Trainee participation and perioperative complications in benign hysterectomy: the effect of route of surgery

Abstract

Intraoperative trainee involvement in hysterectomy is common. However, the effect of intraoperative trainee involvement on perioperative complications depending on surgical approach is unknown. To estimate the effect of intraoperative trainee involvement on perioperative complication after vaginal, laparoscopic, and abdominal hysterectomy for benign disease. Patients undergoing laparoscopic, vaginal, or abdominal hysterectomy for benign disease from 2010 to 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Patients with and without trainee involvement were compared with regard to perioperative complications. Complications that occurred from the start of surgery to 30-days postoperatively were included. Perioperative complications were defined via the use of the validated Clavien-Dindo scale with ≥grade 3 complications defined asmajor and ≤grade 2 complications defined as minor. Major complications included myocardial infarction, pneumonia, venous thromboembolism, deep or organ space surgical-site infection, stroke, fascial dehiscence, unplanned return to the operating room, renal failure, cardiopulmonary arrest, sepsis, intubation greater than 48 hours, and death. Minor complications included urinary tract infection, blood transfusion, and superficial wound infection. To estimate the effect of trainee involvement depending on route of surgery, a stratified analysis was performed. Bivariable analysis and adjusted multivariable logistic regression were used. We identified 22,499 patients, of whom 42.1% had trainee participation. Surgical approaches were vaginal (22.7%), abdominal (47.1%), and laparoscopic (30.2%). The rate of major complication was 3.2%, and minor complication was 7.2%. In bivariable analysis, trainee involvement was associated with major complications in vaginal hysterectomy (3.3% vs 2.3%, P= .03), but not laparoscopic (3.0% vs 2.9%, P= .78) or abdominal hysterectomy (4.4% vs 3.6%, P= .07). Trainee involvement was also associated with minor complication in vaginal (7.3% vs 5.4%, P= .007), laparoscopic (5.9% vs 4.3%, P < .001), and abdominal hysterectomy (14.1% vs 9.2%, P < .001). In a multivariable analysis in which we adjusted for age, body mass index, medical comorbidity, American Society of Anesthesiologists score, and surgical complexity, the association between trainee involvement in vaginal hysterectomy and major complication persisted (adjusted odds ratio 1.45, 95% confidence interval 1.03-2.04); however, when operative time was added to the model, there was no longer an association between trainee involvement and major complication (adjusted odds ratio 1.26, 95% confidence interval 0.89-1.80). Surgical approach influences the relationship between trainee involvement and perioperative complication. Operative time is a key mediator of the relationship between trainee involvement and complication, and may be a modifiable risk factor.