SGS 2014

SCOTTSDALE, ARIZ. – Using a Foley catheter guide during midurethral sling surgery does not appear to reduce the risk of injury to the bladder and urethra, according to a retrospective study presented at the annual scientific meeting of the Society of Gynecologic Surgeons.

Surgeons used the guide in 24.5% of the 310 women undergoing retropubic midurethral sling surgery, reported first author Dr. Jeannine M. Miranne, an ob.gyn. at Medstar Washington Hospital Center and Georgetown University, Washington.

The rate of cystotomy was 1.3% in the guide group and 5.6% in the no-guide group, a statistically indistinguishable difference and one that remained so even after adjustment for potential confounders. None of the patients studied experienced a urethrotomy.

"Foley catheter guide use does not decrease the risk of intraoperative lower urinary tract injury. However, larger prospective studies are needed to confirm this finding, given the possibility of a type 2 error," Dr. Miranne concluded.

Session attendee Dr. Eric Sokol, an assistant professor of obstetrics and gynecology, and of urology at Stanford (Calif.) University, wondered if injury rates were affected by the specific sling used.

"What I imagine has possibly influenced your results is the fact that you have changed also the sling that you use. As I understand it, you are using a lot of Advantage Fit slings," he said. In his experience in training residents, the bladder is often inadvertently punctured when this sling is used. "When I use other slings, with a rigid handle and a bigger curve, they don’t go in the bladder. So do you think there might be an influence of the exact sling that you are using?"

"There definitely may be an influence," Dr. Miranne replied. "Unfortunately, the majority of physicians in our group used the Advantage Fit sling for approximately 90% of their cases that were included. So it’s really hard to determine whether or not that played a role in the cystotomy rate in our study. But that’s definitely something to consider when you think about cystotomy – the type of retropubic sling."

Another attendee commented that using a Foley catheter guide adds an annoying, time-consuming step to the surgery. "It wasn’t our idea, but we have used the cystoscope shaft, and we will use that to manipulate the urethra. You have to put that in anyway to scope the patient, and it saves a lot of time putting things in and taking them out," he said at the meeting, which was jointly sponsored by the American College of Surgeons.

Giving some background to the study, Dr. Miranne said that "synthetic midurethral sling has become a gold-standard surgical procedure for stress urinary incontinence. Different techniques have been introduced to decrease the risk of intraoperative lower urinary tract injury during sling placement. One such technique involves use of a rigid Foley catheter guide during retropubic sling placement."

"Although the manufacturer of the original tension-free vaginal tape continues to recommend Foley catheter guide use in its instructions, it is unclear whether use of this device decreases the risk of intraoperative lower urinary tract injury," she noted.

For the study, the investigators included women undergoing retropubic midurethral sling surgery at a single academic center during 2011 and 2012. They excluded any who underwent autologous bladder neck, transobturator, or mini-/single-incision sling surgery.

On average, the patients were 57 years old and had a body mass index of 28 kg/m², according to Dr. Miranne. Overall, 17% had previously undergone anti-incontinence surgery and 20% had previously undergone prolapse surgery, with no significant difference between groups.

Patients in the no-guide group were more likely to have anterior prolapse (95% vs. 78%) and to have a concomitant prolapse repair (65% vs. 51%). They were less likely to have a resident or fellow as first assistant in the surgery (91% vs. 99%) and to have local retropubic anesthesia (71% vs. 96%). Similar proportions had a concomitant hysterectomy.

In addition to showing no significant difference in injury rates, analyses revealed that the groups were statistically the same with respect to mean intraoperative time; mean blood loss; and mean hospital stay, which was less than 1 day for the entire cohort.

Dr. Miranne disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Using a Foley catheter guide during midurethral sling surgery does not appear to reduce the risk of injury to the bladder and urethra, according to a retrospective study presented at the annual scientific meeting of the Society of Gynecologic Surgeons.

Surgeons used the guide in 24.5% of the 310 women undergoing retropubic midurethral sling surgery, reported first author Dr. Jeannine M. Miranne, an ob.gyn. at Medstar Washington Hospital Center and Georgetown University, Washington.

The rate of cystotomy was 1.3% in the guide group and 5.6% in the no-guide group, a statistically indistinguishable difference and one that remained so even after adjustment for potential confounders. None of the patients studied experienced a urethrotomy.

"Foley catheter guide use does not decrease the risk of intraoperative lower urinary tract injury. However, larger prospective studies are needed to confirm this finding, given the possibility of a type 2 error," Dr. Miranne concluded.

Session attendee Dr. Eric Sokol, an assistant professor of obstetrics and gynecology, and of urology at Stanford (Calif.) University, wondered if injury rates were affected by the specific sling used.

"What I imagine has possibly influenced your results is the fact that you have changed also the sling that you use. As I understand it, you are using a lot of Advantage Fit slings," he said. In his experience in training residents, the bladder is often inadvertently punctured when this sling is used. "When I use other slings, with a rigid handle and a bigger curve, they don’t go in the bladder. So do you think there might be an influence of the exact sling that you are using?"

"There definitely may be an influence," Dr. Miranne replied. "Unfortunately, the majority of physicians in our group used the Advantage Fit sling for approximately 90% of their cases that were included. So it’s really hard to determine whether or not that played a role in the cystotomy rate in our study. But that’s definitely something to consider when you think about cystotomy – the type of retropubic sling."

Another attendee commented that using a Foley catheter guide adds an annoying, time-consuming step to the surgery. "It wasn’t our idea, but we have used the cystoscope shaft, and we will use that to manipulate the urethra. You have to put that in anyway to scope the patient, and it saves a lot of time putting things in and taking them out," he said at the meeting, which was jointly sponsored by the American College of Surgeons.

Giving some background to the study, Dr. Miranne said that "synthetic midurethral sling has become a gold-standard surgical procedure for stress urinary incontinence. Different techniques have been introduced to decrease the risk of intraoperative lower urinary tract injury during sling placement. One such technique involves use of a rigid Foley catheter guide during retropubic sling placement."

"Although the manufacturer of the original tension-free vaginal tape continues to recommend Foley catheter guide use in its instructions, it is unclear whether use of this device decreases the risk of intraoperative lower urinary tract injury," she noted.

For the study, the investigators included women undergoing retropubic midurethral sling surgery at a single academic center during 2011 and 2012. They excluded any who underwent autologous bladder neck, transobturator, or mini-/single-incision sling surgery.

On average, the patients were 57 years old and had a body mass index of 28 kg/m², according to Dr. Miranne. Overall, 17% had previously undergone anti-incontinence surgery and 20% had previously undergone prolapse surgery, with no significant difference between groups.

Patients in the no-guide group were more likely to have anterior prolapse (95% vs. 78%) and to have a concomitant prolapse repair (65% vs. 51%). They were less likely to have a resident or fellow as first assistant in the surgery (91% vs. 99%) and to have local retropubic anesthesia (71% vs. 96%). Similar proportions had a concomitant hysterectomy.

In addition to showing no significant difference in injury rates, analyses revealed that the groups were statistically the same with respect to mean intraoperative time; mean blood loss; and mean hospital stay, which was less than 1 day for the entire cohort.

Dr. Miranne disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Using a Foley catheter guide during midurethral sling surgery does not appear to reduce the risk of injury to the bladder and urethra, according to a retrospective study presented at the annual scientific meeting of the Society of Gynecologic Surgeons.

Surgeons used the guide in 24.5% of the 310 women undergoing retropubic midurethral sling surgery, reported first author Dr. Jeannine M. Miranne, an ob.gyn. at Medstar Washington Hospital Center and Georgetown University, Washington.

The rate of cystotomy was 1.3% in the guide group and 5.6% in the no-guide group, a statistically indistinguishable difference and one that remained so even after adjustment for potential confounders. None of the patients studied experienced a urethrotomy.

"Foley catheter guide use does not decrease the risk of intraoperative lower urinary tract injury. However, larger prospective studies are needed to confirm this finding, given the possibility of a type 2 error," Dr. Miranne concluded.

Session attendee Dr. Eric Sokol, an assistant professor of obstetrics and gynecology, and of urology at Stanford (Calif.) University, wondered if injury rates were affected by the specific sling used.

"What I imagine has possibly influenced your results is the fact that you have changed also the sling that you use. As I understand it, you are using a lot of Advantage Fit slings," he said. In his experience in training residents, the bladder is often inadvertently punctured when this sling is used. "When I use other slings, with a rigid handle and a bigger curve, they don’t go in the bladder. So do you think there might be an influence of the exact sling that you are using?"

"There definitely may be an influence," Dr. Miranne replied. "Unfortunately, the majority of physicians in our group used the Advantage Fit sling for approximately 90% of their cases that were included. So it’s really hard to determine whether or not that played a role in the cystotomy rate in our study. But that’s definitely something to consider when you think about cystotomy – the type of retropubic sling."

Another attendee commented that using a Foley catheter guide adds an annoying, time-consuming step to the surgery. "It wasn’t our idea, but we have used the cystoscope shaft, and we will use that to manipulate the urethra. You have to put that in anyway to scope the patient, and it saves a lot of time putting things in and taking them out," he said at the meeting, which was jointly sponsored by the American College of Surgeons.

Giving some background to the study, Dr. Miranne said that "synthetic midurethral sling has become a gold-standard surgical procedure for stress urinary incontinence. Different techniques have been introduced to decrease the risk of intraoperative lower urinary tract injury during sling placement. One such technique involves use of a rigid Foley catheter guide during retropubic sling placement."

"Although the manufacturer of the original tension-free vaginal tape continues to recommend Foley catheter guide use in its instructions, it is unclear whether use of this device decreases the risk of intraoperative lower urinary tract injury," she noted.

For the study, the investigators included women undergoing retropubic midurethral sling surgery at a single academic center during 2011 and 2012. They excluded any who underwent autologous bladder neck, transobturator, or mini-/single-incision sling surgery.

On average, the patients were 57 years old and had a body mass index of 28 kg/m², according to Dr. Miranne. Overall, 17% had previously undergone anti-incontinence surgery and 20% had previously undergone prolapse surgery, with no significant difference between groups.

Patients in the no-guide group were more likely to have anterior prolapse (95% vs. 78%) and to have a concomitant prolapse repair (65% vs. 51%). They were less likely to have a resident or fellow as first assistant in the surgery (91% vs. 99%) and to have local retropubic anesthesia (71% vs. 96%). Similar proportions had a concomitant hysterectomy.

In addition to showing no significant difference in injury rates, analyses revealed that the groups were statistically the same with respect to mean intraoperative time; mean blood loss; and mean hospital stay, which was less than 1 day for the entire cohort.

Dr. Miranne disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Laparoscopic hysterectomy takes longer when residents participate, but is generally as safe as when an attending physician performs the surgery alone, a study showed.

A resident was involved in 46% of the 3,441 cases that were done for benign indications between 2008 and 2011 and identified in the National Surgical Quality Improvement Program (NSQIP) database.

Patients whose surgery involved a resident had higher levels of comorbidity and were higher-risk surgical candidates, according to data presented at the annual meeting of the Society of Gynecologic Surgeons.

Compared with patients whose surgery was performed by an attending physician alone, those whose surgery involved a resident took an average of 44 minutes, or about 25% longer.

However, rates of serious adverse outcomes and death were statistically indistinguishable. The group for whom a resident was involved did have higher rates of transfusion of more than 4 U of packed red blood cells and of readmission.

"Our study is the first of its kind to study this topic in the gynecologic field in such a large sample size," said lead author Dr. Elena Igwe, a third-year obstetrician-gynecologist resident at Temple University Hospital in Philadelphia.

The longer operative time for resident-involved cases "may be accounted for by the obvious training environment of gynecologic and anesthesia residents, medical students, as well as scrub nurse students. Also, more time may have been spent if there were greater intraoperative complications such as bleeding or organ injury that were not captured by the NSQIP database," she said at the meeting, jointly sponsored by the American College of Surgeons.

"Although there was a statistically significant increase in transfusion and readmissions in the resident-involved group, there was no overall effect on morbidity or mortality. Therefore, although laparoscopic hysterectomy may take longer to accomplish with a resident involved, the clinically significant safety profile is largely unchanged," Dr. Igwe said.

Invited discussant Dr. Marie Fidela Paraiso, head of female pelvic medicine and reconstructive surgery at the Cleveland Clinic, commented, "The findings of your investigation are not surprising in that training cases require significantly longer OR times – this is the story of an academician’s life – increased transfusions (cause uncertain) and increased 30-day admits. However, it is reassuring that morbidity and severe complications and 30-day mortality are not different despite greater patient acuity in the training cohort."

She added, "Due to a limit in training hours, alternatives to hysterectomy, and a variation of tools and routes for hysterectomy, resident experience in laparoscopic hysterectomy is likely to decrease. How do you apply your findings to guide future training?" she asked.

Considerable time is required to become skilled at this surgery, Dr. Igwe replied. "If the average resident is going to do less hysterectomies during their duration as a resident, then there are two potential ways to deal with this situation. One, you can increase the length of ob.gyn. training; of course, the lack of federal funding may not make this a very attractive option. Or two, split the specialty into a track system or alternative curriculum system, where a portion of residents go into a specialized gyn. track and receive the majority of hysterectomy and other major surgery trainings, and have the privilege to perform these procedures. A general ob.gyn. residency can therefore potentially be reduced to 3 years, and these practitioners would focus on more routine ob.gyn. and preventive gynecologic care," she suggested.

"We as a society can take the initiative to do this ourselves, or insurance companies, based on the Affordable Care Act initiative and driven by outcome-based research, will make us do this based on our performances, and this may not be a pretty thing," she added.

One session attendee expressed concern about potential selection bias in the study. "It’s possible that for the more complicated cases, the attendings asked the residents to assist them, and therefore we may be unduly giving the residents credit for the increased morbidity," he said.

"That is a concern, but that’s just one of the limitations of the NSQIP database that we were not able to adjust for," Dr. Igwe said.

Another attendee commented, "Your data is reassuring, but it begs the question, we don’t know the degree to which residents were actually involved, and it makes me think ... what would be a more meaningful way to measure this issue of the interaction between resident involvement and patient morbidity?"

"If there was a way to actually record or establish how much a resident is actually doing, that would be the best thing," Dr. Igwe said.

In the study, relative to the patients operated on by attending physicians only, patients whose surgery involved a resident were on average older, were more likely to be inpatients, had higher Charlson comorbidity scores, and had higher American Society of Anesthesiologists classes.

The mean operative time was 179 minutes when a resident was involved and 135 minutes when the attending physician operated alone, reported Dr. Igwe. There was no significant difference between junior residents (those in postgraduate year 1 or 2) and senior residents (all other years).

The group having a resident involved had significantly higher rates of transfusion with more than 4 U of packed red blood cells (2.0% vs. 0.4%) and readmission (5.5% vs. 2.9%). The difference in transfusion rates was greater for junior residents than for senior residents.

However, the groups were statistically indistinguishable with respect to the proportion of patients having at least one complication, experiencing severe morbidity, dying within 30 days, developing infections or sepsis, or having thromboembolic complications.

"The limitations of this study are largely those of the NSQIP database," Dr. Igwe noted. "We were unable to control for attending surgeon experience, presence of additional trainees in the operating room, or tallying up the intraoperative complications. Also, the degree of resident participation is not clearly defined, and there is no data about the conversion rate from laparoscopic to open cases."

Dr. Igwe disclosed no relevant financial conflicts of interest.

SCOTTSDALE, ARIZ. – Laparoscopic hysterectomy takes longer when residents participate, but is generally as safe as when an attending physician performs the surgery alone, a study showed.

A resident was involved in 46% of the 3,441 cases that were done for benign indications between 2008 and 2011 and identified in the National Surgical Quality Improvement Program (NSQIP) database.

Patients whose surgery involved a resident had higher levels of comorbidity and were higher-risk surgical candidates, according to data presented at the annual meeting of the Society of Gynecologic Surgeons.

Compared with patients whose surgery was performed by an attending physician alone, those whose surgery involved a resident took an average of 44 minutes, or about 25% longer.

However, rates of serious adverse outcomes and death were statistically indistinguishable. The group for whom a resident was involved did have higher rates of transfusion of more than 4 U of packed red blood cells and of readmission.

"Our study is the first of its kind to study this topic in the gynecologic field in such a large sample size," said lead author Dr. Elena Igwe, a third-year obstetrician-gynecologist resident at Temple University Hospital in Philadelphia.

The longer operative time for resident-involved cases "may be accounted for by the obvious training environment of gynecologic and anesthesia residents, medical students, as well as scrub nurse students. Also, more time may have been spent if there were greater intraoperative complications such as bleeding or organ injury that were not captured by the NSQIP database," she said at the meeting, jointly sponsored by the American College of Surgeons.

"Although there was a statistically significant increase in transfusion and readmissions in the resident-involved group, there was no overall effect on morbidity or mortality. Therefore, although laparoscopic hysterectomy may take longer to accomplish with a resident involved, the clinically significant safety profile is largely unchanged," Dr. Igwe said.

Invited discussant Dr. Marie Fidela Paraiso, head of female pelvic medicine and reconstructive surgery at the Cleveland Clinic, commented, "The findings of your investigation are not surprising in that training cases require significantly longer OR times – this is the story of an academician’s life – increased transfusions (cause uncertain) and increased 30-day admits. However, it is reassuring that morbidity and severe complications and 30-day mortality are not different despite greater patient acuity in the training cohort."

She added, "Due to a limit in training hours, alternatives to hysterectomy, and a variation of tools and routes for hysterectomy, resident experience in laparoscopic hysterectomy is likely to decrease. How do you apply your findings to guide future training?" she asked.

Considerable time is required to become skilled at this surgery, Dr. Igwe replied. "If the average resident is going to do less hysterectomies during their duration as a resident, then there are two potential ways to deal with this situation. One, you can increase the length of ob.gyn. training; of course, the lack of federal funding may not make this a very attractive option. Or two, split the specialty into a track system or alternative curriculum system, where a portion of residents go into a specialized gyn. track and receive the majority of hysterectomy and other major surgery trainings, and have the privilege to perform these procedures. A general ob.gyn. residency can therefore potentially be reduced to 3 years, and these practitioners would focus on more routine ob.gyn. and preventive gynecologic care," she suggested.

"We as a society can take the initiative to do this ourselves, or insurance companies, based on the Affordable Care Act initiative and driven by outcome-based research, will make us do this based on our performances, and this may not be a pretty thing," she added.

One session attendee expressed concern about potential selection bias in the study. "It’s possible that for the more complicated cases, the attendings asked the residents to assist them, and therefore we may be unduly giving the residents credit for the increased morbidity," he said.

"That is a concern, but that’s just one of the limitations of the NSQIP database that we were not able to adjust for," Dr. Igwe said.

Another attendee commented, "Your data is reassuring, but it begs the question, we don’t know the degree to which residents were actually involved, and it makes me think ... what would be a more meaningful way to measure this issue of the interaction between resident involvement and patient morbidity?"

"If there was a way to actually record or establish how much a resident is actually doing, that would be the best thing," Dr. Igwe said.

In the study, relative to the patients operated on by attending physicians only, patients whose surgery involved a resident were on average older, were more likely to be inpatients, had higher Charlson comorbidity scores, and had higher American Society of Anesthesiologists classes.

The mean operative time was 179 minutes when a resident was involved and 135 minutes when the attending physician operated alone, reported Dr. Igwe. There was no significant difference between junior residents (those in postgraduate year 1 or 2) and senior residents (all other years).

The group having a resident involved had significantly higher rates of transfusion with more than 4 U of packed red blood cells (2.0% vs. 0.4%) and readmission (5.5% vs. 2.9%). The difference in transfusion rates was greater for junior residents than for senior residents.

However, the groups were statistically indistinguishable with respect to the proportion of patients having at least one complication, experiencing severe morbidity, dying within 30 days, developing infections or sepsis, or having thromboembolic complications.

"The limitations of this study are largely those of the NSQIP database," Dr. Igwe noted. "We were unable to control for attending surgeon experience, presence of additional trainees in the operating room, or tallying up the intraoperative complications. Also, the degree of resident participation is not clearly defined, and there is no data about the conversion rate from laparoscopic to open cases."

Dr. Igwe disclosed no relevant financial conflicts of interest.

SCOTTSDALE, ARIZ. – Laparoscopic hysterectomy takes longer when residents participate, but is generally as safe as when an attending physician performs the surgery alone, a study showed.

A resident was involved in 46% of the 3,441 cases that were done for benign indications between 2008 and 2011 and identified in the National Surgical Quality Improvement Program (NSQIP) database.

Patients whose surgery involved a resident had higher levels of comorbidity and were higher-risk surgical candidates, according to data presented at the annual meeting of the Society of Gynecologic Surgeons.

Compared with patients whose surgery was performed by an attending physician alone, those whose surgery involved a resident took an average of 44 minutes, or about 25% longer.

However, rates of serious adverse outcomes and death were statistically indistinguishable. The group for whom a resident was involved did have higher rates of transfusion of more than 4 U of packed red blood cells and of readmission.

"Our study is the first of its kind to study this topic in the gynecologic field in such a large sample size," said lead author Dr. Elena Igwe, a third-year obstetrician-gynecologist resident at Temple University Hospital in Philadelphia.

The longer operative time for resident-involved cases "may be accounted for by the obvious training environment of gynecologic and anesthesia residents, medical students, as well as scrub nurse students. Also, more time may have been spent if there were greater intraoperative complications such as bleeding or organ injury that were not captured by the NSQIP database," she said at the meeting, jointly sponsored by the American College of Surgeons.

"Although there was a statistically significant increase in transfusion and readmissions in the resident-involved group, there was no overall effect on morbidity or mortality. Therefore, although laparoscopic hysterectomy may take longer to accomplish with a resident involved, the clinically significant safety profile is largely unchanged," Dr. Igwe said.

Invited discussant Dr. Marie Fidela Paraiso, head of female pelvic medicine and reconstructive surgery at the Cleveland Clinic, commented, "The findings of your investigation are not surprising in that training cases require significantly longer OR times – this is the story of an academician’s life – increased transfusions (cause uncertain) and increased 30-day admits. However, it is reassuring that morbidity and severe complications and 30-day mortality are not different despite greater patient acuity in the training cohort."

She added, "Due to a limit in training hours, alternatives to hysterectomy, and a variation of tools and routes for hysterectomy, resident experience in laparoscopic hysterectomy is likely to decrease. How do you apply your findings to guide future training?" she asked.

Considerable time is required to become skilled at this surgery, Dr. Igwe replied. "If the average resident is going to do less hysterectomies during their duration as a resident, then there are two potential ways to deal with this situation. One, you can increase the length of ob.gyn. training; of course, the lack of federal funding may not make this a very attractive option. Or two, split the specialty into a track system or alternative curriculum system, where a portion of residents go into a specialized gyn. track and receive the majority of hysterectomy and other major surgery trainings, and have the privilege to perform these procedures. A general ob.gyn. residency can therefore potentially be reduced to 3 years, and these practitioners would focus on more routine ob.gyn. and preventive gynecologic care," she suggested.

"We as a society can take the initiative to do this ourselves, or insurance companies, based on the Affordable Care Act initiative and driven by outcome-based research, will make us do this based on our performances, and this may not be a pretty thing," she added.

One session attendee expressed concern about potential selection bias in the study. "It’s possible that for the more complicated cases, the attendings asked the residents to assist them, and therefore we may be unduly giving the residents credit for the increased morbidity," he said.

"That is a concern, but that’s just one of the limitations of the NSQIP database that we were not able to adjust for," Dr. Igwe said.

Another attendee commented, "Your data is reassuring, but it begs the question, we don’t know the degree to which residents were actually involved, and it makes me think ... what would be a more meaningful way to measure this issue of the interaction between resident involvement and patient morbidity?"

"If there was a way to actually record or establish how much a resident is actually doing, that would be the best thing," Dr. Igwe said.

In the study, relative to the patients operated on by attending physicians only, patients whose surgery involved a resident were on average older, were more likely to be inpatients, had higher Charlson comorbidity scores, and had higher American Society of Anesthesiologists classes.

The mean operative time was 179 minutes when a resident was involved and 135 minutes when the attending physician operated alone, reported Dr. Igwe. There was no significant difference between junior residents (those in postgraduate year 1 or 2) and senior residents (all other years).

The group having a resident involved had significantly higher rates of transfusion with more than 4 U of packed red blood cells (2.0% vs. 0.4%) and readmission (5.5% vs. 2.9%). The difference in transfusion rates was greater for junior residents than for senior residents.

However, the groups were statistically indistinguishable with respect to the proportion of patients having at least one complication, experiencing severe morbidity, dying within 30 days, developing infections or sepsis, or having thromboembolic complications.

"The limitations of this study are largely those of the NSQIP database," Dr. Igwe noted. "We were unable to control for attending surgeon experience, presence of additional trainees in the operating room, or tallying up the intraoperative complications. Also, the degree of resident participation is not clearly defined, and there is no data about the conversion rate from laparoscopic to open cases."

Dr. Igwe disclosed no relevant financial conflicts of interest.