Chen Crystal B, Palazzo Francesco, Doane Stephen M, Winter Jordan M, Lavu Harish, Chojnacki Karen A, Rosato Ernest L, Yeo Charles J, Pucci Michael J
Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Sidney Kimmel Medical College, Thomas Jefferson University, 1100 Walnut Street, 5th Floor, Philadelphia, PA, 19107, USA.
Surg Endosc. 2017 Apr;31(4):1627-1635. doi: 10.1007/s00464-016-5150-0. Epub 2016 Aug 5.
Laparoscopic cholecystectomy (LC) is a commonly performed surgical procedure; however, it is associated with an increased rate of bile duct injury (BDI) when compared to the open approach. The critical view of safety (CVS) provides a secure method of ductal identification to help avoid BDI. CVS is not universally utilized by practicing surgeons and/or taught to surgical residents. We aimed to pilot a safe cholecystectomy curriculum to demonstrate that educational interventions could improve resident adherence to and recognition of the CVS during LC.
Forty-three general surgery residents at Thomas Jefferson University Hospital were prospectively studied. Fifty-one consecutive LC cases were recorded during the pre-intervention period, while the residents were blinded to the outcome measured (CVS score). As an intervention, a comprehensive lecture on safe cholecystectomy was given to all residents. Fifty consecutive LC cases were recorded post-intervention, while the residents were empowered to "time-out" and document the CVS with a doublet photograph. Two independent surgeons scored the videos and photographs using a 6-point scale. Residents were surveyed pre- and post-intervention to determine objective knowledge and self-reported comfort using a 5-point Likert scale.
In the 18-week study period, 101 consecutive LCs were adequately captured and included (51 pre-intervention, 50 post-intervention). Patient demographics and clinical data were similar. The mean CVS score improved from 2.3 to 4.3 (p < 0.001). The number of videos with CVS score >4 increased from 15.7 to 52 % (p < 0.001). There was strong inter-observer agreement between reviewers. The pre- and post-intervention questionnaire response rates were 90.7 and 83.7 %, respectively. A greater number of residents correctly identified all criteria of the CVS post-intervention (41-93 %, p < 0.001) and offered appropriate bailout techniques (77-94 %, p < 0.001). Residents strongly agreed that the CVS education should be included in general surgery residency curriculum (mean Likert score = 4.71, SD = 0.54). Residents also agreed that they are more comfortable with their LC skills after the intervention (4.27, σ = 0.83).
The combination of focused education along with intraoperative time-out significantly improved CVS scores and knowledge during LC in our institution.
腹腔镜胆囊切除术（LC）是一种常见的外科手术；然而，与开放手术相比，其胆管损伤（BDI）发生率有所增加。安全关键视野（CVS）提供了一种可靠的胆管识别方法，有助于避免BDI。执业外科医生并非普遍采用CVS，也未将其传授给外科住院医师。我们旨在试行一项安全胆囊切除术课程，以证明教育干预可提高住院医师在LC过程中对CVS的遵循程度和识别能力。
对托马斯杰斐逊大学医院的43名普通外科住院医师进行前瞻性研究。在干预前期记录了51例连续的LC病例，此时住院医师对测量结果（CVS评分）不知情。作为干预措施，为所有住院医师举办了一场关于安全胆囊切除术的综合讲座。干预后记录了50例连续的LC病例，此时住院医师有权“暂停”并用双份照片记录CVS。两名独立的外科医生使用6分制对视频和照片进行评分。在干预前后对住院医师进行调查，以使用5分制李克特量表确定客观知识和自我报告的舒适度。
在为期18周的研究期间，共充分记录并纳入了101例连续的LC病例（51例干预前，50例干预后）。患者的人口统计学和临床数据相似。CVS平均评分从2.3提高到4.3（p < 0.001）。CVS评分>4的视频数量从15.7%增加到52%（p < 0.001）。评审人员之间存在很强的观察者间一致性。干预前后问卷的回复率分别为90.7%和83.7%。更多的住院医师在干预后正确识别了CVS的所有标准（41%-93%，p < 0.001），并提供了适当的补救技术（77%-94%，p < 0.001）。住院医师强烈同意普通外科住院医师课程应纳入CVS教育（平均李克特评分为4.71，标准差为0.54）。住院医师还表示，干预后他们对LC技能更有信心（4.27，标准差为0.83）。
在我们机构中，针对性教育与术中暂停相结合显著提高了LC期间的CVS评分和知识水平。
