Resident Participation in Index Laparoscopic General Surgical Cases: Impact of the Learning Environment on Surgical Outcomes S Scott Davis Jr, MD, FACS, Farah A Husain, MD, FACS, Edward Lin, DO, MBA, FACS, Kalyana C Nandipati, MD, Sebastian Perez, MSPH, John F Sweeney, MD, FACS BACKGROUND: The NSQIP database enables measurement of postoperative outcomes across a spectrum of practice settings. This allows for observations about potential effects of resident participation in surgical care during training. STUDY DESIGN: We queried the NSQIP database for 6 index laparoscopic surgical procedures performed during 2005À2008. Selected procedures require varying skill level (eg, appendectomy, chole- cystectomy, gastric bypass, fundoplication, colectomy, and inguinal hernia), and 79,720 cases were identified. Preoperative, operative, and postoperative outcomes for each procedure were tabulated. Operative and postoperative outcomes assessed included operative time, hospital length of stay, mortality, morbidity, and return to the operating room. Initial analysis compared cases done with a resident present with cases done without residents. Subset anal- ysis was done to determine possible differences in outcomes based on the level of resident participating, divided into Junior (PGY1À2), Senior (PGY3À5), or Fellow (PGY>5). Groups were scrutinized for both clinical and statistical differences. RESULTS: Preoperative characteristics were similar between groups. Operative times were 20% to 47% longer with resident participation, with bigger differences seen in more basic procedures. Mortality and return to the operating room were not clinically different between the groups. Morbidity rates were higher in all procedures with resident participation. More senior resi- dents were associated with longer operative times, without adverse impact on outcomes. CONCLUSIONS: Resident participation increases operative times for laparoscopic surgery considerably. Morbidity is statistically higher with resident participation but differences are unlikely to be clin- ically significant. Resident participation is a surrogate for the learning environment. These find- ings provide impetus for additional development of training techniques that occur outside the operating room. (J Am Coll Surg 2013;216:96e104. Ó 2013 by the American College of Surgeons) With a growing appreciation for the unsustainability of the current financial models for the delivery of health care, recent years have seen a mounting focus by involved parties on increasing quality and efficiency of health care. Payors are increasingly closer to demanding proof, beyond sheer numbers, that care delivered by physicians is both effective and cost efficient. Before the availability of large national databases such as NSQIP, observations of surgical outcomes were made using regionalized datasets. 1,2 These studies focus primarily on morbidity and mortality rates and less on indicators of operating room efficiency. It is para- mount to define the scope and role that surgical educa- tion will have going forward in an era where there is increasing pressure to provide high-quality surgical care in a cost-effective manner. In addition, public Disclosure Information: Nothing to disclose. Disclaimer: The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. Abstract presented at the American College of Surgeons 97th Annual Clin- ical Congress, Surgical Forum, San Francisco, October 2011. Received July 16, 2012; Revised August 10, 2012; Accepted August 14, 2012. From the Division of General and Gastrointestinal Surgery (Davis, Husain, Lin, Nandipati, Sweeney) and Department of Surgery Patient Safety and Data Management Program (Perez, Sweeney), Emory University School of Medicine, Atlanta, GA. Correspondence address: S Scott Davis Jr, MD, FACS, Division of General and Gastrointestinal Surgery, Emory University, 1364 Clifton Rd, NE, Suite H-124, Atlanta, GA 30322. email: sdavisj@emory.edu 96 ª 2013 by the American College of Surgeons ISSN 1072-7515/12/$36.00 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jamcollsurg.2012.08.014