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ELECTIVE INGUINAL HERNIA REPAIR: IS INCREASED RESIDENT AUTONOMY ASSOCIATED WITH EARLY POSTOPERATIVE CLINICAL OUTCOME?
I Lorenzo, CM Tonelli, C Bunn, S Kulshrestha, SP Agnew, ZM Abdelsattar, MS Baker, FA Luchette
Loyola University Medical Center

Background
Recent socioeconomic pressures and work hour restrictions have limited opportunities for surgical trainees to operate autonomously and have raised concern regarding the preparation of graduating residents for independent practice. Few studies evaluate the association between resident autonomy, postoperative clinical outcome, and patient safety.

Methods
We queried the Veterans Affairs Surgical Quality Improvement Program database to identify patients undergoing elective, unilateral, non-recurrent inguinal hernia repair (IHR) between 2004 and 2019. Cases were categorized by level resident autonomy: attending scrubbed (AS) or not scrubbed (NS). Multivariable regression was used to identify factors associated with early postoperative outcomes. Cases performed AS were then 2:1 propensity matched for age, race, body mass index (BMI), ASA, comorbid cardiovascular disease, smoking history, approach (open versus laparoscopic), anesthesia method and resident post-graduate year to those performed NS. Operative times (OT) and rates of postoperative morbidity for matched cohorts were compared using standard statistical methods.

Results
49,540 patients met inclusion criteria, 42,818 (86%) underwent AS IHR, 6,722 (14%) NS. On univariate comparison, patients undergoing AS IHR were more likely to be >65 years old (45.6% vs 43.1%), Caucasian (64% vs 62%), obese (16% vs 14%), ASA class 3 or 4 (57.2% vs 53.9%) and be non-smokers (67% vs 65%) than those undergoing NS IHR (all p80 years (OR 2.33, 95% CI [1.60, 3.38]), obese BMI (OR 2.20, 95% CI [1.75, 2.78]), ASA class 4 (OR 3.27, 95% CI [1.62, 6.60]), smoking (OR 1.32, 95% CI [1.09, 1.59]). 6,722 patients undergoing NS IHR were propensity matched to 13,444 patients undergoing AS IHR. On matched cohorts comparison (Table 1), patients undergoing NS IHR had longer OTs than those undergoing AS IHR but had comparable rates of surgical site infection, postoperative morbidity and mortality.

Conclusion
While resident independence is associated with a modest increase in OT, elective IHR performed autonomously by current surgical residents are done safely with acceptable early postoperative outcomes.


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