Advanced Laparoscopic Fellowship and General Surgery Residency can Coexist without Detracting from S

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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. OHeron
• Michelle A. Mathiason, M.S.

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Surgical Endoscopy (2001) 151066-1070.
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Rattner DW, et al.

• 47 of residents felt that additional training
  was necessary to perform advanced laparoscopic
  procedures

Surgical Endoscopy (2001) 151066-1070.
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Rattner DW, et al.

• 47 of residents felt that additional training
  was necessary to perform advanced laparoscopic
  procedures
• 65 of respondents would pursue an additional
  year of advanced laparoscopic training if it were
  available

Surgical Endoscopy (2001) 151066-1070.
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of MIS Fellowships

• 1993 lt10 programs
• 2004 80 programs
• 2005 91 programs
• 2006 108 programs
• 2007 127 programs

National Resident Matching Program. Results and
Data. Specialties Matching Service 2008
Appointment Year. NRMP, February 2008
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of MIS Fellowships
of Bariatric Procedures

• 1993 lt10 programs
• 2004 80 programs
• 2005 91 programs
• 2006 108 programs
• 2007 127 programs

National Resident Matching Program. Results and
Data. Specialties Matching Service 2008
Appointment Year. NRMP, February 2008
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The Concern
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Objective

• To evaluate the impact of adding an advanced
  laparoscopic fellowship on general surgery
  residency case volume at our institution

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Gundersen Lutheran

• 325 bed community-based teaching hospital
• ACGMEaccredited general surgery residency since
  1974
• 2 chief residents each year

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Gundersen Lutheran

• August 2001, established a minimally invasive
  clinical bariatric surgery program
• In July 2003, initiated minimally invasive
  bariatric/advanced laparoscopic fellowship

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Four Surgical Services

• Vascular
• Trauma
• Endocrine/oncology
• Minimally Invasive Surgery/Bariatric

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Four Surgical Services

• Ideally, there is a junior and senior resident
  assigned to each service
• All chief residents spend three months on each
  service
• The only MIS case exclusively performed by
  fellows is laparoscopic gastric bypasses
• 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

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Initiation of Laparoscopic Fellowship Program
Resident Laparoscopic Case Load
Resident Fellow Laparoscopic Case Load
2000
2004
2007
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Statistical Analysis

• T-test was used to compare pre fellowship to post
  fellowship case numbers
• Statistical significance was defined as plt0.05

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Fellows Experience
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Resident Case Volume Pre/Post-Fellowship
140.5 19.4
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Resident Case Volume Pre/Post-Fellowship
140.5 19.4
193.3 34.5
P0.003
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Resident Case Volume Pre/Post-Fellowship
140.5 19.4
193.3 34.5
77 17.8
P0.003
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Resident Case Volume Pre/Post-Fellowship
140.5 19.4
193.3 34.5
77 17.8
113.3 23.5
P0.003 P0.005
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All Non-Bariatric Laparoscopic Cases per Surgeon
during Graduating Year
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All Non-Bariatric Laparoscopic Cases per Surgeon
during Graduating Year
In addition to these laparoscopic cases, fellows
performed a mean of 101 laparoscopic bariatric
cases during their fellowship year.
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Laparoscopic Inguinal Herniorrhaphy
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Laparoscopic Inguinal Herniorrhaphy
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Laparoscopic Inguinal Herniorrhaphy
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Laparoscopic Antireflux Surgery
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Laparoscopic Antireflux Surgery
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Laparoscopic Antireflux Surgery
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Laparoscopic Partial Colectomy
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Laparoscopic Partial Colectomy
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Laparoscopic Partial Colectomy
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Discussion
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Discussion

• 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

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Discussion

• 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
• 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

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Discussion

• 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
• 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
• Open communication and excellent working
  relationship between residency director and
  fellowship director is essential

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Limitations
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Limitations

• 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

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Limitations

• 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
• 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

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Limitations

• 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
• 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
• 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
  residentfellow interactions

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Conclusion

• General surgery resident experience with basic
  and non-bariatric advanced laparoscopic cases did
  not decrease with the addition of an advanced
  laparoscopic fellowship

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Conclusion

• General surgery resident experience with basic
  and non-bariatric advanced laparoscopic cases did
  not decrease with the addition of an advanced
  laparoscopic fellowship
• Residents operative case volume during their
  chief year was not negatively impacted

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Conclusion

• 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

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