Does it really matter if the surgeon is female or male?

Scientific articles examining surgeon sex-related aspects of surgical outcomes often attract significant attention and public interest, unlike many other surgical studies. Recent examples include findings from a population-based study in Canada, which demonstrated lower healthcare costs at 30-day, 90-day, and 1-year intervals for patients operated on by female surgeons compared to those operated on by male surgeons across 25 common elective or emergent surgical procedures. ¹ In addition, a study based on data from the Swedish cholecystectomy quality registry, focusing on cholecystectomies, found that female surgeons tended to perform operations at a slower pace but with fewer complications. ² Given the interest generated by these trials, it is imperative that such research is meticulously conducted with a keen awareness of methodological limitations. A thorough understanding is essential for genuinely improving surgical practices for all patients.

In this issue of Scandinavian Journal of Surgery, ³ the authors utilized a well-validated high-quality registry to identify 1113 patients undergoing surgery for colon cancer, supplemented by additional medical chart review. After adjusting for various confounders (patient sex, American Society of Anesthesiology (ASA) score, cancer stage, surgical volume, experience, approach, emergency surgery, and indication for emergency cases), Engdahl et al. concluded that there was no difference between female and male surgeons in the short- or long-term outcomes following elective resections. However, in patients undergoing emergency surgery, there were statistically significantly fewer complications, re-operations, R1 resections, intensive care unit (ICU) admissions, and better long-term survival when the emergency surgery was performed by female surgeons.

While the found associations are intriguing, caution is warranted due to potential residual confounding. The definition of the most senior actively participating surgeon poses challenges, as the distribution of female surgeons deemed senior may have evolved over the study period. In addition, the significance of surgeon sex appears pronounced in emergency colon resections, where other confounders may play a greater role. Moreover, the proportion of patients not undergoing emergency surgery either due to comorbidities or diversion stoma treatment remains unaccounted for both collectively and by surgeon sex. Discrepancies in the definition of emergency colon cancer resection compared to the Swedish Colorectal Cancer Registry further complicate outcome comparisons. ⁴

Modern surgery is a collaborative effort. Surgeons strive for optimal procedures on suitable patients at an optimal timing to optimize positive outcomes. Research should primarily aim to enhance knowledge and medical practices. Colorectal surgeons exhibit distinct personality traits compared to the general population, with certain traits influencing anastomotic decision-making in specific scenarios. ⁵ Work environment and how we communicate may also impact surgical outcomes. ⁶ Further exploration of personality, risk-taking, and decision-making in surgery is necessary. It is essential to discern whether these factors, rather than sex, primarily drive observed differences in outcomes. As we can adapt our behavior, future studies should focus on the modifiable factors beyond the sex of the surgeon.