Endoscopic endonasal pituitary surgery: impact of surgical education on operation length and patient morbidity

Abstract

Objectives To determine the difference in operative times and associated complications for cases performed solely by attending-level surgeons versus cases assisted by surgeons-in-training for endoscopic endonasal pituitary surgeries. Design Retrospective chart review. Setting Tertiary-care academic medical center. Participants A total of 228 patients having undergone endoscopic endonasal pituitary surgery from 2005 to 2011. Main Outcome Measure Duration of surgery comparing attending only (AO) and trainee-assisted (TA) surgeries. Results Thirty-seven (19%) of 198 cases were identified as AO surgeries, the remaining 161 (81%) were TA. Operative times (minutes) for the AO group were significantly shorter than the TA group (149.1 ± 54.8 vs 219.5 ± 83.7, p < 0.001). The AO group had fewer intraoperative cerebrospinal fluid leaks (30% vs 39%, p = 0.318), decreased estimated blood loss (408 mL vs 523 mL, p = 0.176), fewer postoperative complications (27% vs 37%, p = 0.268), and shorter length of stay (3.5 vs 4.3 days, p = 0.294). Conclusions This is the first study in otolaryngology or neurosurgery to compare operative times and outcomes for AO versus TA cases at a single academic institution. Operative times were significantly decreased and a trend toward a decrease in patient morbidity was noted for cases performed solely by attendings. The valuation of teaching activities in the operating room is a necessary first step toward optimizing the allocation of resources and funding of surgical education.

Keywords: endoscopic endonasal approach; pituitary surgery; residency training; skull base surgery; surgical education.

Fig. 1

Grouped comparison of surgery durations for AO and TA cases. A higher proportion of TA cases are longer in duration than AO cases. When surgery durations are grouped in 100-minute intervals, the breakdown shown above is as follows: 0 to 100 min: AO, 6 cases (16% of AO cases); TA, 6 cases (4% of TA cases); 101 to 200 min: AO, 27 cases (73% of AO cases); TA, 73 cases (45% of TA cases); 201 to 300 min: AO, 3 cases (8% of AO cases); TA, 53 cases (33% of TA cases); 301 to 400 min: AO, 1 case (3% of AO cases); TA, 22 cases (14% of TA cases); 401 to 500 min: AO, 0 cases; TA, 7 cases (4% of TA cases).

Fig. 2

Comparison of operative times between groups based on tumor extent and method of closure. Mean duration of surgery is significantly longer with trainee assistance for more complex cases involving either extrasellar extension of tumor or a method of closure requiring tissue reconstruction. Mean durations of surgeries for attending only (AO), trainee-assisted (TA), and all cases grouped by extent of tumor relative to the boundaries of the sella turcica. The mean duration of surgery for TA cases is significantly longer than that of AO cases when there is extrasellar extension of tumor (**p < 0.001). This difference decreases but remains significant when the tumor is confined to the sella (*p = 0.027; A). Mean durations of surgeries for AO, TA, and all cases grouped by the method of closure utilized at the end of the surgery. The mean duration of surgery for TA cases is significantly longer than that of AO cases when tissue reconstruction is necessary (**p < 0.001), but not when simple closures are performed (p = 0.162; B).