Increasing resident utilization and recognition of the critical view of safety during laparoscopic cholecystectomy: a pilot study from an academic medical center (original) (raw)

Abstract

Background

Laparoscopic cholecystectomy (LC) is a commonly performed surgical procedure; however, it is associated with an increased rate of bile duct injury (BDI) when compared to the open approach. The critical view of safety (CVS) provides a secure method of ductal identification to help avoid BDI. CVS is not universally utilized by practicing surgeons and/or taught to surgical residents. We aimed to pilot a safe cholecystectomy curriculum to demonstrate that educational interventions could improve resident adherence to and recognition of the CVS during LC.

Methods

Forty-three general surgery residents at Thomas Jefferson University Hospital were prospectively studied. Fifty-one consecutive LC cases were recorded during the pre-intervention period, while the residents were blinded to the outcome measured (CVS score). As an intervention, a comprehensive lecture on safe cholecystectomy was given to all residents. Fifty consecutive LC cases were recorded post-intervention, while the residents were empowered to “time-out” and document the CVS with a doublet photograph. Two independent surgeons scored the videos and photographs using a 6-point scale. Residents were surveyed pre- and post-intervention to determine objective knowledge and self-reported comfort using a 5-point Likert scale.

Results

In the 18-week study period, 101 consecutive LCs were adequately captured and included (51 pre-intervention, 50 post-intervention). Patient demographics and clinical data were similar. The mean CVS score improved from 2.3 to 4.3 (p < 0.001). The number of videos with CVS score >4 increased from 15.7 to 52 % (p < 0.001). There was strong inter-observer agreement between reviewers. The pre- and post-intervention questionnaire response rates were 90.7 and 83.7 %, respectively. A greater number of residents correctly identified all criteria of the CVS post-intervention (41–93 %, p < 0.001) and offered appropriate bailout techniques (77–94 %, p < 0.001). Residents strongly agreed that the CVS education should be included in general surgery residency curriculum (mean Likert score = 4.71, SD = 0.54). Residents also agreed that they are more comfortable with their LC skills after the intervention (4.27, σ = 0.83).

Conclusion

The combination of focused education along with intraoperative time-out significantly improved CVS scores and knowledge during LC in our institution.

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References

  1. Shaffer EA (2006) Gallstone disease: epidemiology of gallbladder stone disease. Best Pract Res Clin Gastroenterol 20(6):981–996
    Article PubMed Google Scholar
  2. Roslyn JJ, Binns GS, Hughes EF, Saunders-Kirkwood K, Zinner MJ, Cates JA (1993) Open cholecystectomy. A contemporary analysis of 42,474 patients. Ann Surg 218(2):129–137
    Article CAS PubMed PubMed Central Google Scholar
  3. Flum DR, Cheadle A, Prela C, Dellinger EP, Chan L (2003) Bile duct injury during cholecystectomy and survival in medicare beneficiaries. JAMA 290(16):2168–2173. doi:10.1001/jama.290.16.2168
    Article CAS PubMed Google Scholar
  4. Richardson MC, Bell G, Fullarton GM (1996) Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: an audit of 5913 cases. West of Scotland laparoscopic cholecystectomy audit group. Br J Surg 83(10):1356–1360
    Article CAS PubMed Google Scholar
  5. Sicklick JK, Camp MS, Lillemoe KD et al (2005) Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann Surg 241(5):786–792 (discussion 793-5)
    Article PubMed PubMed Central Google Scholar
  6. Tornqvist B, Stromberg C, Persson G, Nilsson M (2012) Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study. BMJ 345:e6457. doi:10.1136/bmj.e6457
    Article PubMed PubMed Central Google Scholar
  7. Bauer TW, Morris JB, Lowenstein A, Wolferth C, Rosato FE, Rosato EF (1998) The consequences of a major bile duct injury during laparoscopic cholecystectomy. J Gastrointest Surg 2(1):61–66
    Article CAS PubMed Google Scholar
  8. de Reuver PR, Sprangers MA, Rauws EA et al (2008) Impact of bile duct injury after laparoscopic cholecystectomy on quality of life: a longitudinal study after multidisciplinary treatment. Endoscopy 40(8):637–643. doi:10.1055/s-2008-1077444
    Article PubMed Google Scholar
  9. Olsen D (1997) Bile duct injuries during laparoscopic cholecystectomy. Surg Endosc 11(2):133–138
    Article CAS PubMed Google Scholar
  10. Davidoff AM, Pappas TN, Murray EA et al (1992) Mechanisms of major biliary injury during laparoscopic cholecystectomy. Ann Surg 215(3):196–202
    Article CAS PubMed PubMed Central Google Scholar
  11. Strasberg SM, Hertl M, Soper NJ (1995) An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 180(1):101–125
    CAS PubMed Google Scholar
  12. Sanford DE, Strasberg SM (2014) A simple effective method for generation of a permanent record of the critical view of safety during laparoscopic cholecystectomy by intraoperative “doublet” photography. J Am Coll Surg 218(2):170–178. doi:10.1016/j.jamcollsurg.2013.11.003
    Article PubMed Google Scholar
  13. Yegiyants S, Collins JC (2008) Operative strategy can reduce the incidence of major bile duct injury in laparoscopic cholecystectomy. Am Surg 74(10):985–987
    PubMed Google Scholar
  14. Misra M, Schiff J, Rendon G, Rothschild J, Schwaitzberg S (2005) Laparoscopic cholecystectomy after the learning curve: what should we expect? Surg Endosc 19(9):1266–1271. doi:10.1007/s00464-004-8919-5
    Article CAS PubMed Google Scholar
  15. Avgerinos C, Kelgiorgi D, Touloumis Z, Baltatzi L, Dervenis C (2009) One thousand laparoscopic cholecystectomies in a single surgical unit using the “critical view of safety” technique. J Gastrointest Surg 13(3):498–503. doi:10.1007/s11605-008-0748-8
    Article CAS PubMed Google Scholar
  16. Strasberg SM (2013) A teaching program for the “culture of safety in cholecystectomy” and avoidance of bile duct injury. J Am Coll Surg 217(4):751. doi:10.1016/j.jamcollsurg.2013.05.001
    Article PubMed Google Scholar
  17. Archer SB, Brown DW, Smith CD, Branum GD, Hunter JG (2001) Bile duct injury during laparoscopic cholecystectomy: results of a national survey. Ann Surg 234(4):549–558 (discussion 558-9)
    Article CAS PubMed PubMed Central Google Scholar
  18. Strasberg SM, Pucci MJ, Brunt LM, Deziel DJ (2016) Subtotal cholecystectomy—”fenestrating” vs “reconstituting” subtypes and the prevention of bile duct injury: definition of the optimal procedure in difficult operative conditions. J Am Coll Surg 222(1):89–96. doi:10.1016/j.jamcollsurg.2015.09.019
    Article PubMed Google Scholar
  19. Coccolini F, Catena F, Pisano M et al (2015) Open versus laparoscopic cholecystectomy in acute cholecystitis. systematic review and meta-analysis. Int J Surg 18:196–204. doi:10.1016/j.ijsu.2015.04.083
    Article PubMed Google Scholar
  20. Caputo L, Aitken DR, Mackett MC, Robles AE (1992) Iatrogenic bile duct injuries. the real incidence and contributing factors—implications for laparoscopic cholecystectomy. Am Surg 58(12):766–771
    CAS PubMed Google Scholar
  21. Nenner RP, Imperato PJ, Alcorn CM (1992) Serious complications of laparoscopic cholecystectomy in new york state. N Y State J Med 92(5):179–181
    CAS PubMed Google Scholar
  22. Fullum TM, Downing SR, Ortega G et al (2013) Is laparoscopy a risk factor for bile duct injury during cholecystectomy? JSLS 17(3):365–370. doi:10.4293/108680813X13654754535638
    Article PubMed PubMed Central Google Scholar
  23. Windsor JA, Pong J (1998) Laparoscopic biliary injury: more than a learning curve problem. Aust N Z J Surg 68(3):186–189
    Article CAS PubMed Google Scholar
  24. Vettoretto N, Saronni C, Harbi A, Balestra L, Taglietti L, Giovanetti M (2011) Critical view of safety during laparoscopic cholecystectomy. JSLS 15(3):322–325. doi:10.4293/108680811X13071180407474
    Article PubMed PubMed Central Google Scholar
  25. Buddingh KT, Hofker HS, ten Cate Hoedemaker HO, van Dam GM, Ploeg RJ, Nieuwenhuijs VB (2011) Safety measures during cholecystectomy: results of a nationwide survey. World J Surg 35(6):1235–1241. doi:10.1007/s00268-011-1061-3 (discussion 1242-3)
    Article CAS PubMed PubMed Central Google Scholar

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Acknowledgments

The authors would like to thank Christian de Laszlo for his support and assistance in the technical acquisition of data for this study. Additionally, we would like to thank the nursing staff at the Thomas Jefferson University Hospitals for their continued assistance in the excellent and safe care of our patients.

Funding

Funding was received from Department of Surgery Pilot Research Grant, Thomas Jefferson University.

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Authors and Affiliations

  1. Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Sidney Kimmel Medical College, Thomas Jefferson University, 1100 Walnut Street, 5th Floor, Philadelphia, PA, 19107, USA
    Crystal B. Chen, Francesco Palazzo, Stephen M. Doane, Jordan M. Winter, Harish Lavu, Karen A. Chojnacki, Ernest L. Rosato, Charles J. Yeo & Michael J. Pucci

Authors

  1. Crystal B. Chen
  2. Francesco Palazzo
  3. Stephen M. Doane
  4. Jordan M. Winter
  5. Harish Lavu
  6. Karen A. Chojnacki
  7. Ernest L. Rosato
  8. Charles J. Yeo
  9. Michael J. Pucci

Corresponding author

Correspondence toMichael J. Pucci.

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Disclosures

The authors, specifically Ms. Chen, Doctors Doane, Palazzo, Winter, Lavu, Chojnacki, Rosato, Yeo, and Pucci, have no conflicts of interest or financial ties to disclose.

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Chen, C.B., Palazzo, F., Doane, S.M. et al. Increasing resident utilization and recognition of the critical view of safety during laparoscopic cholecystectomy: a pilot study from an academic medical center.Surg Endosc 31, 1627–1635 (2017). https://doi.org/10.1007/s00464-016-5150-0

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