Resident first assistance in bariatric surgery: do patients pay a price?

Background: First assistance during metabolic and bariatric surgery (MBS) often consists of either a general surgery resident (GSR), minimally invasive surgery fellow (MISF), or advanced practice provider (APP). While APPs may be consistent members of the bariatric team, GSRs and MISFs are often rotating members. It is unclear to what extent the inclusion of APPs versus surgical trainees (GSRs or MISFs) affect surgical outcomes.

Objectives: The aim of this study was to determine the effect of first assistant type on adverse outcomes following sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB).

Setting: Academic hospital.

Methods: From the 2015-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program databases, we identified conventional laparoscopic and robot-assisted SG or RYGB performed with an APP, GSR, or MISF as first assistant. Patient demographics, co-morbidities, and operative characteristics were used to create 1:1 case-matched first-assistant cohorts, and perioperative outcomes were compared. Variables were compared using the χ test, Mann-Whitney U test, and regression models. Analyses were performed with StataMP 17. A P value <.05 and a 95% confidence interval exclusive of 1 or 0 were considered statistically significant.

Results: Of 414,623 included cases, an APP, GSR, and MISF served as first assistant in 58%, 28%, and 14%, respectively. Mean operative length was longer in GSR (P < .001) and MISF (P < .001) versus APP cases and similar between GSR and MISF cases (P = .08). Compared with an APP as first assistant, the odds of approach conversion (P < .001), readmission (P < .001), and overall morbidity (P < .001) were significantly higher in GSR and MISF cases. Compared with an APP, GSR cases also were associated with higher odds of admission to the intensive care unit (P < .001), reintervention (P < .001), bleeding (P = .002), venous thromboembolism (P < .001), and surgical site infection (P < .001). Most outcomes were similar between GSR and MISF as first assistant cases.

Conclusions: While training future surgeons is an important aspect of bariatric surgery, inexperienced trainees or shifting roles within a surgical team may confer increased surgical risks to patients. Strategies are needed to optimize patient safety while maintaining a robust resident experience.