Laparoscopic Appendectomy as an Initial Step in Independent Laparoscopic Surgery by Surgical Residents

Abstract

Background:

Laparoscopic appendectomy (LA) can be used as a training model for the start of the independent experience of young residents. We tried to evaluate whether LA is a risk factor for patients when it is done by novice surgeons during the different steps of their training.

Materials and Methods:

A retrospective study of all the patients who underwent LA in our department between 2000 and 2008 was conducted. The patients were operated on by novice surgeons, chief residents, and senior surgeons. Preoperative variables were compared, as well as surgical outcomes and complications.

Results:

During the study period, 477 LA, were performed on 320 women and 157 men, with a mean age of 39 years. In 11 cases (2.3%), the operation was converted. No difference was found in preoperative patient status. There was no difference between groups in the rate of accurate preoperation diagnosis, in comparison with the pathologic report. The rates of conversion, postoperative complications, and negative appendectomies were similar between residents and seniors. These findings were also found in a subgroup analysis, in which we compared each group.

Conclusions:

There is no additional risk in a LA done by a resident, whether a chief or a novice. LA is a good model for training young surgeons in laparoscopic surgery: It enables the young surgeon to engage and lead a real case and does not imbue any risk upon the patient.

Introduction

In the last two decades, we have seen a spiraling increase in the use of laparoscopic techniques in various fields of general surgery.^1–3 However, there was no adequate thought of how to train young residents to use and become proficient in these techniques; thus, the paradigm of “see one, do one, teach one,” which prevailed before the laparoscopic era, became unacceptable. Laparoscopy requires special skills in handling laparoscopic instruments, working in three-dimensional (3D) space when looking at a 2D monitor and absence of the tactile sensation of surrounding tissue. Finally, young operator movements in the operative field cannot be controlled by an experienced assistant, except by verbal communication. In recent years, various new training programs were introduced to acquaint young surgeons with laparoscopy, including virtual reality trainers,⁴ advanced simulators,^5,6 and animal laboratory models. But, at the end of the day, surgeons need to operate on people, and thus one has to find the best way to introduce novice surgeons into laparoscopic surgery in the living person,⁷ to define the best operation to introduce and let a junior surgeon participate and lead, with safety and minimal damage and complications to the would-be patient.

The appendectomy is the most frequent procedure performed by residents on-call in the absence of an attending senior surgeon. Laparoscopic appendectomy (LA) has also been advocated as a good model for surgical trainees.⁸ The problem is determining when the learning curve has ended and the resident can be an independent operator. Several studies considered safety, feasibility, and effectiveness of LA for the treatment of acute appendicitis in the hands of both experienced (i.e., seniors) and novice surgeons.^8–10 The current study aimed to enhance and evaluate our understanding of LA in the hands of novice versus senior surgeons. We tried to determine the contributing, as well as risk, factors across all surgical expertise levels in each group of surgeons.

Materials and Methods

The medical records of patients who underwent LA for suspected acute appendicitis between January 2000 and August 2008 in Surgery “A” at Soroka University Medical Center (Beer Sheva, Israel) were reviewed retrospectively.

Patients who underwent an incidental or elective appendectomy were excluded from the study. The retrieved data included patient demographics, preoperative laboratory and imaging data, intraoperative findings and pathology results, operator experience, surgery time, intra- and postoperative complications, surgery outcome, and length of postoperative hospital stay. Time to surgery was counted from admission to the emergency room to the time when the surgical procedure was started. Surgeons were divided into three groups: junior residents (1–5 years of residency), senior residents (chief residents in last year of their residency), and senior surgeons. The results of these two resident groups and seniors as the main surgeons during LA were compared. Finally, subgroups of seniors versus junior residents, seniors versus senior residents, and junior residents versus chief residents were analyzed. We evaluated the outcomes and complication rates in patients who underwent LAs by senior surgeons and by residents during various periods of their residency. An evaluation of predictors for complications across all levels of surgical expertise was performed.

All procedures were performed by, or under the guidance of, the attending surgeon or chief resident. In difficult cases of significant inflammation, surgery was accomplished by the attending surgeon.

A standard LA via three ports had been carried out. A diagnosis of acute appendicitis was based solely on the pathologic findings of the appendix. A complicated appendicitis was defined by the finding of a gangrenous or perforated appendix, as well as the presence of an intra-abdominal abscess. Patients with a histologically normal appendix or patients with intraoperative findings of other intra-abdominal pathologies were classified as a “negative” appendectomy. Postoperative complications were determined as infectious when postoperative fever, intra-abdominal abscess or phlegmon, wound infection, or urinary-tract infections were present after surgery.

Sample-size calculation

Sample size was computed from using the WINPEPI computer program (http://www.brixtonhealth.com/pepi4windows.html), using the COMPARE function (simple proportions study) with the following assumptions. We used previous research data and concluded that it is assumed that an odds ratio of 3 or less is negligible, power is 80%, and α = 0.05. The proportion assumed in seniors as the baseline was 6%, and a ratio of 1:1 was defined. Upon these assumptions, the minimal sample size needed was 151 in each group or 302 in total. After continuity correction, the number was set at 342.

Statistical analysis

The data were coded and stored by using a Microsoft Office Excel program and analyzed with SPSS 13.0 (SPSS, Inc., Chicago, IL). Data are reported as mean ± standard deviation. The comparison of groups was conducted by using Pearson's chi-square for categoric variables and Fisher's exact tests for dichotomous variables, when applicable. A comparison of quantitative variables was done by using parametric (e.g., t-test) and a-parametric tests (e.g., Mann-Whitney test). Differences were considered statistically significant at P < 0.05.

Results

A total of 477 consecutive LAs were attempted in our department during the study period. Of these, 11 (2.3%) were converted to open appendectomy. There were 157 (33%) males and 320 females, with average age upon operation of 37 ± 16.3 years. The average duration of illness before admission was 40.2 ± 45.5 hours, while the average time to surgery was 12.4 ± 10.4 hours.

Prior to surgery, 85 (17.8%) of the patients underwent an imaging test (computed tomography or ultrasound). There was no difference between groups in using preoperative imaging, neither in the seniors versus residents (P = 0.595) nor in the grouping of seniors versus chief residents versus residents (P = 0.7). Further, 403 of our patients (84.5%) had no background illness prior to admission. The presurgical diagnosis of 379 patients (79.5%) was for suspected acute appendicitis, while pathology results showed that 358 of the cases, in fact, had acute appendicitis (94.4%). Other common presurgical diagnoses were abdominal pain (61 patients; 13.1%) and peritonitis (25 patients; 5.4%). Overall, 50 patients (14%) had complicated appendicitis. In 116 cases (24.5%), there was no inflammation in the appendix during surgery: 49 (42.2%) patients had gynecologic pathology, 5 (4.3%) mesenteric lymphadenitis, 3 (2.6%) acute diverticulitis, and 3 (2.6%) torsion of the epiploic appendix and omentum, 1 (0.9%) tumor of the appendix, and 1 (0.9%) Meckel's diverticulitis. No intra-abdominal pathology was found in the remaining 54 (46.5%) patients. The appendix was removed in these cases, and pathologic examination revealed acute appendicitis in 4 (0.8%), 3 of which were carcinoids. Surgery was led by a senior surgeon in 293 cases (61.4%) and by a resident in 184 cases (38.6%). A subgroup analysis of the residents showed that 56 (30.5%) were residents in their final year.

Preoperative patient data are presented in Table 1. As depicted, there were no differences between the groups in any variable, except body temperature, which was significantly different; clinically, this difference has no real meaning and thus is negligible. When looking at the operation itself, there were no differences between groups in surgery time, rate of conversions, and postoperative complications (Table 2). The readmittance rate, which was significantly greater in last-year residents (14.3%), was lowest in young residents (4.7%). To be sure that our results are depicting the real situation, we grouped all residents together and compared them to the senior surgeons. Similar to the previous results, there were no significant differences between seniors and residents in all variables checked, except duration of surgery, which was, as expected, a bit shorter in the hands of senior surgeons (Table 3).

Table 1.

Preoperative Data

	Seniors	Senior residents	Junior residents	P-value
Number of patients	293	56	128	—
Age (mean, years)	40.1	37.2	35.25	0.172^*
% female	60.3	13.8	25.9	0.147^**
Mean length of illness before admission (hours)	42.5	31.2	38.9	0.221^*
Mean time to surgery (hours)	11.8	12.9	13.9	0.166^*
ASA (median)	1	1	1	0.625^***
Body temperature (mean, °C)	37.5	37.5	37.2	0.031^*
WBC (mean, × 1000/mm³)	12.4	12.1	12.4	0.793^*

One-way analysis of variance (ANOVA); **chi-square test; ***Kruskal-Wallis test.

ASA, American Society of Anesthesiologists; WBC, white blood cell.

Table 2.

Surgical Outcomes

	Seniors	Senior Residents	Junior residents	P-value
Mean length of surgery (minutes)	36.4	37.2	39.9	0.054^*
Conversion rate (%)	2.7	1.8	2.3	0.91^**
Complicated appendicitis (%)	14.6	22.7	8.4	0.07^**
Negative appendectomy rate (%)	24.7	20.0	25.8	0.7^**
Readmission rate (%)	6.1	14.3	4.7	0.047^**
Postoperative complications (%)	5.8	10.7	7	0.398^**
Infectious complications (%)	3.4	8.9	3.1	0.13^**
Mean postoperative stay (days)	2.39	2.27	2.35	0.95^*

One-way analysis of variance (ANOVA); **chi-square test.

Table 3.

Comparison of Surgical Outcomes: All Residents Versus Seniors

	Seniors	Residents	P-value
Mean length of surgery (minutes)	36.4	39.1	0.037^*
Conversion rate (%)	2.7	2.2	0.77^**
Readmission rate (%)	6.1	7.6	0.53^**
Postoperative complications (%)	5.8	8.2	0.318^**
Infectious complications (%)	3.4	4.9	0.422^**
Complicated appendicitis (%)	14.6	12.9	0.658
Negative appendectomy (%)	24.7	24.0	0.863
Mean postoperative stay (days)	2.4	2.3	0.784^*

Student's t-test; **chi-square test.

Discussion

The resident-training program in laparoscopic surgery is still under debate. When using animal laboratories, virtual trainers and stimulators are recommended as teaching tools before the resident's laparoscopic handling in the operating room. More than 2000 surgical procedures are performing in our department annually. Seventy percent of them are done laparoscopically. In our department, residents are getting their first laparoscopic experience from camera holding and aiding in various laparoscopic procedures. After the first 6 months, they start with a scheduled laparoscopic cholecystectomy and, later, an emergency laparoscopic appendectomy under attending guidance. During the first year, all residents pass a 2-day course in the Israeli Center of Simulation in Tel Aviv as a part of their teaching program. Residents are trained gradually in advanced laparoscopic procedures. In the fourth year, they start independent on-call duties. Since this period, most emergency laparoscopic procedures are performed by residents, either by themselves or under senior supervision. We allow a totally independent LA for senior residents with good surgical technique during the last year of their residency. Overall, our residents are doing 60–80 LAs during their residency. It starts with 5 procedures during postgraduate year 1 (PGY1) and is followed by 10–15 LAs performed annually during subsequent of their teaching. According to the National Board in General Surgery, the syllabus of procedures should be accomplished prior to a resident's accreditation. It includes at least 25 LAs.

In light of our hypothesis, we can safely say that LA, in the hands of residents (as a whole), is as safe and efficient as in the hands of senior surgeons. Our study has shown no surplus of morbidity or mortality in those who were operated on by residents. The operation duration was, as expected, longer in the hands of residents, in comparison to seniors. But, even though this 3.5-minute difference was significant, it does not make a difference clinically. Reinforcing this is the fact that there were no differences in clinical outcomes and morbidity of patients.

The number of hospital readmissions following LA was greater in chief residents, a finding that was not seen in novice residents or seniors. A possible explanation of this might be the fact that chief residents are residents in their final year, they lack the experience that senior surgeons have, and thus are more prone to technical errors; on the other hand, they share with seniors their confidence in their work and thus are less cautious with patients and tend to discharge them a bit sooner than is warranted.

In light of known research on the subject, our results are no surprise. Bencini et al.¹¹ investigated this subject in the cholecystectomy and, like us, found no differences in the complication rate or length of stay of patients who were operated on by seniors versus residents. Just as we have shown, Bencini et al. found that the duration of surgery was longer for residents, even though they tended to operate on less complicated patients. Our data showed no such discrepancy, and residents have operated on as complicated a series of patients as seniors, and thus we believe our results are more reliable due to the fact that the case mix was the same in the two groups.

We should not be surprised by these results, since research has shown that even if surgeons are assisted by residents, they tend to have fewer complications.¹² The teaching atmosphere, and the need for an attending to be in the operating room (OR) and assist the young surgeon, has a beneficial effect on both sides; thus, even though we would expect more complications in novice surgeons, this is not the case when discussing LA, which only enhances our belief that this should be the basic laparoscopic procedure that young surgeons should undertake. We believe that an early change of first operator's place between resident and senior or performing of a difficult part (e.g., dissection of appendix) by a senior, allows surgery safety and prevents unnecessary complications.

Our study, as well as Bencini et al.'s,¹¹ has shown that this is not the case, and, if one uses a structured, well-planned residency-training program in laparoscopy, no more harm is inflicted on the patients, and thus the need for solely relying on these simulators seems to be overestimated. One has to remember that these simulators not only cost money, but they consume another valuable resource—the residents' time, which we believe can be better spent in the OR than in those trainers, if the resident has a structured plan that would help him or her acquire the needed skills. This does not mean that simulators are obsolete, but that more research should be aimed at formulating the exact time frame (we believe they should be used in PGY1) and the amount of time allotted to them, so they can be used most effectively.

Measurement of proficiency of junior residents in laparoscopic surgery is mostly subjective by personal feeling of assistants attending during surgery. SAGES considered 20–25 laparoscopic procedures as a learning curve to achieve laparoscopic technique. This is variable for younger surgeons and depends on their personal handling and coordination. On our opinion, the early involvement of young residents in various laparoscopic procedures and staging performance under senior guidance can give better results further on in their laparoscopic experience.

Study limitations

One major limitation of this study was that the results were derived from a single medical institute, which might be problematic in trying to generalize from our results to other medical centers.

Another limitation was the retrospective nature of our study, which made it difficult for us to give a causal explanation to our findings. This type of research is also very dependent on the quality of data gathered, and we had to rely on printed material, instead of checking out the facts themselves (e.g., we relied on the summary and operational notes of the surgeons, which might have mistakenly forgotten to assign the senior who was there, etc.). We will try to conduct a prospective, multicentric study in various Israeli teaching hospitals to compare residents' proficiency in LA in various periods of their residency.

Conclusions

LA done by residents is as safe as that done by senior surgeons. We, therefore, believe that when trying to determine the proper means to train young surgeons in laparoscopy, one should seriously consider LA to be the first independent operation a young surgeon leads under the supervision of an attending or chief resident. We do believe that a structured training program is essential for this to occur, since, if the novice surgeon has no knowledge of camera holding, trocar placement, or tissue handling, he or she cannot perform this kind of operation. We call upon other medical centers to investigate this operation as the bridge to leading a laparoscopic surgery and urge other surgeons and educators to determine the most efficient, safe way to train the surgeons of the next decade.

Footnotes

Disclosure Statement

No competing financial interests exist.

References

Gervaz

, Huber

, Morel

. Surgical management of gastrointestinal stromal tumours. Br J Surg, 2009; 96:567–578.

Medeiros

, Rosa

, Bozzetti

, Fachel

, Furness

, Garry

, Rosa

, Stein

. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database Syst Rev, 2009; CD004751.

Peters

, Mukhtar

, Yunus

, Khan

, Pappalardo

, Memon

. Meta-analysis of randomized, clinical trials comparing open and laparoscopic antireflux surgery. Am J Gastroenterol, 2009; 104:1548–1561; quiz, 1547, 1562.

Munz

, Almoudaris

, Moorthy

, Dosis

, Liddle

, Darzi

. Curriculum-based solo virtual reality training for laparoscopic intracorporeal knot tying: Objective assessment of the transfer of skill from virtual reality to reality. Am J Surg, 2007; 193:774–783.

Woodrum

, Andreatta

, Yellamanchilli

, Feryus

, Gauger

, Minter

. Construct validity of the LapSim laparoscopic surgical simulator. Am J Surg, 2006; 191:28–32.

Andreatta

, Woodrum

, Birkmeyer

, Yellamanchilli

, Doherty

, Gauger

, Minter

. Laparoscopic skills are improved with LapMentor training: Results of a randomized, double-blinded study. Ann Surg, 2006; 243:854–860; discussion, 860–853.

Chou

, Lockyer

, Cole

, McLaughlin

. Assessing postgraduate trainees in Canada: Are we achieving diversity in methods? Med Teach, 2009; 31:e58–e63.

Sai Prasad

, Chui

, Jacobsen

. Laparoscopic appendicectomy in children: A trainee's perspective. Ann Acad Med (Singapore), 2006; 35:694–697.

Hwang

, Pagano

, Wichterman

, Dunnington

, Alfrey

. Resident versus no resident: A single-institutional study on operative complications, mortality, and cost. Surgery, 2008; 144:339–344.

10.

Hedrick

, Turrentine

, Sanfey

, Schirmer

, Friel

. Implications of laparoscopy on surgery residency training. Am J Surg, 2009; 197:73–75.

11.

Bencini

, Bernini

, Martini

, Rossi

, Farsi

, Boffi

, Miranda

, Moraldi

, Moretti

. Safety of laparoscopic cholecystectomy performed by surgical residents. Chir Ital, 2008; 60:819–824.

12.

Massarweh

, Devlin

, Symons

, Broeckel Elrod

, Flum

. Risk tolerance and bile duct injury: Surgeon characteristics, risk-taking preference, and common bile duct injuries. J Am Coll Surg, 2009; 209:17–24.