Surgeon Knowledge, Behavior, and Opinions Regarding Intraoperative Cholangiography

Background

The risk of common bile duct injury during laparoscopic cholecystectomy (LC) is 50% to 70% lower when an intraoperative cholangiogram (IOC) is used, and this effect is exaggerated among less experienced surgeons. Routine IOC is not universal, and barriers to its use, including surgeon knowledge, behavior, and attitudes, should be understood in developing quality-improvement interventions aimed at increasing IOC use.

Study Design

There were 4,100 general surgeons randomly selected from the American College of Surgeons who were mailed a survey about IOC. Surveys with a valid exclusion (retired, no LC experience) were considered responsive but were excluded from data analysis.

Results

Forty-four percent responded, with 1,417 surveys analyzed (mean age 51.8±9.6 years; 89.2% men; 55.3% private practice). Twenty-seven percent of respondents defined themselves as routine IOC users and 91.3% of routine users reported IOC use in more than 75% of LCs performed. Academic surgeons were less often routine users compared with nonacademics (15% versus 30%; p < 0.001). Selective users were more often low-volume (less than 20 LC/year) surgeons (8% versus 15%) as compared with routine users, who were more often high-volume (more than100 LC/year) surgeons (27% versus 20%). Routine users had more favorable and accurate opinions about IOC (less costly and more protective of injury) than did selective users. Thirty-nine percent of routine users thought IOC decreased the risk of common bile duct injury by at least half compared with 10% of selective users.

Conclusions

Surgeons at greatest risk for causing common bile duct injury (inexperienced, low-volume surgeons) and those who have the greatest opportunity to train others are less likely to use IOC routinely. These represent target groups for quality-improvement interventions aimed at broader IOC use.

Abbreviations and Acronyms: CBDI, common bile duct injury, IOC, intraoperative cholangiography, LC, laparoscopic cholecystectomy