Comparison of Outcomes of Abdominal Wall Reconstruction Performed by Surgical Fellows vs Faculty

Abstract

Importance: Concern regarding surgical trainees' operative autonomy has increased in recent years, emphasizing patient safety and preparation for independent practice. Regarding abdominal wall reconstruction (AWR), long-term outcomes of fellow autonomy have yet to be delineated.

Objectives: To evaluate the long-term outcomes of AWRs performed by fellows and compare them with those of AWRs performed by assistant, associate, and senior-level professors.

Design, setting, and participants: This retrospective cohort study included patients who underwent AWR for ventral hernias or repair of tumor resection defects at a 710-bed tertiary cancer center between March 1, 2005, and June 30, 2019. The analysis was conducted between January 2020 and December 2021.

Exposure: Academic rank of primary surgeon.

Main outcomes and measures: The primary outcome was hernia recurrence. Secondary outcomes were surgical site occurrence, surgical site infection, length of hospital stay, unplanned return to the operating room, and 30-day readmission. Multivariable hierarchical models were constructed to identify predictive factors.

Results: Of 810 consecutive patients, 720 (mean [SD] age, 59.8 [11.5] years; 375 female [52.1%]) met the inclusion criteria. Mean (SD) body mass index was 31.4 (6.7), and mean (SD) follow-up time was 42 (29) months. Assistant professors performed the most AWRs (276 [38.3%]), followed by associate professors (169 [23.5%]), senior-level professors (157 [21.8%]), and microsurgical fellows (118 [16.4%]). Compared with fellows and more junior surgeons, senior-level professors tended to operate on significantly older patients (mean [SD] age, 59.9 [10.9] years; P = .03), more patients with obesity (103 [65.6%]; P = .003), and patients with larger defects (247.9 [216.0] cm; P < .001), parastomal hernias (27 [17.2%]; P = .001), or rectus muscle violation (53 [33.8%]; P = .03). No significant differences were found for hernia recurrence, surgical site occurrence, surgical site infection, 30-day readmission rates, or length of stay among the fellows and assistant, associate, and senior-level professors in adjusted models. Compared with fellows, assistant professors (OR, 0.22; 95% CI, 0.08-0.64) and senior-level professors (OR, 0.20; 95% CI, 0.06-0.69) had lower rates of unplanned return to the operating room.

Conclusions and relevance: This cohort study provides evidence-based reassurance that providing fellows with autonomy in performing AWRs does not compromise long-term patient outcomes. These findings may incite efforts to increase appropriate surgical trainee autonomy, thereby empowering future generations of competent, independent surgeons.