A Simulator-Based Resident Curriculum for Laparoscopic Common Bile Duct Exploration Resulting in Increased Clinical Utilization of the Procedure

Ezra N Teitelbaum, MD¹, Nathaniel J Soper, MD¹, Rym El Khoury, MD¹, Ran B Luo, MD², Benjamin Schwab, MD¹, Byron F Santos, MD³, Alexander P Nagle, MD¹, Eric S Hungness, MD¹. ¹Northwestern University, ²University of California at San Diego, ³Dartmouth-Hitchcock Medical Center

Introduction: Despite demonstrated clinical advantages, laparoscopic common bile duct exploration (LCBDE) remains an underutilized operation for choledocholithiasis, with only 7% of such patients in the United States treated with LCBDE at the time of cholecystectomy, as opposed to 93% with both ERCP and laparoscopic cholecystectomy. To address this, we implemented a previously-validated simulator-based resident curriculum to teach LCBDE. In this study, we examined the impact of this curriculum on clinical utilization of LCBDE at our institution.

Methods: Senior residents at a single institution underwent a two-month LCBDE curriculum involving reading and video didactics, and training on a LCBDE-specific simulator using a ‘deliberate practice’ learning model.  Residents completed pre and post-curriculum tests, with the passing score determined using an Angoff method. The curriculum occurred in three phases over three academic years: in the first stage (2012-13) residents were trained individually by a fellow preceptor, in the second (2013-4) residents were paired with an OR nurse and trained as a team, and in the third (2014-15) chief residents who had passed the curriculum during the prior phases served as trainers for additional curriculum-naïve PGY-4 resident and OR nurse teams. Clinical volume of LCBDE before and after curriculum implementation was determined using department billing data.

Results: 20 residents and 10 nurses underwent the curriculum. During the first phase, 10 residents trained individually. All 10 failed the pre-test and passed the post-test. During the second phase, 7 resident-nurse teams were trained. 6 teams failed the pre-test and all 7 passed the post-test. During the third phase, chief residents who had passed the curriculum trained 3 additional resident-nurse teams. All 3 failed the pre-test and all passed the post-test. During the 6 academic years (2006-12) preceding curriculum implementation, a mean of 1.7 (range 0 to 4) LCBDEs per year were performed at our institution, as compared to a mean of 8.3 (range 5 to 13) per year after implementation (2012-present) (p < .05). All LCBDEs in the post-curriculum period were performed by residents who had undergone the curriculum, and 58% of these cases were performed by attending surgeons who did not have prior clinical experience with LCBDE. Over the study period, the number of laparoscopic cholecystectomies performed yearly did not change significantly.

Conclusion: A resident curriculum for LCBDE resulted in increased clinical utilization of the procedure. Further study is needed to determine the effect of this curriculum on clinical outcomes for patients with choledocholithiasis.