Laparoscopic cholecystectomy performed by general surgery residents. Is it safe? How much does it cost?

ABSTRACT Objective: to evaluate the effectiveness and safety of laparoscopic cholecystectomies performed by residents of the first and second-year of a general surgery residency program. We studied the primary total cost of treatment and complication rates as primary outcomes, comparing the groups operated by senior and resident surgeons. Methods: this was a retrospective cohort study of patients who underwent laparoscopic cholecystectomy performed in a training hospital of large surgical volume in Brazil, in the period between June 1, 2018 and May 31, 2019. The study population comprised patients who underwent elective cholecystectomy due to uncomplicated chronic calculous cholecystitis or to the presence of gallbladder polyps with surgical indication. We divided the cases into three groups, based on the graduation of the main surgeon at the time of the procedure: first-year residents (R1), second-year residents (R2), and trained general surgeons (GS). Results: during the study period, 1,052 laparoscopic cholecystectomies were performed, of which 1,035 procedures met the inclusion criteria, with 78 (7.5%) patients operated on with the participation of first-year residents (R1), 500 (48.3%) patients with the participation of second-year residents (R2), and 457 (44.2%) with the participation of senior surgeons only. There was no difference in conversion rates, complications, and reporting of adverse events between groups. We observed a significant difference regarding hospitalization costs (p = 0.003), with a higher mean for the patients operated with the participation of R1, of US$ 2,671.13, versus US$ 2,414.60 and US$ 2,396.24 for the procedures performed by senior surgeons and R2, respectively. Conclusions: laparoscopic cholecystectomy with the participation of residents is safe, even in their first years of training. There is an additional cost of about 10% in the treatment of patient operated with the participation of first-year residents. There was no significant difference in the cost of the group operated by second-year residents.


INTRODUCTION
M ore than a century ago, William Stewart Halsted established one of the first surgery training programs, which was based on the concept of levels of responsibility of the so-called resident, based on his years of experience 1,2 . Since then, the surgical community has debated the delicate balance between medical education and patient care 3 .
The participation of residents in the operating room is a fundamental step in the training of the surgeon. Even with advances in the field of simulation, there is no substitute for practical teaching in the field 4 .
Appendectomies, herniorrhaphies, and cholecystectomies are relatively simple surgical procedures that traditionally offer ample opportunity for residents to acquire basic training in their operative skills at a relatively early stage of their careers 5 .
The replacement of open cholecystectomy by laparoscopic approach as a standard treatment for calculous gallbladder disease occurred in the early 1990s 6 . Laparoscopy is a challenging access route in terms of guidance, as supervision is often only vocal and requires major changes in operative settings for the tutor to intervene 3 .
On the other hand, the laparoscopic approach has become the standard for many types of operations and is routinely performed, even in smaller hospitals 3 .
Thus, the development of laparoscopic skills is mandatory in a general surgery residency program. In this context, laparoscopic cholecystectomy is among the first and most frequent laparoscopic experiences of the surgery resident 8 .
In the literature, there are conflicting data regarding the increase in morbidity and mortality of patients in whose procedure there has been the participation of a resident [7][8][9][10][11][12][13] . In addition to issues related to patient safety, there is a common perception that the resident's involvement may have an economic impact 9,14,15 . were classified by the Severity of Illness (SOI) as "1", 12

Figure 1. Distribution of patients according to group. Figure 2. Graphic of the need for the assistants' intervention.
There were no statistically significant differences in the characteristics of patients operated between the three groups ( Surgeons groups, respectively. There were no significant differences between the groups regarding the need of ICU and of blood transfusion (Table 5).
However, there was a difference in the time of surgery (Figure 3), the mean duration of procedures performed by experienced surgeons being 50 minutes, and 53 and 60 minutes when there was participation of R2 and R1, respectively (p <0.001). There was also a difference as to hospitalization costs (p = 0.003), with a higher mean hospitalization cost for patients operated on by an R1, US$ 1,802.08, There was no difference in conversion rates, complications, and reports of adverse events between the groups (Tables 6 and 7).

DISCUSSION
The profile of operated patients followed the prevalence of chronic gallbladder calculous disease, more frequent in obese women in the sixth decade of life 17 . As for associated diseases, we opted for the use of SOI in the stratification of cases, since this score is   authors also suggest that the presence of residents in the service may reduce the patients' stay, perhaps due to the greater manpower available to perform bureaucratic tasks. However, they also make no distinction between the profile of operated patients and residents' training degree 4,19 .
As for complication rates (regardless of type or severity), notifications of adverse events, need for blood transfusion, and use of ICU, we observed no differences between the three groups. This suggests that it is safe to perform laparoscopic cholecystectomy with the participation of residents in the first years of surgical observed that there was a cost difference between the group operated by first-year residents in relation to the second-year residents and the group operated only by senior surgeons. This difference was 11.47% more for the R1 group. There was no significant difference between the R2 and senior groups.
As the cost of operating room minute does not enter into this account, everything leads us to believe that the cost difference is probably due to the longer hospital stay, which, as previously discussed, may reflect the greater presence of postoperative symptoms / signs due to a longer procedure. Another possible hypothesis would be the greater concern about early discharging patients operated on by R1s.
Quantifying the financial cost of surgical resident education is no easy task. But it is evident that there must be a cost of training, especially in the first years. It is natural that, as the resident gains experience, this economic impact is mitigated in the hospital budget.
On the other hand, the financial return for the community or even for the educational institution to train a highly competent surgeon is immeasurable.
We recognize some limitations of our work. This is a single-center study. The retrospective observational design, without randomization, is inherently associated with the risk of bias in the selection of cases, with less complex cases being prioritized for residents, especially in the first year. Future multicenter randomized controlled trials are essential to increase the strength of evidence of our findings.

CONCLUSIONS
It is safe to perform laparoscopic cholecystectomy with the participation of residents, even in their first years of training, with no differences between groups as for complication rates (regardless of type or severity), adverse event reports, need of blood products transfusion, and use of ICU.
There is an additional cost of about 10% in the treatment of a patients operated with the participation of a first-year resident, there being no significant difference in the cost of the group operated by residents of the second year.
Teaching any trade requires time and dedication and usually involves some cost. In the health area, in addition to the factors mentioned, one cannot forget the concern with the safety of the main element of this process, the patient. But in this work, we were able to contribute with the idea that it is possible to prepare a new generation of surgeons who will be able to exercise their profession in a safe and effective manner, in a sustainable manner, even with the pressure of maintaining the efficiency of the institutions.