Northwestern University Feinberg School of Medicine
Introduction: Laparoscopic common bile duct exploration (LCBDE) is an underutilized therapy for choledocholithiasis. The driving factors of this practice gap are poorly defined. We sought to evaluate the attitudes and practice patterns of surgeons who underwent training courses using an LCBDE simulator.
Methods: Surgeons completed a half-day simulator-based mastery-learning LCBDE curriculum at national courses, including the American College of Surgeons Advanced Skills Training for Rural Surgeons. Attitudes were assessed with Likert surveys immediately before and after curriculum completion. Follow-up surveys were distributed electronically.
Results: 159 surgeons completed simulation training during six courses. Surgeon attitudes regarding the overall superiority of LCBDE vs. ERCP shifted towards favoring LCBDE after course participation (4.0 vs 3.0; Likert scale 1-5, p<0.001). 44% of surgeons completed follow-up surveys at a mean of 3 years post-course. Surgeons remained confident in their ability to perform LCBDE, with only 14% rating their skill as a significant barrier to practice, as compared with 43% prior to course participation (p<0.01). However, only 28% of surgeons saw an increase in LCBDE volume. Deficiencies in OR staff knowledge and instrument availability were the most significant barriers to post-course practice implementation and were inversely correlated with LCBDE case volume (ρ = -0.44 and -0.47, both p<0.01). Availability of fluoroscopy and surgeon compensation were not significant barriers. On multivariate analysis, OR staff knowledge was a significant predictor of LCBDE volume (F(6,35) = 2.59, p<0.05). Surgeons who experienced OR staff knowledge as a mild or absent barrier performed nearly 4 times more LCBDE than those who rated staff knowledge as a moderate, strong, or complete barrier.
Conclusions: Surgeons trained at an LCBDE course retained long-term confidence in their procedural ability. Practice implementation was hindered by deficiencies in OR staff knowledge and instrument availability. Surgeons with knowledgeable operating room staff performed significantly more LCBDE than those with less capable assistance. These barriers should be addressed in future curricula to improve procedural adoption.
