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Failing to prepare: the erosion of intraoperative cholangiography in the rising surgical workforce—a national review of general surgery residents’ laparoscopic cholecystectomy and intraoperative cholangiogram experience

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Katharine E. Caldwell
Katharine E. Caldwell
Katharine E. Caldwell
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Elizabeth Wood at Wake Forest University
Elizabeth Wood
L Michael Brunt at Washington University in St. Louis
L Michael Brunt
Lucas P Neff at Wake Forest University
Lucas P Neff
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Background With the advent of advanced imaging and endoscopy, we hypothesized that IOC resident training has declined and is currently insufficient. To this end, we evaluated the national general surgery resident experience with laparoscopic cholecystectomy both with and without intraoperative cholangiography. Methods The National Accreditation Council for Graduate Medical Education (ACGME) operative logs were evaluated from 2012 to 2023 for general surgery residents. The number of completed laparoscopic cholecystectomy (CCY) operations and CCY with cholangiogram were evaluated and compared by postgraduate year, program (academic, community, hybrid, military), and resident role (first assistant, surgeon junior, and surgeon chief). ANOVA testing was used to analyze the data. Results The cholecystectomy case volumes of graduating general surgery residents in all cholecystectomies increased between the 2012–2013 and 2022–2023 academic years (123.9 v 143, p < 0.01). The number of performed CCY + IOC declined significantly over this period (25.1 v 21.6, p = 0.02). University-affiliated programs demonstrated statistically lower numbers of IOCs than community-based (19.3 v 34.1, p < 0.01), hybrid (24.0, p < 0.01), or military programs (26.3, p < 0.01). Community-based programs performed more CCY with IOC than any other group (p < 0.01). Despite the number of CCY + IOC declining during the study period, an increasing percentage of the CCY + IOC were performed by chief (PGY5) residents (p < 0.01). Conclusion Trainee experience with IOC is declining. The decreased rate and number of IOCs performed by residents has correlated with a “seniorization” of resident experience. This change may result in a future general surgeon workforce with inadequate IOC experience and ultimately impact patient safety. To bolster experience with both technique and interpretation, liberal IOC should be advocated for in training environments. A national IOC assessment may be necessary to address this looming deficit.
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Surgical Endoscopy
https://doi.org/10.1007/s00464-025-11733-1
Failing toprepare: theerosion ofintraoperative cholangiography
intherising surgical workforce—a national review ofgeneral
surgery residents’ laparoscopic cholecystectomy andintraoperative
cholangiogram experience
KatharineE.Caldwell1· ElizabethC.Wood2· L.MichaelBrunt1· LucasP.Ne2· CarlWestcott2· MichaelM.Awad1·
ShanL.Kalmeta3· VahagnC.Nikolian3· MaggieE.Bosley3
Received: 11 November 2024 / Accepted: 6 April 2025
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2025
Abstract
Background With the advent of advanced imaging and endoscopy, we hypothesized that IOC resident training has declined
and is currently insufficient. To this end, we evaluated the national general surgery resident experience with laparoscopic
cholecystectomy both with and without intraoperative cholangiography.
Methods The National Accreditation Council for Graduate Medical Education (ACGME) operative logs were evaluated
from 2012 to 2023 for general surgery residents. The number of completed laparoscopic cholecystectomy (CCY) operations
and CCY with cholangiogram were evaluated and compared by postgraduate year, program (academic, community, hybrid,
military), and resident role (first assistant, surgeon junior, and surgeon chief). ANOVA testing was used to analyze the data.
Results The cholecystectomy case volumes of graduating general surgery residents in all cholecystectomies increased
between the 2012–2013 and 2022–2023 academic years (123.9 v 143, p < 0.01). The number of performed CCY + IOC
declined significantly over this period (25.1 v 21.6, p = 0.02). University-affiliated programs demonstrated statistically
lower numbers of IOCs than community-based (19.3 v 34.1, p < 0.01), hybrid (24.0, p < 0.01), or military programs (26.3,
p < 0.01). Community-based programs performed more CCY with IOC than any other group (p < 0.01). Despite the num-
ber of CCY + IOC declining during the study period, an increasing percentage of the CCY + IOC were performed by chief
(PGY5) residents (p < 0.01).
Conclusion Trainee experience with IOC is declining. The decreased rate and number of IOCs performed by residents has
correlated with a “seniorization” of resident experience. This change may result in a future general surgeon workforce with
inadequate IOC experience and ultimately impact patient safety. To bolster experience with both technique and interpreta-
tion, liberal IOC should be advocated for in training environments. A national IOC assessment may be necessary to address
this looming deficit.
Keywords Intraoperative cholangiogram· Laparoscopic cholecystectomy· Trainee· Resident· Autonomy
Intraoperative cholangiography (IOC) is utilized to delineate
biliary anatomy, aid in prevention of bile duct injury, identify
common bile duct stones, and facilitate intervention for stone
removal [1]. Routine versus selective use of IOC remains
controversial as there is conflicting evidence regarding the
prevention of common bile duct injuries (BDI), although
it may improve early injury recognition [2–7]. Advocates
for selective cholangiography highlight the increase in time
and resources necessary to perform routine IOC despite the
low incidence of unsuspected retained stones and similar
rates of BDI [8]. Regardless of frequency, the ability for
a surgeon to confidently perform and accurately interpret
cholangiograms is advantageous, especially in the setting of
altered foregut anatomy such as Roux-en-Y gastric bypass
and Other Interventional Te
chniques
* Maggie E. Bosley
bosleym@ohsu.edu
1 Washington University ofSt. Louis School ofMedicine,
St.Louis, MO, USA
2 Wake Forest School ofMedicine, Winston-Salem, NC, USA
3 Oregon Health & Science University, Portland, OR, USA
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
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Biliary tract visualization using near-infrared imaging with indocyanine green during laparoscopic cholecystectomy: results of a systematic review
Article
Full-text available
  • Jul 2017
  • SURG ENDOSC
Background: Near-infrared imaging with indocyanine green (ICG) has been extensively investigated during laparoscopic cholecystectomy (LC). However, methods vary between studies, especially regarding patient selection, dosage and timing. The aim of this systematic review was to evaluate the potential of the near-infrared imaging technique with ICG to identify biliary structures during LC. Methods: A comprehensive systematic literature search was performed. Prospective trials examining the use of ICG during LC were included. Primary outcome was biliary tract visualization. Risk of bias was assessed using ROBINS-I. Secondly, a meta-analysis was performed comparing ICG to intraoperative cholangiography (IOC) for identification of biliary structures. GRADE was used to assess the quality of the evidence. Results: Nineteen studies were included. Based upon the pooled data from 13 studies, cystic duct (Lusch et al. in J Endourol 28:261-266, 2014) visualization was 86.5% (95% CI 71.2-96.6%) prior to dissection of Calot's triangle with a 2.5-mg dosage of ICG and 96.5% (95% CI 93.9-98.4%) after dissection. The results were not appreciably different when the dosage was based upon bodyweight. There is moderate quality evidence that the CD is more frequently visualized using ICG than IOC (RR 1.16; 95% CI 1.00-1.35); however, this difference was not statistically significant. Conclusion: This systematic review provides equal results for biliary tract visualization with near-infrared imaging with ICG during LC compared to IOC. Near-infrared imaging with ICG has the potential to replace IOC for biliary mapping. However, methods of near-infrared imaging with ICG vary. Future research is necessary for optimization and standardization of the near-infrared ICG technique.
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Diagnostic value of magnetic resonance cholangiopancreatography in choledocholithiasis
Article
Full-text available
  • Mar 2015
To evaluate the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) in patients with choledocholithiasis. We systematically searched MEDLINE, EMBASE, Web of Science, and Cochrane databases for studies reporting on the sensitivity, specificity and other accuracy measures of diagnostic effectiveness of MRCP for detection of common bile duct (CBD) stones. Pooled analysis was performed using random effects models, and receiver operating characteristic curves were generated to summarize overall test performance. Two reviewers independently assessed the methodological quality of studies using standards for reporting diagnostic accuracy and quality assessment for studies of diagnostic accuracy tools. A total of 25 studies involving 2310 patients with suspected choledocholithiasis and 738 patients with CBD stones met the inclusion criteria. The average inter-rater agreement on the methodological quality checklists was 0.96. Pooled analysis of the ability of MRCP to detect CBD stones showed the following effect estimates: sensitivity, 0.90 (95%CI: 0.88-0.92, χ (2) = 65.80; P < 0.001); specificity, 0.95 (95%CI: 0.93-1.0, χ (2) = 110.51; P < 0.001); positive likelihood ratio, 13.28 (95%CI: 8.85-19.94, χ (2) = 78.95; P < 0.001); negative likelihood ratio, 0.13 (95%CI: 0.09-0.18, χ (2) = 6.27; P < 0.001); and diagnostic odds ratio, 143.82 (95%CI: 82.42-250.95, χ (2) = 44.19; P < 0.001). The area under the receiver operating characteristic curve was 0.97. Significant publication bias was not detected (P = 0.266). MRCP has high diagnostic accuracy for the detection of choledocholithiasis. MRCP should be the method of choice for suspected cases of CBD stones.
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ACGME Operative Case Log Accuracy Varies Among Surgical Programs
Article
  • Sep 2020
Objective: This study evaluates the accuracy of reported the Accreditation Council for Graduate Medical Education (ACGME) operative case logs from graduated residents compared to institutional operating room electronic records (ORER). We hope this will help guide review committees and institutions develop complete, accurate resident case logs. Design: This is a retrospective, cross-sectional study of general surgery (GS), neurosurgery (NS), and orthopedic surgery (OS) resident physicians. ACGME and ORER cases from 2009 to 2010 were analyzed and each case and current procedural terminology (CPT) code directly compared (ORER vs. ACGME). Setting: Single academic tertiary-care medical center (University of Kentucky, Lexington, KY). Participants: Eleven thousand nine hundred and twenty-three cases for 46 residents among the 3 residency programs were analyzed. Results: There was an overall logging accuracy of 72% for ORER cases reflected in the ACGME case logs. OS residents had a higher rate of logging accuracy (OS 91%, GS 69%, NS 58%, chi-square p = 0.014) and mean annual number of cases compared to the other 2 programs (OS 452, GS 183, NS 237, ANOVA p = 0.001). NS residents had higher accuracy of CPT codes than post-graduate years 2 to 5 in other programs (p < 0.017). There was a strong positive correlation between the number of cases completed per resident and case logging accuracy, (rho = 0.769, p < 0.001) consistent for NS and GS, but not OS. Conclusions: This study shows only 72% of a residents' operative experience is captured in the ACGME case log across 3 surgical programs. There is significant variability among surgical programs and among post-graduate year cohorts regarding case log and CPT code accuracy. There is a strong correlation with the total number of cases performed and increasing case log accuracy. Low case log accuracy may reflect individual resident behavior instead of program operative exposure. Further studies are needed to determine if ORER may serve as a more complete assessment of the operative experience of a resident and program.
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Safe Cholecystectomy Multi-society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy
Article
  • May 2020
Background: BDI is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI. Methods: Literature reviews were conducted for 18 key questions across 6 broad topics around cholecystectomy directed by a steering group and subject experts from 5 surgical societies (Society of Gastrointestinal and Endoscopic Surgeons, Americas Hepato-Pancreato-Biliary Association, International Hepato-Pancreato-Biliary Association, Society for Surgery of the Alimentary Tract, and European Association for Endoscopic Surgery). Evidence-based recommendations were formulated using the grading of recommendations assessment, development, and evaluation methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus. Results: Consensus was reached on 17 of 18 questions by the guideline development group and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team. Conclusions: These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.
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A review of general surgery resident experience in common bile duct exploration in the ERCP era
Article
  • Feb 2020
  • AM J SURG
Background: Use of minimally invasive techniques for management of common bile duct (CBD) stones has led to declining number of CBD explorations (CBDE) performed at teaching and non-teaching institutions. We evaluate the impact of this decline on surgery training in bile duct procedures. Study design: National operative data for general surgery residents (GSR) were examined from 2000 to 2018. Biliary operations including, cholecystectomy open and laparoscopic, and CBDE open and laparoscopic were evaluated for mean number of cases per graduating GSR. Results: Despite increases in number of GSR, case numbers for laparoscopic cholecystectomy increased 39% from 84 to 117, p < .00001, per GSR. Mean number of cases for open CBDE, however, decreased 74% from 2.7 to 0.7, p < .00001, per GSR and laparoscopic CBDE declined 22% from 0.9 to 0.7 per resident. Conclusion: GSR operative case volume in CBDE has declined significantly creating a training deficiency for this complex skill. Novel simulation, including fresh cadavers, may offer the best option with high-fidelity, dynamic training to mitigate the loss of low volume, high acuity procedures.
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Readiness of US General Surgery Residents for Independent Practice
Article
  • Jul 2017
Objective: This study evaluates the current state of the General Surgery (GS) residency training model by investigating resident operative performance and autonomy. Background: The American Board of Surgery has designated 132 procedures as being "Core" to the practice of GS. GS residents are expected to be able to safely and independently perform those procedures by the time they graduate. There is growing concern that not all residents achieve that standard. Lack of operative autonomy may play a role. Methods: Attendings in 14 General Surgery programs were trained to use a) the 5-level System for Improving and Measuring Procedural Learning (SIMPL) Performance scale to assess resident readiness for independent practice and b) the 4-level Zwisch scale to assess the level of guidance (ie, autonomy) they provided to residents during specific procedures. Ratings were collected immediately after cases that involved a categorical GS resident. Data were analyzed using descriptive statistics and supplemented with Bayesian ordinal model-based estimation. Results: A total of 444 attending surgeons rated 536 categorical residents after 10,130 procedures. Performance: from the first to the last year of training, the proportion of Performance ratings for Core procedures (n = 6931) at "Practice Ready" or above increased from 12.3% to 77.1%. The predicted probability that a typical trainee would be rated as Competent after performing an average Core procedure on an average complexity patient during the last week of residency training is 90.5% (95% CI: 85.7%-94%). This falls to 84.6% for more complex patients and to less than 80% for more difficult Core procedures. Autonomy: for all procedures, the proportion of Zwisch ratings indicating meaningful autonomy ("Passive Help" or "Supervision Only") increased from 15.1% to 65.7% from the first to the last year of training. For the Core procedures performed by residents in their final 6 months of training (cholecystectomy, inguinal/femoral hernia repair, appendectomy, ventral hernia repair, and partial colectomy), the proportion of Zwisch ratings (n = 357) indicating near-independence ("Supervision Only") was 33.3%. Conclusions: US General Surgery residents are not universally ready to independently perform Core procedures by the time they complete residency training. Progressive resident autonomy is also limited. It is unknown if the amount of autonomy residents do achieve is sufficient to ensure readiness for the entire spectrum of independent practice.
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Nationwide Assessment of Trends in Choledocholithiasis Management in the United States From 1998 to 2013
Article
  • Aug 2016
Importance There are currently 2 widely accepted treatment strategies for patients presenting to the hospital with choledocholithiasis. However, the rate of use for each strategy in the United States has not been evaluated, and their trends over time have not been described. Furthermore, an optimal management strategy for choledocholithiasis has yet to be defined. Objective To evaluate secular trends in the management of choledocholithiasis in the United States and to compare hospital length of stay between patients with choledocholithiasis treated with endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy (ERCP+LC) vs laparoscopic common bile duct exploration with laparoscopic cholecystectomy (LCBDE+LC). Design, Setting, and Participants In this cohort study, we studied patients with a primary diagnosis of choledocholithiasis that were included in the National Inpatient Sample between 1998 and 2013 from a representative sample of acute care hospitals in the United States. Patients with cholangitis or pancreatitis were excluded. Main Outcomes and Measures Unadjusted and risk-adjusted median hospital length of stay. Results Of the 37 207 patients included in our analysis, 36 048 (96.9%) were treated with ERCP+LC and 1159 (3.1%) were treated with LCBDE+LC. The mean (SD) age of patients treated with ERCP+LC was 50.7 (21.1) years and was 51.9 (20.9) years for those treated with LCBDE+LC; 25 788 (69.3%) were female. Analysis of the National Inpatient Sample data indicates that there are an average of 26 158 patients with choledocholithiasis admitted in the United States each year. The overall use of CBDE for patients with choledocholithiasis decreased from 39.8% of admissions in 1998 to 8.5% in 2013 (P < .001). A decrease was also seen for open CBDE (30.6% vs 5.5%; P < .001) and laparoscopic CBDE (9.2% vs 3.0%; P < .001) independently. Rates of management with LCBDE+LC decreased from 5.3% to 1.5% (P < .001), while rates of ERCP+LC increased from 52.8% to 85.7% (P < .001). The unadjusted median hospital length of stay was shorter for patients treated with LCBDE+LC than for those treated with ERCP+LC (3.0 vs 4.0 days; P < .001). After risk-adjustment, the median length of stay remained 0.5 days shorter for patients treated with LCBDE+LC than with ERCP+LC (3.5 vs 4.0 days; P < .001). Conclusions and Relevance This study highlights the marked decline in the use of both open and laparoscopic CBDE in the United States as well as the benefit to the length of stay LCBDE+LC has over ERCP+LC. Despite a persistent need for CBDE and the potential benefits of LCBDE+LC over ERCP+LC for managing choledocholithiasis, if current trends continue, CBDE may be at risk of disappearing from the surgical armamentarium.
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Who Will Be Able to Perform Open Biliary Surgery in 2025?
Article
  • Apr 2016
  • J AM COLL SURGEONS
Background: Although laparoscopic cholecystectomy (LC) is the gold standard, some patients still require an open cholecystectomy (OC). This study evaluates the mean number of OCs performed by each graduating general surgery resident during each of 3 decades. Study design: Data were obtained from all patients undergoing a cholecystectomy during 3 decades: prelaparoscopic era (1981 to 1990), first decade of LC (1991 to 2001), and recent decade of LC (2004 to 2013). Data were prospectively collected and retrospectively reviewed and analyzed by chi-square or Fisher's exact test. Results: Compared with the prelaparoscopic decade, the number of patients undergoing an OC decreased considerably, by 67%, during the first decade of LC, and by 92% during the most recent decade at the 2 core teaching hospitals. Mean number of OCs performed per graduating chief general surgery resident decreased significantly for both laparoscopic decades compared with the prelaparoscopic decade (70.4, 22.4, and 3.6, respectively). In the last decade at the core institutions, 683 (8.8%) patients also underwent an intraoperative cholangiogram (IOC) and 36 (0.5%) underwent common bile duct exploration (CBDE). When biliary cases done at affiliated institutions during the last decade were included, the mean number of OCs (from 3.6 to 10.2), IOCs (from 683 to 2,098), and CBDEs (from 36 to 116) all increased (p < 0.001) per graduating chief general surgery resident. Conclusions: There has been a considerable decline in the number of OCs, IOCs, and CBDEs available to our trainees during the past 30 years. New training paradigms should include renewed focus on performing an IOC and/or CBDE as clinically indicated during LC; high-quality simulation programs for OC, IOC, and CBDE; and the availability of an advanced video library depicting complicated open biliary procedures.
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Has Intraoperative Cholangiography during Laparoscopic Cholecystectomy Become Obsolete in the Era of Preoperative Endoscopic Retrograde and Magnetic Resonance Cholangiopancreatography?
Article
  • Jan 2015
  • J AM COLL SURGEONS
Preoperative ERCP, magnetic resonance cholangiopancreatography (MRCP), and intraoperative cholangiography (IOC) are standard procedures in evaluating patients with suspected choledocholithiasis. This study evaluates the changing practice patterns over time of these 3 procedures in a large cohort of patients undergoing laparoscopic cholecystectomy (LC) at a single tertiary care center. Data from all patients undergoing an LC with or without preoperative ERCP, MRCP, or an IOC from January 1, 2004 to December 31, 2013 were retrospectively reviewed from billing data obtained by CPT code and analyzed by chi-square testing. During 10 years, 7,427 patients underwent successful LC. The number of patients undergoing successful IOC (11.9% to 7.6%) or preoperative ERCP (7.2% to 1.5%) decreased significantly during that time interval (p < 0.01). In the last 6 years, 4,506 patients underwent successful LC. The number of patients from this group undergoing a preoperative MRCP (0.9% to 8.6%) or MRCP and ERCP (0.4% to 3.6%) increased significantly (p < 0.001). Despite a shift from IOC and preoperative ERCP to preoperative MRCP alone or with ERCP, a significant percentage (7.6%) of patients still underwent IOC in 2013. Use of IOC during LC has decreased but is not considered obsolete, rather, it remains a valuable tool for the evaluation of bile duct anatomy, bile duct injury, or suspected choledocholithiasis. Intraoperative cholangiography during uncomplicated LC should be emphasized in teaching programs to insure general surgery resident competency with the procedure. Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
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