in the infectious, wound, neurorenal, thromboembolic, septic, and cardiopulmonary complications. Cases with resident involvement had significantly increased rates of postoperative transfusion of packed red blood cells (2% vs 0.4%; P < .0001), reoperation (2.2% vs 1.3%; P ¼ .048), and a 30-day readmission (5.5% vs 2.9%; P ¼ .015). In models that were adjusted for factors that differed between the 2 groups, cases with resident involvement had increased odds of receiving postoperative blood transfusion (odds ratio [OR], 4.98; 95% confidence interval [CI], 2.18e11.33), reoperation (OR, 1.7, 95% CI, 1.01e2.89) and readmission (OR, 1.93, 95% CI, 1.09e3.42). CONCLUSION: Resident involvement in total laparoscopic hysterectomy for benign disease was associated with clinically appreciable longer surgical time and small differences in the rates of postoperative transfusions, reoperation, and readmission. However, the rates of overall complications, severe complications, and 30-day mortality rate remain comparable.
Key words: laparoscopic hysterectomy, NSQIP, resident involvement, surgical outcome
Cite this article as: Igwe E, Hernandez E, Rose S, et al. Resident participation in laparoscopic hysterectomy: impact of trainee involvement on operative times and surgical outcomes. Am J Obstet Gynecol 2014;211:484.e1-7.
T
he Halstedian theory of residency and fellow training, based on a continuing learning process with gradual increases in responsibility, is currently the basis of all US training
programs.1 In an era of enhanced emphasis on patient safety, it is of paramount importance to understand how trainee involvement affects surgical outcomes. This concern has been well
studied in the vascular, orthopedic, and general surgery fields. Most researchers have come to a similar conclusion that trainee involvement leads to increased surgical times along with clinically
From the Department of Obstetrics and Gynecology, Temple University Hospital, Philadelphia, PA (Drs Igwe and Hernandez), and Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI (Drs Rose and Uppal). Received April 1, 2014; revised May 30, 2014; accepted June 11, 2014. The authors report no conflict of interest. The American College of Surgeons (ACS) intermittently audits the data to ensure its integrity. The ACS National Surgical Quality Improvement Program and the hospitals participating in the ACS National Surgical Quality Improvement Program are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. Presented as Oral Plenary at the 40th Annual Scientific Meeting of the Society of Gynecologic Surgeons, Scottsdale, AZ, March 24-26, 2014. Corresponding author: Shitanshu Uppal, MD. [email protected] 0002-9378/$36.00 ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.06.024
See related editorial, page 444
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ajog.org insignificant increases in minor morbidities. However, no appreciable effect on mortality rate has been reported.2-8 Among reproductive-aged women, hysterectomy is the second most frequent surgical procedure. With the growth of minimally invasive procedures, of the approximately 600,000 hysterectomies performed each year in the United States, 12% are being performed laparoscopically.9,10 The laparoscopic hysterectomy has been shown consistently to decrease postoperative pain, reduce postoperative morbidity, and decrease hospital stay.11-13 The obvious advantages of this desirable approach make it imperative that obstetrics and gynecology residents receive adequate exposure and experience to this technique. To find a balance between patient safety and resident education, the direct effects of resident participation in the operating room must be scrutinized by evaluation of postoperative outcomes. This current study aimed to investigate the effect of resident involvement in benign laparoscopic hysterectomies on the postoperative surgical outcomes.
M ATERIALS
AND
M ETHODS
Data sources and patient population The National Surgical Quality Improvement Program (NSQIP) database was analyzed for this study. NSQIP is an American College of Surgeons (ACS) initiative that allows for the collection of risk-adjusted data to facilitate the assessment of outcome measures after surgery. A trained surgical clinical reviewer prospectively collects the NSQIP data. Validated data from patients’ medical charts allows quantification of 30-day, risk-adjusted surgical outcomes, which includes after discharge at which time approximately 50% of complications occur. The NSQIP dataset includes data for patients who underwent a total laparoscopic hysterectomy for a benign disease from Jan. 1, 2008 to Dec. 31, 2011. Patients who underwent supracervical or laparoscopic-assisted vaginal hysterectomy were excluded from the analysis. The human subjects committee at the University of Wisconsin policy on publicly available datasets with deidentified
patient information makes this study exempt from institutional review board review.
Data collection and analysis From the NSQIP database, we abstracted the details of patients’ preoperative laboratory values, comorbidities, details of the procedure, postoperative complications, and death. The Charlson Index, a measure of comorbidity, was derived from recorded medical history in our cohort. Medical comorbidities were assigned a score (Charlson score) according to the method described by Charlson et al14,15 and the Deyo et al16 modification for use with administrative databases.16 The Charlson Index has been previously studied in a gynecologic population.17,18 Postoperative complications were then classified into the following categories; vascular (bleeding that requires reoperation, deep vein thrombosis), cardiopulmonary (pneumonia, pulmonary embolism, reintubation, prolonged intubation, myocardial infarction, and cardiac arrest), wound (superficial or deep surgical site infections or wound dehiscence), infectious (superficial, deep and organ space surgical site infections, urinary tract infection, pneumonia, systemic sepsis, and septic shock), neurorenal (acute renal failure, progressive renal insufficiency, urinary tract infections, cardiovascular accident/stroke, coma >24 hours, peripheral nerve injury), thromboembolic (pulmonary embolism and deep vein thrombosis), and transfusion (any units of blood transfused). The complexity of surgery was determined by the total relative value units assigned to the procedure. Additionally, the database was queried for Current Procedural Terminology codes 44180 and 58660, which are used in circumstances of extensive lysis of adhesions. Cases with these additional procedural codes were labeled as requiring “extensive lysis of adhesions.” Readmission data were available only for the year 2011. Three separate variables were created to quantify the number of postoperative complications that were experienced by the patients. These 3 variables were 1 complications (patients who experienced at least 1 complication in any domain),
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3 complications (patients who experienced 3 complications in any domain), and severe morbidity (patients who experienced 1 of the following complications: organ space surgical site infection, wound dehiscence, cerebrovascular accident with coma lasting >24 hours, pulmonary embolism, ventilator support for >48 hours, progressive renal insufficiency that required dialysis, or septic shock).
Analysis of the level of training NSQIP variable “Level of Residency Supervision” was used to determine the role of the residents in the surgery. The dataset provides information on the highest level of supervision provided by the attending staff surgeon for the case. For the cases with resident involvement, NSQIP variable “Highest Level of Resident Surgeon” was used to determine the postgraduate year of training. Trainees in the first 2 years of training were categorized as “junior residents” and all other postgraduate-year trainees were categorized as “senior residents.” Statistical analysis Mean and median values were used to describe continuous data, with discrete variables displayed as totals and frequencies. For univariate analyses, 2-tailed t tests and Mann-Whitney U tests were used to compare continuous data; the Fisher exact and c2 tests were used for categoric variables, as appropriate. Binary logistic regression was used to control for covariates that were noted to be significant on univariate analysis (P < .05). Point estimates are expressed as odds ratios (ORs) and 95% confidence intervals (95% CI) are provided.
R ESULTS A total of 5478 patients were identified as having undergone laparoscopic hysterectomy with/without bilateral salpingooophorectomy. After the exclusion of 1910 cases in which the data for the resident/attending involvement was not available and 127 cases with discrepant information, a total of 3441 patients were considered for analysis. From these, 480 cases did not have details of the postgraduate year level and were not
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FIGURE 1
Total number of cases by resident involvement
Igwe. Resident participation in laparoscopic hysterectomy. Am J Obstet Gynecol 2014.
considered in the subgroup analysis and during the logistic regression modeling at which time postgraduate-year level was considered a confounding factor. Figure 1 provides the distribution of trainees with regard to the year of training. The details of the breakdown of the Current Procedural Terminology codes that were retrieved from the NSQIP database are summarized in Table 1.
Patient demographics and baseline comorbidity characteristics The mean age of the patients in this cohort was 47.43 11.06 years, and the mean body mass index was 30.62 7.92 kg/m2. Data for the preoperative comorbidities and demographics are listed in Table 2. Cases with resident involvement had statistically significantly higher mean
age, Charlson morbidity scoring, percentage of patients who underwent inpatient surgery, and higher American Society of Anesthesiologists classification. The minimal difference in the mean Charlson score (022 vs 069), however, is not clinically relevant. However, no difference was noted in the body mass index, percentage of cases done as emergency, weight loss of >10% in last 6 months, patients who underwent surgery in the last 30 days, and various preoperative laboratory parameters that included hematocrit, albumin, and platelet levels. Surgical complexity, as determined by the billed total relative value units for the procedures, was noted marginally higher in resident group (0.68 units), which is unlikely to be clinically relevant. The number of cases that required extensive lysis of adhesions was similar in the 2 groups: attending alone 81 cases (4.4 %) vs resident involved 63 cases (4%); P ¼ .55.
Operative times The mean operative time in the group with resident involvement was 43.83 minutes longer than the cases with no resident involvement (179.29 vs 135.46 minutes; P < .0001), and the total duration of anesthesia was 56.97 minutes longer in the resident group (240.47 vs 183.50 minutes; P < .0001). Subanalysis of operative times between the junior resident and senior resident groups demonstrated no difference in the operative time (178 vs 181 minutes; P ¼ .87), and each group had statistically higher operative time
compared with attending-alone group (Figure 2).
Reoperation rates The overall rate of reoperation was 1.7%; 59 patients underwent reoperation from the entire cohort. The cases with resident involvement had higher reoperation rate (2.2% vs 1.3%; P ¼ .048). On subgroup analysis, the readmission rate was noted to be 1.6% for junior resident, 2.3% for senior resident, and 1.3% for the attending-alone groups (P ¼ .097). Readmission rates Readmission rates were calculated on 2011 data. Cases with resident involvement had a higher rate of readmission (5.5% vs 2.9%; P ¼ .015). On subgroup analysis, the readmission rate was noted to be 4.2% for junior resident, 5.6% for senior resident, and 2.9% for the attending-alone groups (P ¼ .078). Complications The overall rate of experiencing at least 1 complication in this cohort was 5.4% for the attending-alone and 6.8% for the resident-involved groups (P ¼ .52). There was no difference in the infectious, wound, neurorenal, thromboembolic, septic, and cardiopulmonary complications. However, a higher incidence of patients in the resident-involved group underwent postoperative transfusion of packed red blood cells (2% vs 0.4%). Additionally, the overall composite variable for severe morbidity was similar between the 2 groups (1% vs 1.3%; P ¼ .26; Table 3). Comparison of the complications between the junior
TABLE 1
Benign laparoscopic hysterectomy Current Procedural Terminology codes from the National Surgical Quality Improvement Program Current Procedural Terminology code: laparoscopic hysterectomy
Total cases in the National Surgical Quality Improvement Program (n [ 5478), n
Cases with available resident participation data (n [ 3441), n
Resident participation, %
58570 (<250 g)
1613
1119
37.2
58571 (<250 g with ovaries)
3013
1732
50.3
58572 (>250 g)
531
373
52.3
58573 (>250 g with ovaries)
321
210
50.0
Igwe. Resident participation in laparoscopic hysterectomy. Am J Obstet Gynecol 2014.
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ajog.org resident and senior resident groups did not demonstrate any difference in the rate of complications (Table 4).
Multivariate regression model On binary logistic regression modeling, after being controlled for factors significantly different between the 2 groups at significance level of 0.1 (age, Charlson score, and complexity of surgery), resident involvement remained the significant factor with approximately 5 times higher risk of receiving postoperative blood transfusion (OR, 4.98; 95% CI, 2.18e11.33; P < .0001). A second regression model was constructed for reoperation and readmission rates. Resident involvement remained significant, with nearly twice the reoperation risk (OR, 1.7; 95% CI, 1.01e2.89) and readmission risk (OR, 1.93; 95% CI, 1.09e3.42; P ¼ .025).
TABLE 2
Baseline preoperative parameters between the 2 groups Attending alone (n [ 1850)
Variable
Resident involved (n [ 1591)
P value
Patient demographics 45.61 10.61
Age, ya Inpatient, n (%) Emergency, n (%)
48.70 10.99
< .001
919 (49.7)
878 (55.2)
.01
2 (0.1)
5 (0.3)
.169
459 (24.8%)
300 (18.9%)
Comorbidities and risk factors Smoker, % Charlson score
0.22 0.79
a
Body mass index, kg/m
2a
30.56 7.56
0.69 1.37
< .001 < .001
30.7 8.34
.59 < .01
American Society of Anesthesiologists class, n (%)
C OMMENT The apprenticeship model of training demands that the attending surgeon trains residents with the goal of the resident becoming autonomous. Although this goal has not changed over the past century, stricter patient safety measures have led to heightened concern in outcomes in procedures that involve trainees. We studied these concerns in the field of benign gynecology, by analyzing laparoscopic hysterectomy cases with resident involvement vs attending alone. In the current study of the data from 3441 patients that were considered for analysis from NSQIP, mean operative times were increased statistically significantly by nearly 45 minutes in cases with resident involvement. In addition, the total duration of anesthesia was nearly 1 hour longer on an average. Analysis of the outcomes indicated that the laparoscopic hysterectomies with resident involvement are just as safe as those performed by an attending alone. However, cases with resident involvement had a greater incidence of postoperative transfusion of packed red blood cells, increased reoperation rate, and increased readmission rates. Other studies in the field of general surgery have evaluated operative times
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1
242 (13.1)
161 (10.1)
2
1313 (71.1)
1061 (66.7)
3
285 (15.45)
357 (22.4)
4
6 (0.3)
12 (0.8)
Surgery in last 30 days, n (%)
5 (0.3)
10 (0.6)
Weight loss >10% in last 6 mo, n (%)
4 (0.2)
6 (0.4)
.09
Preoperative laboratory profilea 38.79 3.81
38.54 4.02
.07
278.55 73.49
273.03 72.38
.03
4.13 0.39
4.13 0.42
.84
Creatinine, mg/dL
0.78 0.46
0.79 0.41
.45
International normalized ratio
1.04 0.48
1.02 0.16
.49
Hematocrit, % Platelets, 10 /L 9
Albumin, g/L
Surgical complexity
a
Extensive lysis of adhesions, n (%)
81 (4.4)
63 (4)
.55
Relative value unitsa
21.25 8.35
21.93 8.29
.02
Data are given as mean SD.
Igwe. Resident participation in laparoscopic hysterectomy. Am J Obstet Gynecol 2014.
in cases with resident involvement and reported similar findings. HernandezIrizarry et al5 examined mean operative times with resident involvement for 6223 laparoscopic hernia repairs from the ACS-NSQIP from 2007-2009. Operative times were increased significantly from 45-64 minutes when residents were involved. Another group used the ACSNSQIP database for 3 general surgery procedures (laparoscopic appendectomy, cholecystectomy, and open inguinal
hernia repairs) that were performed from 2005-2008.6 There was a significant increase in operative times with resident involvement, on average, 16.6 minutes longer. These findings are in line with our current study of average increase in time of 43.83 minutes in laparoscopic hysterectomies. Although the increase in times in our study is numerically higher, the percentage increase of 25% in time is comparable with the general surgery studies described. This increase in
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FIGURE 2
Operative time by resident involvement
Igwe. Resident participation in laparoscopic hysterectomy. Am J Obstet Gynecol 2014.
operating room time may be a reflection of the training environment, which involves surgical residents, anesthesia residents, medical students, and surgical tech students in the operating room. The financial implications of the increased operative time can be significant. One
group calculated that the estimated financial costs of a 13-minute increase in operative time with resident involvement (when extrapolated to all general surgery residents across the country who graduate with approximately 1000 cases) nears $53 million annually.19 Although the precise reasons could not be ascertained from NSQIP database, our study highlights the importance of further research to find out the causes of the operating room time increases with trainee involvement. Advani et al8 looked at laparoscopic appendectomy in uncomplicated appendicitis with regard to resident involvement. They found an increase in serious morbidity (1.8% vs 1.3%; P ¼.01) and an increase in overall morbidity (3.7% vs 2.8%; P ¼ .004). Although these numbers were statistically significant, they were deemed not clinically significant. Another study that included general surgical and vascular operations found that resident involvement was associated with statistically higher morbidity rates (OR, 1.07; 95% CI, 1.02e1.10) but
decreased mortality rates (OR, 0.97; 95% CI, 0.9e1.05) in all procedures, with no true associated clinical significance.7 In our study, the only complications that we found to be increased significantly with resident involvement was transfusion of packed red blood cells (OR, 4.98), reoperation rate (OR, 1.8) and 30-day readmission rates (OR, 1.9). No other difference was identified in morbidity or mortality rate. The subanalysis based on resident training level did not change these findings. Literature with the involvement of residents during gynecologic surgery is sparse. Akingba et al20 retrospectively reviewed 424 cases of women who underwent benign hysterectomies and found no significant difference in postoperative complications other than seroma formation in the attending-only group. This study was not powered adequately to evaluate laparoscopic cases, because only 8.25% of hysterectomies were laparoscopic. In addition, they reported that the degree of
TABLE 3
Complications, morbidity, and death with attending alone vs resident involvement Complication
Attending alone (n [ 1850), n (%)
Resident involved (n [ 1591), n (%)
100 (5.4)
108 (6.8)
P value
Unadjusted odds ratio (95% confidence interval)
No. of complications 1 3 Severe morbidity Death at 30 d
0 18 (1) 1 (0.1)
5 (0.3) 20 (1.3) 0
.052 NA .26 NA
NS NA NA NA
Type of complication Wound Cardiopulmonary
14 (0.8)
21 (1.3)
.07
NS
9 (0.5)
11 (0.7)
.29
NS
86 (4.6)
67 (4.2)
.29
NS
4 (0.2)
8 (0.5)
.12
NS
58 (3.1)
39 (2.5)
.13
NS
Transfusion >4 units packed red blood cells
7 (0.4)
32 (2.0)
< .0001
Septic
8 (0.4)
7 (0.4)
.59
NS
Reoperation
24 (1.3)
35 (2.2)
.048
1.7 (1.01e2.89)
Readmission (n ¼ 1213)
19 (2.9)
34 (5.5)
.015
1.94 (1.09e3.44)
Infectious Thromboembolic Neurorenal
NA, not available; NS, not significant. Igwe. Resident participation in laparoscopic hysterectomy. Am J Obstet Gynecol 2014.
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TABLE 4
Complications, morbidity, and death with junior vs senior resident involvement Complication
Attending alone (n [ 1850), n (%)
Junior resident involved (n [ 255), n (%)
Senior resident involved (n [ 1252), n (%)
P value
No. of complications
100 (5.4)
17 (6.7)
86 (6.9)
.22
5 (0.4)
NS
17 (1.4)
.33
1
0
3
18 (1)
0 1 (0.4)
Severe morbidity
1 (0.1)
Death at 30 d
14 (0.8)
6 (2.4)
15 (1.2)
.05
9 (0.5)
1 (0.4)
10 (0.8)
.491
86 (4.6)
11 (4.3)
52 (4.2)
.80
8 (0.6)
.09
Type of complication Wound Cardiopulmonary Infectious
4 (0.2)
0
0
0
.67
58 (3.1)
3 (1.2)
34 (2.7)
.20
Thromboembolic
7 (0.4)
7 (2.7)
24 (1.9)
.001
Neurorenal
8 (0.4)
0
7 (0.6)
.47
26 (5.6)
.078
Readmission (n ¼ 1157)
19 (2.9)
4 (4.2)
Igwe. Resident participation in laparoscopic hysterectomy. Am J Obstet Gynecol 2014.
attending experience correlated with shorter operative times. Although this study does not compare well with ours, because we solely investigated laparoscopic hysterectomies and used a much larger database, the morbidity and mortality results are in line with the findings of others. Our study has significant limitations that are largely the limitations of the NSQIP database. First, the NSQIP database does not capture intraoperative complications; therefore, any conclusions of intraoperative complications that cause increased bleeding and increased transfusion are purely speculative. However, increased reoperation rate in cases that involved with residents and a longer operative time do point towards increased intraoperative complications as a potential cause. Nevertheless, the overall rates of reoperation and readmission are so low (in the range of 2%) that this does not alter the overall conclusion of our study. In addition, NSQIP data does not provide the reason for reoperation or readmission; therefore, it is difficult to assess the exact reasons of reoperation or readmission, which may or may not be associated with resident involvement. Moreover, we did not have the ability to stratify residents by
program characteristics, most notably teaching vs nonteaching, to control for attending surgeon experience or presence/absence of additional trainees in the operating room, and to determine the degree of resident involvement, such as by holding the laparoscope vs being the primary surgeon. One of the most concerning limitations of NSQIP data is the lack of statistics on the rate of conversion of laparoscopic cases to open. Lack of this information could significantly change the outcomes of our study. The type of total laparoscopic hysterectomy performed (robotic vs conventional laparoscopy) also could not be assessed. A higher robotic hysterectomy proportion in either group could have resulted in increased operative time related to robotic docking. Although these limitations of the NSQIP database leave further questions to be answered in future studies, strengths of our study include the use of standardized definitions for patient characteristics, clinical outcomes, and the ability to risk adjust for patient comorbidities and to grant equal comparison between groups. This current study is the first in the benign gynecologic field to use this database to examine outcomes with resident involvement.
In conclusion, as far as the overall safety to resident involvement is concerned, our study highlights that this can be done safely in gynecologic training. Although laparoscopic hysterectomy may take longer to accomplish with a resident involved, the safety profile is largely unchanged. It is paramount that further studies are carried out to ascertain the role of adjuncts to training, such as simulation laboratories, video learning to assist in training and skills assessment, and presurgery debriefing to reduce the total operating room time. REFERENCES 1. Cameron JL. William Stewart Halsted: our surgical heritage. Ann Surg 1997;225:445-58. 2. Kern SQ, Lustik MB, McMann LP, Thibault GP, Sterbis JR. Comparison of outcomes after minimally invasive versus open partial nephrectomy with respect to trainee involvement utilizing the American College of Surgeons National Surgical Quality Improvement Program. J Endourol 2014;28:40-7. 3. Schoenfeld AJ, Serrano JA, Waterman BR, Bader JO, Belmont PJ Jr. The impact of resident involvement on post-operative morbidity and mortality following orthopaedic procedures: a study of 43,343 cases. Arch Orthop Trauma Surg 2013;133:1483-91. 4. Castleberry AW, Clary BM, Migaly J, et al. Resident education in the era of patient safety: a
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