Back to the Future: Open Cholecystectomy ‘hybrid’ Model Developed Through Historical Re-enactment.

Objective: Cholecystectomy is the most frequently performed general surgical procedure. Prior to Mouret (1987), surgical trainees were routinely exposed to the open procedure which was the gold standard treatment of the time. The aims of reducing postoperative morbidity and length of hospital stay have historically driven the change in surgical approach; from open to laparoscopic, and now potentially Natural Orifice Translumenal Endoscopic Surgery. Laparoscopy is the current gold standard. However, conversion to open is sometimes the only option to achieve a safe patient outcome. Conversion rates are low, account for less than 1% of cases and will continue to drop as trainees become more proficient with difficult cases. However, it will be problematic where open surgery is the only option as trainees will become increasingly de-skilled due to decreasing lack of access to expertise with open cholecystectomy, coupled with no formal open simulator training. No dedicated ‘part-task’ simulator technologies exist for open training. In addition, there is loss of access to expertise (‘lost knowledge’) with historically (pre-Mouret) routine open procedures due to staff retirement and loss of teaching tools from the 1970’s and 1980’s. In this study, we will present an open cholecystectomy hybrid model coupled with our novel frame-work of historical re-enactment that was used to partly validate the model’s authenticity and recreate contextualised pre-1990’s surgical teaching environments using ‘pre-Mouret’ expertise.

Method: A senior surgical team (surgeon, scrub nurse and anaesthetist) who routinely performed open cholecystectomies in the 1980s was interviewed and their recollections and viewpoints directly applied to the development of an open ‘hybrid’ model consisting of a porcine liver and gall-bladder accommodated within a silicone human abdomen. Historical contextualisation was provided by the ‘Open Heart’ exhibit at the Science Museum London that was converted to re-create a ‘state-of-the-art’ general surgical operating theatre from 1983, within which the senior surgical team operated on the model with modern day trainees and medical students. The teaching sessions were audiovisually recorded with focus group interviews conducted immediately post-procedure.

Results:

Preliminary results show that we were able to successfully input ‘pre-Mouret’ expertise into our hybrid model to create an open teaching tool. Our surgical team commented on the realism of the contextualised model and its ability to re-create a 1980’s teaching session. Students commented on how much they learnt via doing, observation and asking questions.

Conclusions: Our study shows that historical re-enactment using expertise that ‘was there at the time’ is a very useful tool driving the development of an open simulator model. Using ‘lost knowledge’ we have been able to face validate our model and expose surgical trainees to the lost art of open cholecystectomy. Further work will include using historical expertise to develop more complex open models to facilitate the continued archiving of ‘lost knowledge’ and eventually providing a data-base of open surgical teaching tools to equip trainees with more surgical skills.