Advanced Laparoscopic Fellowship and General Surgery Residency can Co-exist without Detracting from Surgical Resident Op

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. Surgical Endoscopy (2001) 15:1066-1070.

3. Rattner DW, et al. • 47% of residents felt that additional training was necessary to perform advanced laparoscopic procedures Surgical Endoscopy (2001) 15:1066-1070.

4. 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) 15:1066-1070.

5. # of MIS Fellowships* • 1993: <10 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

6. # of MIS Fellowships* # of Bariatric Procedures • 1993: <10 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

7. The Concern

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

9. Gundersen Lutheran • 325 bed community-based teaching hospital • ACGME–accredited general surgery residency since 1974 • 2 chief residents each year

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

11. Four Surgical Services • Vascular • Trauma • Endocrine/oncology • Minimally Invasive Surgery/Bariatric

12. 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”

13. Initiation of Laparoscopic Fellowship Program Resident Laparoscopic Case Load Resident + Fellow Laparoscopic Case Load 2000 2004 2007

14. Statistical Analysis • T-test was used to compare pre fellowship to post fellowship case numbers • Statistical significance was defined as p<0.05

15. Fellows’ Experience

16. Resident Case Volume Pre/Post-Fellowship 140.5 ± 19.4

17. Resident Case Volume Pre/Post-Fellowship 140.5 ± 19.4 193.3 ± 34.5 * P=0.003

18. Resident Case Volume Pre/Post-Fellowship 140.5 ± 19.4 193.3 ± 34.5 77 ± 17.8 * P=0.003

19. Resident Case Volume Pre/Post-Fellowship 140.5 ± 19.4 193.3 ± 34.5 77 ± 17.8 113.3 ± 23.5 * P=0.003; **P=0.005

20. All Non-Bariatric Laparoscopic Cases per Surgeon during Graduating Year

21. 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.

22. Laparoscopic Inguinal Herniorrhaphy

23. Laparoscopic Inguinal Herniorrhaphy

24. Laparoscopic Inguinal Herniorrhaphy

25. Laparoscopic Antireflux Surgery

26. Laparoscopic Antireflux Surgery

27. Laparoscopic Antireflux Surgery

28. Laparoscopic Partial Colectomy

29. Laparoscopic Partial Colectomy

30. Laparoscopic Partial Colectomy

31. Discussion

32. 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

33. 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

34. 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

35. Limitations

36. 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

37. 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

38. 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 resident–fellow interactions

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

40. 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

41. 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