A National Review of the Frequency of Minimally Invasive Surgery Among General Surgery Residents: Assessment of ACGME Case Logs During 2 Decades of General Surgery Resident Training

Importance  Minimally invasive surgery (MIS) has created a shift in how many surgical diseases are treated. Examining the effect on resident operative experience provides valuable insight into trends that may be useful for restructuring the requirements of resident training.

Objective  To evaluate changes in general surgery resident operative experience regarding MIS.

Design, Setting, and Participants  Retrospective review of the frequency of MIS relative to open operations among general surgery residents using the Accreditation Council for Graduate Medical Education case logs for academic years 1993-1994 through 2011-2012.

Exposures  General surgery residency training among accredited programs in the United States.

Main Outcomes and Measures  We analyzed the difference in the mean number of MIS techniques and corresponding open procedures across training periods using 2-tailed t tests with statistical significance set at P < .05.

Results  Of 6 467 708 operations with the option of MIS, 2 393 030 (37.0%) were performed with the MIS approach. Of all MIS operations performed, the 5 most common were cholecystectomy (48.5%), appendectomy (16.2%), groin hernia repair (10.0%), abdominal exploration (nontrauma) (4.4%), and antireflux procedures (3.6%). During the study period, there was a transition from a predominantly open to MIS approach for appendectomy, antireflux procedures, thoracic wedge resection, and partial gastric resection. Cholecystectomy is the only procedure for which MIS was more common than the open technique throughout the study period (P < .001). The open approach is more common for all other procedures, including splenectomy (0.7% MIS), common bile duct exploration (24.9% MIS), gastrostomy (25.9% MIS), abdominal exploration (33.1% MIS), hernia (20.3% MIS), lung resection (22.3% MIS), partial or total colectomy (39.1%), enterolysis (19.0% MIS), ileostomy (9.0% MIS), enterectomy (5.2% MIS), vagotomy (1.8% MIS), and pediatric antireflux procedures (35.9% MIS); P < .001.

Conclusions and Relevance  Minimally invasive surgery has an increasingly prominent role in contemporary surgical therapy for many common diseases. The open approach, however, still predominates in all but 5 procedures. Residents today must become efficient at performing multiple techniques for a single procedure, which demands a broader skill set than in the past.

Although the first laparoscopic cholecystectomy in the United States was performed in 1988, it was not until academic year (AY) 1993-1994 that the first minimally invasive designations became available for use in the general surgery case logs.¹ The adoption of minimally invasive surgery (MIS) has significantly affected resident education during the past 2 decades. While most would agree that MIS benefits patients, there is concern that laparoscopic surgery poses challenges for general surgery resident training.^2-4 Specifically, some worry that trainees will be inadequately prepared to operate independently owing to the addition of MIS, which demands an expanded skill set in a time when work hours and residency length are not anticipated to increase.^1,5,6

While previous studies have examined specific periods^1,5,7 or representative academic years,⁸ the purpose of this study was to examine all available data to ascertain changes in resident operative experience since the introduction of MIS.

We hypothesized that during the study period, MIS would surpass the open approach in the number of cases logged by surgery residents for cases in which the operation can be performed open or laparoscopically.

All available general surgery resident case log data were requested from the Accreditation Council of Graduate Medical Education (ACGME). General surgery residents record their operative experiences in the ACGME database during all 5 years of clinical training, which is then compiled annually. Summary reports were obtained for all graduating general surgery residents from AY 1989-1990 through AY 2011-2012. Minimally invasive surgery case definitions were added to the log beginning in AY 1993-1994. The data were divided into 4 periods: period 1 (AY 1993-1994 through AY 1997-1998), period 2 (AY 1998-1999 through AY 2002-2003), period 3 (AY 2003-2004 through AY 2007-2008), and period 4 (AY 2008-2009 through AY 2011-2012). Period 1 saw the introduction of MIS coding to the resident case logs. Period 2 was an era of stabilization before the implementation of work-hour restrictions. Period 3 was delineated by implementation of work-hour restrictions in 2003. Period 4 represents the first cohort of residents trained within the limitations of the 80-hour workweek.

During period 1, cases that had both open and MIS designations included adult antireflux operations, gastrostomy tube placement, gastric resection, vagotomy, appendectomy, partial and total colectomy, laparotomy (trauma and nontrauma), cholecystectomy, common bile duct exploration, splenectomy (trauma and nontrauma), inguinal or femoral herniorrhaphy, thoracotomy (trauma and nontrauma), lung wedge resection, and lobectomy. Subsequent additions included enterolysis on July 1, 1997, ileostomy and pediatric antireflux procedures on July 1, 1998, and gastric reduction for obesity on July 1, 2009. The data do not include the MIS designation for partial gastric resection, partial and total colectomy, cholecystectomy, thoracotomy, and lung wedge resection during period 3 or for total colectomy during period 4, making comparison of those operations during those periods impossible. The mean number of total major cases, defined as the cases that count toward the graduation requirement and calculated as the number of MIS techniques divided by the number of total major cases recorded in each period, was compared across periods. The mean number of MIS cases was also broken down by type of case and compared across periods. Finally, the mean number of MIS cases performed during the chief year divided by the total number of cases performed during that year relative to the proportion during the previous 4 years of residency was compared across periods. Analyses were performed using 2-tailed t tests with significance set at P < .05 using the Analysis Toolpak in Microsoft Excel (Microsoft Corp).

Minimally invasive surgery accounted for 8.9% of all total major cases in period 1 compared with 14.0% in period 2, 10.1% in period 3, and 21.8% in period 4 (eFigure 1 in the Supplement). There was a statistically significant rise from period 1 to period 2, a decline from period 2 to period 3, and a rise from period 3 to period 4. Minimally invasive surgery contributed to a significantly higher percentage of total major cases in period 4 compared with period 1 (P < .001).

Of the 6 467 708 cases with open and MIS designations, 4 074 678 (63.0%) were listed as open and 2 393 030 (37.0%) were listed as MIS. Of the MIS cases, the 5 most commonly logged procedures included cholecystectomy (1 148 654 [48.5%]), appendectomy (382 885 [16.2%]), groin hernias (239 303 [10.0%]), exploratory abdominal procedure (nontrauma) (957 212 [4.4%]), and antireflux procedures (957 212 [3.6%]). When compared with the open approach, the cases in which MIS was the more common approach overall were cholecystectomy (82.3%), antireflux procedures (58.5%), and gastric reduction for morbid obesity (56.6%) (P < .001). The open approach is more common for all other procedures, including splenectomy (0.7% MIS), common bile duct exploration (24.9% MIS), gastrostomy (25.9% MIS), abdominal exploration (33.1% MIS), hernia (20.3% MIS), lung resection (22.3% MIS), partial or total colectomy (39.1%), enterolysis (19.0% MIS), ileostomy (9.0% MIS), enterectomy (5.2% MIS), vagotomy (1.8% MIS), and pediatric antireflux procedures (35.9% MIS); P < .001.

Of the open- and MIS-designated procedures for which there were sufficient data, the percentage performed using MIS was calculated for each period (Table). The only case for which MIS was more common than the open approach for all periods was cholecystectomy. Procedures in which MIS became the more common approach during the 4 periods include appendectomy, antireflux, thoracic wedge resection, and partial gastric resection (eFigure 2 in the Supplement).

Thirty-seven percent of all MIS cases were performed during the chief year in period 1, 28.7% in period 2, 31.9% in period 3, and 29.0% in period 4 (eFigure 3 in the Supplement). There was a statistically significant decline from period 1 to period 2, a rise from period 2 to period 3, and a decline from period 3 to period 4 (P < .001 for all comparisons).

Since its introduction, MIS has become commonplace in nearly all surgical disciplines. While it has been well accepted as a technique for thoracic and abdominal cases alike, its introduction into the general surgery curriculum has raised concerns for surgical educators. Even from the outset, there has been concern that the introduction of MIS would lead to qualitative changes in the operative experience of surgical residents, such as a decrease in the number of open procedures performed.⁹ It also creates a challenging environment for educators who must provide experience in 2 unique skill sets for the same operations.⁹

While benefitting patients, these shifts toward adoption of MIS have posed unforeseen challenges for surgical educators. The introduction of MIS represents a new skill set that may have minimal overlap with the open approach. Despite some indications that new trainees come to surgical residency better prepared to learn MIS,¹⁰ a recent survey of program directors found that achieving proficiency with MIS procedures involves steep learning curves and that most residents require more procedures than the Resident Review Committee currently requires.^2,4,11 Recent resident surveys echo these concerns; many respondents believe additional laparoscopic training after residency is necessary to achieve competence.^3,6,12

In an attempt to address the concern that trainees require more MIS experience for technical competence, effective July 1, 2007, the Resident Review Committee increased the MIS case requirements from 34 to 60 for basic and from 0 to 25 for complex laparoscopy. The increased requirement may present challenges for training programs. First, only about half of the programs in the United States have dedicated MIS rotations.¹¹ It may be difficult for programs to achieve the new requirements without recruiting new faculty or rearranging operative rotations.¹³ Second, even if programs are able to fulfill these new requirements, it does not address the issue that residents must learn 2 different methods for the same procedure. Given that there has been minimal change in the number of total major cases performed during the study period (there was an average of 924 total major cases performed in AY 1993-1994 and an average of 980 in AY 2011-2012), MIS cases are replacing cases that were previously performed using the open technique. This increase in the required skill set affects resident competency in both the MIS and open approach.^1,5,7 Third, with the focus on training surgical residents in the MIS approach, there are also financial implications related to longer operative times.^14-16 Finally, in the context of duty-hour restrictions, it may be difficult for residents to spend time practicing technical skills with simulators before using them in the operating room.^17-22

The last year of training is often referred to as the chief year and is crucial because it is the final year of apprenticeship before independent practice.²³ The percentage of minimally invasive cases performed during the chief year has been relatively constant during the study period. The slightly elevated percentage in period 1 may represent skew because the MIS designation was not available prior to their fifth year. These findings are in contrast to studies that demonstrate that MIS is primarily performed by senior residents.^24-26 The ACGME case logs only provide information on the fifth year, so it is possible that the shift described by the other studies is occurring primarily in the third and fourth years of training.

While this is the largest review to date of the effects of MIS on surgery resident operative experience of which we are aware, this study has limitations. First, this is a retrospective review of self-reported data, which may introduce recall bias. Its accuracy is limited by potential underreporting, which may occur once requirements are reached. In addition, the inconsistently recorded MIS designations must be taken into account when formulating conclusions from the data. As an example of the inconsistent coding, the decline in the percentage of laparoscopic cases performed during period 3 is likely an underestimate of the total cases because the Resident Review Committee eliminated the laparoscopic designation for cholecystectomy from AY 2004-2005 through AY 2008-2009. As the definitions and case requirements change, so do the trends in reporting.²⁷ Another form of misclassification may arise because there is not a separate designation for robotic or combined open and laparoscopic cases.

Ongoing evaluation and analysis of the effect of MIS on the general surgery operative log is imperative because it is a gauge for the depth and breadth of surgical training. The rise in MIS has shifted the resident operative experience, but this shift has not been uniform for all procedures. Nonetheless, 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.

Accepted for Publication: May 21, 2014.

Corresponding Author: Morgan K. Richards, MD, Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific St, PO Box 356410, Seattle, WA 98195.

Published Online: December 30, 2014. doi:10.1001/jamasurg.2014.1791.

Author Contributions: Drs Gow and Richards had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Richards, Drake, Goldin, Khandelwal, Gow.

Acquisition, analysis, or interpretation of data: Richards, McAteer, Drake, Goldin, Gow.

Drafting of the manuscript: Richards, Gow.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Richards, McAteer, Goldin, Gow.

Administrative, technical, or material support: Gow.

Study supervision: Goldin, Khandelwal, Gow.

Conflict of Interest Disclosures: None reported.

Previous Presentation: This study was presented at the 85th Annual Meeting of the Pacific Coast Surgical Association; February 17, 2014; Dana Point, California.