The Impact of Operating Surgeon Experience, Supervised Trainee vs. Trained Surgeon, in Vascular Surgery Procedures: A Systematic Review and Meta-Analysis

Abstract

This review demonstrates that supervised trainees, with appropriate training and suitable experience, can perform surgical procedures in select vascular cases without any detriment to patient care. Developing and maintaining supported training programmes for vascular trainees to maximise their surgical exposure is essential, ensuring high standards of care for tomorrow's patients.Objective: The operative caseload of a surgeon has a positive influence on post-operative outcomes. For surgical trainees to progress effectively, maximising operating room exposure is essential, vascular surgery being no exception. Our aim was to ascertain the impact of supervised trainee led vs. expert surgeon led procedures on post-operative outcomes, across three commonly performed vascular operations. Methods: A literature search was undertaken using the MEDLINE, Web of Science, and Cochrane databases up to 1 January 2018. Studies reporting outcomes following major lower limb amputation, fistula formation, or carotid endarterectomy (CEA) that involved a direct comparison between supervised trainee and experts were included, with odds ratios (ORs) calculated. Primary outcomes varied depending on the specific procedure: amputationsdrate of amputation revision within 30 days; fistula formationdprimary patency; CEAdstroke rate at 30 days. Meta-analysis with the Mantel-Haenszel method was performed for each outcome. Results: Sixteen studies were included in the final review. Overall, trainees accounted for a third of all procedures analysed (n ¼ 2 421/7 017; 34.5%). Only one study was identified that described rates of amputation revision, precluding any further analysis. Four studies on fistula formation were included, showing no significant difference in outcomes between trainees and experts in primary patency (OR 1.68, 95% confidence interval [CI] 0.42e6.75). Nine studies were identified reporting post-CEA stroke rates, also demonstrating no difference between trainees and experts (OR 0.89, 95% CI 0.59e1.32). Conclusion:In select cases, with appropriate training and suitable experience, supervised trainees can perform surgical procedures without any detriment to patient care. To ensure high standards for patients of the future, supported training programmes are essential for today's surgical trainees.

Operating room organization and surgical performance: a systematic review

“…On the other hand, Bougie et al [ 11 ] evaluated only the bleeding rate and the operative time, which increased. Another review [ 12 ] specified the importance of the seniority/experience of the operator on the speed of execution of the procedures and the reduction of unexpected intraoperative events. Some authors also evaluated the impact of the surgeon gender, finding in a study involving 1,165,711 patients, that those treated by female surgeons exhibited lower rates of adverse postoperative outcomes, including mortality at 90 days and 1 year, compared to patients treated by male surgeons, highlighting potential differences in patient outcomes based on physician gender [ 97 ].Three reviews have described an effect of music in the operating room, but only evaluated the effects on expert surgeons or surgeons in training who were working on experimental models, rather than in-vivo.…”

Supportive and collaborative interdependence: Distinguishing residents’ contributions within health care teams

“…When residents perform as data gatherers, coordinators, facilitators, managers, negotiators, fixers, advocates, integrators, consolidators, initiators and catalysts, collaborative interdependence prompts us to assess these not just as individual actions but also as contributions that shape the conditions that allow a health care team to function successfully or unsuccessfully. Understanding how residents shape health care team function is a critical question, but it is often reduced to exploration of their impact on operative time or the relationship between level of training and surgical outcomes 35,36 . In one of the few studies to tackle this question from what we could now call an ‘interdependence’ lens, Elbardissi and colleagues 37 quantitatively evaluated the effects of both individual surgeon experience and the cumulative experience of attending surgeon—cardiothoracic fellow collaborations in isolated coronary artery bypass graft (CABG) procedures, concluding that the primary driver of operative efficiency in CABG procedure was how many times the attending surgeon and fellow had worked together, rather than the individual experience of the attending surgeon.…”

“…Understanding how residents shape health care team function is a critical question, but it is often reduced to exploration of their impact on operative time or the relationship between level of training and surgical outcomes. 35,36 In one of the few studies to tackle this question from what we could now call an 'interdependence' lens, Elbardissi and colleagues 37 quantitatively evaluated the effects of both individual surgeon experience and the cumulative experience of attending surgeon-cardiothoracic fellow collaborations in isolated coronary artery bypass graft (CABG) procedures, concluding that the primary driver of operative efficiency in CABG procedure was how many times the attending surgeon and fellow had worked together, rather than the individual experience of the attending surgeon. We would encourage more research into how the nature and quality of interdependence between trainees and other team members influences important process and outcome measures.…”

Expert consensus on the establishment and maintenance of native arteriovenous fistula

“…Although the results did not find a significant difference in the primary patency rate between surgeries performed by primary physicians and experienced physicians (the complexity of the surgery might be different), the final recommendation was still that junior physicians should accumulate experience through appropriate training and perform surgical operations under the guidance of experienced physicians and without harming the interests of patients. 53 …”

“…Although the results did not find a significant difference in the primary patency rate between surgeries performed by primary physicians and experienced physicians (the complexity of the surgery might be different), the final recommendation was still that junior physicians should accumulate experience through appropriate training and perform surgical operations under the guidance of experienced physicians and without harming the interests of patients. 53 In summary, junior doctors should receive training, and gradually perform operations under the leadership of experienced doctors. Another finding of the abovementioned study was that doctors of different specialties performed internal fistula operations, including 13,110 cases of vascular surgery (45.2%), 9398 cases (32.3%) of general surgery, 2313 cases (8%) of thoracic surgery, 1517 cases (5.2%) of other specialized operations, and 2696 cases (9.3%) of unknown specialized operations.…”