Surgical experience
Surgery has traditionally been more experience based than evidence based, and much of the enormous advancements in of surgical treatment over the last 200 years have taken place without rigorous scientific trials 1).
Competency-based training refers to a learning model where students must demonstrate the required level of knowledge and skill (competency) on a task prior to advancing to the next task.
Budden et al. from the University of Alberta Hospital assessed the case volume and self-perceived competence of current mandatory skills in peripheral nerve surgery.
Design: Cross-sectional survey based study examining case volume and self-reported competence in peripheral nerve surgery.
Setting: Canadian Neurosurgery and Plastic Surgery accredited residency programs PARTICIPANTS: All Canadian Neurosurgery and Plastic Surgery senior trainees (PGY 3+) invited to participate RESULTS: Much variability exists in both exposure to cases and perceived senior resident competence for both plastic and neurosurgery residents. Confidence in surgical ability as perceived competency is lower in trainees for more advanced peripheral nerve procedures. Self- reported confidence increased with post-graduate experience.
Conclusions: Overall, the findings in this study highlight the importance of increasing operative experience in complex peripheral nerve surgery among surgical residents 2).
Surgical experience is considered paramount for excellent outcome of transsphenoidal surgery (TSS). However, objective data demonstrating the surgical success in relation to the experience of pituitary surgery units or individual experience of pituitary surgeons is sparse.
Based on literature data, Honegger et al., investigated the influence of experience with TSS for pituitary neuroendocrine tumors on endocrinological remission rates and on operative complications. The surgical experience was assessed by calculating the number of transsphenoidal operations per year.
For TSS of microprolactinomas, mean remission rates were 77% in centers with < 2 operations per year for microprolactinomas, 82% with 2-4 operations, 84% with 4-6 operations, and 91% with > 6 operations. A yearly experience with more than 10 initial operations for Cushing's disease (CD) warrants a remission rate exceeding 70%. Remission rates in CD exceeding 86% have only been reported for single surgeon series. Extraordinarily high complication rates were found in some series with < 25 yearly total operations for pituitary neuroendocrine tumors. Major vascular complications were less than 2% and revision rates for rhinorrhea usually < 2.5% in centers performing > 25 transsphenoidal operations per year.
Honegger et al., conclude that a center with experience of > 25 transsphenoidal operations for pituitary neuroendocrine tumors per year provides a high likelihood of safe TSS. Surgery for CD requires a particularly high level of practice to guarantee excellent remission rates. The endocrinologist has the unique opportunity to audit the surgical success by hormone measurement and to refer patients to neurosurgeons with proven excellence 3).