Tetsuya Nakazato, MD, PhD1, Shanley Deal, MD2, Stephanie Novak, MS1, Bailey Su, MD1, Kristine Kuchta, MS1, Michael Ujiki, MD1. 1NorthShore University Health System, 2Virginia Mason Medical Center
INTRODUCTION: We hypothesized that practicing surgeons would achieve a better critical view of safety (CVS) during laparoscopic cholecystectomy after participation in a structured curriculum. Three criteria are required to achieve the CVS: hepatocystic triangle clearance, separation of the lower third of the gallbladder from the liver bed, and only two structures seen entering the gallbladder.
METHODS: The study was approved as a quality initiative in order to improve outcomes during laparoscopic cholecystectomy. All surgeons performing laparoscopic cholecystectomy at a regional health system were videotaped by an observer whose true purpose was not known to the surgeon. Each surgeon was recorded multiple times before and after a curriculum focusing on the CVS, that was led by a member of the SAGES Safe Laparoscopic Cholecystectomy Task Force. Videos were then randomly ordered and graded by two expert surgeons who were blinded to the operator and whether the surgeries were performed before or after the curriculum. Differences in achieving the CVS pre and post training were assessed with the Wilcoxon Singed-Rank test. A p-value of <0.05 was considered statistically significant.
RESULTS: Twelve surgeons (5 general, 4 acute care, 3 minimally invasive) with an average experience of 17.9 ± 6.3 years participated. Four surgeons (33.3%) reported no previous bile duct injury, four (33.3%) reported one, two (16.7%) reported two, and two (16.7%) reported three. After the curriculum, there was a significant improvement in correctly identifying whether the CVS was achieved in 10 random videos from the internet (7.9±1.5 v 9.3±0.8, p=0.006). Surgeons also reported increased confidence on a 5-point Likert scale in accurately identifying the CVS (4.5±0.5 v 4.9±0.3, p=0.017). Lastly, surgeons achieved all three CVS criteria more often after the curriculum: two structures connected to the gallbladder (0.8±0.7 v 1.6±0.6, p 0.002), cystic plate clearance (0.2±0.2 v 1.0±0.5, p <0.001), and hepatocystic triangle clearance (0.8±0.5 v 1.5±0.4, p 0.001). Total scores were also significantly improved (1.8±1.4 v 4.0±1.5, p<0.001).
CONCLUSION: A structured curriculum on achieving a quality CVS for practicing, experienced surgeons improved their confidence and frequency of obtaining the critical view of safety during laparoscopic cholecystectomy. By utilizing a naturalistic observation technique, we were able to minimize Hawthorne effect and maximize generalizability. We recommend that the curriculum be considered for widespread use in an effort to decrease the bile duct injury rate.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95489
Program Number: S088
Presentation Session: Plenary I
Presentation Type: Podium