GRP2017 6467814
GRP2017 6467814
GRP2017 6467814
Research Article
Difficult Laparoscopic Cholecystectomy and Trainees:
Predictors and Results in an Academic Teaching Hospital
Copyright © 2017 Hussein M. Atta et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Laparoscopic cholecystectomy (LC) is one of the first laparoscopic procedures performed by surgical trainees. This study aims to
determine preoperative and/or intraoperative predictors of difficult LC and to compare complications of LC performed by
trainees with that performed by trained surgeons. A cohort of 180 consecutive patients with cholelithiasis who underwent LC
was analyzed. We used univariate and binary logistic regression analyses to predict factors associated with difficult LC. We
compared the rate of complications of LCs performed by trainees and that performed by trained surgeons using Pearson’s
chi-square test. Patients with impacted stone in the neck of the gallbladder (GB) (OR, 5.0; 95% CI, 1.59–15.77), with
adhesions in the Triangle of Calot (OR, 2.9; 95% CI, 1.27–6.83), or with GB rupture (OR, 3.4; 95% CI, 1.02–11.41) were more
likely to experience difficult LC. There was no difference between trainees and trained surgeons in the rate of cystic artery injury
(p = 144) or GB rupture (p = 097). However, operative time of LCs performed by trained surgeons was significantly shorter
(median, 45 min; IQR, 30–70 min) compared with the surgical trainees’ operative time (60 min; IQR, 50–90 min). Surgical
trainees can perform difficult LC safely under supervision with no increase in complications albeit with mild increase in
operative time.
Table 1: Comparison of patient characteristics between difficult and Table 2: Classification table.
easy LCs.
Predicted
Difficult LC Easy LC Observed Difficult LC
Characteristics p value Percentage correct
(n = 58) (n = 122) Easy Difficult
Preoperative characteristics Easy 113 9 92.6
Male gender† 16 (27.6%) 17 (13.9%) 0.038 Difficult 24 34 58.6
Age >65 years 1 (1.7%) 4 (3.3%) 1.000 Overall percentage 81.7
BMI, ≥30 kg/m2 10 (17.2%) 19 (15.5%) 0.829
Smoking 6 (8.6%) 5 (4.1%) 0.179 25 unsupervised LCs. We found that there is no statistically
Elevated liver enzymes 1 (1.7%) 1 (0.8%) 0.542 significant difference between trainees and trained surgeons
Previous abdominal operation 12 (20.1%) 21 (17.2%) 0.681 in the rate of cystic artery injury (4.9% and 1.0%, Pearson’s
Hypertension 5 (8.6%) 8 (6.6%) 0.412 chi-square, p = 0 144) or GB rupture (17.1% and 30.7%,
Diabetes mellitus 3 (5.2%) 2 (1.6%) 0.330 p = 0 097). As expected, we found that operative time of
Liver cirrhosis 3 (5.2%) 2 (1.6%) 0.330 LCs performed by trained surgeons was significantly
shorter (median, 45 min; IQR, 30–70 min) compared with
Previous biliary hospitalization 13 (22.4%) 18 (14.8%) 0.212
surgical trainees’ operative time (60 min; IQR, 50–90 min)
Palpable GB 0 3 (2.5%) 0.552
(Mann-Whitney U test, p = 0 001) (Figure 1).
GB wall thickness, ≥4 mm† 38 (65.5%) 49 (40.2%) 0.002
GB transverse diameter,
18 (31.0%) 40 (32.8%) 0.866 4. Discussion
<2, >5 cm
GB sludge† 32 (55.2%) 22 (18%) 0.000
This study suggested that impacted stone in the neck of the
Impacted stone in the GB, the presence of adhesions in the Triangle of Calot, GB
23 (39.7%) 7 (5.7%) 0.000
neck of GB† rupture, and injury to the cystic artery predicted increase in
Pericholecystic fluid collection† 5 (8.6%) 1 (0.82%) 0.014 the likelihood of having difficult LC. Furthermore, we
CBD diameter, >10 mm 2 (3.4%) 4 (3.3%) 1.000 showed also that in case of difficult LC performed by surgical
CBD stones 1 (1.7%) 1 (0.82%) 0.542 trainees under direct supervision of trained surgeons, there
Surgeon LC skill, <10 LCs† 19 (32.8%) 22 (18%) 0.036 was no increase in the LC complications, cystic artery injury,
Surgeon LC skill, >25 LCs 26 (44.8%) 75 (61.5%) 0.028 GB rupture, or conversion when compared with trained sur-
geons. There is, however, infrequent increase in the operative
Intraoperative characteristics
time of LCs performed by surgical trainees.
Operative time, >60 min 57 (98.3%) 40 (32.8%) 0.000
Currently, LC is the standard of care for patients with
Operative blood loss, >50 mL 30 (51.7%) 29 (23.8%) 0.000 cholelithiasis and is the first laparoscopic surgical procedure
Triangle of Calot adhesions† 36 (62.1%) 29 (23.7%) 0.000 to be performed by general surgery trainees in many teaching
Ruptured GB† 29 (50%) 19 (15.6%) 0.000 hospitals [20]. These laparoscopic skills must be passed on to
Spilled stones† 20 (34.5%) 10 (8.2%) 0.000 junior surgeons without compromising patient safety. In our
Cystic artery injury 6 (10.3%) 0 0.001 surgical training program, we do not use surgical simulators
or cadaveric surgery for laparoscopic surgery training but we
CBD injury 0 0 0
solely rely on extended operative assistance. Our surgical
Conversion 1 (1.7%) 0 0.322
†
trainees start performing LC only after assisting in at least
characteristics included in binary logistic regression analysis. 150 LCs during their previous three years of surgical training.
This study showed also that surgical trainees, who performed
Triangle of Calot, and GB rupture during LC are indepen- LCs under direct supervision of trained surgeons, had no
dent predictors of difficult LC (Table 3). Patients with increase in the LC complications when compared with
impacted stone in the neck of the GB are about five times trained surgeons. However, the operative time is longer in
(odds ratio [OR], 5.0; 95% confidence interval [CI], 1.59– LCs performed by surgical trainees compared with trained
15.77) likely to undergo a difficult LC. This model also shows surgeons. In agreement with our results, Lavy et al. reported
that patients with adhesions in the Triangle of Calot (OR, 2.9; a comparative study of LC performed by residents with that
95% CI, 1.27–6.83) or with GB rupture during LC (OR, 3.4; performed by senior surgeons [20]. They found that the only
95% CI, 1.02–11.41) are about three times more likely to significant difference between the groups was a longer
experience difficult LC (Table 3). operative time, while the conversion rate and complication
rate were the same. In a similar study comparing consultant
3.3. Outcome of Trainee-Performed LCs. Although our surgeons, trainee surgeons, and trained surgeons, the authors
regression model did not select trainees as a predictor of found that there were no differences among the three groups
difficult LC, however, we hypothesized that there may be a in conversion rates, bile duct injury rates, general compli-
difference between the rate of complications of LCs per- cation rates, or length of stay; however, the duration of
formed by trainees with experience of less than ten LCs and operation in the trainee surgeons was significantly longer
that performed by trained surgeons with skills of more than compared to the other two groups [21]. In the setting of
4 Gastroenterology Research and Practice
Table 3: Binary logistic regressions analysis of risk factors for difficult LC.
80 Conflicts of Interest
60
The authors declare that there is no conflict of interest
40 regarding the publication of this article.
20
References
0
[1] W. Ji, L. T. Li, Z. M. Wang, Z. F. Quan, X. R. Chen, and J. S. Li,
Surgical trainee Trained surgeons “A randomized controlled trial of laparoscopic versus open
<10 LCs > 25 LCs cholecystectomy in patients with cirrhotic portal hyperten-
sion,” World Journal of Gastroenterology, vol. 11, no. 16,
Figure 1: Boxplots (median, interquartile range, max, and min) of
pp. 2513–2517, 2005.
LC operative time of surgical trainees and trained surgeons (min).
*significant differences between surgical trainees and trained [2] A. J. McMahon, I. T. Russell, J. N. Baxter et al., “Laparoscopic
surgeons. versus minilaparotomy cholecystectomy: a randomized trial,”
Lancet, vol. 343, no. 8890, pp. 135–138, 1994.
[3] S. L. Zacks, R. S. Sandler, R. Rutledge, and R. S. Brown Jr, “A
LC for acute cholecystitis, Abelson et al. reported that population-based cohort study comparing laparoscopic chole-
advanced laparoscopic fellowship-trained surgeons had sig- cystectomy and open cholecystectomy,” The American Journal
nificantly lower conversion rate and shorter operative time of Gastroenterology, vol. 97, no. 2, pp. 334–340, 2002.
than the nonfellowship-trained surgeons; however, the [4] F. Keus, H. G. Gooszen, and C. J. van Laarhoven, “Open,
complication rates were not significantly different [22]. small-incision, or laparoscopic cholecystectomy for patients
The low incidence of conversions in our cohort of 180 with symptomatic cholecystolithiasis. An overview of
consecutive patients with gall stone disease is primarily Cochrane Hepato-Biliary Group reviews,” The Cochrane
due to the fact that this series did not include LC per- Database of Systematic Reviews, no. 1, article CD008318, 2010.
formed in patients with acute cholecystitis, pancreatitis, [5] K. M. Harboe and L. Bardram, “The quality of cholecystec-
or CBD stone. A study from a single university medical tomy in Denmark: outcome and risk factors for 20,307 patients
from the national database,” Surgical Endoscopy, vol. 25, no. 5,
center reported a conversion rate of 2.6%, and the diag-
pp. 1630–1641, 2011.
nosis of acute cholecystitis was more common among
[6] J. A. Shea, M. J. Healey, J. A. Berlin et al., “Mortality and
converted cases [15]. In a recent analysis of preoperative
complications associated with laparoscopic cholecystectomy.
risk factors for conversion from a prospective U.K. data- A meta-analysis,” Annals of Surgery, vol. 224, no. 5,
base of 8820 patients, Sutcliffe et al. reported a rate of pp. 609–620, 1996.
conversion when the indication for LC was for cholecys- [7] A. Agrusa, G. Romano, G. Frazzetta et al., “Role and outcomes
titis (6.5%) to be higher than that for colic (1.2%) or for of laparoscopic cholecystectomy in the elderly,” International
pancreatitis (2.1%) but only lower than that of CBD Journal of Surgery, vol. 12, Supplement 2, pp. S37–S39, 2014.
stone (9.1%) [23]. [8] V. L. Harrison, J. P. Dolan, T. H. Pham et al., “Bile duct injury
after laparoscopic cholecystectomy in hospitals with and with-
out surgical residency programs: is there a difference?” Surgical
5. Conclusion Endoscopy, vol. 25, no. 6, pp. 1969–1974, 2011.
[9] M. Rosen, F. Brody, and J. Ponsky, “Predictive factors for con-
This study demonstrated that operative complications of LC version of laparoscopic cholecystectomy,” American Journal of
performed by surgical trainees who had extended operative Surgery, vol. 184, no. 3, pp. 254–258, 2002.
exposure and who performed LC under direct supervision [10] B. Tang and A. Cuschieri, “Conversions during laparoscopic
of trained surgeons are not different from those per- cholecystectomy: risk factors and effects on patient out-
formed by trained surgeons except in moderate increase come,” Journal of Gastrointestinal Surgery, vol. 10, no. 7,
of operative time. pp. 1081–1091, 2006.
Gastroenterology Research and Practice 5