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Laparoscopic Surgery Fellowship and Senior Surgeon Mentoring: Necessities in Era of Limited Open Cholecystectomy Experience During General Surgery Residency
Kenneth Sirinek*, Wayne Schwesinger
Surgery, UTHSCSA, San Antonio, TX
Recently, several authors have stated that general surgeons trained in the open cholecystectomy (OC) era are technically more comfortable with that procedure and will readily convert from a laparoscopic cholecystectomy (LC) to an OC when confronted with aberrant or obscured biliary anatomy. In contrast, the general surgeons trained in the LC era may persist longer with the laparoscopic approach due to limited experience with the open procedure. Laparoscopic cholecystectomies lasting longer than two hours have a fourfold increase in complications, most notably bile duct injuries. This study evaluates and compares the LC → OC rate and initial OC rate for two surgeons trained in OC era with 25 years of LC experience each to 13 general surgeons (8 laparoscopic fellowship trained, and 5 general surgery (GS) residency only) trained in laparoscopic era only.
Methods: Data from all patients undergoing a cholecystectomy from 1/1/2002 to 12/31/14 were prospectively collected and retrospectively reviewed. The number of years of laparoscopic cholecystectomy experience during that time interval was calculated for each surgeon. Data were analyzed by Chi-Square (P<.05).
Results: 15 general surgeons with a total laparoscopic cholecystectomy experience of 72 years performed a total of 8805 cholecystectomies with a LC → OC rate of 1.9%, initial OC rate of 2.4% and total OC rate of 4.3% (Table). Compared to general surgeons trained in OC era and laparoscopic fellowship trained general surgeons, the residency only general surgeons in LC era had a significantly higher LC → OC conversion rate (1.9%, 1.7%, vs 2.7%) and a significantly lower initial OC rate (2.8%, 2.1%, vs 1.2%). Bile duct injury rate was significantly higher for both residency only and laparoscopic fellowship trained general surgeons in LC era compared to those trained in OC era (0.9%, 0.25% vs 0.06%)
Conclusions: High volume cholecystectomy practice (8805 procedures) resulted in a very low LC → OC conversion rate, and total OC rate compared to 5-10% for each in nationally reported series. Two senior surgeons trained in OC era performed 5029/8805 (57%) of all cholecystectomies and performed more LC → OC (46 each) and initial OC (70 each) compared to 8 fellowship trained general surgeons (LC → OC 6, initial OC 7) and to 5 residency only general surgeons (LC → OC 3, initial OC 1). Limited clinical experience with OC during GS residency without laparoscopic fellowship may have contributed to the higher incidence of bile duct injuries in the practice of the five general surgeons in the laparoscopic era. Although more difficulty cases were sometimes referred to the senior surgeons, these data suggest that close mentoring of junior general surgeons is necessary (ie Transition to Practice program of the ACS as one alternative) to lower associated cholecystectomy complications, primarily common bile duct injuries.
| # Surgeons (Laparoscopic yrs) | Attempted LC | LC → OC (%) | Initial OC (%) | Total OC (%) | Total Cholecystectomies | | Residency - Prelaparoscopic Era | | | | | | | 2 Senior Professors (25) | 4889 | 92 (1.9%) | 140 (2.8%) | 232 (4.6%) | 5029 | | Residency - Laparoscopic Era | | | | | | | 8 Fellowship Trained Faculty (37) | 2716* | 47 (1.7%) | 57 (2.1%) | 104 (3.8%) | 2773* | | 5 Residency Only Faculty (10) | 991*+ | 27 (2.7%)*+ | 12 (1.2%)*+ | 39 (3.9%) | 1003*+ | | 13 Total Faculty (47) | 3707 | 74 (2.0%) | 69 (1.8%) | 143 (3.8%) | 3776 | | Total 15 General Surgeons (72) | 8596 | 166 (1.9%) | 375 (4.3%) | 375 (4.3%) | 8805 |
*P<.05 vs senior professor, +P<.05 vs fellowship trained faculty
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