Bile duct injury during laparoscopic cholecystectomy - Results of a national survey

Objective To determine whether surgical residency training has influenced the occurre nce of common bile duct injuries during laparoscopic cholecystectomy, and t o asses the anatomic and technical details of bile duct injuries from the p ractices of surgeons trained in laparoscopic cholecystectomy after residenc y versus surgeons trained in laparoscopic cholecystectomy during residency. Summary Background Data Shortly after the introduction of laparoscopic cholecystectomy, the rate of injury to the common bile duct increased to 0.5%, and injuries were more c ommonly reported early in each surgeon's experience. It is not known whethe r learning laparoscopic cholecystectomy during surgery residency influences this pattern. Methods An anonymous questionnaire was mailed to 3,657 surgeons across the United S tates who completed an Accreditation Council for Graduate Medical Education (ACGME)-approved residency between 1980 and 1990 (group A) or 1992 and 199 8 (group B). All surgeons in group A learned laparoscopic cholecystectomy a fter residency, and all those in group B learned laparoscopic cholecystecto my during residency. Information obtained included practice description, nu mber of laparoscopic cholecystectomies completed since residency, postgradu ate training in laparoscopy, and annual volume of laparoscopic cholecystect omy in the surgeon's hospital. In addition, technical details queried inclu ded the completion of a cholangiogram, the interval between injury and iden tification, the method of repair, and the site of definitive treatment. The primary endpoint was the occurrence of a major bile duct injury during lap aroscopic cholecystectomy (bile leaks without a major bile duct injury were not tabulated). Results Forty-five percent (n = 1,661) of the questionnaires were completed and ret urned. Mean practice experience was 13.6 years for group A and 5.4 years fo r group B. At least one injury occurrence was reported by 422 surgeons (37. 6%) in group A and 143 surgeons (26.5 %) in group B. Forty percent of the i njuries in group A occurred during the first 50 cases compared with 22% in group B. Thirty percent of bile duct injuries in group A and 32.9% of all i njuries in group B occurred after a surgeon had performed more than 200 lap aroscopic cholecystectomies. Independent of the number of laparoscopic chol ecystectomies completed since residency, group A surgeons were 39 % more li kely to report one or more biliary injuries and 58% more likely to report t wo or more injuries than their counterparts in group B. Bile duct injuries were more likely to be discovered during surgery if a cholangiogram was com pleted than if cholangiography was omitted (80.9% vs. 45.1 %). Sixty-four p ercent of all major bile duct injuries required biliary reconstruction, and most injuries were definitively treated at the hospital where the injury o ccurred. Only 14.7% of injuries were referred to another center for repair. Conclusions Accepting that the survey bias underestimates the true frequency of bile du ct injuries, residency training decreases the likelihood of injuring a bile duct, but only by decreasing the frequency of early "learning curve" injur ies. If one accepts a liberal definition of the learning curve (200 cases), it appears that at least one third of injuries are not related to inexperi ence but may reflect fundamental errors in the technique of laparoscopic ch olecystectomy as practiced by a broad population of surgeons in the United States. Intraoperative cholangiography is helpful for intraoperative discov ery of injuries when they occur. Most injuries are repaired in the hospital where they occur and are not universally referred to tertiary care centers .