McKinley Sophia K, Brunt L Michael, Schwaitzberg Steven D
Department of Surgery, Massachusetts General Hospital, 55 Fruit St., Boston, MA, 02114, USA,
Surg Endosc. 2014 Dec;28(12):3385-91. doi: 10.1007/s00464-014-3605-8. Epub 2014 Jun 18.
Over 700,000 laparoscopic cholecystectomies are performed yearly in the US. Despite multiple advantages of laparoscopic surgery, the increased rate of bile duct injury (BDI) compared to the traditional, open approach to cholecystectomy remains problematic. Due to the seriousness of bile duct injury, the time has come for an aggressive educational campaign to better train laparoscopic surgeons in order to reduce the incidence of this life-threatening and expensive complication.
We performed a literature review of what is currently known about the causes of bile duct injury during laparoscopic cholecystectomy. Based on these reviews, we identified educational theories of expertise that may be relevant in understanding variable rates of BDI between surgeons. Finally, we applied educational theories of expertise to the problem of BDI in laparoscopic cholecystectomy to propose how to develop and design an effective educational approach for the prevention of BDI.
Multiple studies demonstrate that the primary causes of BDI during laparoscopic cholecystectomy are non-technical. Additionally, there exists a learning curve in which the rates of BDI are higher in a surgeon's earlier cases compared to later cases and that some surgeons perform laparoscopic cholecystectomy with significantly fewer injuries than others. Educational theories indicate that interventions that optimize novice to expert development require (1) revealing expert knowledge to novices and (2) scaffolding the mental habits of expert-like learners.
BDI is an appropriate target for the application of educational theories of expertise. Designing better educational interventions for the prevention of BDI will require uncovering the hidden knowledge of expert surgeons and incorporating the processes of reinvestment and progressive problem solving that are inherent to expert performance.
在美国，每年进行超过70万例腹腔镜胆囊切除术。尽管腹腔镜手术有诸多优势，但与传统的开放性胆囊切除术相比，胆管损伤（BDI）发生率的增加仍然是个问题。由于胆管损伤的严重性，开展积极的教育活动以更好地培训腹腔镜外科医生，从而降低这种危及生命且费用高昂的并发症的发生率，时机已经成熟。
我们对目前已知的腹腔镜胆囊切除术中胆管损伤的原因进行了文献综述。基于这些综述，我们确定了可能与理解外科医生之间BDI发生率差异相关的专业知识教育理论。最后，我们将专业知识教育理论应用于腹腔镜胆囊切除术中的BDI问题，以提出如何开发和设计一种有效的预防BDI的教育方法。
多项研究表明，腹腔镜胆囊切除术中BDI的主要原因是非技术性的。此外，存在一个学习曲线，即外科医生早期病例中的BDI发生率高于后期病例，而且一些外科医生进行腹腔镜胆囊切除术时的损伤明显少于其他医生。教育理论表明，优化新手到专家发展的干预措施需要（1）向新手揭示专家知识，以及（2）搭建类似专家学习者的思维习惯。
BDI是应用专业知识教育理论的合适目标。设计更好的预防BDI的教育干预措施将需要揭示专家外科医生的隐藏知识，并纳入专家表现中固有的再投资和逐步解决问题的过程。
