Trainee Autonomy in Emergency Hernia Repair: Educational and Clinical Outcomes From a Propensity Score-Matched Study.

BACKGROUND: The role of graduated autonomy in surgical training remains a central challenge in competency-based education, particularly in emergency settings where supervision may be indirect. This study evaluates whether senior trainees can safely perform emergency abdominal wall hernia repairs within a structured autonomy framework. METHODS: A retrospective cohort study included adult patients undergoing emergency abdominal wall hernia repair (2010-2024). Cases were classified as trainee-led or attending-led. Propensity score matching (1:1) was performed using preoperative clinical variables. The primary outcome was 90-day postoperative complications (Clavien-Dindo classification). Multivariable logistic regression identified independent predictors of complications. RESULTS: A total of 592 patients were included, of whom 426 remained after propensity score matching (213 per group). Baseline characteristics were generally well balanced between groups. Overall 90-day complication rates were similar between trainee-led and attending-led surgeries (33.8% vs. 38.0%, p = 0.420). Major complications (Clavien-Dindo ≥ III) were more frequent in the attending-led group (12.2% vs. 5.6%, p = 0.027). Attending-led cases were also associated with higher intensive care unit admission rates and longer hospital stays. No significant differences were observed in mortality, readmission, or recurrence rates. On multivariable analysis, trainee-led surgery was not independently associated with postoperative complications (odds ratio 1.06, 95% confidence interval 0.68-1.66, p = 0.801). Higher Charlson Comorbidity Index and longer operative duration were independently associated with increased complication risk, while mesh use was protective. CONCLUSIONS: Within a structured training environment, senior trainees performing emergency hernia repairs achieved outcomes comparable to attending surgeons. These findings support competency-based progression and the safe implementation of graduated autonomy in emergency surgical education.