Residents may need more minimally invasive surgery training

Last Updated: 2015-01-06

By Will Boggs MD

NEW YORK (Reuters Health) - With the increasing prominence of minimally invasive surgery (MIS), general surgery residents may need a broader skill set than in the past, researchers say.

"Integration of new technology into practice affects the resident training environment," Dr. Morgan K. Richards, from Seattle Children's Hospital in Washington, told Reuters Health by email. "Over the last two decades, MIS techniques have become well-established and are an integral part of the resident operative experience."

Some have expressed concerns that general surgery resident training, with its work-hour and other constraints, might not allow for adequate training in these new techniques

Dr. Richards and Dr. Kenneth W. Gow from University of Washington School of Medicine, also in Seattle, examined the operative experiences of general surgery residents included in the Accreditation Council of Graduate Medical Education database for:

-1993-1994 through 1997-1998 (period 1, when MIS coding was introduced to resident case logs),

-1998-1999 through 2002-2003 (period 2, before implementation of work-hour restrictions),

-2003-2004 through 2007-2008 (period 3, implementation of work-hour restrictions), and

-2008-2009 through 2011-2012 (period 4, the first cohort of residents trained within the 80-hour workweek limits).

The percentage of all "total major cases" managed with MIS went from 8.9% in period 1 to 14.0% in period 2, 10.1% in period 3, and 21.8% in period 4, the authors reported December 30th online in JAMA Surgery.

The most commonly logged MIS procedures were cholecystectomy, appendectomy, groin hernias, exploratory abdominal procedures, and antireflux procedures.

But for the entire study period, MIS was more common than open surgery for only three procedures: cholecystectomy (82.3% of these cases), antireflux procedures (58.5%), and gastric reduction for morbid obesity (56.6%). For all other common procedures, open surgery was the more common approach.

As time passed, MIS became the more common procedure for appendectomy, antireflux, thoracic wedge resection, and partial gastric resection. MIS was more common than open surgery for cholecystectomy for all periods.

The percentage of cases performed with MIS during the chief resident year actually declined from period 1 (37.0%) to period 4 (29.0%).

"MIS cases are replacing cases that were previously performed using the open technique," the authors note. "This increase in the required skill set affects resident competency in both the MIS and open approach."

"Although we were not surprised that there was an overall increasing trend in the use of minimally invasive operative techniques, we did not expect to see certain operations done almost exclusively with the MIS technique," Dr. Richards said. "This led us to wonder if residents are receiving sufficient training in the open technique of these operations."

What's the solution? The authors suggest that "educators and trainees must consider adjusting to the dichotomous training environment whether through more simulation, dedicated MIS rotations, or additional training years to achieve comfort with autonomous operator status."

"Since our study was observational and hypothesis-generating, we can't necessarily draw conclusions as to the best intervention," Dr. Richards said. "That being said, our thought is that, in an ideal world, residents would be judged based on competency rather than the number of operations performed."

She added, "Further study is warranted to determine if there is a change in patient-related outcomes with this change in the operative techniques."

In a September 2014 paper in Advances in Surgery, Dr. Samer Mattar from Oregon Health & Science University in Portland and Dr. Daniel T. McKenna of Indiana University in Carmel, Indiana called for changes "in the structure, assessment, and mentorship of future residents to prepare them to enter the marketplace and practice safe medicine with confidence and authority." (The paper is here: http://bit.ly/1ywW7WJ.)

Dr. Mattar told Reuters Health by email, "Market demands and popular expectations were the underlying drivers for the shift in MIS utilization. However, the rapid advent and disordered adoption of laparoscopic principles in surgical training have been at the crux of the crisis in training that we now experience."

"Rising concerns in patient rights and safety, and economic realities, will no longer allow for the traditional model of training in the operating room," he said. "There needs to be more creativity, innovation, and optimization of simulation platforms, coupled with their utilization earlier on in the course of surgical training, even at the medical student level. These are all, incidentally, actions that are being actively pursued by educational and training organizations."

Dr. Mattar added, "Advancing technology has also impacted surgical training in other ways. Innovations in diagnostic and therapeutic imaging and percutaneous procedures have rendered many surgical procedures, especially in the realm of vascular surgery, trauma, infections, etc. essentially unnecessary in the majority of cases. Intraabdominal abscesses, vascular strictures and aneurysms, solid organ blunt trauma are just a few examples of how current management has shifted into the non-operative realm. While such advancement is undoubtedly of major benefit to patients, it does detract from residents' overall operative experience."

SOURCE: http://bit.ly/1KiFyBJ

JAMA Surg 2014.