Surgical training is a multifaceted process that requires technical proficiency, clinical decision-making, patient management, and integration of basic and clinical sciences. Surgical residents refine their skills through hands-on experience, which has been the core of surgical education for over a century. Since the late 19th century, visionary surgeons have emphasized the need for structured training programs offering clinical practice, research, and mentorship in diverse environments. These early proponents argued that residency programs should foster not only technical skills but also critical thinking, clinical reasoning, and the ability to manage complex cases [1]. In 2010, Shanghai introduced a standardized residency training system designed to develop highly skilled surgeons who would advance surgery and educate future generations [2]. The system aims to provide surgeons with comprehensive clinical knowledge, improving diagnostic and procedural skills while also fostering research capabilities [3].

A critical area in surgical training is the diagnosis and management of acute abdominal syndrome, a condition characterized by sudden, severe abdominal pain due to various underlying causes. This syndrome includes multiple emergency conditions, many of which require immediate surgical intervention. These conditions, such as bowel obstruction, perforated viscus, and ischemic bowel disease, present diagnostic challenges due to their varied causes and overlapping symptoms. Prompt diagnosis is crucial, as delays can lead to serious complications or death [4]. Residents must develop strong diagnostic acumen and clinical judgment to manage these dynamic conditions effectively [5].

Recognizing its importance, our department integrated acute abdominal syndrome diagnosis and treatment into the standardized curriculum for gastrointestinal surgery residents. Since 2017, a structured teaching program focused on acute abdominal syndrome has been implemented to enhance residents' diagnostic and decision-making abilities. This program includes detailed teaching on clinical presentation, differential diagnosis, and management strategies, emphasizing timely surgical intervention [6]. The goal is to improve diagnostic skills, particularly for postoperative complications in gastric tumor surgeries, where issues like infection, hemorrhage, and anastomotic leaks are common [7].

This study evaluates the impact of acute abdominal syndrome-directed teaching on residents’ diagnostic accuracy for complications following gastric tumor surgery. We analyzed data from residents trained at Ruijin Hospital between 2012 and 2024, comparing the diagnostic performance of those who received AAS-focused training with those who did not. We hypothesize that specialized training will improve diagnostic accuracy, highlighting its effectiveness in enhancing clinical competence [8].

Descriptive statistics were used to analyze the demographic and professional background distributions of residents from different specialties. A chi-square test was performed to determine whether there were significant differences in the proportion of residents who obtained a medical practitioner qualification certificate upon entering the program. A t-test was used to compare the diagnostic scores between two groups of residents: those who had received acute abdomen-oriented clinical teaching and those who had not. Data are presented as the mean ± standard deviation. Statistical analysis was performed using SAS 'PROCGLM' 8.0, with a p-value of < 0.05 considered statistically significant [14].

Between August 2012 and August 2024, 449 residents underwent standardized residency training in the Department of Gastrointestinal Surgery at Ruijin Hospital, affiliated with Shanghai Jiao Tong University School of Medicine. The cohort included 352 males (78.3%) and 97 females (21.7%). Of these, 310 residents (69%) came from surgical specialties, while 139 residents (31%) were from non-surgical fields such as pediatrics, anesthesiology, obstetrics and gynecology, and general practice.

In the surgical specialty group, 174 residents (38.8%) specialized in general surgery subspecialties, and 87 (19.4%) specialized in gastrointestinal surgery. The residents had diverse educational backgrounds, including clinical and scientific postgraduates, long-cycle clinical postgraduates, 4 + 4 clinical postgraduates, and those holding the "Four-in-One Certificates" for clinical professional masters. The remaining 139 non-surgical residents rotated through the gastrointestinal surgery department from other medical fields.

The distribution of residents with and without medical practitioner qualifications at the time of entry was analyzed (Table 1). Of the surgical residents, 168 (54.2%) had medical qualifications, while 142 (45.8%) did not. Among the qualified residents, 50% (84/168) received acute abdomen-oriented clinical training, whereas the remaining 50% did not. Similarly, of the 142 residents without medical licensure, 77 (54.2%) received training, while 65 (45.8%) did not.

Among the general surgery specialty residents, 48 (53.3%) received acute abdomen training, while 42 (46.7%) did not. Among gastrointestinal surgery residents, 24 (52.2%) received training. Non-surgical residents were similarly split, with 40 (44.4%) with a medical qualification receiving training, and 20 (40.8%) without a medical qualification receiving it. Chi-square tests showed no significant differences in licensure status across the subgroups (p > 0.05).

From August 2012 to August 2024, 2257 gastric tumor patients who underwent transabdominal gastrectomy at the Department of Gastrointestinal Surgery were retrospectively analyzed. The cohort consisted of 1457 males (64.5%) and 800 females (35.5%) with a median age of 60 years (range: 27–90 years). Among the patients, 1937 (85.8%) had gastric cancer, whereas 320 (14.2%) had other gastric tumors. A total of 1727 patients (76.5%) underwent distal gastrectomy and 530 patients (23.5%) underwent total gastrectomy. All diagnoses were confirmed using postoperative paraffin pathology.

The analysis of postoperative complications revealed the following common issues: anastomotic leakage (1.55%), pelvic and abdominal infections (3.94%), postoperative bleeding (1.15%), mechanical bowel obstruction (1.6%), paralytic ileus (4.39%), and delayed wound healing (1.82%). In cases in which secondary surgeries were required, the primary causes included abdominal and pelvic infections (1.82%), mechanical bowel obstruction (1.37%), paralytic ileus (1.82%), and postoperative bleeding (0.67%). Mortality due to complications was relatively low, with severe infections (0.31%) being the leading cause of death, followed by anastomotic leakage, pelvic and abdominal infections, respiratory complications, and embolism complications (0.09%) each [15].

As shown in Table 2, the mean clinical case analysis scores for diagnosing postoperative complications in gastric tumors were significantly higher for residents who had received acute abdomen-oriented clinical training than for those who had not. Specifically:

All comparisons between the groups were statistically significant (p < 0.05).

Further analysis was conducted to assess whether having a medical license at the time of entry into the residency program influenced the diagnostic performance. The results showed that residents who received acute abdomen-oriented teaching consistently demonstrated higher diagnostic accuracy for postoperative complications irrespective of whether they had a medical license upon entering the program. This trend was particularly evident among gastrointestinal surgery-focused residents, who showed the most significant improvement in diagnostic scores after completing acute abdomen-oriented training [16].

Acute abdominal syndrome refers to a collection of clinical conditions characterized by sudden severe abdominal pain and tenderness, often indicating serious underlying surgical issues. These conditions necessitate urgent evaluation and intervention by an attending surgeon to determine whether surgery is required. The diagnosis of acute abdominal syndrome is particularly challenging owing to its broad range of potential causes, many of which extend beyond the abdominal cavity and can involve non-surgical or systemic diseases [17].

One of the greatest hurdles in diagnosing acute abdominal syndrome is the need for rapid and accurate decision making in a high-pressure, time-sensitive environment. The diagnostic approach involves detailed medical history, thorough physical examination, laboratory investigations, and imaging studies. However, the most critical component remains clinical history and physical examination, both of which must be methodical and comprehensive. Although laboratory and imaging studies have significantly enhanced diagnostic capabilities, they should not overshadow the importance of clinical skills [18]. Surgeons, particularly residents, must develop proficiency in history taking and physical examination, as these are the foundation of effective surgical practice and are frequently tested in clinical examinations.

The differential diagnosis of acute abdominal syndrome is broad, influenced by factors such as age, sex, medical history, and presenting symptoms. For instance, appendicitis is common in younger patients [19], while older adults are more likely to have conditions like biliary diseases, bowel obstruction, ischemic bowel disease, or diverticulitis [20]. This highlights the need for a comprehensive diagnostic approach that considers both common and rare causes.

Acute abdominal syndrome causes can be categorized as surgical or nonsurgical. Surgical causes, such as perforated ulcers, bowel obstructions, and abdominal trauma, typically require surgery. Non-surgical causes include systemic medical conditions like metabolic disorders (e.g., diabetic ketoacidosis), hematologic conditions (e.g., sickle cell crises), and toxin-induced illnesses (e.g., drug overdoses) [21–22]. While nonsurgical causes may not need surgery, they can mimic surgical emergencies, making their exclusion essential. Distinguishing these causes requires high clinical suspicion and a thorough evaluation of patient demographics, clinical presentation, and physical findings.

The surgical causes of acute abdominal syndrome often require urgent surgical intervention and can be classified into five broad categories:

Understanding these categories is vital for surgical residents, as they are commonly encountered in the emergency department, accounting for about 25% of surgical cases in general hospitals. This knowledge is a key focus in surgical training.

Given the urgency of many surgical conditions associated with acute abdominal syndrome, the diagnostic workflow must be expeditious and thorough. The typical workflow begins with history taking, followed by physical examination, laboratory tests, and imaging studies [23].

Although imaging tools such as CT scans, X-rays, and ultrasound have significantly enhanced diagnostic accuracy, clinical history and physical examination remain the most important elements in evaluating acute abdominal syndrome. For example, a sudden onset of right lower quadrant pain accompanied by fever and leukocytosis strongly suggests appendicitis, whereas diffuse abdominal tenderness and signs of sepsis might point to perforation or peritonitis.

Although imaging studies are invaluable for confirming a diagnosis, clinical judgment based on the patient’s symptoms, physical examination findings, and history remains the cornerstone in guiding treatment. Surgeons must rely on their clinical acumen to determine which tests are necessary to ensure that the diagnostic process does not delay the initiation of urgent treatment.

This study highlights the diverse backgrounds of residents in the Gastrointestinal Surgery Department, with many lacking prior experience in general surgery or gastrointestinal surgery. Despite this, our findings indicate that residents who received acute abdomen-oriented clinical teaching demonstrated significantly higher diagnostic accuracy in identifying postoperative complications of gastric tumors. This improvement was particularly notable among residents without prior surgical experience, reinforcing the effectiveness of targeted acute abdominal training in enhancing clinical competence. Such training provides residents with a foundational understanding of surgical emergencies, which is essential for handling high-stake situations in clinical practice [24].

The strong correlation between common postoperative complications and acute abdominal syndrome in gastrointestinal surgery is another benefit of acute abdominal training. In this study, anastomotic leakage, infection, postoperative bleeding, and bowel obstruction were the most prevalent complications observed in gastric tumor surgery. These complications are often associated with acute abdominal syndrome, and provide excellent teaching opportunities for residents.

National data support this with a high incidence of serious postoperative complications, particularly anastomotic leakage and severe infections, which are frequently associated with increased morbidity and mortality. According to 2016 data from the Chinese Gastrointestinal Oncology Surgical Alliance, the incidence of grade 3 or higher postoperative complications in gastric cancer surgeries was 3.8%, with hemorrhage, severe infections, and anastomotic leakage leading to morbidity and mortality [25].

As healthcare continues to shift towards multidisciplinary team (MDT) models, the management of acute abdominal syndrome increasingly involves collaboration across various specialties. Surgeons, anesthesiologists, radiologists, pathologists, and critical care teams all contributed to the comprehensive management of these patients. This multidisciplinary approach improves diagnostic accuracy and patient outcomes by addressing all facets of patient care such as pain management, nutritional support, and infection control [26].

For surgical residents, it is essential to understand how to work within MDTs, as this collaborative approach is becoming standard in acute care settings. Therefore, training in acute abdominal syndrome should not only emphasize surgical techniques, but also include training in working effectively with other healthcare professionals. This prepares the residents to develop the communication and teamwork skills necessary for modern clinical practice.

This study's strengths include a large cohort of 449 residents undergoing standardized gastrointestinal surgery training over 12 years, providing robust data. Statistical methods like chi-square and t-tests enabled comparisons of diagnostic performance between residents with and without acute abdomen-oriented teaching. The study demonstrates how targeted teaching improves diagnostic accuracy, particularly for those without prior surgical experience, addressing a critical issue in surgical education [27]. Including residents from both surgical and non-surgical backgrounds highlights how structured training can enhance clinical competence across specialties, offering valuable insights for residency programs [28].

However, the study's retrospective design introduces potential recall bias and uncontrolled confounding factors, limiting the ability to account for all variables affecting diagnostic performance, such as teaching methods or resident experience [29]. The single-institution setting at Ruijin Hospital limits generalizability, and multi-center studies would strengthen these findings [30]. Future studies should include real-world data or longitudinal follow-up to assess the long-term effects of acute abdomen-oriented training [31–32].

Acute abdominal syndrome is a rapidly progressing condition that, if not diagnosed and treated promptly, can lead to serious complications or death. Its fast clinical course provides immediate feedback on residents' clinical skills. Surgical residents must recognize the urgency of diagnosing and managing this condition and use each case to refine their diagnostic and decision-making abilities. Given its time-sensitive nature and broad impact, comprehensive training in acute abdominal syndrome management is essential. Incorporating this into standardized residency programs equips residents to handle these emergencies, improving patient outcomes and surgical care quality [33].