OPINION
GENERAL SURGERY NEWS / AUGUST 2020
Achieving the ‘Holy Grail’ in Laparoscopic Cholecystectomy By FREDERICK L. GREENE, MD
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arely does a manuscript get published in our mainstream and peer-reviewed surgical literature that mandates reading by all general surgeons. In my view, the recent and simultaneous publication in Annals of Surgery (2020;272:3-23) and Surgical Endoscopy (2020;34:2827-2855) by the Bile Duct Injury (BDI) Task Force achieves this benchmark. This monumental effort, launched in 2014 with the establishment of the Safe Cholecystectomy Task Force by the Society of American Gastrointestinal and Endoscopic Surgeons, led by Michael Brunt and his colleagues, reflects a multiorganizational Delphi approach to reduce the rate of BDI as a consequence of laparoscopic cholecystectomy. After working six years and poring over multiple studies, studying innumerable databases and hosting an in-person consensus conference in 2018, this group has brought its recommendations to the mainstream surgical community. Since management of gallbladder disease is one of the most common surgical forays for both general surgical trainees and practicing general surgeons, the findings of this task force require study, reflection and embracing by all of us. With 750,000 to 1 million cholecystectomies performed yearly in the United States, the BDI rate, estimated to be between 0.15% and 0.3%, translates to 2,300 to 3,000 BDIs per year! Hopefully most of our readership have been fortunate to avoid any association with this demoralizing outcome. For others, the acute and longterm consequences for both patient and surgeon are devastating. The BDI task force has valiantly attempted to extrapolate administrative database information and literature reviews in making 18 recommendations for creating a safer environment for patients undergoing laparoscopic cholecystectomy. The authors are quick to point out that recommendations based solely on solid data may be ephemeral. This caution, however, does not diminish the import of well-thought-out recommendations from a cadre of experts. One of the weaknesses in considering these strategies of data collection is the problem is always bigger than you think. We are constantly reminded of this phenomenon during the current COVID19 pandemic; there are always more infections than are extrapolated from existing testing data and hospital admissions. In considering BDI, many cases go unreported which leads to underreporting in global calculations. The task force
authors share their own frustrations in that after 30 years of performing laparoscopic cholecystectomy, there is still no national registry capturing BDI data. Unfortunately, there never will be. I was pleased that the task force embraced one of the strategies that I used beginning in 1990, and have been privileged to teach to surgical residents: intraoperative cholecystectomy (IOC). While
not guaranteeing a completely safe dissection and subsequent avoidance of injury, IOC is touted by the task force as being a vital strategy that will help mitigate injury. Unfortunately, I fear that in most surgical training programs, the will and the interest to teach IOC by a preponderance of clinical surgeons is waning. It is my fervent hope that our current leaders in academic training programs will embrace the concepts of both utilization of the “critical view of safety” and IOC as promoted by the task force.
As I began, this seminal report for the mitigation of BDI should be mandatory reading for every practicing surgeon and surgical trainee. We will never fully avoid the devastation of this consequence in the performance of modern cholecystectomy. However, it is our duty to our patients and ourselves to ponder critically the outcomes over the past 30 years as we pursue the “grail” in our endeavor to ■ achieve optimal safety. —Dr. Greene is a surgeon in Charlotte, N.C.
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