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Effect Modification Of Resident Autonomy And Seniority On Perioperative Outcomes In Laparoscopic Cholecystectomy
*Thomas H Shin, *Robert Naples, *Judith C French, *Cathleen M Khandelwal, *Warren Rose, *Diya Alaedeen, *Jie Dai, *Jeremy M Lipman, *Michael J Rosen, Clayton Petro
Cleveland Clinic Foundation, Cleveland, OH

Objective
While impact of resident operative involvement has been examined in relation to perioperative outcomes, insight into its effect modification by resident autonomy and seniority remains limited.
Methods
Patient and operator-specific data was collected from adult laparoscopic cholecystectomies at a tertiary academic institution and its regional affiliates between 2018 and 2019. Multivariate modeling compared postoperative outcomes between cases completed with or without resident involvement and its effect modification by resident seniority and autonomy per Zwisch scale. Outcomes include 30-day postoperative complications, hospital readmission rate, and operative time.
Results
Multivariate analysis of 344 laparoscopic cholecystectomies revealed resident involvement in laparoscopic cholecystectomy did not significantly change odds of 30-day postoperative complications (OR 2.52, p=0.185, 95%CI 0.64-9.92) or hospital readmission (OR 1.68, p=0.538, 95%CI 0.36-7.23). Operative time is significantly increased compared to faculty-only cases (IRR 1.37, p<0.001, 95%CI 1.26-1.48). While accounting for case difficulty and resident performance evaluated by SIMPL criteria, stratification by resident autonomy measured by Zwisch scale or seniority reveal no effect modification on 30-day postoperative complications, readmissions, or operative time. The effect of resident involvement on longer relative rates of operative time loses its significance in supervision-only cases (IRR 1.18, p=0.069, 95%CI 0.99-1.41). Cross-sectional view of cases in our dataset demonstrate a progression towards improved performance and autonomy across all levels of case difficulty with each successive postgraduate year.
Conclusion
While resident involvement and autonomy are associated with significantly longer operative times in laparoscopic cholecystectomy, their lack of significant effect on postoperative outcomes argues strongly for continued resident involvement and supervised operative independence.



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