Teaching Laparoscopic Adrenalectomy to Surgical Residents

Introduction

Surgical education of surgery residents is a major topic for investigation since Sir William Halsted introduced his residency program at the Johns Hopkins Hospital in the 19th century. ¹ In recent years, with the changes seen in healthcare systems around the world, including the emphasis on patient safety, efficiency in the surgical theater, and changes to the residents' work conditions, surgical education of residents has changed as well. ² The introduction of laparoscopy has augmented the variety of surgical procedures and surgical approaches needed to be taught as part of the training of surgical residents. ³ Laparoscopy has also become the gold standard in many basic surgical procedures like appendectomy and cholecystectomy, and is gaining popularity among patients and physicians, reducing the volume of several surgical procedures, considered once to be fundamental for acquiring initial surgical skills.^4–6

Adrenalectomy is performed for various etiologies in adrenal diseases. It is the treatment of choice in a wide range of diseases, including benign, malignant, and nonfunctional (incidentalomas) adrenal tumors. Since its introduction in the early 1990's, laparoscopic approach has become the gold standard for the major part of adrenal resections, with a few exceptions such as inaccessible tumors, large tumors, or tumors invading surrounding structures. ⁷ Although laparoscopic adrenalectomy is fairly common and is performed for various etiologies, it is still considered a complex procedure that requires a fair amount of experience to assure good surgical outcome. ⁸ Our aim in this study was to assess whether laparoscopic adrenalectomy, when performed by senior residents (PGY4 and above), is safe with good guidance by experienced surgeons.

Materials and Methods

We conducted a cohort retrospective analysis of all patients who underwent laparoscopic adrenalectomy between June 2008 and June 2014, reviewing patients' demographic data and presurgical data. Patients undergoing nephrectomy with adrenalectomy were excluded from this series. We compared between patients operated (first surgeon) by a senior and certified surgeon and patients operated by a senior resident (PGY 4–6). All surgical procedures were attended by a certified surgeon, whether acting as the first surgeon or as the tutor of the operating resident. In all procedures included in the study, the operating team composed of a single senior surgeon and a single resident per surgery. All patients were operated in the transabdominal approach and analysis of surgical data and postoperative outcome was compared between the two groups. The study was approved by the local institutional review board before collection of data.

Results

Overall, 53 patients were included in the study. The study included 21 men and 32 women with a mean age of 54 years. Patients' demographic data are outlined in Table 1.

Patients were operated due to various etiologies, most commonly benign adrenal tumors (27 cases, 50.9%), followed by large nonfunctioning adrenal tumors (16 cases, 30.1%), adrenal cancer (8 cases, 15%), and adrenal hyperplasia (2 cases, 3.7%). Most patients demonstrated the adrenal pathology in the left adrenal gland (31 cases, 58.4%) rather than the right adrenal (22 cases, 41.6%). Average tumor size was 53 mm (range 20–136).

All patients were operated laparoscopically using the transabdominal approach. Overall, 18 patients (33.9%) were operated (first surgeon) by 6 different senior residents (PGY4-6) tutored by 4 senior surgeons, and 35 patients (66.1%) were operated by 6 certified senior surgeons. Four out of six residents were in their sixth year of residency, one in the fifth year, and one in the fourth year. Two residents performed four laparoscopic adrenalectomies, 3 performed three surgical procedures, and 1 resident performed a single laparoscopic adrenalectomy. We found no difference in operative time between the two groups (P = .36) with a mean of 131.1 minutes in the group operated by senior surgeons and a mean of 125.7 in the group operated by senior residents. Intraoperative complications occurred in 6 patients (11.3%), most commonly bleeding (5 patients) of an estimated blood loss of 400 to 600 cc of blood. One patient suffered from hemodynamic instability due to hormonal irregularity during the surgery that was controlled with vasoactive medication. There were no differences in intraoperative complications (P = .76) between the patients operated by residents (2 patients) and the group operated by the senior surgeons. Postoperative complications were seen in 9 patients (16.9%) and are outlined in Table 2. No differences in postoperative complications (P = .96) were seen between the two groups.

Out of 53 surgical procedures, 30 (56.6%) were left-sided adrenalectomies. Twenty-three (43.4%) were right-sided adrenalectomies with no bilateral adrenalectomies performed. Residents performed much more left-sided procedures ⁹ than right-sided procedures, ³ while senior surgeons performed an almost equal number of procedures for each side (17 right sided versus 18 left-sided adrenalectomies). This translated to a statistically significant difference comparing between the two surgeon groups (P = .03), demonstrating a clear selection of left laparoscopic adrenalectomy as the preferred procedure for resident teaching. Another factor evaluated was adrenal pathology. Most procedures were for adrenal adenomas (27 patients, 50.9%) with residents performing almost half (13 procedures or 48.1%) of all adrenalectomies for adrenal adenoma. This translated into a tendency toward surgery education in selected cases of adrenal adenoma, but without statistical difference (P = .08).

Length of stay varied and averaged at 5.03 days following surgery (range 2–19 days). There were no significant differences (P = .34) between length of stay following surgery performed by residents (5.17 days) and senior surgeons (4.77 days). No mortality was seen following surgery. Postoperative follow-up averaged at 15.83 months.

Discussion

Adrenalectomy is performed for various etiologies in adrenal diseases. It is the treatment of choice in a wide range of diseases, including benign, malignant, and nonfunctional adrenal tumors. Since its introduction in the early 1990's, laparoscopic approach has become the gold standard for the major part of adrenal resections, with a few exceptions such as bilateral adrenal resection, inaccessible tumors, large tumors, or tumors invading surrounding structures. ⁷

One of the major aspects regarding laparoscopic adrenalectomies is the surgical approach to the adrenal gland. Several approaches exist, including transabdominal (anterior), retroperitoneal (posterior), and the highly specialized single-access retroperitoneoscopic approach.^10,11 Initial reports on robotic-assisted adrenalectomies also show promising results. ¹² Each approach has advantages and limitations. For example, the retroperitoneal approach shows better results with bilateral tumors, but it has limited exposure compared with the transabdominal approach. ¹³ Another difference in surgical approach regards the side of the resected adrenal. Right adrenalectomy is traditionally considered a more complex surgery due to its venous drainage to the inferior vena cava, with shorter surgical margins than the left side. ¹⁴

These and other factors have a crucial effect on the learning curve in laparoscopic adrenalectomy. Several studies about a single surgeons' or experts' learning curve in laparoscopic adrenalectomy exist.^9,15–17 Eto et al. ¹⁵ demonstrated an excellent learning curve for three experienced surgeons in laparoscopic adrenalectomy for several adrenal tumors and diseases. Fiszer et al. ⁹ demonstrated that to achieve a good outcome for operated patients, a minimum of 40 to 50 procedures should be performed by the surgeon. Goitein et al. ⁸ arrived to similar conclusion with the need for at least 30 procedures to achieve good surgical results. Maccabee et al. ¹⁸ reviewed the surgical outcomes in two large medical centers and concluded that very few surgeons acquire surgical experience with laparoscopic adrenalectomy and that the learning curve for surgeons decreases estimated blood loss but not operative time. In contrast, several publications describe laparoscopic adrenalectomy as a safe procedure with a relatively short surgical outcome.^19,20

Although laparoscopic surgery is vastly used and is a key part of surgical educations of surgery residents, there is little data regarding the teaching of laparoscopic adrenalectomy as part of the training program. It seems that most publications consider laparoscopic adrenalectomy as a complex surgical procedure that should be performed by experienced surgeons. Zhang et al. ²¹ compared initial results of experts without staged learning to those of surgical trainees that used staged training with model boxes and animal models to show better results with the latter group. Sommerey et al. ²⁰ concluded that surgical experience for surgical trainees requires at least 15 procedures before achieving the capability to operate without supervision. In our study, all senior surgeons in this series were reluctant leaving the blood supply stoppage and dissection to the residents and mentioned left-sided adrenalectomy as the safer option for resident training, as it is clearly reflected in the results. Several senior surgeons highlighted the importance of tutoring on the achievement of a “critical view,” defining the junction between the adrenal vein and the left renal vein (or inferior vena cava). Complete knowledge of surgical steps and anatomy, along with a good experience with laparoscopic surgery of the resident as evaluated by the senior surgeon, was mentioned as critical for possible tutoring in laparoscopic adrenalectomy.

There are several limitations to this study. The retrospective nature is an obvious drawback, as well as the difficulty to evaluate the level of involvement by the operating surgeons. Another drawback is the difficulty to evaluate the level of the residents' surgical experience before their first laparoscopic adrenalectomy. Although all the residents in this article are several years into the residency, an exact estimation of their surgical skill is problematic.

Our series demonstrates that with proper guidance by senior and certified surgeons with significant experience with laparoscopic adrenalectomy, senior residents are capable to achieve similar surgical results with this complex surgical procedure. To achieve surgical independence with laparoscopic adrenalectomy, there is need for adequate guidance and a sufficient amount of surgical procedures performed, as recommended by previous publications.

Conclusion

Laparoscopic adrenalectomy is a complex surgical procedure, but with adequate supervision, senior surgical trainees are capable to achieve a surgical outcome similar to that of a senior surgeon. Left laparoscopic adrenalectomy is often preferred for resident tutoring as opposed to right-sided adrenalectomy. Laparoscopic adrenalectomy should be a part of the surgical training of surgery residents to achieve surgical independence with this procedure.