Does anesthesia type affect surgical resident operative autonomy for open inguinal hernia repairs?

Purpose Decreasing resident operative autonomy is an alarming trend, and reasons behind it are multifactorial. One possible reason may be shifts in anesthetic technique. We hypothesize that when patients are not under general anesthesia, attending physicians are less willing to give residents operative autonomy. The purpose of this study is to determine if the observed decrease in resident operative autonomy is related to changes in anesthetic technique for open inguinal hernia repair (OIHR). Methods This is a retrospective analysis of the Veterans Affairs Surgical Quality Improvement Program database. All OIHR performed at teaching Veterans Affairs (VA) hospitals from January 2004 to September 2019 were included. Level of resident autonomy is defined as follows: attending primary surgeon with or without a resident (AP), resident primary surgeon with attending scrubbed (AR), and resident primary without attending scrubbed (RP). Type of anesthesia is categorized as general anesthesia (GA) and non-general anesthesia, which include epidural/spinal (SA), local/regional (LA/RA), and/or monitored anesthesia care (MAC). Primary outcome was level of resident autonomy by anesthesia type, both overall and controlled for year of operation. Student t test, Chi Squared, and Wilcoxon ranked sum tests were used to analyze level of resident autonomy and anesthesia type of OIHR. Results A total of 106,162 OIHR were included in the analysis. The percentage of RP OIHR decreased steadily over time from 2004 to 2019, from 18.5% to 3.5% for GA procedures ( p < 0.001) and from 13.1% to 2.4% for non-GA procedures ( p < 0.001). Overall, there were significant higher rate of RP cases (8.8% vs 8.3%) and AP cases (24.8% vs 21.4%) and lower rate of AR cases (66.5% vs 70.3%) in GA compared to non-GA ( p < 0.001). The adjusted odds of an RP case in non-GA were 0.87 (95% CI 0.82–0.93, p < 0.001). Adjusted odds of an RP case were 1.01 (0.92–1.10, p = 0.89) for SA, 0.79 (0.72–0.86, p < 0.001) for MAC, and 0.71 (0.51–0.97, p = 0.03) for LA/RA. The percentage of OIHR done under GA has increased, from 63% in 2004 to 86% in 2019. Conclusion Resident were less likely to be allowed autonomy on non-GA cases from 2004 to 2007. However, this difference has disappeared in later years as autonomy has decreased. The VA has seen an increase in GA used for OIHR. The trend in decreased resident autonomy in OIHR may be linked to anesthesia type.