advanced laparoscopic fellowship and general surgery residency can co-exist without detracting from...
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Advanced Laparoscopic Fellowship and General
Surgery Residency can Co-exist without Detracting from Surgical Resident Operative
Experience
Shanu N. Kothari, M.D., F.A.C.S.Thomas H. Cogbill, M.D., F.A.C.S.
Colette T. O’HeronMichelle A. Mathiason, M.S.
Surgical Endoscopy (2001) 15:1066-1070.
• 47% of residents felt that additional training was necessary to perform advanced laparoscopic procedures
Surgical Endoscopy (2001) 15:1066-1070.
Rattner DW, et al.
• 47% of residents felt that additional training was necessary to perform advanced laparoscopic procedures
• 65% of respondents would pursue an additional year of advanced laparoscopic training if it were available
Surgical Endoscopy (2001) 15:1066-1070.
Rattner DW, et al.
• 1993: <10 programs
• 2004: 80 programs• 2005: 91 programs• 2006: 108 programs• 2007: 127 programs
* National Resident Matching Program. Results and Data. Specialties Matching Service 2008 Appointment Year. NRMP,
February 2008
# of MIS Fellowships*
• 1993: <10 programs
• 2004: 80 programs• 2005: 91 programs• 2006: 108 programs• 2007: 127 programs
* National Resident Matching Program. Results and Data. Specialties Matching Service 2008 Appointment Year. NRMP,
February 2008
-
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
2001 2002 2003 2004 2005
Su
rger
ies
-
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
# of MIS Fellowships*
# of Bariatric Procedures
The Concern
Residents Graduating with Suboptimal
Advanced Laparoscopic Case Load
More Advanced Laparoscopic Fellowships
More Advanced Laparoscopic Fellows Competing for Cases
Objective
• To evaluate the impact of adding an advanced laparoscopic fellowship on general surgery residency case volume at our institution
Gundersen Lutheran
• 325 bed community-based teaching hospital
• ACGME–accredited general surgery residency since 1974
• 2 chief residents each year
Gundersen Lutheran
• August 2001, established a minimally invasive clinical bariatric surgery program
• In July 2003, initiated minimally invasive bariatric/advanced laparoscopic fellowship
Four Surgical Services
• Vascular• Trauma• Endocrine/oncology • Minimally Invasive
Surgery/Bariatric
Four Surgical Services
– Ideally, there is a junior and senior resident assigned to each service
– All chief residents spend three months on each service
– The only MIS case exclusively performed by fellows is laparoscopic gastric bypasses
– Fellows are allowed to perform non-bariatric advanced laparoscopic cases if the complexity of the procedure is beyond the skill level of a resident on the service, as determined by the attending surgeon, or the case is uncovered. Otherwise, all advanced laparoscopic cases are performed with the resident as “surgeon” and the attending or fellow as “teaching assistant”
Initiation of Laparoscopic
Fellowship Program
2000 2004 2007
Resident Laparoscopic Case Load
Resident + Fellow Laparoscopic Case Load
Statistical Analysis
• T-test was used to compare pre fellowship to post fellowship case numbers
• Statistical significance was defined as p<0.05
Fellows’ ExperienceFellow
Graduate Year
Basic Laparoscopi
c
Advanced Laparoscopic Non-Bariatric
Advanced Laparoscopic Bariatric
Total
2004 31 40 106 177
2005 42 76 100 218
2006 50 66 113 229
2007 30 85 83 198
0
25
50
75
100
125
150
175
200
225
250
Pre-Fellowship
Mea
n #
Cas
es
Basic Cases
Resident Case Volume Pre/Post-Fellowship
140.5 ± 19.4
0
25
50
75
100
125
150
175
200
225
250
Pre-Fellowship Post-Fellowship
Me
an
# C
as
es
Basic Cases*
Resident Case Volume Pre/Post-Fellowship
* P=0.003
140.5 ± 19.4 193.3 ± 34.5
0
25
50
75
100
125
150
175
200
225
250
Pre-Fellowship Post-Fellowship
Mea
n #
Cas
es
Basic Cases*
Advanced Cases**
Resident Case Volume Pre/Post-Fellowship
* P=0.003
140.5 ± 19.4
193.3 ± 34.5
77 ± 17.8
0
25
50
75
100
125
150
175
200
225
250
Pre-Fellowship Post-Fellowship
Me
an
# C
as
es
Basic Cases*
Advanced Cases**
Resident Case Volume Pre/Post-Fellowship
* P=0.003; **P=0.005
140.5 ± 19.4
193.3 ± 34.5
77 ± 17.8 113.3 ± 23.5
All Non-Bariatric Laparoscopic Cases per Surgeon during Graduating Year
All Non-Bariatric Laparoscopic Cases per Surgeon during Graduating Year
*In addition to these laparoscopic cases, fellows performed a mean of 101 laparoscopic bariatric cases during their fellowship year.
0
5
10
15
20
25
30
35
40
2000 2001 2002 2003 2004 2005 2006 2007Year
N
National Average SJ + SC
Laparoscopic Inguinal Herniorrhaphy
0
5
10
15
20
25
30
35
40
2000 2001 2002 2003 2004 2005 2006 2007Year
N
GL Average SJ + SC National Average SJ + SC
Laparoscopic Inguinal Herniorrhaphy
0
5
10
15
20
25
30
35
40
2000 2001 2002 2003 2004 2005 2006 2007Year
N
GL Fellow GL Average SJ + SC National Average SJ + SC
Laparoscopic Inguinal Herniorrhaphy
0
5
10
15
20
25
30
35
40
2000 2001 2002 2003 2004 2005 2006 2007Year
N
National Average SJ + SC
Laparoscopic Antireflux Surgery
0
5
10
15
20
25
30
35
40
2000 2001 2002 2003 2004 2005 2006 2007Year
N
GL Average SJ + SC National Average SJ + SC
Laparoscopic Antireflux Surgery
0
5
10
15
20
25
30
35
40
2000 2001 2002 2003 2004 2005 2006 2007Year
N
GL Fellow GL Average SJ + SC National Average SJ + SC
Laparoscopic Antireflux Surgery
0
5
10
15
20
25
30
35
40
2000 2001 2002 2003 2004 2005 2006 2007Year
N
National Average SJ + SC
Laparoscopic Partial Colectomy
0
5
10
15
20
25
30
35
40
2000 2001 2002 2003 2004 2005 2006 2007Year
N
GL Average SJ + SC National Average SJ + SC
Laparoscopic Partial Colectomy
0
5
10
15
20
25
30
35
40
2000 2001 2002 2003 2004 2005 2006 2007Year
N
GL Fellow GL Average SJ + SC National Average SJ + SC
Laparoscopic Partial Colectomy
Discussion
Discussion
• A high volume of basic and advanced laparoscopic procedures should be performed at the sponsoring institution to limit competition for those cases by residents and fellows
Discussion
• A high volume of basic and advanced laparoscopic procedures should be performed at the sponsoring institution to limit competition for those cases by residents and fellows
• Clear cut ground rules need to be established and followed – who is assigned to be surgeon, under what circumstances, and who is primarily responsible for perioperative management of each patient
Discussion• A high volume of basic and advanced laparoscopic
procedures should be performed at the sponsoring institution to limit competition for those cases by residents and fellows
• Clear cut ground rules need to be established and followed – who is assigned to be surgeon, under what circumstances, and who is primarily responsible for perioperative management of each patient
• Open communication and excellent working relationship between residency director and fellowship director is essential
Limitations
Limitations
• Our general surgery program is small, and the lack of a chief resident on the MIS service for 6 months of the year may positively affect our fellows’ operating experience and may not be applicable to large surgery programs that always have a chief resident on service
Limitations
• Our general surgery program is small, and the lack of a chief resident on the MIS service for 6 months of the year may positively affect our fellows’ operating experience and may not be applicable to large surgery programs that always have a chief resident on service
• Several MIS fellowships have more than one fellow present and this may dilute the exposure of a defined set of advanced MIS cases amongst residents and fellows even further
Limitations• Our general surgery program is small, and the lack of a
chief resident on the MIS service for 6 months of the year may positively affect our fellows’ operating experience and may not be applicable to large surgery programs that always have a chief resident on service
• Several MIS fellowships have more than one fellow present and this may dilute the exposure of a defined set of advanced MIS cases amongst residents and fellows even further
• The fellowship director makes it very clear that they cannot “steal” cases from the surgery residents; rather acting as a teaching assistant, unless the case is uncovered. As a result, our data may not be comparable to programs that do not have similar “ground rules” for the resident–fellow interactions
Conclusion
• General surgery resident experience with basic and non-bariatric advanced laparoscopic cases did not decrease with the addition of an advanced laparoscopic fellowship
Conclusion
• General surgery resident experience with basic and non-bariatric advanced laparoscopic cases did not decrease with the addition of an advanced laparoscopic fellowship
• Residents’ operative case volume during their chief year was not negatively impacted
Conclusion
• As a result of the cooperative efforts of the fellowship and residency directors as well as an expansion of the total number of laparoscopic cases performed at our institution due to changes in clinical practice, surgery residents reported an increase in the number of laparoscopic cases while a successful fellowship was established
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