Background <p>High-income country evidence suggests female physicians may achieve equal or better patient outcomes, but little is known about how surgeon sex and care-team gender composition affect postoperative recovery in low- and middle-income countries (LMICs). Hospital length of stay after surgery (LOSAS) is a key indicator of recovery efficiency and resource use. We assessed whether surgeon sex and team sex composition are associated with LOSAS in a large LMIC dataset.</p> Methods <p>We analyzed administrative data on 602,608 surgical inpatient admissions from all general hospitals in a western Chinese province (January–December 2023). Records were linked with workforce data to identify surgeon sex and team characteristics. Poisson models estimated associations between surgeon sex, team sex composition, and LOSAS, adjusting for patient- and surgeon-level factors, surgery-type and hospital-month fixed effects, enabling comparisons for identical procedures in the same hospital and month. Post-hoc analyses estimated predicted LOSAS in days.</p> Results <p>Within the sample, 48.4% (<i>N</i> = 363,659) of patients were female. Among the total surgeon population (<i>N</i> = 11,994), 58.7% (<i>N</i> = 7,042) were female. Patients treated by female surgeons had significantly shorter LOSAS relative to those treated by male surgeons in the overall sample (coefficient = -0.017; SE 0.008). These results remained robust across complex scenarios, including emergency department admissions and cases involving multiple surgeries within a single admission. Furthermore, procedures performed by female surgeons assisted by female first assistants had significantly shorter LOSAS (4.73 days) compared to male–male and female–male teams (5.04 days for both pairings). Younger female surgeons (born 1996–2005) had shorter LOSAS (4.50 days), relative to male counterparts (5.13 days).</p> Conclusions <p>In this LMIC setting, female surgeons are associated with shorter LOSAS, even when accounting for case complexity. However, team sex composition and generational differences are influential factors. Our findings suggest shorter LOSAS in female-led teams, specifically those with a female surgeon and a female first assistant, as well as among younger female cohorts. Supporting integration of female surgeons and providing opportunities for female-led teams may therefore enhance recovery efficiency. These results highlight the clinical value of increasing female representation in the surgical workforce.</p> 1) What is already known on this topic <p>Studies from high-income countries have found that female physicians frequently achieve outcomes equal to or better than their male counterparts in measures such as mortality, readmission, and patient satisfaction. However, the bulk of this work focuses on general medicine rather than operative surgical care, and there is only very limited evidence on how surgeon sex, or the gender composition of surgical teams, influences recovery outcomes in low- and middle-income country (LMIC) settings. Existing studies have also relied primarily on hospital-level analyses, with limited ability to isolate differences by types of surgery or seasonality in effects within hospitals.</p> 2) What this study adds <p>Leveraging administrative data on over 600,000 surgical cases from a province in China, this study finds that female surgeons are associated with shorter hospital stays, even when accounting for case complexity. Crucially, the research identifies that female-led teams, consisting of a female surgeon and a female first assistant, achieve shorter stays than male-male pairings. Furthermore, the findings reveal a generational shift, where female surgeons in the youngest birth cohort (1996–2005) exhibit shorter recovery times relative to their male counterparts. Methodologically, the study strengthens this literature by utilizing the largest dataset to date from an LMIC setting, providing the statistical power necessary to conduct nuanced subgroup analyses and draw robust inferences. Moreover, our study addresses potential confounding factors by incorporating surgery-type and hospital-month fixed effects. This provides a greater granular level of control than is typically found in the literature; when combined with detailed indicators for surgical complexity and emergency status, it offers robust evidence that gender composition and generational context are critical determinants of surgical outcomes.</p> 3) How this study might affect research, practice or policy <p>The results suggest that achieving surgical efficiency in resource-constrained health systems may depend on more than simply increasing female surgeon representation. Health systems should consider how team gender composition and generational dynamics shape intraoperative communication, coordination, and patient recovery. For policy makers, this implies that workforce planning should incorporate gender diversity in surgical team design.</p>