Research

JAMA Surgery | Original Investigation

Comparison of Appendectomy Outcomes Between Senior

General Surgeons and General Surgery Residents
Baha Siam, MD; Abbas Al-Kurd, MD; Natalia Simanovsky, MD; Haitham Awesat, MD; Yahav Cohn, BSc;
Brigitte Helou, MD; Ahmed Eid, MD; Haggi Mazeh, MD

Invited Commentary
IMPORTANCE In some centers, the presence of a senior general surgeon (SGS) is obligatory in page 685
every procedure, including appendectomy, while in others it is not. There is a relative paucity
in the literature of reports comparing the outcomes of appendectomies performed by
unsupervised general surgery residents (GSRs) with those performed in the presence of an
SGS.

OBJECTIVE To compare the outcomes of appendectomies performed by SGSs with those

performed by GSRs.

DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis was performed of all patients
16 years or older operated on for assumed acute appendicitis between January 1, 2008, and
December 31, 2015. The cohort study compared appendectomies performed by SGSs and
GSRs in the general surgical department of a teaching hospital.

MAIN OUTCOMES AND MEASURES The primary outcome measured was the postoperative
early and late complication rates. Secondary outcomes included time from emergency
department to operating room, length of surgery, surgical technique (open or laparoscopic),
use of laparoscopic staplers, and overall duration of postoperative antibiotic treatment.

RESULTS Among 1649 appendectomy procedures (mean [SD] patient age, 33.7 [13.3] years;
612 female [37.1%]), 1101 were performed by SGSs and 548 by GSRs. Analysis demonstrated
no significant difference between the SGS group and the GSR group in overall postoperative
early and late complication rates, the use of imaging techniques, time from emergency
department to operating room, percentage of complicated appendicitis, postoperative length
of hospital stay, and overall duration of postoperative antibiotic treatment. However, length
of surgery was significantly shorter in the SGS group than in the GSR group (mean [SD], 39.9
[20.9] vs 48.6 [20.2] minutes; P < .001).

CONCLUSIONS AND RELEVANCE This study demonstrates that unsupervised surgical residents
may safely perform appendectomies, with no difference in postoperative early and late
complication rates compared with those performed in the presence of an SGS.

Author Affiliations: Department of

Surgery, Hadassah-Hebrew
University Medical Center, Jerusalem,
Israel (Siam, Al-Kurd, Awesat, Cohn,
Helou, Eid, Mazeh); Department of
Radiology, Hadassah-Hebrew
University Medical Center, Jerusalem,
Israel (Simanovsky).
Corresponding Author: Haggi
Mazeh, MD, Department of Surgery,
Hadassah-Hebrew University Medical
Center, Mount Scopus, PO Box
JAMA Surg. 2017;152(7):679-685. doi:10.1001/jamasurg.2017.0578 24035, Jerusalem 91240, Israel
Published online April 19, 2017. (hmazeh@hadassah.org.il).

(Reprinted) 679
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 Research Original Investigation
A
cute appendicitis is one of the most common causes
of acute abdomen in the surgical profession, and the
preferred method of treatment is appendectomy.1,2 As
a result, appendectomy (open or laparoscopic) is one of the
most frequent emergency surgical procedures, and more than
300 000 appendectomies are performed annually in the United
States.3
Given that appendectomy is a common surgical proce-
dure, residents are exposed to a large number of appendec-
tomy procedures early in their surgical training.4-6 This fre-
quency makes it an ideal procedure for junior residents to
perform under the guidance of more experienced senior sur-
gical residents. Nevertheless, the level of independence given
to general surgery residents (GSRs) performing appendecto-
mies varies dramatically between institutions nationwide and
worldwide.7-9
A surgeon’s experience has been shown to improve out-
comes in several procedures, such as esophagectomy, pan-
creatoduodenectomy, thyroidectomy, and other complex op-
erations. However, there is a paucity of literature regarding the
effect of surgeon experience on appendectomy outcome.10-13
In a 2013 study published from our institution, Mizrahi et al14
compared pediatric appendectomies performed by GSRs with
those performed by senior pediatric surgeons, showing a shorter
time from emergency department (ED) to operating room (OR)
and a shorter length of hospital stay for the residents’ patients,
with no significant difference in the postoperative early and late
complication rates or the readmission rate. A retrospective analy-
sis by Graat et al15 of 1538 appendectomy patients demon-
strated that it is safe for surgical residents to perform appen-
dectomies, with no increase in complications or negative effect
on quality of care. In a multicenter, prospective study by Singh
et al16 evaluating 2867 appendectomy cases, no additional
patient risk was demonstrated when the operation was per-
formed by an unsupervised surgical resident compared with
operations performed by attendings.
In general, at our institution before 2012, surgical resi-
dents were allowed to perform appendectomy operations
without the presence of senior general surgeons (SGSs). After
2012, the policy changed to require the presence of an SGS in
all appendectomy cases. This unique change at a specific time
point provided the opportunity to compare the outcomes of
operations performed during the 2 different periods. The ob-
jective of this study was to compare the outcomes of appen-
dectomies performed by SGSs with those performed by GSRs.
Methods
A retrospective analysis was performed of appendectomy cases
performed at our institution between January 1, 2008, and De-
cember 31, 2015. Inclusion criteria were all emergency appen-
dectomies for assumed acute appendicitis in patients 16 years
or older. Patients who underwent elective (interval) appen-
dectomy or incidental appendectomy as part of gynecologic
or oncologic operations were excluded from our analysis. The
study was approved by our institution’s institutional review
board committee. The necessity for patient informed con-
680 JAMA Surgery July 2017 Volume 152, Number 7 (Reprinted)
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Appendectomy by Senior General Surgeons vs General Surgery Residents
Key Points
Question Is it safe practice for general surgery residents to
perform appendectomies alone?
Findings This cohort study included 1649 emergency
appendectomies and compared outcomes of appendectomies
performed by senior general surgeons with those performed by
general surgery residents. Analysis demonstrated no significant
difference in the postoperative early and late complication rates,
postoperative length of hospital stay, and overall duration of
antibiotic treatment.
Meaning The results indicate that residents may safely perform
appendectomies without the presence of a senior general
surgeon.
sent was waived by the committee because of the retrospec-
tive nature of the data collection.
Between 2008 and 2012, a substantial proportion of the
appendectomies were performed by GSRs without the pres-
ence of an SGS. Appendectomies performed during this pe-
riod in the presence of an SGS were those performed during
the morning hours or those performed at night when an SGS
happened to be present in the hospital premises. As a general
rule, all other appendectomies were performed by GSRs alone.
After 2012, all of the appendectomies were performed by an
SGS or by a GSR under the supervision of an SGS (Figure).
Relevant data were collected from our medical records.
Information reviewed included patient age and sex, initial
symptoms, duration of symptoms, body temperature, heart
rate, abdominal physical examination findings, white blood
cell (WBC) count, imaging studies performed, and the opera-
tive and postoperative course.
The primary outcome measured was the postoperative
early and late complication rates. All complications were sub-
graded according to the Clavien-Dindo classification system.
Secondary outcomes included time from ED to OR, length of
surgery, surgical technique (open or laparoscopic), use of lapa-
roscopic staplers, and duration of postoperative antibiotic treat-
ment during hospitalization and after discharge.
Figure. Study Flowchart
1860 Appendectomies between
2008-2015
211 Excluded (interval or incidental
appendectomies)
1649 Included in study
931 Appendectomies between 718 Appendectomies between
2008-2012 2012-2015 performed
548 Performed by GSR by SGS or by GSR under
383 Performed by GSR supervision of SGS
in presence of SGS
GSR indicates general surgery resident; SGS, senior general surgeon.
jamasurgery.com
 Appendectomy by Senior General Surgeons vs General Surgery Residents Original Investigation Research

Table 1. Comparison of Preoperative Presentation and Operative Course Between the 2 Study Groups
SGSs GSRs
Variable (n = 1101) (n = 548) P Value
Age, mean (SD), y 35.3 (13.4) 32.9 (12.8) <.001
Female, No. (%) 407 (37.0) 205 (37.4) .21
Duration of symptoms, mean (SD), h 29.4 (57.1) 27.9 (30.8) .57
Alvarado score out of 10, mean (SD) 6.1 (1.5) 6.1 (1.6) .79
Body temperature, mean (SD), °C 36.6 (0.5) 36.6 (0.5) .97
Heart rate, mean (SD), beats/min 84.6 (16) 83.8 (16) .32
WBC count, mean (SD), /μL 13 600 (5461.8) 13 500 (4550.9) .56
Imaging studies performed, No. (%)
US 610 (55.4) 301 (54.9) .81
CT 697 (63.3) 322 (58.8) .09
US and CT 207 (18.8) 77 (14.1) .02
Time from ED to OR, mean (SD), h 10.0 (6.6) 9.6 (8.9) .26 Abbreviations: CT, computed
tomography; ED, emergency
Length of surgery, mean (SD), min 39.9 (20.9) 48.6 (20.2) <.001
department; GSRs, general surgery
Complicated appendicitis, No. (%) 127 (11.5) 69 (12.6) .53 residents; OR, operating room;
Normal appendix, No. (%) 28 (2.5) 20 (3.6) .21 SGSs, senior general surgeons; US,
Laparoscopic appendectomy, No. (%) 1055 (95.8) 493 (90.0) <.001 ultrasonography; WBC, white blood
cell.
Conversion to open surgery, No. (%) 2 (0.2) 0 .31
SI conversion factor: To convert WBC
Use of laparoscopic staplers, No. (%) 149 (13.5) 11 (2.0) <.001
count to ×109/L, multiply by 0.001.

Table 2. Comparison of Postoperative Course Between the 2 Study Groups

SGSs GSRs
Variable (n = 1101) (n = 548) P Value
Postoperative length of hospital stay, mean (SD), d 3.1 (1.8) 3.1 (1.6) .59
Overall duration of postoperative antibiotic treatment, mean (SD), d 3.4 (2.5) 3.5 (2.5) .24 Abbreviations: GSRs, general surgery
residents; SGSs, senior general
Additional home antibiotic treatment, No. (%) 168 (15.3) 119 (21.7) .002
surgeons.

To identify differences between the 2 study groups (SGS
vs GSR), univariate analysis with χ2 test and t test was used.
Statistical calculations were performed using a software pro-
gram (SPSS, version 20; SPSS, Inc), and P < .05 was consid-
ered statistically significant for all comparisons. Data are
presented as the median or the mean (SD), as appropriate.
Results
During the study period, 1860 appendectomies were per-
formed on patients 16 years or older (Figure). After exclusion
of interval or incidental appendectomies, 1649 patients were
included in the study. Of the entire cohort included, 1101 ap-
pendectomies were performed by SGSs and 548 appendecto-
mies were performed by GSRs.
Analysis of the entire cohort of 1649 patients identified a
mean (SD) age of 33.7 (13.3) years, with 612 patients (37.1%)
being female. The median Alvarado score at presentation was
6 (range, 1-10). The mean (SD) WBC count on presentation was
13 500 (4800) /μL (to convert WBC count to ×109/L, multiply
by 0.001), and the mean (SD) duration of symptoms before pre-
sentation to the ED was 29.0 (49.9) hours. The mean (SD) time
from ED to OR was 9.9 (7.4) hours. One hundred patients (6.1%)
underwent an open appendectomy, and the remainder of the
patients underwent a laparoscopic appendectomy, with 2 con-
versions to open surgery. The mean (SD) length of surgery was
42.8 (20.9) minutes, and the mean (SD) postoperative length
of hospital stay was 3.1 (1.8) days.
A comparison of both groups’ baseline variables identified
that patients in the GSR group were significantly younger than
those in the SGS group (mean [SD] age, 32.9 [12.8] vs 35.3 [13.4]
years; P < .001) (Table 1). All other baseline and preoperative
variables were similar for both groups. The diagnosis of acute
appendicitis was confirmed by ultrasound, computed tomog-
raphy, or both in all patients, except for 3 patients who were
taken to surgery with no preoperative imaging. The utility of pre-
operative imaging studies and their influence on decision mak-
ing did not differ between the groups.
Table 1 summarizes the preoperative and operative courses
of both study groups. No significant difference was found in
time from ED to OR in the SGS group vs the GSR group (mean
[SD], 10.0 [6.6] vs 9.6 [8.9] hours; P = .26). Analysis of the op-
erative course showed similar percentages of complicated ap-
pendicitis (ie, perforated or gangrenous) (11.5% in the SGS group
vs 12.6% in the GSR group, P = .53). However, the mean (SD)
length of surgery was significantly shorter in the SGS group
(39.9 [20.9] minutes) compared with the GSR group (48.6 [20.2]
minutes) (P < .001).
Analysis of the patients’ postoperative course demon-
strated no significant difference in the postoperative length of
hospital stay or overall duration of postoperative antibiotic
treatment between the 2 study groups. However, SGSs
prescribed additional home antibiotic treatment in fewer pa-
tients than GSRs (15.3% vs 21.7%, P = .002) (Table 2).
The postoperative early and late complication rates were
similar between the 2 study groups (Table 3). On subgrading
the complications according to the Clavien-Dindo classifica-

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 Research Original Investigation
Table 3. Comparison of Postoperative Complications Between the 2 Study Groups
No. (%)
SGSs
Type of Complication (n = 1101)
Return to the ED 75 (6.8)
Readmission 41 (3.7)
Superficial SSI 36 (3.3)
Deep SSI 13 (1.2)
Bowel injury 1 (0.1)
Stump leak 0 1 (0.2)
Bladder injury 1 (0.1)
Reoperation 5 (0.5)
tion system, no statistically significant differences were ob-
served between the groups.
Discussion
Learning to perform an appendectomy is an integral part of any
surgical resident’s training, providing the resident with basic
skills of open and laparoscopic surgery. At some hospitals, a
board-certified surgeon attends all cases and assists the ju-
nior resident, while at others a more senior GSR suffices. Con-
cerns about patient outcomes have led some training pro-
grams, including ours, to determine that appendectomy should
routinely be performed under the guidance of an SGS. The
present study represents one of the largest available cohorts
of appendectomy patients in which a comparison is per-
formed between those operated on by a GSR alone with those
operated on in the presence of an SGS. Other than a shorter
length of surgery for the SGS group, no significant differ-
ences were identified between the groups.
Few publications have evaluated outcomes of appendec-
tomy cases operated on by residents and compared them with
those operated on by SGSs. The largest cohort to date was pub-
lished by Singh et al16 and included 2867 appendectomy cases,
of which 87% were performed by residents and 72% by unsu-
pervised residents. Graat et al15 (reporting on 1538 appendec-
tomy patients) and Fahrner and Schöb17 (reporting on 1197 ap-
pendectomy patients) published studies with similar findings.
Mizrahi et al14 evaluated appendectomies in 403 pediatric pa-
tients and compared the outcomes with those of appendecto-
mies performed by GSRs vs SGSs in other studies5,9,15-17 (Table 4).
Our cohort of 1649 patients represents the second largest
of the above-mentioned studies. In the present study, appen-
dectomies by unsupervised GSRs were compared with those
performed in the presence of an SGS with regard to preopera-
tive, intraoperative, and postoperative data. Because of the
paucity of studies available in the literature on this topic, we
believe that our cohort represents an important contribution
to the available literature.
In the study by Singh et al,16 a total of 2867 appendecto-
mies were prospectively, nonrandomly divided into those per-
formed by attendings, by senior surgical residents, and by ju-
nior residents, with 72% of the residents’ operations performed
without supervision of an attending. The primary outcome was
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Appendectomy by Senior General Surgeons vs General Surgery Residents
GSRs
(n = 548) P Value
43 (7.8) .44
27 (4.9) .24
22 (4.0) .43
7 (1.3) .86
1 (0.2) .61
.15 Abbreviations: ED, emergency
2 (0.4) .22 department; GSRs, general surgery
residents; SGSs, senior general
4 (0.7) .47
surgeons; SSI, surgical site infection.
the adverse event rate in the first 30 postoperative days. In mul-
tivariate analysis, patients operated on by senior residents were
found to have slightly lower 30-day adverse events rates, al-
though this finding did not reach statistical significance. In con-
trast, junior residents were found to have outcomes similar to
those of attendings.
Mizrahi et al14 compared 246 pediatric appendectomy pa-
tients operated on by GSRs with 157 similar cases performed
by attending pediatric surgeons. A significantly shorter ED to
OR time was demonstrated when patients were operated on
by surgical residents compared with attending pediatric sur-
geons, while our study found no such difference between the
SGS and GSR groups. Graat et al15 also observed no significant
difference in ED to OR time between similar studied groups.
In contrast to the series by Mizrahi et al,14 which showed
a length of surgery 6 minutes shorter for appendectomies per-
formed by GSRs compared with attending pediatric sur-
geons, our study demonstrated that surgical procedures were
almost 9 minutes longer in the GSR group. Although there are
several possible explanations, this result is likely because of
the advanced experience of our SGSs in laparoscopic surgery.
Although Graat et al15 found no difference in operative times
between the studied groups, Fahrner and Schöb17 demon-
strated results similar to ours, with a longer operative time (by
8 minutes) in the resident group compared with the attend-
ing surgeon group.15,17 Among the cohort of patients in the
study by Singh et al,16 junior residents had a significantly larger
proportion of operations lasting more than 60 minutes, when
compared to senior residents and attendings. It could be ar-
gued that the additional operative time in the resident group
may be related to greater caution because of decreased self-
confidence compared with SGSs. Nevertheless, the some-
what longer operative time in the present study did not nega-
tively affect patient outcomes. That said, in an era in which
patient care expenses are under great scrutiny, the impor-
tance of OR costs must always be kept in mind.18 One of many
essential components of these costs is length of surgery; there-
fore, the significance of a 9-minute difference between SGSs
and GSRs should not be underestimated.19
Our study demonstrated a significantly higher open ap-
pendectomy rate in patients operated on by GSRs compared
with those operated on by SGSs (10.0% [55 of 548] vs 4.2% [46
of 1101], P < .001). However, it must be emphasized that be-
fore 2012 open appendectomy was a more common practice.
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 Appendectomy by Senior General Surgeons vs General Surgery Residents Original Investigation Research

Table 4. Summary of Previous Publications Comparing Appendectomy Outcomes Between SGSs and GSRs
Length of Surgery, Mean
Source No. of Patients (SD), mina P Value Complication Rate, % P Value
Shabtai et al,5 2004 (n = 341) Comparing J vs S Residentsb
Laparoscopic 5 J + J 96 (22.8) J + J
appendectomy
79 J + S 84 (22.2) J + S .03 NA NA
67 S + J 75 (24) S + J
Open appendectomy 16 J + J 90 (53.4) J + J
122 J + S 84 (37.8) J + S .02 NA NA
52 S + J 51 (27) S + J
Wong et al,9 2007 (n = 344) Comparing UST vs CS
Laparoscopic 92 UST 65 (22) UST 9 UST
appendectomy <.05 .32
45 CS 52 (18) CS 7 CS
Open appendectomy 122 UST 57 (24) UST 12 UST Abbreviations: CS, consultant
<.05 .69 surgeon; GSRs, general surgery
85 CS 48 (21) CS 7 CS residents; J, junior; NA, not
Graat et al,15 2012 (n = 1538) applicable; NS, not significant;
Unsupervised residents 589 50.0 (18.3) 16 S, senior; SGSs, senior general
surgeons; UST, unsupervised surgical
Supervised residents 597 49.5 (18.7) .02 17 NS trainee.
Surgeons 352 46.7 (17.1 20 a
The numbers in Singh et al16 refer to
Fahrner and Schöb,17 2012 (n = 1197) the percentage of operations with a
Resident surgeons 684 61.34 (25.7) 1.8 duration >60 minutes. Values of the
.0001 .04 exact length of operation were not
Attending surgeons 513 53.65 (29.9) 3.7 presented in the article.
Mizrahi et al,14 2013 (n = 403) b
J + J indicates junior residents
GSRs 246 54 (1.5) 5 operate with the assistance of
.01 .29 another junior resident, J + S
Pediatric surgeons 157 60 (2.1) 7
indicates junior residents operate
Singh et al,16 2014 (n = 2867)c with the assistance of a senior
Junior residents 1183 53.4 13.3 resident, and S + J indicates senior
residents operate with the
Senior residents 1301 48.3 .01 11.8 .53
assistance of junior residents.
Attendings 367 48.4 16.9 c
No documentation of primary
Present Study (n = 1649) operator was identified for 16
GSRs 548 48.6 (20.2) 9.7 patients. For length of surgery,
<.0001 .22 mean and SD values were not
SGSs 1101 39.9 (20.9) 7.9
available.

In an analysis of the subgroup of surgical procedures per-
formed by SGSs before 2012 (n = 383), an open appendec-
tomy rate of 9.4% (n = 36) was demonstrated. Therefore, it
seems that this finding reflects a historical difference rather
than a true variation between the 2 groups.
In our cohort, there was no statistically significant differ-
ence in postoperative early and late complication rates be-
tween patients operated on by GSRs and those operated by
SGSs. Graat et al15 divided appendectomies performed at their
institution into the following 3 groups: appendectomies per-
formed by surgeons alone, appendectomies performed by resi-
dents under surgeon supervision, and appendectomies per-
formed by residents alone. Among the 1538 patients analyzed,
no difference was demonstrated in overall complication or mor-
tality rates between the 3 groups. Mizrahi et al14 demon-
strated similar results, with no significant difference in com-
plication rates between the groups. Although Fahrner and
Schöb17 observed no significant difference in intraoperative
complication rates between GSRs and SGSs in their 1197 pa-
tients analyzed, they found higher 30-day morbidity (3.7% vs
1.8%, P = .04) and greater need for surgical reintervention (2.5%
vs 0.6%, P = .005) in the SGS group.
While other studies14,15 have demonstrated that SGSs pre-
scribed more in-hospital parenteral antibiotic treatment than
surgical residents, the overall duration of postoperative anti-
biotic treatment before discharge in our cohort was similar be-
tween the 2 groups. In contrast, GSRs prescribed additional
home antibiotic treatment more often than SGSs (15.3% vs
21.7%); however, similar to the occurrence of open appendec-
tomy, we hypothesize that this finding represents a historical
variation rather than a true difference between the SGS and
GSR groups. On analysis of the subgroup of patients operated
on by SGSs before 2012 (n = 383), a 23.8% (n = 91) rate of ad-
ditional home antibiotic treatment was found, which is higher
than that in the resident group, although not statistically sig-
nificant. We assume that this historical variation is because of
the increased adherence to guidelines regarding postopera-
tive antibiotic use in more recent years.
In our cohort of appendectomy cases, a normal appendix
was found on postoperative pathological examination in 48 pa-
tients (2.9%), with no significant variation between those op-
erated on by GSRs vs SGSs (Table 1). Mizrahi et al14 demon-
strated similar findings, with a normal appendix rate of 4.5%
and no significant difference between GSRs and pediatric

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 Research Original Investigation Appendectomy by Senior General Surgeons vs General Surgery Residents

surgeons. In contrast, Graat et al15 found a 6% rate of clini-
cally (but not histologically shown) normal appendix, with a
higher prevalence of normal appendix among the SGS group.
Singh et al16 observed no significant difference in the normal
(histologically shown) appendix rate between attendings and
junior or senior residents; however, an overall normal appen-
dix rate of 20.2% was recorded.
The modern-day general surgical residency has evolved in
light of demands for higher levels of supervision. This require-
ment results in less resident autonomy and a lower level of se-
nior resident self-confidence.20 Giving a resident a certain level
of independence in patient care can provide him or her with
important tools needed to develop into an effective senior sur-
geon. The publications reviewed herein, as well as the pre-
sent study, have shown no negative influence on patient safety
in appendectomy cases performed by residents. This safety has
also been demonstrated for other minor surgical procedures.21
Therefore, the question posed is whether the inherent edu-
cational value of appendectomies can be used as a model for
providing resident autonomy, while maintaining patient safety
and outcomes.
Limitations
Our study has several limitations. The fact that all of the GSR
group patients were operated on before 2012, while a substan-
tial proportion of the SGS group patients were operated on in
recent years, presents an obvious historical bias. Therefore,
variability in common practices between the 2 periods may
have affected the observed results. In addition, the level of in-
volvement of the surgical resident in surgical procedures per-
formed in the presence of an SGS cannot be determined by the
records available. It is clear to any individual who has worked
in the OR that this involvement can vary greatly, ranging from
cases in which the resident minimally participates in the op-
eration to cases in which the resident performs the entire op-
eration almost single-handedly under the guidance of the SGS.
Randomized trials are needed to obtain more accurate re-
sults.
Conclusions
The results of this study suggest that the absence of an SGS in
the OR during appendectomies does not seem to negatively
affect patient outcomes. Therefore, we conclude that under stan-
dard conditions more experienced surgical residents can be al-
lowed to perform appendectomies alone. Residents perform-
ing unsupervised appendectomies should be able to recognize
clinical and intraoperative circumstances that necessitate re-
questing the assistance of a more experienced senior surgeon.

ARTICLE INFORMATION
Accepted for Publication: January 20, 2017.
Published Online: April 19, 2017.
doi:10.1001/jamasurg.2017.0578
Author Contributions: Drs Siam and Mazeh had
full access to all the data in the study and take
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Siam, Al-Kurd, Cohn, Eid,
Mazeh.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Siam, Al-Kurd, Awesat,
Cohn, Eid, Mazeh.
Critical revision of the manuscript for important
intellectual content: Siam, Al-Kurd, Simanovsky,
Cohn, Helou, Mazeh.
Statistical analysis: Siam, Al-Kurd, Awesat, Cohn,
Mazeh.
Administrative, technical, or material support: Siam,
Helou.
Study supervision: Siam, Al-Kurd, Eid, Mazeh.
Conflict of Interest Disclosures: None reported.
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 Appendectomy by Senior General Surgeons vs General Surgery Residents Original Investigation Research

19. Fong AJ, Smith M, Langerman A. Efficiency
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2016;204(2):371-383.
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Invited Commentary

Increasing Resident Autonomy Without Compromising

Patient Safety
Rebecca L. Gunter, MD; Jacob A. Greenberg, MD, EdM

General surgery residency training has undergone signifi-
cant changes in recent years, resulting in part from increased
resident duty-hour restrictions and mandated attending su-
pervision in the operating
room, which ostensibly stem
Related article page 679 from concerns regarding pa-
tient safety. However, the
mandate to train future generations of surgeons remains, thus
creating an inherent tension between patient safety and op-
portunities for resident autonomy and independent decision
making.
In this issue of JAMA Surgery, Siam et al1 present the out-
comes of appendectomies performed at their institution in the
period before and after mandated attending presence at all op-
erations. The authors are to be congratulated for taking advan-
tage of this natural experiment to examine the influence of resi-
dent independence on patient outcomes. They found no
significant difference in patient morbidity or mortality and no
difference in markers of decision making, such as preopera-
tive tests ordered or time from emergency department to op-
erating room, when a general surgery resident worked inde-
pendently or under the supervision of an attending surgeon. The
only significant difference was in operative time, with resi-
dents operating independently requiring a mean of almost 9
more minutes to complete the operation than when an attend-
ing surgeon was present.
As the authors note, 1 this investigation is a single-
institution study examining a sole operation, as are the stud-
ies against which they have compared their results, with no
risk adjustment of outcomes. Larger analyses of American Col-
lege of Surgery National Surgical Quality Improvement Pro-
gram data have yielded similar results in terms of increased
operative time when residents participate in operations and
either decreased or equivalent postoperative mortality.2 How-
ever, there may be a trend toward increased rates of post-
operative morbidity, particularly in the case of surgical site
infections.3,4
The potential detrimental influence on patient outcomes
seen when residents participate must be balanced against the
educational needs of residents and the resources required to
train them for independent practice. Fellowship directors have
reported limited operative proficiency among their incoming
fellows, signaling that general surgery residency has not ad-
equately prepared them for the next step in training, likely be-
cause of insufficient opportunities to practice and develop their
skills.5 They also note that simulation alone is unlikely to com-
pensate for this lack of real-life experience. Although valid, con-
cerns over patient safety and operating room efficiency should
not overshadow the need for surgical residents to hone their
craft. In addition, the increased time required for resident edu-
cation should perhaps be accounted for in funding models at
teaching institutions.6
As surgical residency training moves toward milestone and
competency–based training, the work by Siam et al1 is an im-
portant contribution for delineating which operations can be
safely performed independently by residents. Appendectomy
and procedures of similar complexity can and should be used
to facilitate increased resident autonomy and confidence.

ARTICLE INFORMATION REFERENCES 4. Castleberry AW, Clary BM, Migaly J, et al.

Author Affiliations: Department of Surgery,
University of Wisconsin, Madison.
Corresponding Author: Jacob A. Greenberg, MD,
EdM, Department of Surgery, University of
Wisconsin, 600 Highland Ave, Mail Code 7375,
Madison, WI 53792 (greenbergj@surgery.wisc
.edu).
Published Online: April 19, 2017.
doi:10.1001/jamasurg.2017.0582
Conflict of Interest Disclosures: None reported.
1. Siam B, Al-Kurd A, Simanovsky N, et al.
Comparison of appendectomy outcomes between
senior general surgeons and general surgery
residents [published online April 19, 2017]. JAMA
Surg. doi:10.1001/jamasurg.2017.0578
2. Tseng WH, Jin L, Canter RJ, et al. Surgical
resident involvement is safe for common elective
general surgery procedures. J Am Coll Surg. 2011;
213(1):19-26.
3. Scarborough JE, Bennett KM, Pappas TN.
Defining the impact of resident participation on
outcomes after appendectomy. Ann Surg. 2012;255
(3):577-582.
Resident education in the era of patient safety:
a nationwide analysis of outcomes and
complications in resident-assisted oncologic
surgery. Ann Surg Oncol. 2013;20(12):3715-3724.
5. Mattar SG, Alseidi AA, Jones DB, et al. General
surgery residency inadequately prepares trainees
for fellowship: results of a survey of fellowship
program directors. Ann Surg. 2013;258(3):440-449.
6. Vinden C, Malthaner R, McGee J, et al. Teaching
surgery takes time: the impact of surgical education
on time in the operating room. Can J Surg. 2016;59
(2):87-92.

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