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How I Do It
 How I Do It: The Very First Laparoscopic Cholecystectomy as a First-Year Resident, with a Step-by-Step Tutorial
Sujin Parkorcid, Hochang Chaeorcid, Hyeong Seok Kimorcid, Hongbeom Kimorcid, Sang Hyun Shinorcid, In Woong Hanorcid, Jin Seok Heoorcid, So Jeong Yoonorcid
Journal of Surgical Innovation and Education 2024;1(1):10-13.
DOI: https://doi.org/10.69474/jsie.2024.00024
Published online: June 25, 2024

Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea

Corresponding author: So Jeong Yoon, MD, PhD Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea Tel: +82-2-3410-0772, E-mail: 'wooyabi@gmail.com'
• Received: May 21, 2024   • Revised: June 12, 2024   • Accepted: June 17, 2024

© 2024 Korean Surgical Skill Study Group

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Since its introduction in 1987, laparoscopic cholecystectomy (LC) has been widely performed by surgeons as a standard procedure for benign gallbladder diseases. Education and training by hepatobiliary experts are important in order to safely perform LC without critical complications. The present report discusses the first LC performed by a beginner surgeon who was trained with our institutional step-by-step tutorial. The step-by-step mentor-mentee tutorial had a total of four phases: video training, observation in the operating room, participation as an assistant, and finally performing LC independently. At every step, the mentor’s approval was required to move on to the next phase. After completing visual training and observation, the mentee participated in 10 consecutive LCs as an assistant or operator. Finally, LC for a 54-year-old female patient with gallbladder stones was independently performed by the mentee under the mentor’s supervision. The patient was discharged on the first postoperative day without complications. We report a case of LC successfully performed by a beginner surgeon with the aid of a newly established step-by-step tutorial. The tutorial is expected to be applied to numerous surgical trainees after further refinement regarding its safety and feasibility.
  • Keywords: Gallstones, Laparoscopic cholecystectomy, Education, Minimally invasive surgical procedures
Benign gallbladder diseases such as gallstones and polyps are highly prevalent. Their incidence is reported to be increasing [1,2]. If operative treatment is indicated, treatment of choice is cholecystectomy. Laparoscopic cholecystectomy (LC) is considered as the standard, which is performed in most cases [3].
LC is feasible and safe when performed by trained surgeons. However, serious complications such as postoperative bleeding or bile duct injury may occur. The rate of complications is known to be associated with surgical inexperience [4]. Therefore, many previous studies have tried to identify a learning curve for LC and to establish a proper training model for surgical residents [4-6]. In this report, we present the first LC case performed by a first-year resident trained by her mentor along with a newly established institutional tutorial.
An elective cholecystectomy was planned for a 54-year-old female patient with symptomatic gallbladder stone. The patient had underlying chronic liver disease associated with hepatitis B virus. She had no previous history of abdominal surgery. Her body mass index was 26.7 kg/m2. Preoperative computed tomography scans showed a 1.5 cm gallstone with mild gallbladder wall thickening (Fig. 1). This study was approved by the Institutional Review Board (IRB) of the Samsung Medical Center (IRB No: 2024-05-094).
Our institutional tutorial consists of four phases (Table 1): video training, observation, participation (as a first assistant or operator) and operation.
During visual training with more than 50 video clips, the mentee wrote a case review note of every video she watched and presented it to the mentor as a result of the first phase. Followed by observation, the trainee completed the checklist by participating in 10 consecutive LCs as the first assistant or operator. Under close monitoring by the mentor, LC was independently performed by the mentee, with an operation time of 55 minutes.
The patient was discharged on postoperative day 1 without complications. Permanent biopsy showed chronic cholecystitis with a gallbladder stone (Fig. 2). At the first postoperative outpatient clinic, the patient was doing well with clear wound and normal laboratory findings.
Ability to perform LC independently is a prerequisite for obtaining surgery board certification in Korea. However, many surgical residents have a low opportunity to perform LC by themselves, particularly in tertiary centers. This is possibly due to their workload outside operating rooms, or fellow-oriented training of pancreato-biliary surgery.
Several reports have suggested that a structured program is essential to enhancing residents’ ability to safely perform LC [4,7,8]. Therefore, we set a new manual for residents with specific duration of training and detailed instructions. We also let the trainee proceed to next process only with confirmation of the supervisor, so that the trainee could get fully acquainted with every procedure of LC. Finally, the first operation was independently and successfully performed by the trainee.
With this first use of a step-by-step LC tutorial, we identified the importance and potential effectiveness of a structured manual for surgical residents. After a further improvement of applicability and feasibility, this tutorial could be used by many other beginner surgeons to develop their basic technical skills for LC.

Disclosure

No potential conflict of interest relevant to this article was reported.

Funding

This research was supported by a grant (grant number: HI20C1234) of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea.

Author contributions

Conceptualization: SP, SJY; Data curation: SP, HC, HSK, SJY; Formal analysis: SP, HC, HSK, HK, SHS, IWH, JSH, SJY; Investigation: SP, HC, HSK, HK, SHS, IWH, JSH, SJY; Methodology: SP, SJY; Funding acquisition: SJY, IWH; Writing–original draft: SP, HC, HSK, HK, SHS, IWH, JSH, SJY; Writing–review & editing: SP, HC, HSK, HK, SHS, IWH, JSH, SJY.

Figure 1.
Preoperative computed tomography scan of the patient with chronic calculous cholecystitis.
jsie-2024-00024f1.jpg
Figure 2.
Specimen retrieved from the operation.
jsie-2024-00024f2.jpg
Video.
 
Table 1.
Institutional step-by-step tutorial for residents
Phase Detail Duration/Requirement
1st: video training - Understanding biliary anatomy At least 2 weeks/A case review note
- Learning the details of LC
2nd: observation - Observing a mentor performing LC in the operating room At least 1 week/5 cases recommended
- Questions and answers in real time
3rd: participation - A stepwise approach (checklist: proceeding to the next step only after obtaining confirmation from the supervisor) At least 1 week/At least 2 tries fully completed by a mentee
 a. Incision and trocar insertion
 b. Recognition of anatomy: bile duct and Calot’s triangle
 c. Dissection of Calot’s triangle and achieving the “critical view of safety”
 d. Ligation of cystic duct and cystic artery
 e. Dissection of gallbladder from liver bed (troubleshooting tips: a “top-down” technique)
 f. Bleeding control and specimen removal
 g. Closing trocar sites
4th: operation - Performing LC under the supervision of a mentor -

LC, laparoscopic cholecystectomy.

  • 1. Wang X, Yu W, Jiang G, Li H, Li S, Xie L, et al. Global epidemiology of gallstones in the 21st century: a systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2024 Feb 19 [Epub]. DOI: 10.1016/j.cgh.2024.01.051.ArticlePubMed
  • 2. Riddell ZC, Corallo C, Albazaz R, Foley KG. Gallbladder polyps and adenomyomatosis. Br J Radiol. 2023;96:20220115.ArticlePubMedPMC
  • 3. Csikesz NG, Singla A, Murphy MM, Tseng JF, Shah SA. Surgeon volume metrics in laparoscopic cholecystectomy. Dig Dis Sci. 2010;55:2398-2405.ArticlePubMedPDF
  • 4. Jung YK, Kwon YJ, Choi D, Lee KG. What is the safe training to educate the laparoscopic cholecystectomy for surgical residents in early learning curve? J Minim Invasive Surg. 2016;19:70-74.Article
  • 5. Lim SH, Salleh I, Poh BK, Tay KH. Laparoscopic cholecystectomy: an audit of our training programme. ANZ J Surg. 2005;75:231-233.ArticlePubMed
  • 6. Jung YK, Choi D, Lee KG. Learning laparoscopic cholecystectomy: a surgical resident’s insight on safety and training during the initial 151 cases. Indian J Surg. 2021;83:224-229.ArticlePDF
  • 7. Bresadola V, Pravisani R, Pighin M, Seriau L, Cherchi V, Giuseppe S, et al. Clinical strategies to aim an adequate safety profile for patients and effective training for surgical residents: the laparoscopic cholecystectomy model. Ann Med Surg (Lond). 2016;11:58-61.ArticlePubMedPMC
  • 8. Wong HJ, Kojima Y, Su B, Attaar M, Wu H, Campbell M, et al. Long-term retention after structured curriculum on attainment of critical view of safety during laparoscopic cholecystectomy for surgeons. Surgery. 2022;171:577-583.ArticlePubMed

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        How I Do It: The Very First Laparoscopic Cholecystectomy as a First-Year Resident, with a Step-by-Step Tutorial
        J Surg Innov Educ. 2024;1(1):10-13.   Published online June 25, 2024
        DOI: https://doi.org/10.69474/jsie.2024.00024
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      How I Do It: The Very First Laparoscopic Cholecystectomy as a First-Year Resident, with a Step-by-Step Tutorial
      Image Image
      Figure 1. Preoperative computed tomography scan of the patient with chronic calculous cholecystitis.
      Figure 2. Specimen retrieved from the operation.

      Figure 1.

      Figure 2.

      How I Do It: The Very First Laparoscopic Cholecystectomy as a First-Year Resident, with a Step-by-Step Tutorial
      Phase Detail Duration/Requirement
      1st: video training - Understanding biliary anatomy At least 2 weeks/A case review note
      - Learning the details of LC
      2nd: observation - Observing a mentor performing LC in the operating room At least 1 week/5 cases recommended
      - Questions and answers in real time
      3rd: participation - A stepwise approach (checklist: proceeding to the next step only after obtaining confirmation from the supervisor) At least 1 week/At least 2 tries fully completed by a mentee
       a. Incision and trocar insertion
       b. Recognition of anatomy: bile duct and Calot’s triangle
       c. Dissection of Calot’s triangle and achieving the “critical view of safety”
       d. Ligation of cystic duct and cystic artery
       e. Dissection of gallbladder from liver bed (troubleshooting tips: a “top-down” technique)
       f. Bleeding control and specimen removal
       g. Closing trocar sites
      4th: operation - Performing LC under the supervision of a mentor -
      Table 1. Institutional step-by-step tutorial for residents

      LC, laparoscopic cholecystectomy.

      Table 1.

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