Training in laparoscopic cholecystectomy: lessons from a structured training programme

Abstract

INTRODUCTION: Data have shown that structured training in Laparoscopic cho!ecystectomy (LC) reduces morbidity and mortality related to the learning curve. OBJECTIVE: This study was performed to evaluate morbidity, mortality and to provide insight into steps in operation that requires trainees assistance in LC. METHODS: Five higher surgical trainees with no previous laparoscopic experience were evaluated from July 2000. Each trainee should have held a camera during operation, learnt the skills of Veress needle insertion and acquired hand-eye coordination on a laparoscopic trainer. The operation was divided into 4 steps; I. Creation of pneumoperitoneum 2. Port insertion and laparoscopic survey 3. Dissection in Calot's triangle and application of clips 4. Dissection and delivery of the gall bladder. We audited total time taken, complications and the requirement for assistance. RESULTS: 29 LC's were performed. One (3%) was converted to open cholecystectomy to establish biliary drainage from a duct of Luschka. One (3%) death resulted from pulmonary embolism. There was no significant postoperative morbidity. Overall trainer assistance was required on 18 occasions in 8 (26%) patients (step I - 2; step 2 - 4; step 3 - 8; step 4 - 4). Detailed stepwise evaluation revealed frequent requirement for trainer assistance in insertion of the umbilical port (in step 2), delineation of the junction of the cystic duct with infundibulum and common bile duct and application of clips (in step 3 and 4) and the delivery of the gall bladder. Total time taken was (median& range) 2.08 ( 1.5-3 .18) hours. Median number of LC performed by a trainee was 5 (range 3- 7).CONCLUSION: It is possible to undertake structured training in LC safely. Dissection in Calot's triangle required most trainer assistance