Increasing Resident Utilization and Recognition of the Critical View of Safety in Laparoscopic Cholecystectomy: A Pilot Study from an Academic Medical Center

Crystal Chen, Francesco Palazzo, Stephen Doane, Jordan Winter, Harish Lavu, Karen Chojnacki, Ernest Rosato, Charles Yeo, Michael Pucci. Thomas Jefferson University

Background: Laparoscopic cholecystectomy (LC) is a commonly performed surgical procedure; however, it is associated with an increased rate of bile duct injury (BDI). 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 aim 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).  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 previously published by Strasberg. 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, Table 1). There was strong inter-observer agreement between reviewers. The pre and post-intervention questionnaire response rates were both 86.0%. A greater number of residents correctly identified all criteria of the CVS post-intervention (41% to 93%, p<0.001), and offered appropriate bail-out techniques (77% to 94%, p<0.001). Residents strongly agreed that the CVS education should be included in general surgery residency curriculum (median Likert score=5.00, IQR=4.25-5.00). Residents also agreed they are more comfortable with their LC skills after the intervention (4.00, IQR=3.00-5.00). 

Conclusion: The combination of focused education and intraoperative time-out significantly improved CVS scores and knowledge during LC in our institution. We strongly believe that increasing resident awareness and adherence to the CVS will ultimately enhance patient safety.

Average CVS score2.314.32p<0.001
Median CVS score24.75p<0.001
Cases with CVS score > 48 (15.7%)26 (52%)p<0.001
Cases with CVS score = 05 (10%)2 (4%)p=0.436

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