ABSTRACT

Aim:

The Coronavirus disease-19 (COVID-19) pandemic has affected all countries in the world and has created a serious burden on the health systems of countries. Although health systems, which have not encountered such a sudden and intense load for many years, had difficulty in responding to this need at first, measures have been taken to meet this sudden demand in a short time. This change in the health system has led to a decrease in the number of elective surgeries in particular. One of the outcomes of the COVID-19 pandemic is interrupted and insufficient surgery training. In this study, we aimed to assess the effects of COVID-19 on general surgery education in Turkey.

Method:

In the study, a questionnaire consisting of 22 questions including participants’ demographic information, their education level and the average number of cases in the time interval covering the same period of the previous year was used. In the study, the period between January 2019-April 2019 and January 2020-April 2020 was compared, and the operations performed during this period were compared in terms of emergency, elective, laparoscopic and open surgery.

Results:

When the number of elective/emergency hernia, upper gastrointestinal-hepatobiliary and colorectal-benign anorectal operations performed primarily by the assistant under the supervision of the responsible lecturer were compared, it was found that the rates were decreased from 9.67 to 0.76, 7.66 to 1.38 and 7.48 to 2.00, respectively, and all these changes were found to be statistically significant. The rate of emergency operations performed primarily by the lecturer decreased from 34.16% to 28.93% (p=0.045), and the rate of elective surgeries performed primarily by the faculty member decreased from 61.09% to 55.93% (p=0.045 and p=0.411).

Conclusion:

There has been a significant decrease in the number of elective and emergency surgeries due to the change in the health system. We believe that changes should be made by clinics to their training programmes so that this decrease does not affect the training of surgical residents.

Keywords:

COVID-19, general surgery training, laparoscopy, laparotomy

Introduction

With the rapid spread of the new coronavirus starting from China and spreading to the whole world in December 2019, a pandemic has posed serious problems for the economies and health systems of all countries. The first Coronavirus disease-19 (COVID-19) case in Turkey was detected in March of 2020, and the ministry of health and other government agencies have taken precautions to prevent the spread of the disease. Furthermore, it was announced that COVID-19 was no longer an epidemic limited to certain regions and was declared a pandemic in March 2020.

Although health systems, which have not encountered such a sudden and intense load for many years, had difficulty responding to this need at first, measures have been taken to meet this sudden need in a short time. Since COVID-19 primarily affects the respiratory tract, requirements for services such as hospitalisation, intensive care admission and ventilators have increased; therefore, it is certain that a need for new guidelines to help healthcare facilities meet this increased demand has emerged.^1,2,3 Therefore, elective procedures have been postponed, emergency cases have been given priority and non-surgical approaches have been recommended as the first step, even in emergency cases.

This change in the health system has led to a decrease in the number of elective surgeries in particular. Many international professional organisations have advocated that elective surgery should be delayed as much as possible.⁴All these changes have interrupted clinical surgery training and have led to certain new problems. The effects of COVID-19 on surgical residency programmes have only recently been realised, and studies on this subject are limited.

Considering that the COVID-19 pandemic is ongoing, and there is no specific vaccine or treatment method yet, many authors suggest that this prolonged situation will have an increasingly negative effect on resident training.^5,6 Anticipating all these possible effects, clinics need to make changes in their own operations, but few centres have restructured in this direction.⁵ In this study, we aimed to determine the effects of COVID-19 on the health system, in particular on general surgery education.

Performing operations under the supervision of the responsible lecturer in surgical sciences resident training constitutes the basis of surgical training. As in all surgical residency programmes, general surgery has a wide range of emergency cases. Elective cases were stopped in many centres during the COVID-19 pandemic, but some hospitals were excluded from the pandemic, and elective surgeries were intended to continue in those hospitals. However, due to the health service requirement of COVID-19, which constitutes a burden on the health systems of countries, such a distinction could not be made in some countries, and the burdens brought by the COVID-19 pandemic disrupted other health services.

Elective surgeries have been postponed as much as possible since COVID-19 requires additional precautions during the surgical and anaesthesia stages to prevent disease transmission. Since COVID-19 has a much more severe course and causes higher mortality and morbidity in patient populations with susceptibility to immunosuppression, such as cancer patients, non-surgical treatments are the priority in these cases. This has also caused a decrease in the number of elective cancer surgeries.

It is inevitable that surgical training will be affected by the COVID-19 pandemic in a clinic where most of the elective cases consist of a high-risk group for COVID-19 such as elderly patients and patients with other comorbidities. Considering that training of an assistant by a responsible lecturer during surgery may prolong the duration of the operation, and this prolonged period will increase the risk of COVID-19 transmission, it can also be argued that during the pandemic, general surgery assistant training will be disrupted in both emergency and elective cases.

In this study, we aimed to assess the effects of COVID-19 on general surgery education in Turkey based on questionnaire data.

Materials and Methods

In this study, a questionnaire consisting of 22 questions, including participants’ demographic information, their education level and the average number of cases in the time interval covering the same period of the previous year, was used. Questionnaires were sent to general surgery residents all over the country, and 120 residents completely filled out the form (Table 1).

The questionnaires were sent to the participants via e-mail, and the participants were asked to click on the questionnaire link and fill out the questionnaire through the online system. In the study, the period between January 2019-April 2019 and January 2020-April 2020 was compared, and the operations performed during this period were compared in terms of emergency, elective, laparoscopic and open surgery. In addition, the rates of inguinal, incisional and umbilical hernia; upper gastrointestinal-hepatobiliary surgery and colorectal and benign anorectal surgeries performed in the same period were compared in terms of whether the surgery was performed mainly by the lecturer or the resident.

Statistical Analysis

SPSS Statistics for Windows, Version 20.0. (Armonk, NY: IBM Corp.) was used to evaluate the data. Variables were expressed as mean ± standard deviation, percentage and frequency values. In addition, the normality assumption, one of the prerequisites of parametric tests, was tested with the Shapiro-Wilk test. For evaluation of differences between two groups, when the preconditions of parametric tests were met, the matching t-test was used; otherwise, the Wilcoxon test was applied. The statistical significance level was accepted as p<0.05 and p<0.01.

Results

A total of 120 general surgery residents participated in the study. Of them, 62 residents (51.7%) were between the ages of 20 and 29, 56 (46.7%) between 30 and 39 and 2 (1.7%) between 40 and 49. In all, 104 (86.7%) of the respondents were male, while the remaining 16 (13.3%) were female. In terms of the surgical experience, 16 residents (13.3%) had less than 1 year, 10 residents (8.3%) had 1 year, 26 residents (21.7%) had 2 years, 24 assistants (20%) had 3 years, 26 assistants (21.7%) had 4 years and 18 residents (15%) had 5 years or more. Eighty of the participants (66.7%) were working in a public university hospital, 36 (30%) in training and research hospitals and the remaining 4 (3.3%) in a foundation or private university hospital (Table 2).

When the admissions were analysed, it was observed that 37.9% of the emergency cases were operated due to appendicitis, 23.3% due to ileus, 8.6% due to trauma, 12.9% due to mesenteric ischaemia, 15.5% due to upper gastrointestinal perforation and approximately 1.7% due to other surgical emergencies. When the factors that affect surgeons’ choice of laparoscopy or laparotomy in emergency cases were examined, it was found that 3.1% of the participants found laparoscopic surgeries safer in terms of contamination, 23.9% found open operations safer in terms of contamination, 18.9% asserted that surgery times were shorter in open operations, 1.3% thought that they were more skilful in laparoscopic operations, 6.9% thought that they were more skilful in open operations, 0.6% stated that laparoscopic surgeries take less time, 13.2% stated that they make their choices due to hospital policy, 6.9% due to defence of the hospital staff and 5% due to the hospital’s facilities, 10.7% preferred laparoscopy or laparotomy due to the preference of the lecturer and 9.4% due to the defence of the anaesthesia (Table 3).

When the period between January and April 2019 was examined, the weekly average number of emergency cases was calculated as 28.34, while the weekly average number of elective cases in the same period was 69.27. When the cases under the supervision of a responsible lecturer were examined, it was seen that the average number of elective/emergency inguinal, incisional or umbilical hernia operations performed in the same period of 2019 was 9.67, the average number of upper gastrointestinal/hepatobiliary cases was 7.66 and the average number of colorectal and benign anorectal cases was 7.48. When the period between January and April 2020 was examined, the weekly average number of emergency cases was calculated as 16.07, while the weekly average number of elective cases in the same period was 13.22. When cases under the supervision of a responsible lecturer were examined, it was seen that the average number of elective/emergency inguinal, incisional or umbilical hernia surgeries performed in the same period of 2020 was 0.76, the average number of upper gastrointestinal/hepatobiliary cases was 1.38 and the average number of colorectal and benign anorectal cases was 2.0.

When the distribution of surgeries performed between January and April 2019 in terms of laparoscopy or laparotomy was examined, 23.07% of elective/emergency inguinal, incisional or umbilical hernia surgeries, 40.70% of upper gastrointestinal/hepatobiliary surgeries, and 26.60% of colorectal surgeries were performed laparoscopically. In the same period, it was observed that 34.16% of the emergency surgeries were primarily carried out by the responsible lecturer, while this rate was 61.09% for cases elective cases.

When the distribution of surgeries performed between January and April of 2020, were compared in terms of laparoscopy or laparotomy, 4.55% of elective/emergency inguinal, incisional or umbilical hernia surgeries, 5.91% of upper gastrointestinal/hepatobiliary surgeries, and 4.82% of colorectal surgeries were performed laparoscopically. In the same period, it was observed that 28.93% of emergency surgeries were primarily carried out by the responsible faculty member, and this rate was 55.93% for elective cases.

When the periods between January-April 2019 and January-April 2020 were compared, it was determined that the weekly number of emergency cases decreased from 28.34 to 16.07 on average and there is a statistically significant difference (p=0.002). When the elective cases were compared, it was seen that the weekly average number of cases decreased from 69.27 to 13.22, and there was a statistically significant difference (p=0.001). When the number of elective/emergency hernia (inguinal/incisional/umbilical), upper gastrointestinal-hepatobiliary and colorectal-benign anorectal operations performed primarily by the assistant under the supervision of the responsible lecturer were compared, it was found that the rates were decreased from 9.67 to 0.76, 7.66 to 1.38 and 7.48 to 2.00, respectively, and all these changes were found to be statistically significant (p=0.001, 0.001, 0.001, respectively) (Table 4).

While 23.07% of hernia (inguinal/incisional/umbilical) operations were performed laparoscopically in 2019, this rate decreased to 4.55% in the same period of 2020 (p=0.001). When the same comparison was made for upper gastrointestinal-hepatobiliary and colorectal surgeries, it was observed that these rates decreased from 40.71% to 5.91% and from 27.60% to 4.82%, respectively (p=0.001, p=0.001). When the periods of 2019 and 2020 are compared, it is seen that the rate of emergency operations performed primarily by the lecturer decreased from 34.16% to 28.93% (p=0.045), and the rate of elective surgeries performed primarily by the faculty member decreased from 61.09% to 55.93% (p=0.045 and p=0.411) (Table 5).

Discussion

Although the issue of which method (laparoscopy or laparotomy) is safer in terms of transmission risk in infected patients is controversial, the general opinion is that the open method is safer.⁷ Although there is no evidence that COVID-19 causes transmission by vaporisation during the operation, it should be acted on considering the possibility of transmission as it carries a potential risk.⁸ In our study, when the rates of laparoscopy were compared, it was found that there was a statistically significant decrease in the laparoscopy rates in all surgeries performed. Considering that the risk of contamination with laparoscopy is higher, a decrease in laparoscopy rates is predictable. Considering that this situation may cause a deficiency in laparoscopic training of residents, it may be recommended to exclude the diagnosis of COVID-19 by performing preoperative polymerase chain reaction test in elective cases and to operate on COVID-19-negative patients laparoscopically as much as possible. In this way, the deficiency in laparoscopic training can be prevented to some extent.

One of the most important steps of surgical training is that operations are performed primarily by an assistant under the supervision of the responsible lecturer. However, this can prolong the duration of the surgery and increase the risk of possible complications.^9,10 All these factors also cause an increase in the risk of COVID-19 transmission. In our study, during the pandemic period, in which 34.6% of emergency surgeries were primarily performed by the lecturer in 2019, it was observed that this rate decreased to 28.3% in 2020, and a statistically low significant difference was observed. Despite the decrease in the number of emergency cases, the increase in the rate of emergency surgeries primarily performed by the surgical assistant under the supervision of the responsible lecturer is considered as a positive factor in resident training. Likewise, it was observed that the rate of elective surgeries performed primarily by residents increased during the pandemic, but this change was not statistically significant (61.09% vs 55.93%, p=0.411).

When the elective cases before and after the pandemic were compared, considering that the weekly average number of cases decreased from 69.27 to 13.22 and that there was a statistically significant difference between these two periods (p=0.001), there was also a significant difference in the number of elective surgeries performed primarily by the surgery resident. Making a primary case under the supervision of responsible lecturer is one of the most important stages of surgical training, and the interruption of this step may cause major deficiencies in surgical training. Since a protective vaccine or a specific therapeutic drug against COVID-19 cannot be developed today and it is not certain how long this situation will continue, it is thought that the rate of operations performed primarily by the surgical resident should increase in order not to interrupt surgical training.¹¹ We believe that this deficiency can be reduced to some extent by increasing the rate of surgeries primarily performed by the surgery resident insofar as possible according to the experience of the resident.

Conclusion

The COVID-19 pandemic has affected all countries around the world and has created a serious burden on the health systems of countries. There has been a significant decrease in the number of elective and emergency surgeries due to changes in such health systems. It is our opinion that changes should be made by clinics in their training programmes so that this decrease does not affect the training of surgical residents.

Ethics

Ethics Committee Approval: Approval was obtained from Aydın Adnan Menderes University Local Ethics Committee for the study.

Informed Consent: Since the study is a questionnaire form, there is no patient consent form.

Peer-review: Externally and internally peer reviewed.

Authorship Contributions

Surgical and Medical Practices: E.M.Y., U.U.Ş., Concept: E.M.Y., H.Ö., Design: T.Ç., E.M.Y., Data Collection or Processing: U.U.Ç., H.Ö., Analysis or Interpretation: T.Ç., H.Ö., Literature Search: E.M.Y., U.U.Ş., Writing: E.M.Y.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.

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Effects of the COVID-19 Pandemic on General Surgery Training in Turkey