EDUCATION

A Teaching Program for the Culture of Safety in Cholecystectomy and Avoidance of Bile Duct Injury
Steven M Strasberg,
MD, FACS

Since its inception, laparoscopic cholecystectomy has been associated with an increased incidence of bile duct injury.1 Bile duct injury is a seriously morbid iatrogenic condition. Reliable incidence data in the USA are lacking but there is no doubt that it is a continuing problem. A recent study from Sweden, a county with a modern health care system, places the incidence at 1.5%,2 which is disturbingly high. Most major biliary injuries are due to misidentication of bile ducts,3 particularly, misidentication of the common bile duct as the cystic duct. Key concepts in pathogenesis relate to the ability of inammatory contraction to distort biliary anatomy and the confusing effect of aberrant anatomy.3 Many excellent articles and book chapters provide good advice on avoidance of biliary injury.3-10 Our group has promoted the critical view of safety technique for ductal identication and tried to spur its adoption by producing articles that explain its rationale.3,11,12 We have also tried to promote adoption of an attitude of safety and have capsulized it in the phrase culture of safety in cholecystectomy.13 But it seems time to ask whether our classical methods of teaching intraoperative safety and avoidance of bile duct injury are as effective as we would like them to be. In our era of instant electronic information should we try to spur implementation of safe procedures by less conventional means? This video presentation makes an attempt at doing so. The 50-minute presentation can be viewed in 5 clips with the articles online version at http://www.journalacs.org/article/S1072-7515(13)00358X/fulltext, or in full at https://cme-online.wustl.edu/ strasberg/Culture_of_Safety_in_Cholecystectomy.html. In asking why familiarity with the key concepts of cause and avoidance of biliary injuries has not been effective in preventing injuries, the disturbing thought arose that perhaps the key concepts are not really widely grasped. Potentially, these concepts, which are clear to those focused on the subject of biliary injury, are not being effectively transmitted to general surgeons who
Disclosure Information: Nothing to disclose. Received April 18, 2013; Accepted May 1, 2013. From the Section of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Washington University in Saint Louis, and Barnes-Jewish Hospital Saint Louis, MO. Correspondence address: Steven M Strasberg, MD, FACS, Washington University in Saint Louis, 660 South Euclid Ave, Box 8109 Saint Louis, MO 63110. email: strasbergs@wustl.edu

receive a great amount of information on this and other subjects. To try to make the concepts memorable they have been personied. So in this presentation one will encounter Orville Kairvul the surgeon, COSIC the knight and Orvilles friend, and 2 treacherous villains, BIF and Abe Errant. It is hoped that they will embody the concepts and encourage adoption of a culture of safety rst as the central element in cholecystectomy.
REFERENCES 1. Anonymous. A prospective analysis of 1518 laparoscopic cholecystectomies. The Southern Surgeons Club [published erratum appears in N Engl J Med 1991 21;325:1517e1518]. N Engl J Med 1991;324:1073e1078. 2. Tornqvist B, Stromberg C, Persson G, Nilsson M. Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study. BMJ 2012;345:e6457. 3. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101e125. 4. Davidoff AM, Pappas TN, Murray EA, et al. Mechanisms of major biliary injury during laparoscopic cholecystectomy. Ann Surg 1992;215:196e202. 5. Hunter JG. Avoidance of bile duct injury during laparoscopic cholecystectomy. Am J Surg 1991;162:71e76. 6. Lillemoe KD, Yeo CJ, Talamini MA, et al. Selective cholangiography. Current role in laparoscopic cholecystectomy. Ann Surg 1992;215:669e674. 7. Stewart L, Way LW. Bile duct injuries during laparoscopic cholecystectomy: Factors that inuence the results of treatment. Arch Surg 1995;1995:1123e1129. 8. Schol FP, Go PM, Gouma DJ. Risk factors for bile duct injury in laparoscopic cholecystectomy: analysis of 49 cases. Br J Surg 1994;81:1786e1788. 9. Hugh TB. New strategies to prevent laparoscopic bile duct injuryesurgeons can learn from pilots. Surgery 2002;132: 826e835. 10. Way LW, Stewart L, Gantert W, et al. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. [See comment.] Ann Surg 2003;237:460e469. 11. Strasberg SM, Eagon CJ, Drebin JA. The hidden cystic duct syndrome and the infundibular technique of laparoscopic cholecystectomyethe danger of the false infundibulum. J Am Coll Surg 2000;191:661e667. 12. Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg 2010;211:132e138. 13. Strasberg SM. Biliary injury in laparoscopic surgery: part 2. Changing the culture of cholecystectomy. J Am Coll Surg 2005;201:604e611.

2013 by the American College of Surgeons Published by Elsevier Inc.

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ISSN 1072-7515/13/$36.00 http://dx.doi.org/10.1016/j.jamcollsurg.2013.05.001