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Trainee Involvement in Surgery Is an Asset to the Surgical Team.

study using NSQIP data, which concludes that general surgery trainee involvement in emergency surgery is associated with adverse outcomes. This is a powerful message, which if adopted without careful critique by policy makers, could have farreaching effects for the surgical education of trainees and subsequently the delivery of future surgical services. However, the data presented have too many limitations to advocate such a controversial message. The most important limitation is that NSQIP does not report the level of trainee participation or supervision. This limits most of the authors’ discussion to assumptions they make about trainee involvement. We recently reported an analysis of the safety of trainee participation in appendectomy in a predominantly UK setting, with contrasting results to the Kasotakis et al study. Our study adjusted for seniority of operating surgeon, trainee grade, and supervision status, concluding that trainee surgeons performed to the same standards as attending surgeons in selected cases. With 72% of appendectomies being performed by unsupervised trainees, adjusted models showed that supervised senior, supervised junior, and unsupervised junior trainees showed no difference in 30-day adverse event rates compared with attendings [odds ratio (OR)1⁄4 1.07 (P1⁄4 0.834), OR 1⁄4 0.93 (P 1⁄4 0.773), and OR 1⁄4 0.83 (P1⁄4 0.264), respectively]; unsupervised senior trainees had a lesser rate of adverse events [OR 1⁄4 0.71 (P 1⁄4 0.045)]. Kasotakis et al correctly identified the nonrandom assignment of emergency cases to trainee participation. They attempted to address this inherent bias using a coarsened exact matching algorithm. Despite matching, the trainee group managed fewer uncomplicated appendicitis cases and more operative bowel obstructions and more herniae with bowel obstruction and intestinal ischemia. Furthermore, there are technical aspects of surgical difficulty at operation that are not quantified by the limited number of comorbidities matched for. Some pertinent examples would be previous surgery, atypical or distorted anatomy, and staging of any malignancy. These factors may mandate the need