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Cirugía paraguaya

versión On-line ISSN 2307-0420

Cir. parag. vol.46 no.3 Asunción dic. 2022 

Original article

Impact on the training of resident physicians in general surgery due to the pandemic generated by the SARS-CoV-2 virus

1Universidad Nacional de Asunción. Facultad de Ciencias Médicas, Hospital de Clínicas. II Cátedra de Clínica Quirúrgica. San Lorenzo, Paraguay


Introducción el proceso formativo de los residentes de cirugía general fue afectado a nivel global por la pandemia de SARS-CoV-2 y surge la necesidad de reinventarse con nuevos programas de formación. El objetivo fue estudiar el impacto de la pandemia en la formación de los residentes de cirugía general.

Materiales y métodos:

estudio observacional realizado en el Hospital de Clínicas de Paraguay, tomando dos grupos: egresados (no afectados por la pandemia) y residentes (formados durante la pandemia)


46 encuestados: 10 fueron egresados y 36 residentes. El promedio de cirugías menores y apendicectomías realizadas por un egresado y un residente de primer año pasó de 25,8 y 56,6 a 7,8 y 14,5 respectivamente. Al comparar herioplastias y colecistectomias convencionales entre egresados y residentes de segundo año pasaron de 42 y 55 a 20,3 y 21,1. 56,3% de los residentes no realizócurso de simulación, y todas las clases pasaron a ser virtuales.


la pandemia afectó la formación de los residentes, con una disminución importante en el volumen de cirugías realizadas, de un 50 a 75%. El aumento en la utilización de plataformas virtuales colaboro a no interrumpir el proceso enseñanza - aprendizaje.

Palabras clave: COVID-19; SARS-CoV-2; infeccionesporcoronavirus; pandemias; cirugíageneral; educaciónmédica; programas de postgrado



Overall, general Surgery Training Programs have been affected by the SARS-CoV-2 pandemic and there is this need to reinventthem with new training programs. The objective of this studywas to analyze the impactth epandemic hashadon general Surgery Training Programs.

Materials and methods:

Observational studyconducted at Hospital de Clínicas, Paraguay including 2 groups: postgraduates (un affected by the pandemic) and residents (trained during the pandemic).


46 physiciansresponded to the survey: 10 were postgraduates and 36 residents. The mean number of minor surgeries and appendectomies performed by postgraduates andfirst-yearresidentswentfrom 25.8 and 56.6 down to 7.8 and 14.5, respectively. Whenherioplasties and conventional cholecystectomies were compared between postgraduates and second-year residents, they went from 42 and 55 down to 20.3 and 21.1, respectively. A total of56.3% ofresidentsdid not takeanysimulationcourses, and all classeswere online.


The pandemic affected the trainingofresidents with a significant decrease in the volume of surgeries performed, from 50% upto 75%. The increaseduse of online platforms allowed the continuation of the teaching-learning process.

Keywords: COVID-19; SARS-CoV-2; Coronavirus infections; Pandemic; General surgery; Medical education; Postgraduateprograms


The SARS-CoV-2 pandemic has changed all human activities radically. This has also become evident in the healthcare sector, pedagogical activities organized, risk of contagion to the healthcare professional, lesshealth professionals available, and fewer surgical patients taken care of. In addition, fewer surgeries have been performed, lengths of stay (LoS) have been shorter, and there have been less doctors on call, and less involvementin surgeries that are key to train residents not only in general surgery but also in other medical specialties (1,2.

The pandemic has arranged health professionalsdifferently and with different scenarios. It has required dramatic changes, and impacted professionals in training (medical and nursing students, for example) by reducing their attendance to hospital in 83.86%; damage to residents—who have had to focused on call in 60% of the cases and these have become more spaced out in 18.82%—is not much lower. Also, they have had to limit their surgical training 3.

Back onMarch 10, 2022, the Paraguayan Ministry of Public Health and Wellbeing reported the very first case of SARS-CoV-2 in Paraguay. This event was followed by a national quarantine across the country that includedsocial isolation, school and college lockdowns, and closures of centers with all sorts of socialinteractions. On the health level, the medical attentionof patients with underlying diseases, severe or emergency cases was prioritized. Also, a team working system was organized to reduce the exposure of the treating personnel to the virus due to danger of mass contagion4.

It is important to understand and comprehendhow the consequenciesofthe pandemic have affected the training of general surgeons regardingthe need for looking for solutions and different ways of moving forward with the training process—learning, continuing medical educational in the COVID-19 era, and introduction of new techniques for the training process. Now the paradigm has changed, and the models of learning are not focused on surgical knowledge per se anymore.Instead,redistribution strategies should be developed for academic and practical activities not only to teach general surgery but alsoget residents involved and prepared for new non-surgical roles like pandemic healthcare response if the number of patients with COVID-19 goes off the charts again1,2.

The objective of this investigation is to describe the impact or the consequencies of the SARS-CoV-2 pandemic in the training process of residents of I and II Chair of General SurgeryatHospital de Clínicas who were involved in the specialization course in General Surgery, FCM - UNA held in Asunción, Paraguay from March 2020 through February 2021.


This is a descriptive, observational, quantitative, cross-sectional study with non-probabilistic sampling of consecutive cases. The target population was representative of postgraduates in general surgery and residents in general surgery, all from Hospital de Clínicas (I and II Chair of General Surgery).

Group #1—postgraduates—was elected since during their medical training, the SARS-CoV-2 pandemic was non-existent. On the contrary, group #2—residents—were actually affected by the pandemic during their medical training. The following inclusion criteria were used for the study: postgraduates from 2019 and 2020, and residents who were already working as residents of first, second, and third year.

Authorization was requested from the corresponding Heads of General Surgery (from I and II Chair of General Surgery) from the Faculty of Medical Sciences of the National University of Asunción, Paraguay so a survey could be submitted topostgraduates, residents, and obtain the corresponding data.

The data mining technique was a survey submitted through Google-meet platform. Survey was built around a questionnaire of open and closed questions of the study subjects, postgraduates, and general surgery residents. Survey was coded and loaded in an electronic spreadsheet (Excel, Microsoft), and then analyzed using descriptive statistics.

Ethical principles were observed in this study at all times. Since it was a prospective study, primary sources or data were used in most of the information collected. The principle of confidentiality of the study subjects was observed too. Afterwards, a copy with the results was delivered to the different heads of the different surgical units that participated in the surveys in the first place.


A total of 46 surveys were submitted (26 to women and to 20 men). Out of the total, 10 were postgraduates (group #2), and 36 were residents (group #2) (see Table 1).

Table 1.  Demographic characteristics of residents and postgraduates 

Group N % Mean age
First-year residents 11 23.9% 25.5 years old
Second-year residents 13 28.3% 26 years old
Third-year residents 12 26.1% 27.2 years old
Postgraduates 10 21.7% 28.8 years old
Total 46 100% -

When asked, postgraduates said that all the theoretical and practical classes of their residency program in general surgery took place on-site unlike the residents’ classes who claimed that 100% of their theoretical activities were conducted online.

A total of 93% of respondents used an online platform for the entire asynchronous training process (Classroom), while Google-meet® and Zoom® platforms were used for the synchronous theoretical classes. We should mention that 75% of the residents were not involved in any previous training programs of the aforementioned platforms.

The mean number of surgeries performed was significantly lower during the pandemic. From a mean numberof 55 open cholecystectomies performed by postgraduates down to 21.1 performed bysecond-year residents. Same thing happened with other surgeries like appendicectomies, from a mean number of 56.6 procedures performed by postgraduates down to 41.6 performed bythird-year residents, and 14.5 byfirst-year residents (see Table 2 and Figure 1)

Table 2.  Mean surgeries performed by general surgery postgraduates and residents at Hospital de Clínicas,Asunción, Paraguay 

Type of surgery R1 R2 R3 Postgraduates
Minor surgery 7.8 9.5 24 25.8
Appendicectomy 14.5 16.6 41.6 56.6
Hernioplasty * 20.3 22 42
Conventional cholecystectomy * 21.1 25.6 55
Laparoscopic cholecystectomy # # 35 40
Colectomy # # 22.1 23.3
Gastrectomy # # 1 1
Thoracotomy # # 0.5 0.6

Note: R1, first-year resident; R2, second-year resident; R3, third-year resident.

* Non eligibleprocedure for first-year residents according to the program.

# Non eligibleprocedure for first- or second-year residents according to the program.

Figure 1.  Mean surgeries performed by general surgery postgraduates and residents. Note: postgraduates were not affected by the SARS-CoV-2 pandemic. R3, third-year resident; R2, second-year resident; R1, first-year resident. N =46 

A total of 56.3% out of all respondents did not do any simulation training. The remaining 43.7% did so in simulation models designed to train suture techniques in biological tissues (porcine tissue) and/or practice with laparoscopic training boxes to acquire the skills needed to perform laparoscopies.

During the pandemic, 95% of respondents said they participated in courses, congresses and/or online webinars on surgical updates.

When the use of personal protective equipment (PPI) was studied, all residents claimed they used biological biosafety PPIs. The following data on the type of mask used were obtained: KN95 in 62.2% of respondents, N95 in 16.2%, and surgical masks in 21.6%. A total of 56.8% of the residents surveyed becameinfected with SARS-CoV-2.


The SARS-CoV-2 pandemic has changed surgery units dramatically from fewer surgeries being performed just by prioritizing emergency surgeries only to rearrangingthe entire bedsystem. Also, due tothe patients’ fear of contagion of going to health centers seeking medical attention1,3.

Regarding the introduction of information and communication technologies (ICT), the department of training, as it is the case with all universities nationwide, used platforms to move forward with the process of training—learning. This means that the department of training had to reinvent itself to move forward with the transmission and transfer of knowledge. Still, a significant imbalance was seen between practical and theoretical activities because although students had the opportunity to participate in their postgraduate classes, courses or congresses online, they could only do so in their theoretical postgraduate classes1,5,6.

Regarding the simulation courses that becamenecessary to replace practical activities andsurgical skill training, according to respondents, 56.3% of the residents did not conductany simulation courses, which damaged the training process. However, the study conducted by Uribe discusses the creation of several simulation centers introduced by the departments of training to alleviate the deficit5.

When the mean number of surgeries performed by postgraduates and residents was compared, a lower number of appendicectomies was seen(up to 75%)when postgraduates were compared to first-year residents. Hernioplasties and conventional cholecystectomies performed between postgraduates and second-year residents were compared too. Here there was, also, an additional reduction of 50%. This reduction was seen everywhereand affectedthe residents’ training mainly. As a matter of fact, in Chile, Uribe et al. say confirmed that,with the pandemic, surgeries dropped 90% in some residency programs5. Also, according to Rabe et al., the way to assess students changed too. Transition from personal on-site to online examinations made skills much more difficult to assess due tothe lack of real-world demonstrations of the concepts and skills learned6.

In our study, 56.8% of the residents got infected and had to quarantine, which extended the no contact periods with the patients even further and reduced the number of surgeries performed. Brooks et al. say that quarantine was associated with negative psychological effects like post-traumatic stress syndrome, confusion, and even wrath7.


Before the pandemic, classes of the general surgery residency program were on-site. After the pandemic, they all became online classes.

The mean number of appendicectomies performed dropped down to 75% when, prior to the pandemic, general surgery postgraduates were compared to first-year residents who had their medical training during the pandemic. Overall, the number of all types of surgeries dropped dramatically.

Less than half the residents used simulations like their learning method during the pandemic performing sutures in ex-vivo tissues in anatomical models or in laparoscopic training boxes.

Almost all respondents participated in online courses, congresses or webinars during the pandemic.

A total of 80% of respondents used N95 or KN95 masks during the pandemic, and 56.8% of the residents who responded to the survey became infected with SARS-CoV-2 (COVID-19).


1. Cabrera-Vargas LF, Luna Jaspe C, Pedraza Ciro M. Adaptación de la residencia de cirugía general en Colombia a la pandemia del COVID-19: programa de enseñanza quirúrgica virtual. RevColombCir2020; 35:256-263. [ Links ]

2. Cabrera Vargas LF, Herrera G, Mendoza Zuchini A, Pedraza M, Sánchez S, Pulido J. Aplicación de las redes sociales en la educación del cirujano general. @Cirbosque rompiendo el paradigma. CirAndal. 2020; 31(1):15-20. [ Links ]

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4. Ferreira Gould MS,CoronelDiaz G, Rivarola Vargas MA. Impacto sobre la salud mental durante la pandemia COVID 19 en Paraguay. Rev. virtual Soc. Parag. Med. Int. 2021;8(1):61-68. [ Links ]

5. Uribe M, MartínezSalinas GA, Sepúlveda R, Lanzarini E, García C, Cárcamo C, Abba J. Efectos de la pandemia en los programas de formación en cirugía. Problemas y soluciones. Rev. Cirugia 2021;73(1):107-113. [ Links ]

6. Rabe A, Sy M, Cheung WYW and Lucero-Prisno DE. COVID-19 and Health Professions Education: A 360° View of the Impact of a Global Health Emergency [version 1]. MedEdPublish 2020, 9:148 ( [ Links ]

7. Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, Rubin GJ. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020 Mar 14;395(10227):912-920. doi: 10.1016/S0140-6736(20)30460-8. Epub 2020 Feb 26. PMID: 32112714; PMCID: PMC7158942 [ Links ]

4Authors’ contributions: All the authors contributed equally to develop the protocol, its application, and drafting of final report, and corrections.

5Conflicts of interest: None whatsoever.

6Financing: the authors declare that they have not received any type of funding for the realization of this article

Received: September 15, 2022; Accepted: November 12, 2022

Corresponding author: Dr. Rosa Ferreira E-mail address: Address: Mcal. López casi Cruzada de la Amistad, San Lorenzo

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