Nonoperative management of liver and/or splenic injuries: effect on resident surgical experience

Changes in the management of trauma over the past few years are significantly affecting postgraduate surgical education, with the lack of operative trauma experience being a major concern in some programs. This problem is accentuated in residency programs that obtain their trauma caseload primarily from blunt injury. Our experience over the past 6 years confirms that the growing trend toward nonoperative management of blunt liver and spleen injuries in adults is likely to exacerbate this problem. Blunt trauma admissions to our Level I trauma center increased from 2888 from 1991 through 1993 (group A) to 3587 from 1994 through 1996 (group B). Liver and/or splenic injuries occurred with equal frequency in both groups. Whereas diagnostic peritoneal lavage was used in 26 per cent of group A, its use dropped to 2 per cent in group B as abdominal computerized tomography was used more frequently to evaluate these patients. Nonoperative management increased from 10 per cent of group A to 54 per cent of group B. As a result, therapeutic laparotomies dropped from 85 in group A (58% of patients with liver/splenic injuries) to 74 (35%) in group B and nontherapeutic laparotomies from 48 (33%) to 23 (11%). While the evolution in the management of blunt liver and splenic injuries has resulted in the avoidance of nontherapeutic laparotomies, the operative caseload available to surgical housestaff has been adversely affected. Although the Residency Review Committee has stressed the importance of the critical care management of these patients, the criteria used to evaluate the number of trauma cases in postgraduate surgical education may need to be revised.