How surgical training in Switzerland affects outcomes and new predictors for teaching

Abstract

Abstract Objective Teaching in the operating room represents the cornerstone of surgical education. Residents need to perform a sufficient number of basic procedures in order to gain independence. However, it is still debated what impact surgical teaching has on outcomes. With this study, we provide recent data of a large national cohort and identify new factors that are associated with increased teaching. Methods We studied common procedures that are essential for surgical training: Laparoscopic Appendectomy (LA), Laparoscopic Cholecystectomy (LC), ostomy closure (OC), laparoscopic (LH) and Open Inguinal Hernia Repair (OH). The national database of the Swiss association for quality management in surgery was screened, and 72072 patients were identified from 2009 to 2019. Teaching was defined as a procedure mainly performed by a surgeon in training under supervision. Results A minority of basic surgical procedures were used for teaching (LA 28.1%, LC 22.3%, OC 21.5%, OH 31.8%, LH 6.3%), even in teaching hospitals of > 200 beds (LA 33.0%, LC 32.9%, OC 27%, OH 51.5%, LH 6.5%). During the study period, there was also generally a trend towards less teaching, exemplified by the two most frequent procedures: LA 35.6 to 26.7% (-25.0%, p = <0.001), LC 27.6 to 18.9% (-31.5%, p = <0.001). Operating time was significantly longer for procedures that were used for teaching with a more pronounced effect for inguinal hernia repairs: LA 63.4 vs 57.5min (+10.3%, p = <0.001), LC 84.0 vs 74.9min (+12.1%, p = <0.001), OC 88.6 vs 81.6min (+8.6%, p = <0.001), OH 81.5 vs 68.3min (+19.3%, p = <0.001), LH 97.9 vs 73.8min (+32.7%, p = <0.001). The overall complication rate for LA (2.6 vs 1.8%, p = <0.001) and LC (3.6 vs 2.8%, p = <0.001) were slightly higher in the no-teaching group and without a significant difference between the groups for OC, LH and OH. We identified the following parameters associated with increased teaching: A hospital size above 200 beds (OR = 2.48, p = <0.001), an operation during office hours (OR = 1.27, p = <0.001), the summer months (OR = 1.11, p = <0.001) and weekdays (OR = 1.10, p = 0.003). Conclusion The teaching of basic surgical procedures appears safe. Even if associated with longer operating times, it should be promoted as teaching is currently only performed in a minority of procedures (10-33%).