SCOTTSDALE, ARIZ. – Laparoscopic hysterectomy takes longer when residents participate, but is generally as safe as when an attending physician performs the surgery alone, a study showed.
A resident was involved in 46% of the 3,441 cases that were done for benign indications between 2008 and 2011 and identified in the National Surgical Quality Improvement Program (NSQIP) database.
Patients whose surgery involved a resident had higher levels of comorbidity and were higher-risk surgical candidates, according to data presented at the annual meeting of the Society of Gynecologic Surgeons.
Compared with patients whose surgery was performed by an attending physician alone, those whose surgery involved a resident took an average of 44 minutes, or about 25% longer.
However, rates of serious adverse outcomes and death were statistically indistinguishable. The group for whom a resident was involved did have higher rates of transfusion of more than 4 U of packed red blood cells and of readmission.
"Our study is the first of its kind to study this topic in the gynecologic field in such a large sample size," said lead author Dr. Elena Igwe, a third-year obstetrician-gynecologist resident at Temple University Hospital in Philadelphia.
The longer operative time for resident-involved cases "may be accounted for by the obvious training environment of gynecologic and anesthesia residents, medical students, as well as scrub nurse students. Also, more time may have been spent if there were greater intraoperative complications such as bleeding or organ injury that were not captured by the NSQIP database," she said at the meeting, jointly sponsored by the American College of Surgeons.
"Although there was a statistically significant increase in transfusion and readmissions in the resident-involved group, there was no overall effect on morbidity or mortality. Therefore, although laparoscopic hysterectomy may take longer to accomplish with a resident involved, the clinically significant safety profile is largely unchanged," Dr. Igwe said.
Invited discussant Dr. Marie Fidela Paraiso, head of female pelvic medicine and reconstructive surgery at the Cleveland Clinic, commented, "The findings of your investigation are not surprising in that training cases require significantly longer OR times – this is the story of an academician’s life – increased transfusions (cause uncertain) and increased 30-day admits. However, it is reassuring that morbidity and severe complications and 30-day mortality are not different despite greater patient acuity in the training cohort."
She added, "Due to a limit in training hours, alternatives to hysterectomy, and a variation of tools and routes for hysterectomy, resident experience in laparoscopic hysterectomy is likely to decrease. How do you apply your findings to guide future training?" she asked.
Considerable time is required to become skilled at this surgery, Dr. Igwe replied. "If the average resident is going to do less hysterectomies during their duration as a resident, then there are two potential ways to deal with this situation. One, you can increase the length of ob.gyn. training; of course, the lack of federal funding may not make this a very attractive option. Or two, split the specialty into a track system or alternative curriculum system, where a portion of residents go into a specialized gyn. track and receive the majority of hysterectomy and other major surgery trainings, and have the privilege to perform these procedures. A general ob.gyn. residency can therefore potentially be reduced to 3 years, and these practitioners would focus on more routine ob.gyn. and preventive gynecologic care," she suggested.
"We as a society can take the initiative to do this ourselves, or insurance companies, based on the Affordable Care Act initiative and driven by outcome-based research, will make us do this based on our performances, and this may not be a pretty thing," she added.
One session attendee expressed concern about potential selection bias in the study. "It’s possible that for the more complicated cases, the attendings asked the residents to assist them, and therefore we may be unduly giving the residents credit for the increased morbidity," he said.
"That is a concern, but that’s just one of the limitations of the NSQIP database that we were not able to adjust for," Dr. Igwe said.
Another attendee commented, "Your data is reassuring, but it begs the question, we don’t know the degree to which residents were actually involved, and it makes me think ... what would be a more meaningful way to measure this issue of the interaction between resident involvement and patient morbidity?"
"If there was a way to actually record or establish how much a resident is actually doing, that would be the best thing," Dr. Igwe said.