Current Practices in Biliary Surgery: Do We Practice What We Teach?

Shaun C Daly, MD1, Xuan Li1, Milot Thaqi1, Daniel J Deziel, MD1, Keith W Millikan, MD1, Jonathan A Myers, MD1, Steven Bonomo, MD2, Minh B Luu, MD1. 1Rush University Medical Center, 2Stroger Hospital of Cook County

Objective: Laparoscopic Cholecystectomy (LC) is one of the most commonly performed operations by general surgeons. Despite well-described technical recommendations, we hypothesize the operative approach to vary in clinical practice. The objective of our study was to provide a real-time snapshot of how LC is currently being performed by practicing surgeons.

Methods: We sent an online survey to surgeons regarding their approach to LC. Items surveyed included the ability to identify the critical view of safety (CVS) in picture and description, their usual technique for performing LC, their use of intraoperative bile duct imaging, their techniques for dealing with difficulty anatomy and bile duct injury (BDI). Indications for open conversion were also queried.

Results: 286 of 645 (44.3%) surgeons completed the survey. Surgeons were between the ages of 41-50 (37.8%), male (89.4%), not formally MIS trained (61.5%) and in academic practice (54.8%). Surgeons were in practice for a median of 10 years and performed a median of 100 LC / year. 78.1% correctly identified an intra-operative photo of the CVS. However, 67.9% incorrectly selected a description of the infundibular technique as the CVS. The most common method for cystic duct identification is the infundibular technique (57.9%) and not the CVS (25.3%). Intraoperative cholangiography (IOC) was routinely used by 16.1% of surgeons, while 0.7% routinely used intraoperative ultrasound (LUS). IOC was the most commonly utilized method for dealing with difficult anatomy (76.8%), followed by conversion to open procedure (16.8%). 42.4% of responding surgeons had experienced a BDI. 39.0% would attempt to repair a BDI recognized intraoperatively by laparoscopic means, while 36.7% would convert to open. 64.9% of surgeons who have intraoperatively recognized a BDI and attempted laparoscopic repair did so over a T-tube. 92.5% of surgeons reporting laparoscopic repair of BDI, reported good outcomes. The most common reason for conversion to open procedures is the inability to gain exposure (63.3%).

Conclusion: Despite an undiminished incidence of BDI during LC, the majority of surgeons report that they use the unfundubular approach for identification of the cystic duct and not the CVS. More surgeons would attempt laparoscopic repair of BDI than would open, or seek an intraoperative consult from a senior colleague or transfer to a tertiary medical center (6.1%). These results suggest an urgent need to reexamine how the tenets of safe LC are being taught and disseminated.

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