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Multicenter Study
. 2018 May;55(5):714-719.
doi: 10.1016/j.ejvs.2018.02.026. Epub 2018 Mar 31.

Use of an Assistant Surgeon Does not Mitigate the Effect of Lead Surgeon Volume on Outcomes Following Open Repair of Intact Abdominal Aortic Aneurysms

Sarah E Deery  1 , Thomas F X O'Donnell  1 , Sara L Zettervall  2 , Jeremy D Darling  3 , Katie E Shean  4 , A James O'Malley  5 , Bruce E Landon  6 , Marc L Schermerhorn  7
Affiliations
Multicenter Study

Use of an Assistant Surgeon Does not Mitigate the Effect of Lead Surgeon Volume on Outcomes Following Open Repair of Intact Abdominal Aortic Aneurysms

Sarah E Deery et al. Eur J Vasc Endovasc Surg. 2018 May.

Abstract

Objective/background: While higher lead surgeon volume has been associated with lower mortality following open abdominal aortic aneurysm (AAA) repair, little is known about the impact of using an attending surgeon as assistant surgeon. The aim of this study was to determine whether the presence of an assistant surgeon, particularly a high volume assistant, mitigates the relationship between lead surgeon volume and outcomes.

Methods: All Medicare beneficiaries who underwent intact, open AAA repair between 2003 and 2008 were evaluated and nested regression models were constructed to evaluate the relationship between surgeon and assistant volume and peri-operative mortality, adjusting for comorbid conditions and hospital volume.

Results: In total 28,590 repairs were studied, of which 19,284 (67.5%) were performed by a single surgeon and 9306 (32.5%) included an assistant surgeon. Of cases with an assistant, 12.3% included a high volume assistant surgeon. Lower volume surgeons more frequently used an assistant (lead surgeon Q1 volume: 40%; Q2: 36%; Q3: 34%; Q4: 29%; Q5: 27% [p < .01]). In cases with no assistant, adjusted peri-operative mortality varied monotonically with surgeon volume (Q1: 4.7%; Q2: 4.4%; Q3: 4.1%; Q4: 3.3%; Q5: 3.2%). However, the use of a high or a low volume assistant surgeon, compared with no attending surgeon as assistant, was not associated with lower peri-operative mortality in any lead surgeon volume quintile, even among those operations performed by the lowest volume lead surgeons.

Conclusion: Employing an assistant surgeon does not improve outcomes amongst any quintile of volume of the lead surgeon. As surgeons perform fewer open AAA repairs in the modern era, these data imply that even the help of a high volume assistant surgeon may not mitigate the detrimental effect of a lower volume surgeon.

Keywords: AAA; Assistant; Open repair; Volume.

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Conflict of interest statement

Conflict of Interest

MLS is a consultant for Abbott, Medtronic, and Endologix.

Figures

Figure 1
Figure 1
Number of lead surgeons (A) and assistant surgeons (B) with each 2-year volume count.
Figure 1
Figure 1
Number of lead surgeons (A) and assistant surgeons (B) with each 2-year volume count.
Figure 2
Figure 2
With low-volume lead surgeons in high-volume hospitals, cases with a high-volume assistant have a > 2-fold higher mortality (P < .01). However, among each other quadrant of high-vs. low-volume hospital and lead surgeon, there is no effect from the addition of either a high-volume or a low-volume assistant surgeon, compared to no assistant surgeon (all P > .05).
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