Practice patterns and factors influencing surgical trainees’ involvement in laparoscopic appendectomy in Northern Italy's largest educational network

Introduction Laparoscopic Appendectomy (LA) allows residents to get early exposure to minimally invasive techniques. Despite its importance, involving residents as primary surgeons is a complex process, influenced by more than just clinical factors. Mentorship, environment, and perceptions play crucial roles. This study aimed to explore rates of residents' involvement in LA, the factors influencing the decision-making, and how surgeons and residents perceive the process. Methods We analyzed data from the REsiDENT-1 trial, covering 653 LA performed between 2019 and 2023 in 24 hospitals affiliated with the University of Milan. Adults with intraoperative acute appendicitis were included. Univariable analysis and multivariable logistic regression explored factors impacting residents' involvement and clinical outcomes. A survey captured the perspectives of surgeons and residents. Results Residents approached 35.9% of the procedures, with longer operative times 67.14 (± 28.1) vs 71.68 (± 24.44), p = 0.001. Trainees were more involved in academic hospitals and emergency surgery units and less complex cases with lower complication rates. Residents' involvement was hampered by patients' complexity in the multivariable analysis. Surgeons prioritized non-technical factors such as punctuality and reliability, whereas residents highlighted clinical complexity as a key consideration for the decision-making of the operator. Both groups agreed that structured feedback systems could improve the educational and training experiences. Conclusion LA remains a crucial procedure for surgical training, balancing hands-on learning with patient safety. Structured mentorship in academic and emergency settings could allow safe resident involvement. Future improvements should focus on clear feedback processes, better access to simulations, and standardized competency-based training to prepare residents for independent practice.