Training in Laparoscopic Bile Duct Exploration (LBDE)

Abstract

A nationwide assessment of trends in choledocholithiasis management in the United States from 1998 to 2013 found that the overall use of common bile duct (CBD) exploration (open and laparoscopic) decreased from 39.8% of admissions in 1998 to 8.5% in 2013 [1]. Specifically, laparoscopic bile duct exploration (LBDE) decreased from 9.2% to 3% within the same duration. The decreasing trend in LBDE has resulted in surgeons being less experienced in performing this procedure. When it is undertaken, it is often at the expense of longer operative times and more complications [2]. Another study from the United States evaluated the impact of declining CBD exploration from 2000 to 2018 on surgical training in bile duct procedures [3]. Despite an increase in the number of laparoscopic cholecystectomies performed per general surgery resident (84 to 117; 39%), the mean number of cases for open and laparoscopic CBD exploration per general surgery resident decreased (2.7 to 0.7; 74% and 0.9 to 0.7; 22% respectively). Therefore, general surgery residents in the United States, on average, perform less than one LBDE during their entire training, which has also been confirmed by other authors [4]. Consequently, it is not surprising that 86% of general surgeons in the United States chose pre-operative endoscopic retrograde cholangiopancreatography (ERCP) as the management of choice for pre-operatively known choledocholithiasis in a web-based survey [5]. The situation in the United Kingdom is likely to be similar. In order to promote single-stage management (laparoscopic cholecystectomy + LBDE) of choledocholithiasis and increase its widespread adoption, a comprehensive training program together with mentoring is needed. Training in LBDE should be available to consultants and senior specialist registrars (SpR) in General Surgery and can be delivered during surgical training as well as dedicated LBDE training courses. A reliable and reproducible LBDE training model should be used to facilitate learning and enable translation of acquired skills into clinical practice. The use of a LBDE curriculum has been shown to improve the ability of surgeons to perform both transductal and transcystic exploration on a procedural simulator and increase the institutional utilisation of LBDE [6, 7].KeywordsPorcine Aorto-Renal Artery (PARA) modelLithotripsy Assisted Bile duct Exploration by Laparoendoscopy (LABEL)Laser lithotripsyElectrohydraulic lithotripsyLaparoscopic common bile duct explorationLaparoscopic bile duct explorationCommon bile duct stonesCholedocholithiasis