Comparison of Appendectomy Outcomes Between Senior General Surgeons and General Surgery Residents | Gastrointestinal Surgery | JAMA Surgery | JAMA Network
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Figure.  Study Flowchart
Study Flowchart

GSR indicates general surgery resident; SGS, senior general surgeon.

Table 1.  Comparison of Preoperative Presentation and Operative Course Between the 2 Study Groups
Comparison of Preoperative Presentation and Operative Course Between the 2 Study Groups
Table 2.  Comparison of Postoperative Course Between the 2 Study Groups
Comparison of Postoperative Course Between the 2 Study Groups
Table 3.  Comparison of Postoperative Complications Between the 2 Study Groups
Comparison of Postoperative Complications Between the 2 Study Groups
Table 4.  Summary of Previous Publications Comparing Appendectomy Outcomes Between SGSs and GSRs
Summary of Previous Publications Comparing Appendectomy Outcomes Between SGSs and GSRs
1.
Stewart  B, Khanduri  P, McCord  C,  et al.  Global disease burden of conditions requiring emergency surgery.  Br J Surg. 2014;101(1):e9-e22.PubMedGoogle ScholarCrossref
2.
Bhangu  A, Søreide  K, Di Saverio  S, Assarsson  JH, Drake  FT.  Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management.  Lancet. 2015;386(10000):1278-1287.PubMedGoogle ScholarCrossref
3.
Wu  JX, Dawes  AJ, Sacks  GD, Brunicardi  FC, Keeler  EB.  Cost effectiveness of nonoperative management versus laparoscopic appendectomy for acute uncomplicated appendicitis.  Surgery. 2015;158(3):712-721.PubMedGoogle ScholarCrossref
4.
Richards  MK, McAteer  JP, Drake  FT, Goldin  AB, Khandelwal  S, Gow  KW.  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.  JAMA Surg. 2015;150(2):169-172.PubMedGoogle ScholarCrossref
5.
Shabtai  M, Rosin  D, Zmora  O,  et al.  The impact of a resident’s seniority on operative time and length of hospital stay for laparoscopic appendectomy: outcomes used to measure the resident’s laparoscopic skills.  Surg Endosc. 2004;18(9):1328-1330.PubMedGoogle ScholarCrossref
6.
Malangoni  MA, Biester  TW, Jones  AT, Klingensmith  ME, Lewis  FR  Jr.  Operative experience of surgery residents: trends and challenges.  J Surg Educ. 2013;70(6):783-788.PubMedGoogle ScholarCrossref
7.
Somme  S, To  T, Langer  JC.  Effect of subspecialty training on outcome after pediatric appendectomy.  J Pediatr Surg. 2007;42(1):221-226.PubMedGoogle ScholarCrossref
8.
Whisker  L, Luke  D, Hendrickse  C, Bowley  DM, Lander  A.  Appendicitis in children: a comparative study between a specialist paediatric centre and a district general hospital.  J Pediatr Surg. 2009;44(2):362-367.PubMedGoogle ScholarCrossref
9.
Wong  K, Duncan  T, Pearson  A.  Unsupervised laparoscopic appendicectomy by surgical trainees is safe and time-effective.  Asian J Surg. 2007;30(3):161-166.PubMedGoogle ScholarCrossref
10.
Hwang  CS, Pagano  CR, Wichterman  KA, Dunnington  GL, Alfrey  EJ.  Resident versus no resident: a single institutional study on operative complications, mortality, and cost.  Surgery. 2008;144(2):339-344.PubMedGoogle ScholarCrossref
11.
Hutter  MM, Glasgow  RE, Mulvihill  SJ.  Does the participation of a surgical trainee adversely impact patient outcomes? a study of major pancreatic resections in California.  Surgery. 2000;128(2):286-292.PubMedGoogle ScholarCrossref
12.
Birkmeyer  JD, Stukel  TA, Siewers  AE, Goodney  PP, Wennberg  DE, Lucas  FL.  Surgeon volume and operative mortality in the United States.  N Engl J Med. 2003;349(22):2117-2127.PubMedGoogle ScholarCrossref
13.
Sosa  JA, Bowman  HM, Tielsch  JM, Powe  NR, Gordon  TA, Udelsman  R.  The importance of surgeon experience for clinical and economic outcomes from thyroidectomy.  Ann Surg. 1998;228(3):320-330.PubMedGoogle ScholarCrossref
14.
Mizrahi  I, Mazeh  H, Levy  Y,  et al.  Comparison of pediatric appendectomy outcomes between pediatric surgeons and general surgery residents.  J Surg Res. 2013;180(2):185-190.PubMedGoogle ScholarCrossref
15.
Graat  LJ, Bosma  E, Roukema  JA, Heisterkamp  J.  Appendectomy by residents is safe and not associated with a higher incidence of complications: a retrospective cohort study.  Ann Surg. 2012;255(4):715-719.PubMedGoogle ScholarCrossref
16.
Singh  P, Turner  EJ, Cornish  J, Bhangu  A; National Surgical Research Collaborative.  Safety assessment of resident grade and supervision level during emergency appendectomy: analysis of a multicenter, prospective study.  Surgery. 2014;156(1):28-38.PubMedGoogle ScholarCrossref
17.
Fahrner  R, Schöb  O.  Laparoscopic appendectomy as a teaching procedure: experiences with 1,197 patients in a community hospital.  Surg Today. 2012;42(12):1165-1169.PubMedGoogle ScholarCrossref
18.
Zygourakis  CC, Valencia  V, Moriates  C,  et al.  Association between surgeon scorecard use and operating room costs.  JAMA Surg. Published online December 7, 2016.PubMedGoogle Scholar
19.
Fong  AJ, Smith  M, Langerman  A.  Efficiency improvement in the operating room.  J Surg Res. 2016;204(2):371-383.PubMedGoogle ScholarCrossref
20.
Mattar  SG, Alseidi  AA, Jones  DB,  et al.  General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors.  Ann Surg. 2013;258(3):440-449.PubMedGoogle ScholarCrossref
21.
Wojcik  BM, Fong  ZV, Patel  MS,  et al.  The resident-run minor surgery clinic: a pilot study to safely increase operative autonomy.  J Surg Educ. 2016;73(6):e142-e149.PubMedGoogle ScholarCrossref
Original Investigation
July 2017

Comparison of Appendectomy Outcomes Between Senior General Surgeons and General Surgery Residents

Author Affiliations
  • 1Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
  • 2Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
JAMA Surg. 2017;152(7):679-685. doi:10.1001/jamasurg.2017.0578
Key Points

Question  Is it safe practice for general surgery residents to perform appendectomies alone?

Findings  This cohort study included 1649 emergency appendectomies and compared outcomes of appendectomies performed by senior general surgeons with those performed by general surgery residents. Analysis demonstrated no significant difference in the postoperative early and late complication rates, postoperative length of hospital stay, and overall duration of antibiotic treatment.

Meaning  The results indicate that residents may safely perform appendectomies without the presence of a senior general surgeon.

Abstract

Importance  In some centers, the presence of a senior general surgeon (SGS) is obligatory in every procedure, including appendectomy, while in others it is not. There is a relative paucity in the literature of reports comparing the outcomes of appendectomies performed by unsupervised general surgery residents (GSRs) with those performed in the presence of an SGS.

Objective  To compare the outcomes of appendectomies performed by SGSs with those performed by GSRs.

Design, Setting, and Participants  A retrospective analysis was performed of all patients 16 years or older operated on for assumed acute appendicitis between January 1, 2008, and December 31, 2015. The cohort study compared appendectomies performed by SGSs and GSRs in the general surgical department of a teaching hospital.

Main Outcomes and Measures  The primary outcome measured was the postoperative early and late complication rates. Secondary outcomes included time from emergency department to operating room, length of surgery, surgical technique (open or laparoscopic), use of laparoscopic staplers, and overall duration of postoperative antibiotic treatment.

Results  Among 1649 appendectomy procedures (mean [SD] patient age, 33.7 [13.3] years; 612 female [37.1%]), 1101 were performed by SGSs and 548 by GSRs. Analysis demonstrated no significant difference between the SGS group and the GSR group in overall postoperative early and late complication rates, the use of imaging techniques, time from emergency department to operating room, percentage of complicated appendicitis, postoperative length of hospital stay, and overall duration of postoperative antibiotic treatment. However, length of surgery was significantly shorter in the SGS group than in the GSR group (mean [SD], 39.9 [20.9] vs 48.6 [20.2] minutes; P < .001).

Conclusions and Relevance  This study demonstrates that unsupervised surgical residents may safely perform appendectomies, with no difference in postoperative early and late complication rates compared with those performed in the presence of an SGS.

Introduction

Acute appendicitis is one of the most common causes of acute abdomen in the surgical profession, and the preferred method of treatment is appendectomy.1,2 As a result, appendectomy (open or laparoscopic) is one of the most frequent emergency surgical procedures, and more than 300 000 appendectomies are performed annually in the United States.3

Given that appendectomy is a common surgical procedure, residents are exposed to a large number of appendectomy procedures early in their surgical training.4-6 This frequency makes it an ideal procedure for junior residents to perform under the guidance of more experienced senior surgical residents. Nevertheless, the level of independence given to general surgery residents (GSRs) performing appendectomies varies dramatically between institutions nationwide and worldwide.7-9

A surgeon’s experience has been shown to improve outcomes in several procedures, such as esophagectomy, pancreatoduodenectomy, thyroidectomy, and other complex operations. However, there is a paucity of literature regarding the effect of surgeon experience on appendectomy outcome.10-13

In a 2013 study published from our institution, Mizrahi et al14 compared pediatric appendectomies performed by GSRs with those performed by senior pediatric surgeons, showing a shorter time from emergency department (ED) to operating room (OR) and a shorter length of hospital stay for the residents’ patients, with no significant difference in the postoperative early and late complication rates or the readmission rate. A retrospective analysis by Graat et al15 of 1538 appendectomy patients demonstrated that it is safe for surgical residents to perform appendectomies, with no increase in complications or negative effect on quality of care. In a multicenter, prospective study by Singh et al16 evaluating 2867 appendectomy cases, no additional patient risk was demonstrated when the operation was performed by an unsupervised surgical resident compared with operations performed by attendings.

In general, at our institution before 2012, surgical residents were allowed to perform appendectomy operations without the presence of senior general surgeons (SGSs). After 2012, the policy changed to require the presence of an SGS in all appendectomy cases. This unique change at a specific time point provided the opportunity to compare the outcomes of operations performed during the 2 different periods. The objective of this study was to compare the outcomes of appendectomies performed by SGSs with those performed by GSRs.

Methods

A retrospective analysis was performed of appendectomy cases performed at our institution between January 1, 2008, and December 31, 2015. Inclusion criteria were all emergency appendectomies for assumed acute appendicitis in patients 16 years or older. Patients who underwent elective (interval) appendectomy or incidental appendectomy as part of gynecologic or oncologic operations were excluded from our analysis. The study was approved by our institution’s institutional review board committee. The necessity for patient informed consent was waived by the committee because of the retrospective nature of the data collection.

Between 2008 and 2012, a substantial proportion of the appendectomies were performed by GSRs without the presence of an SGS. Appendectomies performed during this period in the presence of an SGS were those performed during the morning hours or those performed at night when an SGS happened to be present in the hospital premises. As a general rule, all other appendectomies were performed by GSRs alone. After 2012, all of the appendectomies were performed by an SGS or by a GSR under the supervision of an SGS (Figure).

Relevant data were collected from our medical records. Information reviewed included patient age and sex, initial symptoms, duration of symptoms, body temperature, heart rate, abdominal physical examination findings, white blood cell (WBC) count, imaging studies performed, and the operative and postoperative course.

The primary outcome measured was the postoperative early and late complication rates. All complications were subgraded according to the Clavien-Dindo classification system. Secondary outcomes included time from ED to OR, length of surgery, surgical technique (open or laparoscopic), use of laparoscopic staplers, and duration of postoperative antibiotic treatment during hospitalization and after discharge.

To identify differences between the 2 study groups (SGS vs GSR), univariate analysis with χ2 test and t test was used. Statistical calculations were performed using a software program (SPSS, version 20; SPSS, Inc), and P < .05 was considered statistically significant for all comparisons. Data are presented as the median or the mean (SD), as appropriate.

Results

During the study period, 1860 appendectomies were performed on patients 16 years or older (Figure). After exclusion of interval or incidental appendectomies, 1649 patients were included in the study. Of the entire cohort included, 1101 appendectomies were performed by SGSs and 548 appendectomies were performed by GSRs.

Analysis of the entire cohort of 1649 patients identified a mean (SD) age of 33.7 (13.3) years, with 612 patients (37.1%) being female. The median Alvarado score at presentation was 6 (range, 1-10). The mean (SD) WBC count on presentation was 13 500 (4800) /µL (to convert WBC count to ×109/L, multiply by 0.001), and the mean (SD) duration of symptoms before presentation to the ED was 29.0 (49.9) hours. The mean (SD) time from ED to OR was 9.9 (7.4) hours. One hundred patients (6.1%) underwent an open appendectomy, and the remainder of the patients underwent a laparoscopic appendectomy, with 2 conversions to open surgery. The mean (SD) length of surgery was 42.8 (20.9) minutes, and the mean (SD) postoperative length of hospital stay was 3.1 (1.8) days.

A comparison of both groups’ baseline variables identified that patients in the GSR group were significantly younger than those in the SGS group (mean [SD] age, 32.9 [12.8] vs 35.3 [13.4] years; P < .001) (Table 1). All other baseline and preoperative variables were similar for both groups. The diagnosis of acute appendicitis was confirmed by ultrasound, computed tomography, or both in all patients, except for 3 patients who were taken to surgery with no preoperative imaging. The utility of preoperative imaging studies and their influence on decision making did not differ between the groups.

Table 1 summarizes the preoperative and operative courses of both study groups. No significant difference was found in time from ED to OR in the SGS group vs the GSR group (mean [SD], 10.0 [6.6] vs 9.6 [8.9] hours; P = .26). Analysis of the operative course showed similar percentages of complicated appendicitis (ie, perforated or gangrenous) (11.5% in the SGS group vs 12.6% in the GSR group, P = .53). However, the mean (SD) length of surgery was significantly shorter in the SGS group (39.9 [20.9] minutes) compared with the GSR group (48.6 [20.2] minutes) (P < .001).

Analysis of the patients’ postoperative course demonstrated no significant difference in the postoperative length of hospital stay or overall duration of postoperative antibiotic treatment between the 2 study groups. However, SGSs prescribed additional home antibiotic treatment in fewer patients than GSRs (15.3% vs 21.7%, P = .002) (Table 2).

The postoperative early and late complication rates were similar between the 2 study groups (Table 3). On subgrading the complications according to the Clavien-Dindo classification system, no statistically significant differences were observed between the groups.

Discussion

Learning to perform an appendectomy is an integral part of any surgical resident’s training, providing the resident with basic skills of open and laparoscopic surgery. At some hospitals, a board-certified surgeon attends all cases and assists the junior resident, while at others a more senior GSR suffices. Concerns about patient outcomes have led some training programs, including ours, to determine that appendectomy should routinely be performed under the guidance of an SGS. The present study represents one of the largest available cohorts of appendectomy patients in which a comparison is performed between those operated on by a GSR alone with those operated on in the presence of an SGS. Other than a shorter length of surgery for the SGS group, no significant differences were identified between the groups.

Few publications have evaluated outcomes of appendectomy cases operated on by residents and compared them with those operated on by SGSs. The largest cohort to date was published by Singh et al16 and included 2867 appendectomy cases, of which 87% were performed by residents and 72% by unsupervised residents. Graat et al15 (reporting on 1538 appendectomy patients) and Fahrner and Schöb17 (reporting on 1197 appendectomy patients) published studies with similar findings. Mizrahi et al14 evaluated appendectomies in 403 pediatric patients and compared the outcomes with those of appendectomies performed by GSRs vs SGSs in other studies5,9,15-17 (Table 4).

Our cohort of 1649 patients represents the second largest of the above-mentioned studies. In the present study, appendectomies by unsupervised GSRs were compared with those performed in the presence of an SGS with regard to preoperative, intraoperative, and postoperative data. Because of the paucity of studies available in the literature on this topic, we believe that our cohort represents an important contribution to the available literature.

In the study by Singh et al,16 a total of 2867 appendectomies were prospectively, nonrandomly divided into those performed by attendings, by senior surgical residents, and by junior residents, with 72% of the residents’ operations performed without supervision of an attending. The primary outcome was the adverse event rate in the first 30 postoperative days. In multivariate analysis, patients operated on by senior residents were found to have slightly lower 30-day adverse events rates, although this finding did not reach statistical significance. In contrast, junior residents were found to have outcomes similar to those of attendings.

Mizrahi et al14 compared 246 pediatric appendectomy patients operated on by GSRs with 157 similar cases performed by attending pediatric surgeons. A significantly shorter ED to OR time was demonstrated when patients were operated on by surgical residents compared with attending pediatric surgeons, while our study found no such difference between the SGS and GSR groups. Graat et al15 also observed no significant difference in ED to OR time between similar studied groups.

In contrast to the series by Mizrahi et al,14 which showed a length of surgery 6 minutes shorter for appendectomies performed by GSRs compared with attending pediatric surgeons, our study demonstrated that surgical procedures were almost 9 minutes longer in the GSR group. Although there are several possible explanations, this result is likely because of the advanced experience of our SGSs in laparoscopic surgery. Although Graat et al15 found no difference in operative times between the studied groups, Fahrner and Schöb17 demonstrated results similar to ours, with a longer operative time (by 8 minutes) in the resident group compared with the attending surgeon group.15,17 Among the cohort of patients in the study by Singh et al,16 junior residents had a significantly larger proportion of operations lasting more than 60 minutes, when compared to senior residents and attendings. It could be argued that the additional operative time in the resident group may be related to greater caution because of decreased self-confidence compared with SGSs. Nevertheless, the somewhat longer operative time in the present study did not negatively affect patient outcomes. That said, in an era in which patient care expenses are under great scrutiny, the importance of OR costs must always be kept in mind.18 One of many essential components of these costs is length of surgery; therefore, the significance of a 9-minute difference between SGSs and GSRs should not be underestimated.19

Our study demonstrated a significantly higher open appendectomy rate in patients operated on by GSRs compared with those operated on by SGSs (10.0% [55 of 548] vs 4.2% [46 of 1101], P < .001). However, it must be emphasized that before 2012 open appendectomy was a more common practice. In an analysis of the subgroup of surgical procedures performed by SGSs before 2012 (n = 383), an open appendectomy rate of 9.4% (n = 36) was demonstrated. Therefore, it seems that this finding reflects a historical difference rather than a true variation between the 2 groups.

In our cohort, there was no statistically significant difference in postoperative early and late complication rates between patients operated on by GSRs and those operated by SGSs. Graat et al15 divided appendectomies performed at their institution into the following 3 groups: appendectomies performed by surgeons alone, appendectomies performed by residents under surgeon supervision, and appendectomies performed by residents alone. Among the 1538 patients analyzed, no difference was demonstrated in overall complication or mortality rates between the 3 groups. Mizrahi et al14 demonstrated similar results, with no significant difference in complication rates between the groups. Although Fahrner and Schöb17 observed no significant difference in intraoperative complication rates between GSRs and SGSs in their 1197 patients analyzed, they found higher 30-day morbidity (3.7% vs 1.8%, P = .04) and greater need for surgical reintervention (2.5% vs 0.6%, P = .005) in the SGS group.

While other studies14,15 have demonstrated that SGSs prescribed more in-hospital parenteral antibiotic treatment than surgical residents, the overall duration of postoperative antibiotic treatment before discharge in our cohort was similar between the 2 groups. In contrast, GSRs prescribed additional home antibiotic treatment more often than SGSs (15.3% vs 21.7%); however, similar to the occurrence of open appendectomy, we hypothesize that this finding represents a historical variation rather than a true difference between the SGS and GSR groups. On analysis of the subgroup of patients operated on by SGSs before 2012 (n = 383), a 23.8% (n = 91) rate of additional home antibiotic treatment was found, which is higher than that in the resident group, although not statistically significant. We assume that this historical variation is because of the increased adherence to guidelines regarding postoperative antibiotic use in more recent years.

In our cohort of appendectomy cases, a normal appendix was found on postoperative pathological examination in 48 patients (2.9%), with no significant variation between those operated on by GSRs vs SGSs (Table 1). Mizrahi et al14 demonstrated similar findings, with a normal appendix rate of 4.5% and no significant difference between GSRs and pediatric surgeons. In contrast, Graat et al15 found a 6% rate of clinically (but not histologically shown) normal appendix, with a higher prevalence of normal appendix among the SGS group. Singh et al16 observed no significant difference in the normal (histologically shown) appendix rate between attendings and junior or senior residents; however, an overall normal appendix rate of 20.2% was recorded.

The modern-day general surgical residency has evolved in light of demands for higher levels of supervision. This requirement results in less resident autonomy and a lower level of senior resident self-confidence.20 Giving a resident a certain level of independence in patient care can provide him or her with important tools needed to develop into an effective senior surgeon. The publications reviewed herein, as well as the present study, have shown no negative influence on patient safety in appendectomy cases performed by residents. This safety has also been demonstrated for other minor surgical procedures.21 Therefore, the question posed is whether the inherent educational value of appendectomies can be used as a model for providing resident autonomy, while maintaining patient safety and outcomes.

Limitations

Our study has several limitations. The fact that all of the GSR group patients were operated on before 2012, while a substantial proportion of the SGS group patients were operated on in recent years, presents an obvious historical bias. Therefore, variability in common practices between the 2 periods may have affected the observed results. In addition, the level of involvement of the surgical resident in surgical procedures performed in the presence of an SGS cannot be determined by the records available. It is clear to any individual who has worked in the OR that this involvement can vary greatly, ranging from cases in which the resident minimally participates in the operation to cases in which the resident performs the entire operation almost single-handedly under the guidance of the SGS. Randomized trials are needed to obtain more accurate results.

Conclusions

The results of this study suggest that the absence of an SGS in the OR during appendectomies does not seem to negatively affect patient outcomes. Therefore, we conclude that under standard conditions more experienced surgical residents can be allowed to perform appendectomies alone. Residents performing unsupervised appendectomies should be able to recognize clinical and intraoperative circumstances that necessitate requesting the assistance of a more experienced senior surgeon.

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Article Information

Accepted for Publication: January 20, 2017.

Corresponding Author: Haggi Mazeh, MD, Department of Surgery, Hadassah-Hebrew University Medical Center, Mount Scopus, PO Box 24035, Jerusalem 91240, Israel (hmazeh@hadassah.org.il).

Published Online: April 19, 2017. doi:10.1001/jamasurg.2017.0578

Author Contributions: Drs Siam and Mazeh 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: Siam, Al-Kurd, Cohn, Eid, Mazeh.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Siam, Al-Kurd, Awesat, Cohn, Eid, Mazeh.

Critical revision of the manuscript for important intellectual content: Siam, Al-Kurd, Simanovsky, Cohn, Helou, Mazeh.

Statistical analysis: Siam, Al-Kurd, Awesat, Cohn, Mazeh.

Administrative, technical, or material support: Siam, Helou.

Study supervision: Siam, Al-Kurd, Eid, Mazeh.

Conflict of Interest Disclosures: None reported.

References
1.
Stewart  B, Khanduri  P, McCord  C,  et al.  Global disease burden of conditions requiring emergency surgery.  Br J Surg. 2014;101(1):e9-e22.PubMedGoogle ScholarCrossref
2.
Bhangu  A, Søreide  K, Di Saverio  S, Assarsson  JH, Drake  FT.  Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management.  Lancet. 2015;386(10000):1278-1287.PubMedGoogle ScholarCrossref
3.
Wu  JX, Dawes  AJ, Sacks  GD, Brunicardi  FC, Keeler  EB.  Cost effectiveness of nonoperative management versus laparoscopic appendectomy for acute uncomplicated appendicitis.  Surgery. 2015;158(3):712-721.PubMedGoogle ScholarCrossref
4.
Richards  MK, McAteer  JP, Drake  FT, Goldin  AB, Khandelwal  S, Gow  KW.  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.  JAMA Surg. 2015;150(2):169-172.PubMedGoogle ScholarCrossref
5.
Shabtai  M, Rosin  D, Zmora  O,  et al.  The impact of a resident’s seniority on operative time and length of hospital stay for laparoscopic appendectomy: outcomes used to measure the resident’s laparoscopic skills.  Surg Endosc. 2004;18(9):1328-1330.PubMedGoogle ScholarCrossref
6.
Malangoni  MA, Biester  TW, Jones  AT, Klingensmith  ME, Lewis  FR  Jr.  Operative experience of surgery residents: trends and challenges.  J Surg Educ. 2013;70(6):783-788.PubMedGoogle ScholarCrossref
7.
Somme  S, To  T, Langer  JC.  Effect of subspecialty training on outcome after pediatric appendectomy.  J Pediatr Surg. 2007;42(1):221-226.PubMedGoogle ScholarCrossref
8.
Whisker  L, Luke  D, Hendrickse  C, Bowley  DM, Lander  A.  Appendicitis in children: a comparative study between a specialist paediatric centre and a district general hospital.  J Pediatr Surg. 2009;44(2):362-367.PubMedGoogle ScholarCrossref
9.
Wong  K, Duncan  T, Pearson  A.  Unsupervised laparoscopic appendicectomy by surgical trainees is safe and time-effective.  Asian J Surg. 2007;30(3):161-166.PubMedGoogle ScholarCrossref
10.
Hwang  CS, Pagano  CR, Wichterman  KA, Dunnington  GL, Alfrey  EJ.  Resident versus no resident: a single institutional study on operative complications, mortality, and cost.  Surgery. 2008;144(2):339-344.PubMedGoogle ScholarCrossref
11.
Hutter  MM, Glasgow  RE, Mulvihill  SJ.  Does the participation of a surgical trainee adversely impact patient outcomes? a study of major pancreatic resections in California.  Surgery. 2000;128(2):286-292.PubMedGoogle ScholarCrossref
12.
Birkmeyer  JD, Stukel  TA, Siewers  AE, Goodney  PP, Wennberg  DE, Lucas  FL.  Surgeon volume and operative mortality in the United States.  N Engl J Med. 2003;349(22):2117-2127.PubMedGoogle ScholarCrossref
13.
Sosa  JA, Bowman  HM, Tielsch  JM, Powe  NR, Gordon  TA, Udelsman  R.  The importance of surgeon experience for clinical and economic outcomes from thyroidectomy.  Ann Surg. 1998;228(3):320-330.PubMedGoogle ScholarCrossref
14.
Mizrahi  I, Mazeh  H, Levy  Y,  et al.  Comparison of pediatric appendectomy outcomes between pediatric surgeons and general surgery residents.  J Surg Res. 2013;180(2):185-190.PubMedGoogle ScholarCrossref
15.
Graat  LJ, Bosma  E, Roukema  JA, Heisterkamp  J.  Appendectomy by residents is safe and not associated with a higher incidence of complications: a retrospective cohort study.  Ann Surg. 2012;255(4):715-719.PubMedGoogle ScholarCrossref
16.
Singh  P, Turner  EJ, Cornish  J, Bhangu  A; National Surgical Research Collaborative.  Safety assessment of resident grade and supervision level during emergency appendectomy: analysis of a multicenter, prospective study.  Surgery. 2014;156(1):28-38.PubMedGoogle ScholarCrossref
17.
Fahrner  R, Schöb  O.  Laparoscopic appendectomy as a teaching procedure: experiences with 1,197 patients in a community hospital.  Surg Today. 2012;42(12):1165-1169.PubMedGoogle ScholarCrossref
18.
Zygourakis  CC, Valencia  V, Moriates  C,  et al.  Association between surgeon scorecard use and operating room costs.  JAMA Surg. Published online December 7, 2016.PubMedGoogle Scholar
19.
Fong  AJ, Smith  M, Langerman  A.  Efficiency improvement in the operating room.  J Surg Res. 2016;204(2):371-383.PubMedGoogle ScholarCrossref
20.
Mattar  SG, Alseidi  AA, Jones  DB,  et al.  General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors.  Ann Surg. 2013;258(3):440-449.PubMedGoogle ScholarCrossref
21.
Wojcik  BM, Fong  ZV, Patel  MS,  et al.  The resident-run minor surgery clinic: a pilot study to safely increase operative autonomy.  J Surg Educ. 2016;73(6):e142-e149.PubMedGoogle ScholarCrossref
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