Seniority Of Surgeon Research Articles

Influence of Resident and Attending Surgeon Seniority on Operative Performance in Laparoscopic Cholecystectomy

Resident participation in laparoscopic cholecystectomy (LC) is important for education but increases the time of operation. This time cost in training programs is not well-defined, and available data show no decrease in operative time as residents progress in training. We undertook this study to determine the effect of the resident and attending surgeon seniority on the operative performance of LC. We undertook a retrospective review of LCs performed for all indications over two academic years in our training program. Operations were performed by junior (PGY 1-3) or senior (PGY 4-5) residents, assisted by junior (trained after 1994) or senior attending surgeons, none of whom had fellowship training in advanced laparoscopy. Demographics, surgeon, assistant, operative time, and operative complications were recorded. Operative diagnoses were defined as noninflammatory (biliary colic, dyskinesia, or polyps) or inflammatory (cholecystitis, pancreatitis). The primary outcome was time in minutes from skin incision to closure; secondary outcomes were complications and conversions to laparotomy. ANOVA, Student's t-test, and chi2 tests were used as appropriate with statistical significance attributed to P < 0.05. Three hundred fifteen LCs were performed. Two hundred seventy were without conversion to laparotomy or intraoperative cholangiography and were included in time and complication analysis. Junior attendings averaged 4 and senior attendings averaged 21 postresidency years. No differences were found on univariate analysis between groups in demographics or diagnosis category. Operative times were longer for junior residents irrespective of attending seniority: Jr Res/Jr Staff (n = 65): 86 +/- 32 min; Jr/Sr (n = 78): 88 +/- 38 min; Sr/Jr (n = 52): 73 +/- 27 min; Sr/Sr (n = 75): 67 +/- 24 min (P < 0.05). The overall rate of operative complications was higher in junior than senior resident cases (5.6% versus 0.78%, P < 0.05). The most common complication was cystic duct leak, of which 4/5 occurred in junior resident cases. Senior attendings had a trend toward increased conversions (8.4% versus 3.7%, P = 0.09). Resident, but not attending surgeon, seniority influences operative time and complication rate in LC. This information may help surgical educators maximize both resident learning and operative efficiency and safety.

The effect of gender on postoperative mortality afteremergency abdominal surgery

The factors contributing to the high mortality after emergency abdominal surgery are unclear. Recent studies have revealed gender differences in immune function after trauma and in the presence of sepsis. This study tested the hypothesis that factors determining survival after emergency abdominal surgery differ in males and females. Consecutive patients, aged > or =50 years, who underwent emergency abdominal surgery between July 1998 and June 2000 at the Royal and Western Infirmaries in Glasgow, Scotland, were identified for study. Data collected retrospectively included sex, age, severity of surgery, seniority of surgeon and anesthetist, extent of deprivation, and 30-day postoperative mortality. A total of 633 patients were identified for study; 49 (8%) were excluded from analysis because 30-day mortality or surgery details were unavailable. Of the remaining 584 patients, 256 were male and 328 were female. The overall 30-day mortality was 26%, with 74 (29%) males and 79 (24%) females dying within this period. The mortality rates were 25% in males and 10% in females (P = 0.043) after minor surgery, 26% in males and 23% in females (P = NS) after intermediate surgery, and 44% in males and 39% in females (P = NS) after major surgery. On univariate logistic regression analysis in males, increasing age (P < 0.001), severity of surgery (P = 0.04), and seniority of anesthetist (P < 0.001) were associated with mortality. In females, severity of surgery (P < 0.001) was associated with mortality. These results show that in females, 30-day mortality was determined by severity of surgery, whereas in males increasing age and seniority of anesthetist also influenced 30-day mortality.

New technique for inguinal hernia repair

We compared a new fascia transversalis based hernioplasty with mesh repair techniques which leave the fascia transversalis intact. We prospectively randomized 180 consecutive patients with inguinal hernia to undergo one of the three hernia repair techniques. Hernias were repaired either by using the new fascia transversalis repair-Coskun's hernia repair (FTR), based on the plication of fascia using continuous sutures and followed by a second layer of interrupted or continuous sutures between inguinal ligament and conjoint tendon to distribute the tension, or one of the two mesh repair techniques: anterior (Lichtenstein) or posterior (preperitoneal) repair. Parameters such as age, sex, hernia cause, operation time, type of anesthesia, surgeon's seniority, complications, hospital stay and follow-up were evaluated. Recurrence rates were determined through clinical examination. Effect of prostatism, co-morbid disease, operation time, complications and Nyhus type of hernia on recurrences were also analysed. Most patients in each group were operated on under general anesthesia (78% vs. 80% vs. 85% for FTR, Lichtenstein, and preperitoneal repair, respectively) and by surgeons in training (average 78%). Patients were followed up for a median of 36 months. FTR had less complications and an acceptable time for operation whereas preperitoneal repairs needed more seniority, longer operation time, and caused more complications. There were only 3 (1.6%) recurrences, none in the FTR group and two the in Lichtenstein group during first postoperative year. There was no recurrence in preperitoneal repair group. All patients with recurrences had an operation time longer than 60 min and were operated on by surgeons in training. Two patients with recurrences had prostatism symptoms and chronic cough. We conclude that the new FTR is as effective as mesh repair (either anterior or posterior) with an acceptable rate of recurrences, fewer complications, and that it can be performed by the surgeons in training.

Conversion rates in laparoscopic colorectal surgery: a predictive model with, 1253 patients

This study aimed all develop a mathematical model for predicting the conversion rate for patients undergoing laparoscopic colorectal surgery. This descriptive single-center study used routinely collected clinical data from 1,253 patients undergoing laparoscopic surgery between November 1991 and April 2003. A two-level hierarchical regression model was used to identify patient, surgeon, and procedure-related factors associated with conversion of laparoscopic to open surgery. The model was internally validated and tested using measures of discrimination and calibration. Exclusion criteria for laparoscopic colectomy included a body mass greater than 50, lesion diameter exceeding 15 cm, and multiple prior major laparotomies (exclusive of appendectomy, hysterectomy, and cholecystectomy). The average conversion rate for the study population was 10.0% (95% confidence interval [CI], 8.3-11.7%). The independent predictors of conversion of laparoscopic to open surgery were the body mass index (odds ratio [OR], 2.1 per 10 Americans Society of Anesthesiology units increase), (ASA) grade 3 or 4, 1 or 2 (OR, 3.2, 5.8), type of resection (low rectal, left colorectal, right colonic vs small/other bowel procedures; OR, 8.82, 4.76, 2.98), presence of intraoperative abscess (OR, 3.60) or fistula (OR, 4.73), and surgeon seniority (junior vs senior staff OR, 1.56). The model offered adequate discrimination (area under receiver operator characteristic curve, 0.74) and excellent agreement (p = 0.384) between observed and model-predicted conversion rates (range of calibration, 3-32% conversion rate). Laparoscopic conversion rates are dependent on a multitude of factors that require appropriate adjustment for case mix before comparisons are made between or within centers. The Cleveland Clinic Foundation (CCF) laparoscopic conversion rate model is a simple additive score that can be used in everyday practice to evaluate outcomes for laparoscopic colorectal surgery.

Wound infections in day-case hand surgery: a prospective study

There is little published information about postoperative infection rates in day-case hand surgery and the possible factors promoting infection. We report on infection rates observed in day-case hand surgery of 1035 cases over a 2-year period performed by two consultant surgeons. Infection rates of just over 1% were observed. We believe that this low infection rate reflects seniority of surgeon, operative technique and short duration of operation.

Association between surgeon seniority and outcome in intracranial aneurysm surgery

Specialist surgical registrars perform surgery as a requirement of their training, but the effect of the surgeon's level of training on outcome in intracranial aneurysm surgery is not known. This study addresses this question. A cohort of 278 consecutive patients who underwent a craniotomy to clip a recently ruptured intracranial aneurysm between January 1995 and December 1999 was assessed. Patients were divided into three groups according to whether the operating surgeon was a registrar, a senior registrar or a consultant. The frequency of a good outcome (defined as a Glasgow outcome score of 5) was compared in the three groups. Registrars operated on 91 patients (33%), senior registrars on 60 (21%) and consultants on 127 (46%). Between the three groups there was no statistically significant difference in patient age, male : female ratio, the timing of surgery after the haemorrhage, or the proportion of patients requiring preoperative ventriculostomy or with angiographic vasospasm, but more patients operated on by consultants had favourable admission World Federation of Neurological Surgeons grades. About two-thirds of patients achieved a Glasgow outcome score of 5 at 6 months, and there were no statistically significant differences in outcome between the three groups at discharge, at 6 months and at 1 year. Intracranial aneurysm surgery by trainees and consultants was not associated with differences in patient outcome in a cohort of patients treated at a University teaching hospital.

Correlation of Intra-operative Duplex Findings During Carotid Endarterectomy with Neurological Events and Recurrent Stenosis at one Year

Objectives: carotid endarterectomy has been used to treat both asymptomatic and symptomatic disease and this has meant that recurrent stenosis and its effect on late stroke risk have become increasingly important. In this study we compared anatomical defects and residual stenosis identified intra-operatively with recurrent stenosis and new symptoms developing in the first year after surgery. Design, Materials & Methods: two hundred and forty-four consecutive patients undergoing carotid endarterectomy were studied prospectively. Residual anatomical defects were noted; residual stenosis was defined by intra-operative duplex ultrasound as >50%. New stenoses and clinical events during the one-year surveillance period were documented. Results: there was an increased incidence of recurrent stenosis at one year in vessels with residual stenoses ( p<0.001) and in vessels containing a residual anatomical defect ( p=0.037). There was no significant difference in recurrent stenosis rate with respect to closure (primary or patch) or seniority of surgeon but recurrent stenosis was increased in females ( p=0.026). The majority (70%) of restenotic lesions were localised to the origin of the internal carotid artery. The late stroke rate was 0.9% and was not related to recurrent stenosis or symptoms. Conclusions: residual stenosis and intra-luminal defects at completion increase the recurrent stenosis rate at one year. The aetiology of recurrent stenosis is multi-factorial and further studies are required to determine whether it is justified to modify the criteria for re-exploration with a view to reducing recurrent stenosis.

What Is a Reasonable Time From Decision-to-Delivery by Caesarean Section? Evidence From 415 Deliveries

This 12-month prospective study attempted to determine the decision-to-delivery interval (DDI) for women having nonelective cesarean at a major teaching hospital's obstetrical unit. Objects of inquiry included what factors influence the DDI and the effect of the DDI on the infant's condition at birth. Among 330 emergency cesarean deliveries where the decision was made during labor, the mean DDI was 43 minutes when fetal distress was present and 71 minutes when it was not. For 22 crash cesareans, when either serious maternal compromise or impending fetal death was anticipated, the mean interval was 27 minutes. In 34 urgent cases where the decision was made within 24 hours before delivery because of deteriorating fetal or maternal health before labor began, the respective DDI figures were 125 and 97 minutes. Finally, in 29 preempted cases where the decision was made more than 24 hours before membrane rupture or the start of labor, the mean DDI was 140.5 minutes. The DDI did not seem to be a function of the surgeon's seniority. Neither the day of the week on which delivery took place nor the time of day was a significant factor. Intrapartum cesarean delivery tended to take place sooner when labor was relatively advanced. In the emergency cesarean group, the DDI decreased as labor was more advanced up to 9 cm of cervical dilatation. General anesthesia was associated with a shorter DDI than regional anesthesia when emergency cesarean was done for fetal distress. Infants born within 1 hour of the decision tended to be more acidemic than those born later regardless of the indication for cesarean delivery. There were two stillbirths and four neonatal deaths. Although fewer than 40% of intrapartum cesarean deliveries done for fetal distress were carried out within 30 minutes of deciding to do so, the unit standard, there was no overall indication that an interval up to 2 hours imperils the newborn infant. Crash deliveries were an exception. It does not seem necessary to try to complete cesarean delivery as quickly as possible in all cases. Conceivably, maternal anxiety and the consequent hypersecretion of catecholamines have the effect of constricting placental blood vessels and reducing oxygen exchange across the placenta, leading to fetal acidosis.

Risk factors associated with posthemorrhoidectomy secondary hemorrhage: a single-institution prospective study of 4,880 consecutive closed hemorrhoidectomies.

Posthemorrhoidectomy secondary hemorrhage is a rare but serious complication after hemorrhoidectomy. The determination of risk factors for this complication may provide information to improve outcome. A prospective study was conducted to determine the risk factors associated with posthemorrhoidectomy secondary hemorrhage. We studied 4,880 patients who underwent an elective closed hemorrhoidectomy by 9 proctologists in a single institution between January 1994 and July 1996. The variables analyzed included age, gender, surgeon, surgeon's seniority, suture material, aseptic preparation, and use of antibiotics. The logistic regression model was used to assess the independent association of variables with posthemorrhoidectomy secondary hemorrhage. Among the 4,880 patients, 45 (0.9 percent) developed posthemorrhoidectomy secondary hemorrhage. The mean interval from operation to the onset of secondary hemorrhage was 8.8 (range, 5-19) days. Multivariate analysis revealed that patient's gender and individual surgeons were both independently associated with risk of hemorrhage. Male patients were more likely than females to develop posthemorrhoidectomy secondary hemorrhage (relative risk, 2.1; 95 percent confidence interval, 1.1-4.1; P = 0.021). The posthemorrhoidectomy secondary hemorrhage rates among individual surgeons ranged from 0.2 to 2.4 percent (P = 0.003). Our data suggest that male patients are more likely to develop posthemorrhoidectomy secondary hemorrhage than female patients and that intersurgeon variability is highly correlated with this risk.

Ruptured cerebral aneurysm: influence of specialist and trainee-performed operations on outcome.

The results of a series of 160 consecutive patients operated on for ruptured cerebral aneurysm in relation to the surgeon's seniority were studied. The outcome, as measured by the Glasgow Outcome Scale at six months, shows a difference between specialist-neurosurgeon and resident-performed ruptured cerebral aneurysm obliterations, although this difference does not reach statistical significance.

A Study of Pre-Operative Planning in CLS total Hip Arthroplasty

This study involved 200 cementless primary total hip arthroplasties of which 100 had formal pre-operative planning as recommended by the manufacturer using standardised radiographs, templates and tracing paper. The remaining 100 had no formal pre-operative planning. The operations were performed by two different groups of surgeons using different surgical exposures. The variables measured included radiological magnification, component sizing, intra-operative lengthening, positioning of the centre of the femoral head and femoral component fit and fill. Clinical data was obtained from a questionnaire. The results indicate an improved position of the centre of rotation and better leg length equalisation in the planned group. There was no significant difference in the number of intra-operative fractures among the two groups. No correlation was found between femoral fit and upper femoral morphology nor between fit and the surgeon's seniority. There was no significant difference in the incidence of thigh pain in the two groups at an average follow-up of 28 months. The more striking finding was the poorer femoral fit and fill encountered in the unplanned group.