A time-cost analysis of teaching a laparoscopic entero-enterostomy

Determining the success of technical skill training for surgery residents should include not only the efficacy of the training in terms of skills learned but also the cost of the facility where the training occurs and the cost of faculty participation. Traditional training occurs in the operating room, but the cost of faculty time and operating room time has not been well established. Assessing the cost of traditional training may allow us to put the cost of building and maintaining skills laboratories in perspective. To estimate the cost of traditional training we have recorded the time and interventions necessary for our senior residents to do a laparoscopic entero-enterostomy.

Each senior resident (PGY3-5) was asked to perform a laparoscopic entero-enterostomy in its entirety as part of a laparoscopic gastric bypass. After cannulation of the abdomen and division of any adhesions, we timed the residents for the performance of the following group of tasks: finding the ligament of Treitz, dividing the bowel 50-60 cm downstream, and creating a 2-layer anastomosis at 125 or 200 cm distal to the ligament. We tracked total time and number of interventions, which are defined by the attending temporarily taking over the case.

Twelve residents were tracked by this system. The average time to complete the task was 93.7 minutes (+/-11.9 SD). The average number of interventions per case was 1.5 (+/-1.1 SD). Nine residents completed more than 1 procedure. Seven residents reduced their operative time on the second attempt. Operative times between the first and second procedure showed a reduction of 4.4 minutes (+/-17.4 SD), although this was not statistically significant (p = 0.47). No adverse clinical sequelae developed in these small bowel anastomoses. Educational time was calculated by subtracting the resident time from the time it takes an attending or finishing laparoscopic fellow to complete this task (50 minutes). The educational time for each anastomosis was 43.7 minutes. Using the AAMC average salary for an assistant professor of surgery of $180,000 year and assuming a 60-hour work week, this is $45.52 in faculty costs per anastomosis. If the cost of an operating room is $2000 per hour, the educational cost is $1457 per anastomosis. In our program, providing our 15 senior residents an educational opportunity to perform 2 laparoscopic entero-enterostomies would cost $45,061 a year.

Resident education is expensive. Knowledge of the cost of skills training in a traditional operative setting is necessary to put the costs associated with building and maintaining skills laboratories in perspective. Cost analyses and efficacy of teaching will allow us to rate the success of new educational techniques.