The Association Between Trainee Operative Autonomy and Perioperative Complications in Breast Surgery

Operative independence of surgical residents has decreased over time with implications on resident education and preparedness for practice. This study assessed the association between trainee autonomy and perioperative complications and morbidity and mortality in breast surgery.

The 2005-2012 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients undergoing breast surgery. Cases were stratified by trainee involvement: attending primary (AP), resident supervised (RS), and resident primary (RP). Outcomes included wound complication, length of stay (LOS), major complication, and 30-day mortality. Bivariate and multivariable logistic regressions were performed to identify predictors of major complications.

Of 149,936 patients who underwent breast surgery, 67,548 (45.1%) were AP, 81,684 (54.5%) were RS, and 704 (0.47%) were RP. RP cases were older and had higher American Society of Anesthesiologists (ASA) class. More axillary lymphadenectomy was performed as RP cases (AP 40.1% versus RS 45.5% versus RP 49.0%, P < 0.001). Operative time increased with resident autonomy (AP 50 versus RS 73 versus RP 80 min, P < 0.001), while LOS decreased (AP 4.4% versus RS 7.2% versus RP 4.3%, P < 0.001). RP cases had the lowest rate of wound complications (AP 2.1% versus RS 2.3% versus RP 2.0%, P = 0.02). There were no differences in major complication or mortality. Resident autonomy was not an independent predictor of major complications.

While the relationship between trainee operative autonomy and oncologic outcomes remains unclear, autonomy of residents in breast surgery is associated with low rates of complications and mortality. Despite higher involvement with high-risk patients and axillary lymphadenectomy, trainee autonomy in breast surgery is not associated with increased morbidity or mortality.