Learning curve in open groin hernia surgery: nationwide register-based study.

BACKGROUND: Current recommendations regarding the number of open groin hernia repairs that surgical trainees are required to perform during their residency are arbitrarily defined and vary between different curricula. This register-based study sought to investigate the learning curve of surgeons performing open anterior mesh repair for groin hernia by assessing hernia recurrence rates, surgical complications and operating times in relation to the number of procedures performed. METHOD: Nationwide data on open anterior mesh repair for groin hernia performed by surgical residents were collected from the Swedish Hernia Register between 2005 and 2020. The data were analysed in a cohort undergoing procedures carried out by surgeons performing their first registered repair as resident general surgeons. Repairs by surgeons with fewer than 30 repairs were excluded. RESULTS: A total of 38 845 repairs carried out by 663 surgeons were included. Operation time decreased with increasing number of performed procedures, mean (s.d.) operation time was 79 (26) min for the first 15 procedures and 60 (23) min after 241 procedures (P <0.001). A turning point where complication rates began to decrease was seen after 60 procedures. Complication rates were 3.6 per cent (396 of 10 978) for procedures 31-60 and 2.7 per cent (157 of 5 798) for procedures 61-120 (P = 0.002). There was no significant relationship between the number of procedures performed and the rate of operation on for recurrence (P = 0.894). CONCLUSION: Sixty performed procedures during surgical residency is a reasonable target for achieving competency to perform open anterior mesh repair for groin hernia safely without supervision.

Graded operative autonomy in emergency appendectomy mirrors case-complexity: surgical training insights from the SnapAppy prospective observational study.

INTRODUCTION: Surgical skill, a summation of acquired wisdom, deliberate practice and experience, has been linked to improved patient outcomes. Graded mentored exposure to pathologies and operative techniques is a cornerstone of surgical training. Appendectomy is one of the first procedures surgical trainees perform independently. We hypothesize that, given the embedded training ethos in surgery, coupled with the steep learning curve required to achieve trainer-recognition of independent competency, 'real-world' clinical outcomes following appendectomy for the treatment of acute appendicitis are operator agnostic. The principle of graded autonomy matches trainees with clinical conditions that they can manage independently, and increased complexity drives attending input or assumption of the technical aspects of care, and therefore, one cannot detect an impact of operator experience on outcomes. MATERIALS AND METHODS: This study is a subgroup analysis of the SnapAppy international time-bound prospective observational cohort study (ClinicalTrials.gov Trial #NCT04365491), including all consecutive patients aged ≥ 15 who underwent appendectomy for appendicitis during a three-month period in 2020-2021. Patient- and surgeon-specific variables, as well as 90-day postoperative outcomes, were collected. Patients were grouped based on operating surgeon experience (trainee only, trainee with direct attending supervision, attending only). Poisson and quantile regression models were used to (adjusted for patient-associated confounders) assess the relationship between surgical experience and postoperative complications or hospital length of stay (hLOS), respectively, adjusted for patient-associated confounders. The primary outcome of interest was any complications within 90 days. RESULTS: A total of 4,347 patients from 71 centers in 14 countries were included. Patients operated on by trainees were younger (Median (IQR) 33 [24-46] vs 38 [26-55] years, p < 0.001), had lower ASA classifications (ASA ≥ 3: 6.6% vs 11.6%, p < 0.001) and fewer comorbidities compared to those operated on by attendings. Additionally, trainees operated alone on fewer patients with appendiceal perforation (AAST severity grade ≥ 3: 8.7% vs 15.6%, p < 0.001). Regression analyses revealed no association between operator experience and complications (IRR 1.03 95%CI 0.83-1.28 for trainee vs attending; IRR 1.13 95%CI 0.89-1.42 for supervised trainee vs attending) or hLOS. CONCLUSION: The linkage of case complexity with operator experience within the context of graduated autonomy is a central tenet of surgical training. Either subconsciously, or by design, patients operated on by trainees were younger, fitter and with earlier stage disease. At least in part, these explain why clinical outcomes following appendectomy do not differ depending on the experience of the operating surgeon.

Ergonomics and performance of using prismatic loupes in simulated surgical tasks among surgeons - a randomized controlled, cross-over trial.

Introduction: Recently developed prismatic loupes may mitigate the high physical workload and risk of neck disorders associated with traditional surgical loupes among surgeons. However, research in this area, particularly among surgeons, is sparse. This study examines the impact of prismatic loupes on surgeons' physical workload, musculoskeletal discomfort, and performance during simulated surgical tasks. Materials and methods: Nineteen out of twenty recruited surgeons performed three tasks in a fixed-order with their own loupes and both low-tilt (LT) and high-tilt (HT) prismatic loupes, in a randomized order. The primary outcomes were the median inclination angles and velocities of the head, trunk, and upper arms, along with the median muscle activity of the cervical erector spinae (CES), upper trapezius (UT), and lumbar erector spinae (LES) for each pair of loupes. The secondary outcomes included performance (completion time and errors), perceived body-part discomfort, and subjective evaluation of the three pairs of loupes. Results: Using prismatic loupes, either LT or HT, compared with the surgeons' own loupes yielded lower head inclinations (all p < 0.001), lower neck muscle activity (all p < 0.05), and lower neck discomfort in indirect comparisons (p < 0.01) with no significant difference in surgical errors (p = 0.628). However, HT loupes resulted in a longer task completion time in two tasks (p < 0.001). Most surgeons preferred LT loupes (N = 12) for their comfort and visual functions. Discussion: The results indicate that prismatic loupes can reduce physical workload in the neck during simulated surgical task, with no significant difference in surgical errors. Future studies are needed to investigate the long-term effects of prismatic loupes among surgeons.