BN SO61 - Modern Surgical Training: A Comparative Commentary

Abstract Background Laparoscopic cholecystectomy is a cornerstone of benign upper GI surgery; approximately 3% of the population have symptomatic gallstones and over 61,000 laparoscopic cholecystectomies are performed every year in the UK (1). Whilst a relatively safe procedure, bile duct injury is an iatrogenic catastrophe with increased incidence according to the bile duct injury registry. We must consider if the requirements for completion of training (CCT) are robust enough. Indeed, non-surgeons have performed 170 laparoscopic cholecystectomies and would arguably meet the same requirements (2). Method Here we compare CCT requirements for general surgery with upper GI special interest with the requirements for certification in diagnostic endoscopy. This is a procedure performed by upper GI surgeons, with accreditation criteria determined by Joint Advisory Group (JAG) (3) rather than the Joint Committee on Surgical Training (4). Results CCT requires 110 cholecystectomies. Endoscopy requires 250 cases. Within the final 3 months of training, 95% of cases should be physically unassisted and D2 intubation and J manoeuvre should be achieved in 95% of 15 cases. Endoscopy also requires five reflections and attendance of a basic skills course. Cholecystectomy requires three level 4 PBAs (performed fluently without guidance or intervention). Endoscopy requires >25 DOPS with the 5 most recent scoring >90%. 4 summative DOPS must demonstrate competence for independent practice. After CCT, consultants undergo appraisal. After JAG accreditation there is a defined period of supervision. 100 OGDs must be performed a year. Conclusion Diagnostic OGD is an arguably safer and more simple procedure than a laparoscopic cholecystectomy. However, accreditation requirements for each procedure are wildly different. Comparatively, laparoscopic cholecystectomy lacks stringent indices and has no ongoing accreditation requirements. We suggest that a more robust process might act to combat the increasing rate of life-changing bile duct injury during laparoscopic cholecystectomy.