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 signif icantly affecting postgraduate surgical education, with the lack of op erative 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 o f blunt liver and spleen injuries in adults is likely to exacerbate th is problem. Blunt trauma admissions to our Level I trauma center incre ased from 2888 from 1991 through 1993 (group A) to 3587 from 1994 thro ugh 1996 (group B). Liver and/or splenic injuries occurred with equal frequency in both groups. Whereas diagnostic peritoneal lavage was use d 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 evalu ate these patients. Nonoperative management increased from 10 per cent of group A to 54 per cent of group B. As a result, therapeutic laparo tomies 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 l iver and splenic injuries has resulted in the avoidance of nontherapeu tic laparotomies, the operative caseload available to surgical housest aff has been adversely affected. Although the Residency Review Committ ee has stressed the importance of the critical care management of thes e patients, the criteria used to evaluate the number of trauma cases i n postgraduate surgical education may need to be revised.