Advanced Laparoscopic Fellowship and General Surgery ...

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Advanced Laparoscopic Fellowship and General Surgery ...

  1. 1. 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’Heron Michelle A. Mathiason, M.S.
  2. 2. Surgical Endoscopy (2001) 15:1066-1070.
  3. 3. <ul><li>47% of residents felt that additional training was necessary to perform advanced laparoscopic procedures </li></ul>Rattner DW, et al. Surgical Endoscopy (2001) 15:1066-1070.
  4. 4. <ul><li>47% of residents felt that additional training was necessary to perform advanced laparoscopic procedures </li></ul><ul><li>65% of respondents would pursue an additional year of advanced laparoscopic training if it were available </li></ul>Rattner DW, et al. Surgical Endoscopy (2001) 15:1066-1070.
  5. 5. <ul><li>1993: <10 programs </li></ul><ul><li>2004: 80 programs </li></ul><ul><li>2005: 91 programs </li></ul><ul><li>2006: 108 programs </li></ul><ul><li>2007: 127 programs </li></ul>* National Resident Matching Program. Results and Data. Specialties Matching Service 2008 Appointment Year. NRMP, February 2008 # of MIS Fellowships*
  6. 6. <ul><li>1993: <10 programs </li></ul><ul><li>2004: 80 programs </li></ul><ul><li>2005: 91 programs </li></ul><ul><li>2006: 108 programs </li></ul><ul><li>2007: 127 programs </li></ul>* National Resident Matching Program. Results and Data. Specialties Matching Service 2008 Appointment Year. NRMP, February 2008 # of MIS Fellowships* # of Bariatric Procedures
  7. 7. The Concern Residents Graduating with Suboptimal Advanced Laparoscopic Case Load More Advanced Laparoscopic Fellowships More Advanced Laparoscopic Fellows Competing for Cases
  8. 8. Objective <ul><li>To evaluate the impact of adding an advanced laparoscopic fellowship on general surgery residency case volume at our institution </li></ul>
  9. 9. Gundersen Lutheran <ul><li>325 bed community-based teaching hospital </li></ul><ul><li>ACGME–accredited general surgery residency since 1974 </li></ul><ul><li>2 chief residents each year </li></ul>
  10. 10. Gundersen Lutheran <ul><li>August 2001, established a minimally invasive clinical bariatric surgery program </li></ul><ul><li>In July 2003, initiated minimally invasive bariatric/advanced laparoscopic fellowship </li></ul>
  11. 11. Four Surgical Services <ul><li>Vascular </li></ul><ul><li>Trauma </li></ul><ul><li>Endocrine/oncology </li></ul><ul><li>Minimally Invasive Surgery/Bariatric </li></ul>
  12. 12. Four Surgical Services <ul><ul><li>Ideally, there is a junior and senior resident assigned to each service </li></ul></ul><ul><ul><li>All chief residents spend three months on each service </li></ul></ul><ul><ul><li>The only MIS case exclusively performed by fellows is laparoscopic gastric bypasses </li></ul></ul><ul><ul><li>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” </li></ul></ul>
  13. 13. Initiation of Laparoscopic Fellowship Program 2000 2004 2007 Resident Laparoscopic Case Load Resident + Fellow Laparoscopic Case Load
  14. 14. Statistical Analysis <ul><li>T-test was used to compare pre fellowship to post fellowship case numbers </li></ul><ul><li>Statistical significance was defined as p <0.05 </li></ul>
  15. 15. Fellows’ Experience Fellow Graduate Year Basic Laparoscopic 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
  16. 16. Resident Case Volume Pre/Post-Fellowship 140.5 ± 19.4
  17. 17. Resident Case Volume Pre/Post-Fellowship * P=0.003 140.5 ± 19.4 193.3 ± 34.5
  18. 18. Resident Case Volume Pre/Post-Fellowship * P=0.003 140.5 ± 19.4 193.3 ± 34.5 77 ± 17.8
  19. 19. 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
  20. 20. All Non-Bariatric Laparoscopic Cases per Surgeon during Graduating Year
  21. 21. All Non-Bariatric Laparoscopic Cases per Surgeon during Graduating Year <ul><ul><li>*In addition to these laparoscopic cases, fellows performed a mean of 101 laparoscopic bariatric cases during their fellowship year. </li></ul></ul>
  22. 22. Laparoscopic Inguinal Herniorrhaphy
  23. 23. Laparoscopic Inguinal Herniorrhaphy
  24. 24. Laparoscopic Inguinal Herniorrhaphy
  25. 25. Laparoscopic Antireflux Surgery
  26. 26. Laparoscopic Antireflux Surgery
  27. 27. Laparoscopic Antireflux Surgery
  28. 28. Laparoscopic Partial Colectomy
  29. 29. Laparoscopic Partial Colectomy
  30. 30. Laparoscopic Partial Colectomy
  31. 31. Discussion
  32. 32. Discussion <ul><li>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 </li></ul>
  33. 33. Discussion <ul><li>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 </li></ul><ul><li>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 </li></ul>
  34. 34. Discussion <ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>Open communication and excellent working relationship between residency director and fellowship director is essential </li></ul>
  35. 35. Limitations
  36. 36. Limitations <ul><li>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 </li></ul>
  37. 37. Limitations <ul><li>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 </li></ul><ul><li>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 </li></ul>
  38. 38. Limitations <ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul>
  39. 39. Conclusion <ul><li>General surgery resident experience with basic and non-bariatric advanced laparoscopic cases did not decrease with the addition of an advanced laparoscopic fellowship </li></ul>
  40. 40. Conclusion <ul><li>General surgery resident experience with basic and non-bariatric advanced laparoscopic cases did not decrease with the addition of an advanced laparoscopic fellowship </li></ul><ul><li>Residents’ operative case volume during their chief year was not negatively impacted </li></ul>
  41. 41. Conclusion <ul><li>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 </li></ul>

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