The Rise of Minimally Invasive Surgery: 16 Year Analysis of the Progressive Replacement of Open Surgery with Laparoscopy

OBJECTIVE: The expansion of Minimally Invasive Surgery (MIS) has been exponential since the introduction of laparoscopic surgery in the late 1980s. This shift in operative technique has led many to believe that surgery residents are not developing the skills needed to adequately perform open operations. METHODS: We performed a retrospective review of the Accreditation Council for Graduating Medical Education national operative case log database of general surgery residents from January 2003 to December 2019. We compared the open vs. laparoscopic case numbers for six different operations, including cholecystectomy, appendectomy, inguinal hernia repair, colectomy, gastrectomy, and Nissen fundoplication. The Cochran-Armitage test was used to assess the linear trend in the procedures performed. RESULTS: Total average residency case volumes for the procedures studied have increased from 270 to 368 (36%) over the 16-year period with MIS steadily representing a greater proportion of these cases. From 2003 to 2018, MIS representation increased in all studied procedures: cholecystectomy (88% to 94%, p = 0.048), inguinal hernia repair (20% to 47%, p ≤ 0.001), appendectomy (38% to 93%, p ≤ 0.001), colectomy (8% to 43%, p ≤ 0.001), gastrectomy (43% to 84%, p = 0.048), and Nissen (71% to 91%, p = 0.21). CONCLUSION: While the overall operative volume has increased nationally for surgical residents, the representation of open cases has steadily declined since the advent of MIS. The experience needed in open surgery during resident training is still to be determined and may be necessary now that laparoscopy is progressively replacing open operations.