Laparoscopic cholecystectomy has replaced open cholecystectomy as the “gold standard” treatment of symptomatic gallstone disease since its introduction in the late 1980s1. This cultural change is supported scientifically in the literature and in clinical practice with the appeal of less pain, shorter length of stay and an overall quicker recovery period2. However, the rate of intraoperative conversion from a laparoscopic to an open cholecystectomy still ranges from 1% - 15% and is mainly reserved for the “impossible gallbladder” which the operating surgeon cannot complete laparoscopically3-5. The current Tokyo Guidelines advise conversion to open as the first option when laparoscopic progression proves impossible, with partial cholecystectomy and cholecystostomy as further options, none of which are easy for the surgeon with limited experience6.
While open cholecystectomy remains a reliable, “gold-standard” bailout procedure for complicated cases5, 7, the decreasing frequency in clinical practice is likely to prove problematic in surgical training. This presents a concerning gap in the surgical expertise of modern day trainees whereby fewer surgeons will have experience of a technique that is principally reserved for more difficult cases5. Combined with a growing concern with the competencies of general surgery residents and trainees entering independent consultant positions within Europe and North America, this obvious dilemma in training junior surgeons in open biliary surgery will likely continue to not only shift but also question the ability and confidence of trainees going forward8-10. A recent survey of surgical fellows in North America reported that 30% of new fellows could not perform a laparoscopic cholecystectomy independently11. Graduating chief residents in the United States have reported a decrease in open cholecystectomy from 70 in the pre-laparoscopic era to a mean of 3.6 during their entire training over the past decade 11 and in the UK and Ireland, only 3.3% of laparoscopic cholecystectomies are converted to open 12 and the majority of conversions are performed by consultants. For these reasons, we hypothesize that only a small number of the current trainees within the UK and Republic of Ireland feel appropriately exposed to open cholecystectomy and can be comfortable performing these cases independently.
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1. Sain A. Laparoscopic cholecystectomy is the current" gold standard" for the treatment of gallstone disease. Annals of surgery 1996;224(5): 689.
2. Keus F, de Jong J, Gooszen H, Laarhoven CJ. Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database of Systematic Reviews 2006(4).
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10. CholeS Study Group WMRC, Vohra R, Pasquali S, Kirkham A, Marriott P, Johnstone M, et al. Population‐based cohort study of outcomes following cholecystectomy for benign gallbladder diseases. British Journal of Surgery 2016;103(12): 1704-1715.
11. Mattar SG, Alseidi AA, Jones DB, Jeyarajah DR, Swanstrom LL, Aye RW, et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Annals of surgery 2013;258(3): 440-449.