How often do surgeons obtain the critical view of safety during laparoscopic cholecystectomy? Surg Endosc. 2017;31:142-146. [PMID: 27142437 DOI: 10.1007/s00464-016-4943-5]

Artificial intelligence applied to laparoscopic cholecystectomy: what is the next step? A narrative review

Artificial Intelligence (AI) is playing an increasing role in several fields of medicine. AI is also used during laparoscopic cholecystectomy (LC) surgeries. In the literature, there is no review that groups together the various fields of application of AI applied to LC. The aim of this review is to describe the use of AI in these contexts. We performed a narrative literature review by searching PubMed, Web of Science, Scopus and Embase for all studies on AI applied to LC, published from January 01, 2010, to December 30, 2023. Our focus was on randomized controlled trials (RCTs), meta-analysis, systematic reviews, and observational studies, dealing with large cohorts of patients. We then gathered further relevant studies from the reference list of the selected publications. Based on the studies reviewed, it emerges that AI could strongly improve surgical efficiency and accuracy during LC. Future prospects include speeding up, implementing, and improving the automaticity with which AI recognizes, differentiates and classifies the phases of the surgical intervention and the anatomic structures that are safe and those at risk.

Safety of laparoscopic cholecystectomy performed by trainee surgeons with different cholangiographic techniques (SCOTCH): a prospective non-randomized trial on the impact of fluorescent cholangiography during laparoscopic cholecystectomy performed by trainees

AIMS

The identification of the anatomical components of the Calot's Triangle during laparoscopic cholecystectomy (LC) might be challenging and its difficulty may increase when a surgical trainee (ST) is in charge, ultimately allegedly affecting also the incidence of common bile duct injuries (CBDIs). There are various methods to help reach the critical view of safety (CVS): intraoperative cholangiogram (IOC), critical view of safety in white light (CVS-WL) and near-infrared fluorescent cholangiography (NIRF-C). The primary objective was to compare the use of these techniques to obtain the CVS during elective LC performed by ST.

METHODS

This was a multicentre prospective observational study (Clinicalstrials.gov Registration number: NCT04863482). The impact of three different visualization techniques (IOC, CVS-WL, NIRF-C) on LC was analyzed. Operative time and time to achieve the CVS were considered. All the participating surgeons were also required to fill in three questionnaires at the end of the operation focusing on anatomical identification of the general task and their satisfaction.

RESULTS

Twenty-nine centers participated for a total of 338 patients: 260 CVS-WL, 10 IOC and 68 NIRF-C groups. The groups did not differ in the baseline characteristics. CVS was considered achieved in all the included case. Rates were statistically higher in the NIR-C group for common hepatic and common bile duct visualization (p = 0.046; p < 0.005, respectively). There were no statistically significant differences in operative time (p = 0.089) nor in the time to achieve the CVS (p = 0.626). Three biliary duct injuries were reported: 2 in the CVS-WL and 1 in the NIR-C. Surgical workload scores were statistically lower in every domain in the NIR-C group. Subjective satisfaction was higher in the NIR-C group. There were no other statistically significant differences.

CONCLUSIONS

These data showed that using NIRF-C did not prolong operative time but positively influenced the surgeon's satisfaction of the performance of LC.

Automated segmentation of phases, steps, and tasks in laparoscopic cholecystectomy using deep learning

BACKGROUND

Video-based review is paramount for operative performance assessment but can be laborious when performed manually. Hierarchical Task Analysis (HTA) is a well-known method that divides any procedure into phases, steps, and tasks. HTA requires large datasets of videos with consistent definitions at each level. Our aim was to develop an AI model for automated segmentation of phases, steps, and tasks for laparoscopic cholecystectomy videos using a standardized HTA.

METHODS

A total of 160 laparoscopic cholecystectomy videos were collected from a publicly available dataset known as cholec80 and from our own institution. All videos were annotated for the beginning and ending of a predefined set of phases, steps, and tasks. Deep learning models were then separately developed and trained for the three levels using a 3D Convolutional Neural Network architecture.

RESULTS

Four phases, eight steps, and nineteen tasks were defined through expert consensus. The training set for our deep learning models contained 100 videos with an additional 20 videos for hyperparameter optimization and tuning. The remaining 40 videos were used for testing the performance. The overall accuracy for phases, steps, and tasks were 0.90, 0.81, and 0.65 with the average F1 score of 0.86, 0.76 and 0.48 respectively. Control of bleeding and bile spillage tasks were most variable in definition, operative management, and clinical relevance.

CONCLUSION

The use of hierarchical task analysis for surgical video analysis has numerous applications in AI-based automated systems. Our results show that our tiered method of task analysis can successfully be used to train a DL model.

Development of an artificial intelligence system for real-time intraoperative assessment of the Critical View of Safety in laparoscopic cholecystectomy

BACKGROUND

The Critical View of Safety (CVS) was proposed in 1995 to prevent bile duct injury during laparoscopic cholecystectomy (LC). The achievement of CVS was evaluated subjectively. This study aimed to develop an artificial intelligence (AI) system to evaluate CVS scores in LC.

MATERIALS AND METHODS

AI software was developed to evaluate the achievement of CVS using an algorithm for image classification based on a deep convolutional neural network. Short clips of hepatocystic triangle dissection were converted from 72 LC videos, and 23,793 images were labeled for training data. The learning models were examined using metrics commonly used in machine learning.

RESULTS

The mean values of precision, recall, F-measure, specificity, and overall accuracy for all the criteria of the best model were 0.971, 0.737, 0.832, 0.966, and 0.834, respectively. It took approximately 6 fps to obtain scores for a single image.

CONCLUSIONS

Using the AI system, we successfully evaluated the achievement of the CVS criteria using still images and videos of hepatocystic triangle dissection in LC. This encourages surgeons to be aware of CVS and is expected to improve surgical safety.

Validity of video-based general and procedure-specific self-assessment tools for surgical trainees in laparoscopic cholecystectomy

INTRODUCTION

Self-review of recorded surgical procedures offers new opportunities for trainees to extend technical learning outside the operating-room. Valid tools for self-assessment are required prior to evaluating the effectiveness of video-review in enhancing technical learning. Therefore, we aimed to contribute evidence regarding the validity of intraoperative performance assessment tools for video-based self-assessment by general surgery trainees when performing laparoscopic cholecystectomies.

METHODS AND PROCEDURES

Using a web-based platform, general surgery trainees in a university-based residency program submitted recorded laparoscopic cholecystectomy procedures where they acted as the supervised primary surgeon. Attending surgeons measured operative performance at the time of surgery using general and procedure-specific assessment tools [Global Operative Assessment of Laparoscopic Skills (GOALS) and Operative Performance Rating System (OPRS), respectively] and entrustability level (O-SCORE). Trainees self-evaluated their performance from video-review using the same instruments. The validity of GOALS and OPRS for trainee self-assessment was investigated by testing the hypotheses that self-assessment scores correlate with (H1) expert assessment scores, (H2) O-SCORE, and (H3) procedure time and that (H4) self-assessment based on these instruments differentiates junior [postgraduate year (PGY) 1-3] and senior trainees (PGY 4-5), as well as (H5)simple [Visual Analogue Scale (VAS) ≤ 4] versus complex cases (VAS > 4). All hypotheses were based on previous literature, defined a priori, and were tested according to the COSMIN consensus on measurement properties.

RESULTS

A total of 35 videos were submitted (45% female and 45% senior trainees) and self-assessed. Our data supported 2 out of 5 hypotheses (H1 and H4) for GOALS and 3 out of 5 hypotheses (H1, H4 and H5) for OPRS, for trainee self-assessment.

CONCLUSIONS

OPRS, a procedure-specific assessment tool, was better able to differentiate between groups expected to have different levels of intraoperative performance, compared to GOALS, a general assessment tool. Given the interest in video-based learning, there is a need to further develop valid procedure-specific tools to support video-based self-assessment by trainees in a range of procedures.

Critical View of Safety in Laparoscopic Cholecystectomy: A Systematic Review of Current Evidence and Future Perspectives

BACKGROUND

The Critical View of Safety (CVS) has been increasingly recognised as the standard method for identification of the cystic structures, to prevent vasculobiliary injuries during laparoscopic cholecystectomy, however, its adoption has been anything but universal. A significant proportion of surgeons has a poor understanding of the three requirements. To bridge this gap between theory and practice, we aimed to summarise the available evidence on CVS, emphasising on current debates and future perspectives.

METHOD

We systematically reviewed the literature (1995-2021), to identify studies reporting on the CVS. Eligible articles were classified according to methodology and key idea. A quantitative analysis was performed to evaluate effectiveness of the CVS in preventing bile duct injury (BDI).

RESULTS

150 relevant articles were identified, focusing on six main points, (1) safety and effectiveness, (2) intraoperative documentation, (3) complementary imaging techniques, (4) bail-out alternatives, (5) adoption among surgeons, and (6) education and training. The quantitative analysis included 11 studies, with 10,938 cases. Overall, the CVS was achieved in 92.5%. Conversion rate was 4.8%. CVS-related BDI was 0.09% (0.05% technical errors and 0.04% misidentification errors).

CONCLUSION

Routine application of the CVS reduces BDI, but does not eliminate them altogether. Besides operative notes, the CVS should be documented by an imaging modality of sufficient quality. When the CVS cannot be safely established, the threshold for bail-out alternatives or complementary imaging should be low. Adoption by the surgical community worldwide shows great variability and focus should be placed on training through structured educational modules.

The artery first technique: re-examining the critical view of safety during laparoscopic cholecystectomy

INTRODUCTION

Significant discrepancies exist between surgeon-documented and actual rates of critical view of safety (CVS) achievement on retrospective review following laparoscopic cholecystectomy. This discrepancy may be due to surgeon utilisation of the artery first technique (AFT), an exception to the CVS first described by Strasberg et al. The present study aims to characterise the use of the AFT, hypothesising it is used as an adjunct in difficult dissections to maximise exposure of the hepato-cystic triangle ensuring safe cholecystectomy.

METHODS

Prospective digital recording of the operative procedure of patients' undergoing laparoscopic cholecystectomy were undertaken at Christchurch Public Hospital, New Zealand and North Shore Private Hospital, Sydney, Australia. Videos were uploaded to Touch Surgery™ Enterprise. Difficulty was graded, annotated and indications for the AFT quantified using a standardised protocol.

RESULTS

A total of 275 annotated procedures were included in this study. The AFT was employed in 54 (20%) patients; in 13 (24%) patients for bleeding, in 35 (65%) patients where windows one and two were visible, and in 6 (11%) patients no windows were visible within the hepato-cystic triangle. There were significant differences in utilisation across operative grade and by seniority of operator (p < 0.005).

CONCLUSIONS

The data presented here demonstrate the AFT is frequently used, particularly with Grade 3 cholecystectomy. However, more data are needed to confirm the utility and safety of this approach. Analysis of the AFT shows that to understand and improve safety in laparoscopic cholecystectomy appreciating how the operation was undertaken and not just that the CVS was achieved is crucial.

Three-port laparoscopic cholecystectomy is safe and efficient in the treatment of surgical biliary disease: a retrospective cohort study

Multiple studies have suggested that three-port laparoscopic cholecystectomy is both feasible and safe. However, this approach has failed to gain acceptance outside of clinical trials, leaving adopters of this approach vulnerable to medico-legal scrutiny. We hypothesized that the three-port approach to laparoscopic cholecystectomy (LC) is safe and efficient in experienced hands. All LC (including robotic) cases were performed on patients 18 years and older between November 2018 and March 2020. Operations utilizing three ports were compared to those performed using more than three ports. The primary outcomes measured were total operative time, conversion-to-open rate, and the complication rate. A two-sample test was performed to compare operative times, and a Fisher's exact test was used to compare conversion-to-open and complication rates. Linear regression models were used to account for the effect of confounders. 924 total LCs were performed by 30 surgeons in the study period (71 three-port, 853 four or more ports). The mean operative time was 10 min shorter in the three-port group in comparison (64.1 ± 1.4 min vs. 74.4 ± 1.8 min, p < 0.01), despite a threefold higher rate of intraoperative cholangiogram in these cases (23.0% vs. 7.9%, p < 0.001). There was no significant difference in either the conversion-to-open rate (1.6% vs. 5.1%, p = 0.35), or the overall complication rate (7.1% vs. 8.7%, p = 0.82). Operative time for LC performed through three ports was significantly less than those performed through the traditional four port approach, despite utilizing intraoperative cholangiogram nearly three times as often. There was no difference in the conversion-to open rate or complication rate. These results provide considerable evidence that three-port laparoscopic cholecystectomy is comparable to four-port laparoscopic cholecystectomy in operative duration, conversion-to-open rate, and complication rate.

SAGES safe cholecystectomy modules improve practicing surgeons' judgment: results of a randomized, controlled trial

BACKGROUND

Despite the advantages of laparoscopic cholecystectomy, major bile duct injury (BDI) rates during this operation remain unacceptably high. In October 2018, SAGES released the Safe Cholecystectomy modules, which define specific strategies to minimize the risk of BDI. This study aims to investigate whether this curriculum can change the knowledge and behaviors of surgeons in practice.

METHODS

Practicing surgeons were recruited from the membership of SAGES and the American College of Surgeons Advisory Council for Rural Surgery. All participants completed a baseline assessment (pre-test) that involved interpreting cholangiograms, troubleshooting difficult cases, and managing BDI. Participants' dissection strategies during cholecystectomy were also compared to the strategies of a panel of 15 experts based on accuracy scores using the Think Like a Surgeon validated web-based platform. Participants were then randomized to complete the Safe Cholecystectomy modules (Safe Chole module group) or participate in usually scheduled CME activities (control group). Both groups completed repeat assessments (post-tests) one month after randomization.

RESULTS

Overall, 41 participants were eligible for analysis, including 18 Safe Chole module participants and 23 controls. The two groups had no significant differences in pre-test scores. However, at post-test, Safe Chole module participants made significantly fewer errors managing BDI and interpreting cholangiograms. Safe Chole module participants were less likely to convert to an open operation on the post-test than controls when facing challenging dissections. However, Safe Chole module participants displayed a similar incidence of errors when evaluating adequate critical views of safety.

CONCLUSIONS

In this randomized-controlled trial, the SAGES Safe Cholecystectomy modules improved surgeons' abilities to interpret cholangiograms and safely manage BDI. Additionally, surgeons who studied the modules were less likely to convert to open during difficult dissections. These data show the power of the Safe Cholecystectomy modules to affect practicing surgeons' behaviors in a measurable and meaningful way.

Bile duct injury in laparoscopic cholecystectomy with a posterior infundibular approach

Aims: Bile duct injury (BDI) in laparoscopic cholecystectomy (LC) has a significant impact on morbidity and mortality. Although the critical view of safety (CVS) concept is the most widely supported approach to prevent BDI, alternative approaches are used as well. The aim was to evaluate the incidence, severity, and management of bile duct injury in LC, using a posterior infundibular approach. Methods: This retrospective, monocentric cohort study includes patients who underwent LC for gallstone disease. Data were collected in a prospectively maintained database. Patients with BDI were identified and were analyzed in-depth. Results: Between 1999 and 2018, 8389 consecutive patients were included (M/F 3288/5101; mean age 55 (standard deviation; SD ± 17) years). Mean length of postoperative hospital stay was two days (SD ± 4). Fourteen patients died after LC and 21 patients were identified with BDI. Seventeen BDI (81%) patients were managed minimally invasive (14 endoscopic, 3 laparoscopic), and 4 patients via laparotomy (3 hepaticojejunostomy, 1 primary suture). Severe complications (Clavien-Dindo ≥3) after BDI repair were observed in 6 patients. There was no BDI-related mortality. Median follow-up time was 113 months (range 5–238). Conclusion: A posterior infundibular approach in LC was associated with a low incidence of BDI and no BDI-related mortality.

Use of prospective video analysis to understand the impact of technical difficulty on operative process during laparoscopic cholecystectomy

BACKGROUND

An understanding of the impact of operative difficulty on operative process in laparoscopic cholecystectomy is lacking. The aim of the present study was to prospectively analyse digitally recorded laparoscopic cholecystectomy to assess the impact of operative technical difficulty on operative process.

METHODS

Video of laparoscopic cholecystectomy procedures performed at Christchurch Hospital, NZ and North Shore Private Hospital, Sydney Australia were prospectively recorded. Using a framework derived from a previously published standard process video was annotated using a standardized template and stratified by operative grade to evaluate the impact of grade on operative process.

RESULTS

317 patients had their laparoscopic cholecystectomy operations prospectively recorded. Seventy one percent of these videos (n = 225) were annotated. Single ICC of operative grade was 0.760 (0.663-0.842 p < 0.010). Median operative time, rate of operative errors significantly increased and rate of CVS decreased with increasing operative grade. Significant differences in operative anatomy, operative process and instrumentation were seen with increasing grade.

CONCLUSION

Operative technical difficulty is accurately predicted by operative grade and this impacts on operative process with significant implications for both surgeons and patients. Consequently operative grade should be documented routinely as part of a culture of safe laparoscopic cholecystectomy.

Multicentric validation of EndoDigest: a computer vision platform for video documentation of the critical view of safety in laparoscopic cholecystectomy

BACKGROUND

A computer vision (CV) platform named EndoDigest was recently developed to facilitate the use of surgical videos. Specifically, EndoDigest automatically provides short video clips to effectively document the critical view of safety (CVS) in laparoscopic cholecystectomy (LC). The aim of the present study is to validate EndoDigest on a multicentric dataset of LC videos.

METHODS

LC videos from 4 centers were manually annotated with the time of the cystic duct division and an assessment of CVS criteria. Incomplete recordings, bailout procedures and procedures with an intraoperative cholangiogram were excluded. EndoDigest leveraged predictions of deep learning models for workflow analysis in a rule-based inference system designed to estimate the time of the cystic duct division. Performance was assessed by computing the error in estimating the manually annotated time of the cystic duct division. To provide concise video documentation of CVS, EndoDigest extracted video clips showing the 2 min preceding and the 30 s following the predicted cystic duct division. The relevance of the documentation was evaluated by assessing CVS in automatically extracted 2.5-min-long video clips.

RESULTS

144 of the 174 LC videos from 4 centers were analyzed. EndoDigest located the time of the cystic duct division with a mean error of 124.0 ± 270.6 s despite the use of fluorescent cholangiography in 27 procedures and great variations in surgical workflows across centers. The surgical evaluation found that 108 (75.0%) of the automatically extracted short video clips documented CVS effectively.

CONCLUSIONS

EndoDigest was robust enough to reliably locate the time of the cystic duct division and efficiently video document CVS despite the highly variable workflows. Training specifically on data from each center could improve results; however, this multicentric validation shows the potential for clinical translation of this surgical data science tool to efficiently document surgical safety.

Critical view of safety in laparoscopic cholecystectomy: A prospective investigation from both cognitive and executive aspects

Background

The achievement rate of the critical view of safety during laparoscopic cholecystectomy is much lower than expected. This original study aims to investigate and analyze factors associated with a low critical view of safety achievement.

Materials and Methods

We prospectively collected laparoscopic cholecystectomy videos performed from September 2, 2021, to September 19, 2021, in Sichuan Province, China. The artificial intelligence system, SurgSmart, analyzed videos under the necessary corrections undergone by expert surgeons. Also, we distributed questionnaires to surgeons and analyzed them along with surgical videos simultaneously.

Results

We collected 169 laparoscopic cholecystectomy surgical videos undergone by 124 surgeons, among which 105 participants gave valid answers to the questionnaire. Excluding those who conducted the bail-out process directly, the overall critical view of safety achievement rates for non-inflammatory and inflammatory groups were 18.18% (18/99) and 9.84% (6/61), respectively. Although 80.95% (85/105) of the surgeons understood the basic concept of the critical view of safety, only 4.76% (5/105) of the respondents commanded all three criteria in an error-free way. Multivariate logistic regression results showed that an unconventional surgical workflow (OR:12.372, P &lt; 0.001), a misunderstanding of the 2nd (OR: 8.917, P &lt; 0.05) and 3rd (OR:8.206, P &lt; 0.05) criterion of the critical view of safety, and the don't mistake “fundus-first technique” as one criterion of the critical view of safety (OR:0.123, P &lt; 0.01) were associated with lower and higher achievements of the critical view of safety, respectively.

Conclusions

The execution and cognition of the critical view of safety are deficient, especially the latter one. Thus, increasing the critical view of safety surgical awareness may effectively improve its achievement rate.

The Critical View of Safety in Laparoscopic Cholecystectomy: User Trends Among Residents and Consultants

BACKGROUND

The Critical View of Safety (CVS) aims at preventing bile duct injuries (BDIs) in laparoscopic cholecystectomy (LCC). This study investigated CVS utilization among surgeons.

METHODS

Photos from LCCs were scored for satisfactory CVS. Rates of satisfactory CVS, BDIs, and postoperative complications among residents and consultants were compared. A lecture on CVS was given halfway through the study.

RESULTS

The study comprised 1532 patients. Residents had higher rates of satisfactory CVS in elective LCCs compared with consultants (34.9% vs. 23.0%, P<0.001), but not in emergency LCCs (18.4% vs. 15.0%, P=0.252). No significant differences in BDIs or postoperative complications emerged between residents and consultants. After the lecture, elective LCCs were photographed more frequently (80.3% vs. 74.0%, P=0.032), but rates of satisfactory CVS, BDIs, and postoperative complications remained unchanged.

CONCLUSIONS

Utilization of CVS can be affected by a single lecture but affecting rates of satisfactory CVS may require stronger interventions.

Strasberg\'s Critical View: Strategy for a Safe Laparoscopic Cholecystectomy

Background

Every year, worldwide, the celebration for patient safety is carried out; since about 2.6 million people are documented who die each year from events that can potentially be avoided during their medical care, it is even estimated that around 15% of hospital costs can be attributed to treatment resulting in patient safety. As an important part of its dissemination in the medical–surgical community, we present the following article in relation to the critical vision of safety in the bile duct, promoted and published initially by Dr Steven Strasberg, which aims to reduce the number of complications during laparoscopic cholecystectomies.

Materials and methods

A bibliographic search was carried out in PubMed, Medline, Clinical Key, and Index Medicus. From May 2020 to July 2021 in Spanish and English with the following.

Conclusions

Strasberg's critical view is a proposed strategy to minimize the risk to zero during laparoscopic gallbladder surgery. It consists of obtaining a plane in which the surgeon can visualize the anatomical structures that make up the bile duct, as well as its irrigation and drainage. Being able to clearly observe these structures allows the surgeon to cut freely and safely to avoid bile duct injuries which are not so uncommon during this procedure.

How to cite this article

Montalvo-Javé EE, Contreras-Flores EH, Ayala-Moreno EA, et al. Strasberg's Critical View: Strategy for a Safe Laparoscopic Cholecystectomy. Euroasian J Hepato-Gastroenterol 2022;12(1):40–44.

Long-term retention after structured curriculum on attainment of critical view of safety during laparoscopic cholecystectomy for surgeons

BACKGROUND

Obtaining a clear Critical View of Safety helps prevent bile duct injuries during laparoscopic cholecystectomy, which can be improved with a structured Safe Critical View of Safety curriculum. We aimed to determine whether the improvement in obtaining Critical View of Safety postcurriculum is retained long-term.

METHODS

A safe Critical View of Safety curriculum was previously implemented for all surgeons who perform laparoscopic cholecystectomy at a regional health system. Recordings of laparoscopic cholecystectomy cases were collected 1 year after completion of the curriculum, deidentified and randomly ordered, and then graded by 2 blinded expert surgeons using a 6-point Critical View of Safety assessment tool.

RESULTS

A total of 12 surgeons with average experience of 17.9 ± 6.3 years in practice participated in the study. The majority (83%) had performed >700 laparoscopic cholecystectomies, and 4 surgeons (33%) reported 2 or more bile duct injuries in their career. Controlling for gallbladder pathology, Critical View of Safety scores improved from 1.7 ± 0.4 to 4.0 ± 0.4 (P < .001) immediately after completion of the curriculum. However, there was a small decrease in Critical View of Safety score after 1 year (3.2 ± 0.3 from 4.0 ± 0.4, P = .055), while still significantly higher compared to precurriculum (3.2 ± 0.3 vs 1.7 ± 0.4, P < .001). Acute care surgeons had lower Critical View of Safety retention scores compared to general surgeons (1.8 ± 0.5 vs 3.3 ± 0.4, P = .01) and minimally invasive surgeons (1.8 ± 0.5 vs 3.8 ± 0.5, P < .01).

CONCLUSION

A structured curriculum helped improve practicing surgeons' attainment of obtaining the Critical View of Safety during laparoscopic cholecystectomy. However, this improvement decreased after 1 year, suggesting some decay in knowledge retention over time. Therefore, continued educational interventions on Critical View of Safety and safe laparoscopic cholecystectomy may be needed to enhance long-term retention.

Coaching in Surgical Education: A Systematic Review

OBJECTIVE

The objectives of this study were to review the coaching literature to (1) characterize the criteria integral to the coaching process, specifically in surgery, and (2) describe how these criteria have been variably implemented in published studies.

BACKGROUND

Coaching is a distinct educational intervention, but within surgery the term is frequently used interchangeably with other more established terms such as teaching and mentoring.

METHODS

A systematic search was performed of the MEDLINE and Cochrane databases to identify studies that used coach/coaching as an intervention for surgeons for either technical or nontechnical skills. Study quality was evaluated using the Medical Education Research Study Quality Instrument (MERSQI).

RESULTS

A total of 2280 articles were identified and after screening by title, abstract and full text, 35 remained. Thirteen coaching criteria (a-m) were identified in 4 general categories: 1. overarching goal (a. refine performance of an existing skill set), 2. the coach (b. trusting partnership, c. avoids assessment, d. 2-way communication), the coachee (e. voluntary participation, f. self-reflection, g. goal setting, h. action plan, i. outcome evaluation), and the coach-coachee rapport (j. coaching training, k. structured coaching model, l. non-directive, m. open ended questions). Adherence to these criteria ranged from as high of 73% of studies (voluntary participation of coach and coachee) to as low as 7% (use of open-ended questions).

CONCLUSIONS

Coaching is being used inconsistently within the surgical education literature. Our hope is that with establishing criteria for coaching, future studies will implement this intervention more consistently and allow for better comparison and generalization of results.

Are YouTube Videos a Reliable Training Method for Safe Laparoscopic Cholecystectomy? A Simulated Decision-Making Exercise to Assess the Critical View of Safety

Background  The present study assesses the educational value of laparoscopic cholecystectomy videos on YouTube regarding the correct application of the critical view of safety (CVS), and evaluates… surgical trainees' perceptions of the CVS criteria in a simulated, operative decision-making exercise.

Methods  YouTube was systematically searched for laparoscopic cholecystectomy videos, explicitly reporting a satisfactory CVS. The top 30 most popular videos, by number of views, were identified and scored on the 6-point scale by three experienced consultants. After watching a training module on CVS rationale and criteria, 10 trainees, blinded to the consultants' assessment, were instructed to view the videos, score each criterion and answer the binary question “Would you divide the cystic structures?” by “yes” or “no.”

Results  An inadequate CVS was found in 30% of the included videos. No statistical association was noted between number of views, likes, or dislikes with successful CVS rates. Inter-observer agreement between consultants and trainees ranged from minimal to moderate ( k  = 0.07–0.60). Discrepancy between trainees' CVS scores and their simulated decision to proceed to division of the cystic structures was found in 15% of assessments, with intra-observer agreement ranging from minimal to excellent ( k  = 0.27–1.0). For the CVS requirements, inter-observer agreement was minimal for the dissection of the cystic plate ( k  = 0.26) and triangle clearance ( k  = 0.39) and moderate for the identification of two and only two structures ( k  = 0.42).

Conclusion  The CVS is central to the culture of safety in laparoscopic cholecystectomy. Surgical videos are a useful training tool as simulated, operative decision-making exercises. However, public video platforms should be used judiciously, since their content is not peer-reviewed or quality-controlled.

The critical view of safety and bile duct injuries in laparoscopic cholecystectomy: a photo evaluation study on 1532 patients

BACKGROUND

Laparoscopic cholecystectomy (LCC) carries a 0.3-1.8% risk of bile duct injury (BDI). This study investigated if intraoperative photo documentation of the critical view of safety (CVS) is related to lower rates of BDIs and postoperative complications in LCC.

METHODS

Surgeons were instructed to take photos of the view before clipping the cystic duct and artery. Two independent raters scored the photos 0-6 using predefined criteria for CVS. Mean scores of ≥4.5 were satisfactory.

RESULTS

The study consisted of 1532 patients undergoing LCC between April 2018 and October 2019. CVS was satisfactory in 354 (23.1%), unsatisfactory in 823 (53.7%), and photos were missing in 355 (23.2%) patients. Patients with satisfactory CVS had the lowest BDI rate compared with unsatisfactory CVS or missing photos (0.3% vs. 1.0% vs. 2.3%, p = 0.012). Four major BDIs (Strasberg D-E) occurred, but none in patients with satisfactory CVS. Patients with satisfactory CVS had the lowest postoperative complication rate compared with patients with unsatisfactory CVS or without photos (4.8% vs. 7.9 vs. 9.9%, p = 0.011). Of patients with acute cholecystitis, 15.7% had satisfactory CVS, whereas 26.8% without cholecystitis had satisfactory CVS (p < 0.001).

CONCLUSION

Intraoperative photo documentation of satisfactory CVS is associated with lower rates of BDIs and complications.

Intraoperative Time-Out to Promote the Implementation of the Critical View of Safety in Laparoscopic Cholecystectomy: A Video-Based Assessment of 343 Procedures

BACKGROUND

The critical view of safety (CVS) is poorly adopted in surgical practices although it is ubiquitously recommended to prevent major bile duct injuries during laparoscopic cholecystectomy (LC). This study aims to investigate whether performing a short intraoperative time out can improve CVS implementation.

STUDY DESIGN

In this before versus after study, surgeons performing LCs at an academic center were invited to use a 5-second long time out to verify CVS before dividing the cystic duct (5-second rule). The primary aim was to compare the rate of CVS achievement for LCs performed in the year before versus the year after implementation of the 5-second rule. The CVS achievement rate was computed after exclusion of bailout procedures using a mediated video-based assessment made by two independent reviewers. Clinical outcomes, LC workflows, and postoperative reports were also compared.

RESULTS

343 of the 381 LCs performed between December 2017 and November 2019 (171 before and 172 after implementation of the 5-second rule) were analyzed. The 5-second rule was associated with a significantly increased rate of CVS achievement (15.9 vs. 44.1% before vs. after the 5-second rule, respectively; P<0.001). Significant differences were also observed with respect to the rate of bailout procedures (8.2 vs. 15.7%; P=0.04), the median [IQR] time to clip the cystic duct or artery (00:17:26 [00:11:48, 00:28:35] vs. 00:23:12 [00:14:29, 00:31:45] duration; P=0.007), and the rate of postoperative CVS reporting (1.3 vs. 28.8%; P<0.001). Postoperative morbidity was comparable (1.8 vs. 2.3%; P=0.68).

CONCLUSION

Performing a short intraoperative time out was associated with an improved CVS achievement rate. Systematic intraoperative cognitive aids should be studied to sustain the uptake of guidelines.

Surgical data science and artificial intelligence for surgical education

Surgical data science (SDS) aims to improve the quality of interventional healthcare and its value through the capture, organization, analysis, and modeling of procedural data. As data capture has increased and artificial intelligence (AI) has advanced, SDS can help to unlock augmented and automated coaching, feedback, assessment, and decision support in surgery. We review major concepts in SDS and AI as applied to surgical education and surgical oncology.

The critical view of safety during laparoscopic cholecystectomy: Strasberg Yes or No? An Italian Multicentre study

BACKGROUND

Laparoscopic cholecystectomy is considered the gold standard for the treatment of gallbladder lithiasis; nevertheless, the incidence of bile duct injuries (BDI) is still high (0.3-0.8%) compared to open cholecystectomy (0.2%). In 1995, Strasberg introduced the "Critical View of Safety" (CVS) to reduce the risk of BDI. Despite its widespread use, the scientific evidence supporting this technique to prevent BDI is controversial.

METHODS

Between March 2017 and March 2019, the data of patients submitted to laparoscopic cholecystectomy in 30 Italian surgical departments were collected on a national database. A survey was submitted to all members of Italian Digestive Pathology Society to obtain data on the preoperative workup, the surgical and postoperative management of patients and to judge, at the end of the procedure, if the isolation of the elements was performed according to the CVS. In the case of a declared critical view, iconographic documentation was obtained, finally reviewed by an external auditor.

RESULTS

Data from 604 patients were analysed. The study population was divided into two groups according to the evidence (Group A; n = 11) or absence (Group B; N = 593) of BDI and perioperative bleeding. The non-use of CVS was found in 54.6% of procedures in the Group A, and 25.8% in the Group B, and evaluating the operator-related variables the execution of CVS was associated with a significantly lower incidence of BDI and intraoperative bleeding.

CONCLUSIONS

The CVS confirmed to be the safest technique to recognize the elements of the Calot triangle and, if correctly performed, it significantly impacted on preventing intraoperative complications. Additional educational programs on the correct application of CVS in clinical practice would be desirable to avoid extreme conditions that may require additional procedures.

Use of the self-reported critical view of safety in laparoscopic cholecystectomy during residency

BACKGROUND

Even though the goal of safely performing cholecystectomy is already a priority in general surgical training programs, we aimed to study how many residents and attendings reached the critical view of safety (CVS) in laparoscopic cholecystectomy.

MATERIALS AND METHODS

Retrospective review of prospectively collected data of all patients with biliary surgical conditions, which underwent laparoscopic cholecystectomy and their corresponding postoperative notes with self-reported CVS from May 2019 to May 2020 in an academic hospital. Comparisons of operative variables between postgraduate year and attendings were made.

RESULTS

Laparoscopic cholecystectomy was performed in 126 elective cases (62.6%) and 75 (37.3%) emergency cases. On 105 (83.3%) of the elective cases and on 54 (66.7%) emergency cases, a CVS was successfully performed. PGY3 and PGY5 had higher odds of achieving CVS compared to attendings OR 6.09 (95% CI 2.05 to 8.07) and 4.51 (95% CI 1.0 to 10.20), respectively. Overall, attendings had decreased odds ratio of achieving CVS of 0.488 when compared to all residents. Elective procedures had increased odds ratios of achieving CVS of 3.44 (95% CI 1.52 to 7.74). On elective cases, attendings performed significantly faster procedures when compared to PGY2-4, but not PGY5. No differences were seen between operative speeds between PGY. Third-year residents were identified as having the highest frequency of CVS; however, these differences were not statistically significant. In emergency cases, blood loss, operative time, CVS, and bile duct injuries revealed non-significant differences between operators.

CONCLUSION

CVS was reached significantly more often in elective than in emergency surgeries. There is still a lack of residents and attending surgeons who still failed to complete CVS during LC, highlighting the need for further education. Future studies should be attempted to repeat this study with a larger sample size and multiple coaching sessions to determine long-term efficacy.

Knowledge of the Culture of Safety in Cholecystectomy (COSIC) Among Surgical Residents: Do We Train Them Well For Future Practice?

BACKGROUND

Biliary injury is the most feared complication of laparoscopic cholecystectomy (LC). This study aimed to assess the awareness of culture of safety in cholecystectomy (COSIC) concept among the surgical residents in India.

METHODS

A manual survey was conducted among general surgery residents attending a postgraduate course. Survey consisted of questions pertaining to knowledge of various aspects of COSIC, e.g., the critical view of safety (CVS).

RESULTS

With a response rate of 51%, 259 residents were included in this study. They had more exposure to LC (63.3% assisted / performed > 15 LC) than to open cholecystectomy (60.6% assisted / performed ≤ 10 open cholecystectomy). The majority (80.2%) clearly differentiated Calot triangle from the hepatocystic triangle (HCT). However, 25.8% could not correctly define HCT. The majority (88.5%) had seen the Rouviere's sulcus during LC. While almost all (98.4%) respondents claimed to know about the segment 4, only 41.9% could correctly describe it. Awareness of the correct direction of the gallbladder retraction was lower for the infundibulum (53.5%) than for fundus (89.2%). The majority (88.3%) claimed to know CVS but only 11.5% knew it correctly, and 15.1% described > 3 components. The majority (78.7%) practiced to identify the cystic duct-common bile duct junction. Awareness was low for time-out (28.1%), intraoperative cholangiography (20.6%), bailout techniques (18.9%), and for overall COSIC concept (15.7%).

CONCLUSIONS

Knowledge of COSIC among surgical residents seems to be suboptimal, especially for the CVS, time-out, bailout techniques, and overall concept of COSIC. Strategies to educate them more effectively about COSIC are highly imperative to train them well for future practice.

Artificial Intelligence for Surgical Safety: Automatic Assessment of the Critical View of Safety in Laparoscopic Cholecystectomy Using Deep Learning

OBJECTIVE

To develop a deep learning model to automatically segment hepatocystic anatomy and assess the criteria defining the critical view of safety (CVS) in laparoscopic cholecystectomy (LC).

BACKGROUND

Poor implementation and subjective interpretation of CVS contributes to the stable rates of bile duct injuries in LC. As CVS is assessed visually, this task can be automated by using computer vision, an area of artificial intelligence aimed at interpreting images.

METHODS

Still images from LC videos were annotated with CVS criteria and hepatocystic anatomy segmentation. A deep neural network comprising a segmentation model to highlight hepatocystic anatomy and a classification model to predict CVS criteria achievement was trained and tested using 5-fold cross validation. Intersection over union, average precision, and balanced accuracy were computed to evaluate the model performance versus the annotated ground truth.

RESULTS

A total of 2854 images from 201 LC videos were annotated and 402 images were further segmented. Mean intersection over union for segmentation was 66.6%. The model assessed the achievement of CVS criteria with a mean average precision and balanced accuracy of 71.9% and 71.4%, respectively.

CONCLUSIONS

Deep learning algorithms can be trained to reliably segment hepatocystic anatomy and assess CVS criteria in still laparoscopic images. Surgical-technical partnerships should be encouraged to develop and evaluate deep learning models to improve surgical safety.

Fluorescent cholangiography significantly improves patient outcomes for laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) is the most common elective abdominal surgery in the USA, with over 750,000 performed annually. Fluorescent cholangiography (FC) using indocyanine green dye (ICG) permits identification of extrahepatic biliary structures to facilitate dissection without requiring cystic duct cannulation. Achieving the "critical view of safety" with assistance of ICG cholangiogram may support identification of anatomy, safely reduce conversion to open procedures, and decrease operative time. We assess the utility of FC with respect to anatomic visualization during LC and its effects on patient outcomes.

METHODS

A retrospective review of a prospectively maintained database identified patients undergoing laparoscopic cholecystectomy at a single academic center from 2013 to 2019. Exclusion criteria were primary open and single incision cholecystectomy. Patient factors included age, sex, BMI, and Charlson Comorbidity Index. Outcomes included operative time, conversion to open procedure, length of stay (LOS), mortality rate, and 30-day complications. A multivariable logistic regression was performed to determine independent predictors for open conversion.

RESULTS

A total of 1389 patients underwent laparoscopic cholecystectomy. 69.8% were female; mean age 48.6 years (range 15-94), average BMI 29.4 kg/m² (13.3-55.6). 989 patients (71.2%) underwent LC without fluorescence and 400 (28.8%) underwent FC with ICG. 30-day mortality detected 2 cases in the non-ICG group and zero with ICG. ICG reduced operative time by 26.47 min per case (p < 0.0001). For patients with BMI ≥ 30 kg/m², operative duration for ICG vs non-ICG groups was 75.57 vs 104.9 min respectively (p < 0.0001). ICG required conversion to open at a rate of 1.5%, while non-ICG converted at a rate of 8.5% (p < 0.0001). Conversion rate remained significant with multivariable analysis (OR 0.212, p = 0.001). A total of 19 cases were aborted (1.35%), 8 in the ICG group (1.96%) and 11 in the non-ICG group (1.10%), these cases were not included in LC totals. Average LOS was 0.69 vs 1.54 days in the ICG compared to non-ICG LCs (p < 0.0001), respectively. Injuries were more common in the non-ICG group, with 9 patients sustaining Strasberg class A injuries in the non-ICG group and 2 in the ICG group. 1 CBDI occurred in the non-ICG group. There was no significant difference in 30-day complication rates between groups.

CONCLUSION

ICG cholangiography is a non-invasive adjunct to laparoscopic cholecystectomy, leading to improved patient outcomes with respect to operative times, decreased conversion to open procedures, and shorter length of hospitalization. Fluorescence cholangiography improves visualization of biliary anatomy, thereby decreasing rate of CBDI, Strasberg A injuries, and mortality. These findings support ICG as standard of care during laparoscopic cholecystectomy.

Safe Cholecystectomy Multi-society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy

BACKGROUND

BDI is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI.

METHODS

Literature reviews were conducted for 18 key questions across 6 broad topics around cholecystectomy directed by a steering group and subject experts from 5 surgical societies (Society of Gastrointestinal and Endoscopic Surgeons, Americas Hepato-Pancreato-Biliary Association, International Hepato-Pancreato-Biliary Association, Society for Surgery of the Alimentary Tract, and European Association for Endoscopic Surgery). Evidence-based recommendations were formulated using the grading of recommendations assessment, development, and evaluation methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus.

RESULTS

Consensus was reached on 17 of 18 questions by the guideline development group and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team.

CONCLUSIONS

These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.

A practical new strategy to prevent bile duct injury during laparoscopic cholecystectomy. A single-center experience with 5539 cases

Purpose

Bile duct injury (BDI) is a catastrophic complication of cholecystectomy, and misidentification of the cystic anatomy is considered to be the main cause. Although several techniques have been developed to prevent BDI, such as the “critical view of safety”, the infundibular technique, the rates remain higher during laparoscopic cholecystectomy (LC) than during open surgery. We, here, propose a practical new strategy for ductal identification, that can help to prevent laparoscopic bile duct injury.

Methods

A retrospective study of 5539 patients who underwent LC from March 2007 to February 2019 at a single institution was conducted. The gallbladder infundibulum was classified by its position located on an imaginary clock with the gallbladder neck as the center point of the dial, 3-o’clock position as cranial, 6-o’clock as dorsal, 9-o’clock as caudal, and 12-o’clock as ventral, as well as the axial position. Patient demographics, pathologic variables and infundibulum classification were evaluated. Detailed analysis of ductal identification based on gallbladder infundibulum position was performed in this study. All infundibulum positions were recorded by intraoperative laparoscopic video or photographic images.

Results

All the patients successfully underwent LC during the study period. No conversion or serious complications such as biliary injury occurred. Gallbladders with infundibulum of 3-o’clock position, 6-o’clock position, 9-o’clock position, 12-o’clock position, axial position were 12.3%, 23.4%, 28.0%, 4.2%, and 32.1%, respectively. The 3-o’clock and 12-o’clock position were pitfalls that might cause biliary injury.

Conclusion

The gallbladder infundibulum as a navigator is useful for ductal identification to reduce BDI and improve the safety of LC.

Safe cholecystectomy multi-society practice guideline and state-of-the-art consensus conference on prevention of bile duct injury during cholecystectomy

BACKGROUND

Bile duct injury (BDI) is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI.

METHODS

Literature reviews were conducted for 18 key questions across six broad topics around cholecystectomy directed by a steering group and subject experts from five surgical societies (SAGES, AHPBA IHPBA, SSAT, and EAES). Evidence-based recommendations were formulated using the GRADE methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus.

RESULTS

Consensus was reached on 17 of 18 questions by the Guideline Development Group (GDG) and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team.

CONCLUSION

These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.

Live Quality Assurance: Using a Multimedia Messaging Service Group Chat to Instantly Grade Intraoperative Images

BACKGROUND

The technique for attaining photographic evidence of the critical view of safety (CVS) in laparoscopic cholecystectomy (LC) has previously been defined; however, the consistency, accuracy, and feasibility of CVS in practice is unknown. The aim of this study was to use an already established image sharing and grading system to determine the feasibility of timely feedback after sharing intraoperative images of the CVS and to evaluate if and how cholecystitis affects the ability to attain a CVS.

STUDY DESIGN

We studied 193 laparoscopic cholecystectomies performed by 14 surgeons between August 2017 and January 2019. Anterior and posterior intraoperative CVS images were shared using a standard multimedia messaging system (MMS). Images were graded remotely by members of the group using an established scoring system, and their times to response and scores were recorded. Response data were analyzed for the ability to attain timely and consistent CVS scores.

RESULTS

There were 74 urgent laparoscopic cholecystectomies for acute cholecystitis and 119 nonurgent cholecystectomies performed during the study period. Scoring of shared images occurred in less than 5 minutes, and peer review (mean 3 responses) showed agreement that was not significantly different. In patients with acute cholecystitis, a small but significant difference was observed between anterior and posterior image scoring agreement.

CONCLUSIONS

An established image sharing and grading system for CVS can be used for real-time intraoperative feedback without increasing operative time or compromising private health information. The CVS is almost always attainable; however, decreases in CVS quality and grading agreement are observed in patients with acute cholecystitis.

Improving attainment of the critical view of safety during laparoscopic cholecystectomy

INTRODUCTION

We hypothesized that practicing surgeons would successfully achieve a better and more frequent Critical View of Safety (CVS) during laparoscopic cholecystectomy (LC) after participation in a structured Safe CVS Curriculum.

METHODS

All surgeons performing LC at a regional health system had four LC cases recorded: twice before and twice after a curriculum focused on the CVS, which was led by a member of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Safe LC Task Force. Videos were then de-identified and randomly ordered for grading on a 6-point CVS assessment tool by two expert surgeons, who were blinded to the operator and whether the surgeries were performed before or after the curriculum. Confidence surveys and performance on a CVS identification video quiz were also compared pre- and post-curriculum.

RESULTS

Twelve surgeons (five general, four acute care, and three minimally invasive) with an average experience of 17.9 ± 6.3 years participated in the study. After the curriculum, surgeons achieved all three CVS criteria in more cases (1/24 (4%) versus 10/24 (42%), p < 0.004). There was also significant improvement in correctly identifying whether the CVS was achieved in 10 video clips from the Internet (7.9 ± 1.5 vs. 9.3 ± 0.8, p = 0.006) and increased confidence on a 5-point Likert scale in accurately identifying the CVS (4.5 ± 0.5 vs. 4.9 ± 0.3, p = 0.017).

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 LC. We recommend that the Safe CVS Curriculum be considered for widespread use in order to increase the quality and frequency of attaining the Critical View of Safety.

Evaluation of the usefulness of the SAGES Safe Cholecystectomy Program from the viewpoint of the European surgeon

Introduction

Common bile duct injury (CBDI) is a severe complication of laparoscopic cholecystectomy (LC). To minimize its occurrence, SAGES established the Safe Cholecystectomy Program (SCP) with 6 rules to follow during surgery.

Aim

To assess the knowledge of SCP among European surgeons and their opinion on its usefulness.

Material and methods

Data were gathered using questionnaires during surgical conferences in Poland and Denmark. The questionnaire asked about the surgeon’s experience in cholecystectomy and the number of complications in the form of CBDI. It asked about the surgeon’s opinion on the usefulness of SCP rules on a 10-point scale. A comparison between specialists and residents was performed. The study has been registered in the ClinicalTrials.gov – NCT03155321.

Results

One hundred eighty-four questionnaires were gathered. One hundred fourteen (61.96%) specialists (72.8% male, mean age: 50 years) and 70 (38.04%) residents (56% male, mean age: 34 years) completed the questionnaire. Mean work experience was 22 years among specialists and 4.5 years among residents. A high percentage of specialists have experienced CBDI (46% vs. 17% of residents, p = 0.014). More specialists are familiar with the SCP than residents (49.3% vs. 21.7%, p = 0.021). Significant differences in the mean usefulness score were observed for three rules: rules 2 and 6 were found more useful by residents (mean score: 7.07 vs. 6.01, p = 0.025 and 8.70 vs. 8.27, p < 0.001), and rule 3 was found more useful by specialists (mean: 8.73 vs. 8.36, p < 0.001).

Conclusions

The awareness of the SCP in Europe is low. Participants consider the rules of the SCP to be useful during surgery, although there are differences in the usefulness scores between the groups. An educational program to promote and further implement the SCP should be established.

Safe laparoscopic cholecystectomy: Adoption of universal culture of safety in cholecystectomy

The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.

Safe laparoscopic cholecystectomy: Adoption of universal culture of safety in cholecystectomy

The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.

Cut or Do Not Cut? Assessing Perceptions of Safety During Laparoscopic Cholecystectomy Using Surgical Videos

OBJECTIVE

Bile duct injury remains a serious complication of laparoscopic cholecystectomy despite established criteria for the critical view of safety (CVS). Using surgical videos, we compared surgeons' willingness to divide critical structures based on their assessment of the CVS dissection.

DESIGN

Participants reviewed 20 operative videos lasting 1 minute each, edited at various points of the CVS dissection. Participants stated whether the structures were safe to divide, and if not, what steps they would take to achieve an adequate dissection. Videos were independently scored using a validated scale and categorized as an "adequate" or "inadequate" dissection based on the score. Participants were blinded to CVS score and adequacy. Cohen's kappa statistic was used to evaluate inter-rater agreement and responses were compared by univariate analysis.

SETTING

University of Michigan, Ann Arbor, Michigan. Tertiary care university hospital.

PARTICIPANTS

General surgery residents (n = 13) and faculty (n = 13) at the study institution.

RESULTS

There was minimal agreement on willingness to divide critical structures among all participants (κ = 0.25), among faculty (κ = 0.30), and among residents (κ = 0.21). Participants were more willing to divide critical structures when videos showed an adequate CVS dissection (CVS score ≥ 4) than an inadequate dissection (CVS score ≤ 3) (60.4% vs. 16.3%, p = 0.043). For inadequate dissections, participants most commonly recommended further dissection of the hepatocystic triangle (30.8%). There was no significant difference in the rate of unsafe practices (choosing to divide critical structures for videos with an "inadequate" dissection) between faculty and residents (14.2% vs. 18.3%, p = 0.781).

CONCLUSIONS

There was minimal agreement on what constituted a safe CVS dissection and there was no difference in the rate of unsafe practices between trainees and faculty. Education may play a more important role than experience when building a culture of safety for laparoscopic cholecystectomy.

Assessing the effect of the critical view of safety criteria on simulated operative decision-making: a pilot study

BACKGROUND

Despite well-established criteria for identifying the critical view of safety (CVS) during laparoscopic cholecystectomy, its impact on intraoperative decision-making among trainees is unclear.

METHODS

General surgery interns (n = 10) viewed a training module on the CVS criteria and then independently reviewed 20 cholecystectomy videos lasting 1 min each edited at various points of CVS dissection to include examples of both adequate and inadequate dissections. Participants were asked to identify the following CVS criteria for each video-(1) clearance of fat from the hepatocystic triangle; (2) exposure of the cystic plate; and (3) two and only two structures entering the gallbladder-and then decide if the structures were safe to divide.

RESULTS

Inter-rater agreement for each CVS criteria varied: (1) (k = 0.2510), (2) (k = 0.2771), and (3) (k = 0.4298) as did the decision to divide critical structures (k = 0.371). Individual mean rate of dividing structures ranged 5-50% and did not correlate with the total number of CVS criteria identified by each participant (Spearman's rho = 0.247, p = 0.492). Division of structures with incomplete CVS identification occurred in 15% of cases and was isolated to one participant in the majority of cases (88%). Among these cases, omission of the cystic plate dissection occurred in every instance.

CONCLUSIONS

Identification of CVS criteria was not uniform with the least amount of agreement on adequate hepatocystic and cystic plate dissection. Individual variation also exists between identification of CVS criteria and likelihood to divide structures. Video-based assessments that include intraoperative decision-making can help assess individual perceptions of safe practices without the risk of harm to the patient.

IRCAD recommendation on safe laparoscopic cholecystectomy

An expert recommendation conference was conducted to identify factors associated with adverse events during laparoscopic cholecystectomy (LC) with the goal of deriving expert recommendations for the reduction of biliary and vascular injury. Nineteen hepato-pancreato-biliary (HPB) surgeons from high-volume surgery centers in six countries comprised the Research Institute Against Cancer of the Digestive System (IRCAD) Recommendations Group. Systematic search of PubMed, Cochrane, and Embase was conducted. Using nominal group technique, structured group meetings were held to identify key items for safer LC. Consensus was achieved when 80% of respondents ranked an item as 1 or 2 (Likert scale 1-4). Seventy-one IRCAD HPB course participants assessed the expert recommendations which were compared to responses of 37 general surgery course participants. The IRCAD recommendations were structured in seven statements. The key topics included exposure of the operative field, appropriate use of energy device and establishment of the critical view of safety (CVS), systematic preoperative imaging, cholangiogram and alternative techniques, role of partial and dome-down (fundus-first) cholecystectomy. Highest consensus was achieved on the importance of the CVS as well as dome-down technique and partial cholecystectomy as alternative techniques. The put forward IRCAD recommendations may help to promote safe surgical practice of LC and initiate specific training to avoid adverse events.

Acute calculous cholecystitis: Review of current best practices

Acute calculous cholecystitis (ACC) is the most frequent complication of cholelithiasis and represents one-third of all surgical emergency hospital admissions, many aspects of the disease are still a matter of debate. Knowledge of the current evidence may allow the surgical team to develop practical bedside decision-making strategies, aiming at a less demanding procedure and lower frequency of complications. In this regard, recommendations on the diagnosis supported by specific criteria and severity scores are being implemented, to prioritize patients eligible for urgency surgery. Laparoscopic cholecystectomy is the best treatment for ACC and the procedure should ideally be performed within 72 h. Early surgery is associated with better results in comparison to delayed surgery. In addition, when to suspect associated common bile duct stones and how to treat them when found are still debated. The antimicrobial agents are indicated for high-risk patients and especially in the presence of gallbladder necrosis. The use of broad-spectrum antibiotics and in some cases with antifungal agents is related to better prognosis. Moreover, an emerging strategy of not converting to open, a difficult laparoscopic cholecystectomy and performing a subtotal cholecystectomy is recommended by adept surgical teams. Some authors support the use of percutaneous cholecystostomy as an alternative emergency treatment for acute Cholecystitis for patients with severe comorbidities.

A preoperative predictive scoring system to predict the ability to achieve the critical view of safety during laparoscopic cholecystectomy for acute cholecystitis

PURPOSE

The aim of this study was to develop a preoperative scoring system to predict the ability to achieve the critical view of safety (CVS) in patients undergoing emergency laparoscopic cholecystectomy (LC) for acute cholecystitis (AC).

METHODS

A retrospective review of patients who underwent LC for AC between 2012 and 2015 was performed. The achievement or failure of creating the CVS was judged by operative records, video recordings, and interviews of the surgeons. Independent preoperative variables associated with failure were determined by multivariate logistic regression analysis and a prediction scoring system created.

RESULTS

A C-reactive protein (CRP) >5.5 mg/dl, gallstone impaction, and symptom onset to operation >72 h were identified as independently correlated risk factors for the failure to achieve the CVS. A preoperative risk scoring system for the failure to create the CVS (0-5 points) was constructed using these 3 factors: CRP >5.5 mg/dl (2 points), gallstone impaction (1 points), and time from symptom onset to operation >72 h (2 points). When monitoring the frequency of patients who had a failure to create the CVS at each score, the incidence of failure increased as the score increased (P<0.001).

CONCLUSIONS

Using only three preoperative factors, the proposed scoring system provides an objective evaluation of the likelihood that CVS can be achieved in patients undergoing emergency LC for AC.

An Innovative Emergency Laparoscopic Cholecystectomy Technique; Early Results Towards Complication Free Surgery

BACKGROUND

The performance of laparoscopic cholecystectomy could be a technical challenge. Procedure success depends on multiple factors namely: hepatobiliary anatomical variations, pathologic changes in the gallbladder and surrounding tissues, pre-operative interventional attempts, the individual surgeon's skill and finally patient co-morbidities. Anticipating the attendant challenges, can help to avoid several known complications associated with this procedure. Searching a more reliable anatomical topography to adopt during laparoscopic cholecystectomy is the basis for a safe surgical technique.

METHODS

Between January 2012 and August 2015, 525 cases were presented with acute cholecystitis. Patients were classified in to two groups regarding degree of dissection difficulty. The study concept is defined and applied by the author in all study cases. No single case was excluded from the study.

RESULTS

Results are processed in comparative way between both groups of the study. The increased risk results in Group B are related to technical difficulties.

CONCLUSION

The study has offered a novel anatomical concept and safe surgical technique avoiding exploration of Calot's triangle. The new concept has minimized dissection demands and risk of injury related to the traditional laparoscopic cholecystectomy. The study has proposed a potentially secure and empirical laparoscopic cholecystectomy technique that could be considered in every case.