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.

  Pre-intervention Post-intervention p-Value
Average CVS score 2.31 4.32 p<0.001
Median CVS score 2 4.75 p<0.001
Cases with CVS score > 4 8 (15.7%) 26 (52%) p<0.001
Cases with CVS score = 0 5 (10%) 2 (4%) p=0.436

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