title: Influence of resident and attending surgeon seniority on operative performance in laparoscopic cholecystectomy.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Brooke Army Medical Center, Department of General Surgery, San Antonio, Texas 78324, USA. david.kauvar@amedd.army.mil
authors.forename: David S
authors.initials: DS
authors.lastname: Kauvar
authors.forename: Anthony
authors.initials: A
authors.lastname: Braswell
authors.forename: Brandon D
authors.initials: BD
authors.lastname: Brown
authors.forename: Michael
authors.initials: M
authors.lastname: Harnisch
mesh_terms: D000328:Adult; D015992:Body Mass Index; D002763:Cholecystectomy / Q000191:economics / Q000193:education* / Q000379:methods*; D002764:Cholecystitis / Q000175:diagnosis / Q000601:surgery; D002983:Clinical Competence; D005705:Gallbladder Diseases / Q000175:diagnosis / Q000601:surgery; D006801:Humans; D007396:Internship and Residency; D007431:Intraoperative Complications / Q000453:epidemiology; D010535:Laparoscopy / Q000191:economics; D008875:Middle Aged; D010195:Pancreatitis / Q000175:diagnosis / Q000601:surgery; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D013997:Time Factors