Endoscopic Endonasal Pituitary Surgery: Patient and Societal Costs of Surgical Education

Introduction: Endoscopic endonasal surgery for pituitary lesions is a well-established skull base procedure. Endoscopic skull base surgery requires a learning curve, similar to other learned procedures. Simulators are gaining popularity as tools for developing surgical proficiency without placing the patient at risk. Given the increased morbidity and costs associated with longer operative times, we sought to determine the difference in operative times and associated complications for cases performed solely by attending-level surgeons versus cases assisted by surgeons-in-training for standardized skull base procedures.

Methods: After IRB approval was obtained, 51 cases of endoscopic endonasal pituitary surgery from 2005–2011 were identified. Inclusion criteria included operative dictation report from two surgeons (otolaryngology and neurosurgery) and primary pathology of the pituitary gland. Exclusion criteria included intraoperative lumbar drain placement in combination with other procedures. Information was garnered from dictated operative reports, intraoperative records, and discharge summaries.

Results: Thirteen of 51 cases were identified as attending only (AO) surgeries, and the remaining 38 had trainee involvement (TI). Operative times (minutes) for the AO group were significantly shorter than the TI group (156.5 ± 42.9 vs. 198.0 ± 54.6, P = 0.02). No major intraoperative complications were reported in either group. The AO group had fewer minor intraoperative complications (15% vs. 39%) and shorter length of stay (2.9 vs. 6.0 days).

Conclusion: This study is the first to compare operative times and outcomes for attending only versus trainee-involved cases at a single academic institution. Cases performed solely by attendings decrease both operative times and patient morbidity. These results have important implications for the growing impetus to incorporate endoscopic simulation technology into the core curricula of residency and fellowship training programs.