title: Resident participation in index laparoscopic general surgical cases: impact of the learning environment on surgical outcomes.
abstract: BACKGROUND
  The NSQIP database enables measurement of postoperative outcomes across a spectrum of practice settings. This allows for observations about potential effects of resident participation in surgical care during training.
  
  
  METHODS
  We queried the NSQIP database for 6 index laparoscopic surgical procedures performed during 2005-2008. Selected procedures require varying skill level (eg, appendectomy, cholecystectomy, gastric bypass, fundoplication, colectomy, and inguinal hernia), and 79,720 cases were identified. Preoperative, operative, and postoperative outcomes for each procedure were tabulated. Operative and postoperative outcomes assessed included operative time, hospital length of stay, mortality, morbidity, and return to the operating room. Initial analysis compared cases done with a resident present with cases done without residents. Subset analysis was done to determine possible differences in outcomes based on the level of resident participating, divided into Junior (PGY1-2), Senior (PGY3-5), or Fellow (PGY>5). Groups were scrutinized for both clinical and statistical differences.
  
  
  RESULTS
  Preoperative characteristics were similar between groups. Operative times were 20% to 47% longer with resident participation, with bigger differences seen in more basic procedures. Mortality and return to the operating room were not clinically different between the groups. Morbidity rates were higher in all procedures with resident participation. More senior residents were associated with longer operative times, without adverse impact on outcomes.
  
  
  CONCLUSIONS
  Resident participation increases operative times for laparoscopic surgery considerably. Morbidity is statistically higher with resident participation but differences are unlikely to be clinically significant. Resident participation is a surrogate for the learning environment. These findings provide impetus for additional development of training techniques that occur outside the operating room.
authors.affiliation: Division of General and Gastrointestinal Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA. sdavisj@emory.edu
authors.forename: S Scott
authors.initials: SS
authors.lastname: Davis
authors.forename: Farah A
authors.initials: FA
authors.lastname: Husain
authors.forename: Edward
authors.initials: E
authors.lastname: Lin
authors.forename: Kalyana C
authors.initials: KC
authors.lastname: Nandipati
authors.forename: Sebastian
authors.initials: S
authors.lastname: Perez
authors.forename: John F
authors.initials: JF
authors.lastname: Sweeney
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D016208:Databases, Factual; D005260:Female; D013502:General Surgery / Q000193:education*; D006801:Humans; D007223:Infant; D007396:Internship and Residency / Q000379:methods*; D010535:Laparoscopy / Q000193:education* / Q000401:mortality; D007902:Length of Stay / Q000706:statistics & numerical data; D016015:Logistic Models; D008297:Male; D016017:Odds Ratio; D061646:Operative Time; D010043:Outcome and Process Assessment, Health Care; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology; D014481:United States; D055815:Young Adult