Prospective validation of the safety of a laparoscopic cholecystectomy training paradigm featuring incremental autonomy

Background: Surgical training is under scrutiny for the effect increased resident autonomy may have on patient outcomes. We hypothesize that as laparoscopic cholecystectomy (LC) difficulty increases, there will be increased involvement by senior residents and attending physicians with no differences in complications. Methods: Ten acute care surgeons were asked to fill out a postoperative questionnaire regarding surgical difficulty after every LC between 11/9/2016 and 3/30/2017. Either the Jonckheere-Terpstra test, Mantel-Haenzel chi square test, or ANOVA was used to test for the association between perioperative data and surgical difficulty. Results: A total of 190 LCs were analyzed. PGY level, percent of surgery time with attending surgeon involvement, partial cholecystectomy rate, and length of operation all significantly rose with increasing level of difficulty (p < 0.001) with no significant differences in 60-day emergency room bounce-backs, readmission, or complication rates. Conclusions: We found that as LC difficulty increases, so does attending surgeon and/or senior resident involvement, without increased morbidity. Giving autonomy to surgery residents during training may better prepare them for postgraduate practice. We found our mid-level residents can safely perform most laparoscopic cholecystectomies under chief supervision with minimal help from attending surgeons, without an increase in readmissions, complications or emergency room bounce-backs.