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An Old-school Surgical Procedure Faces Obsolescence, Raising Questions

By Tinker Ready  
   April 14, 2016

Few doctors are being trained to do open gallbladder surgery, compared to the numbers of surgeons learning laparoscopic techniques. What does this mean for patient safety and quality of care?

How often does a doctor need to perform a procedure to be competent? That question usually comes up in discussions about new procedures and devices.

But, what about old procedures that are used less and less, but still need to performed every once in a while? For some types of surgery, minimally invasive procedures are now the norm.

Take the cholecystectomy, which I needed after I suddenly felt like I had swallowed a bunch of razor blades. If I had gotten ill decade earlier, I would have been on track for a hospital stay and a major operation. Instead, I spent more time in the hospital being diagnosed, two nights, than I did in surgery—zero nights.

And while the idea of having an organ yanked out of my belly button, so to speak, was kind of surreal, I was happy for the quick recovery and three tiny, now-fading scars.

Still, if something had gone wrong or if my surgeons had found an unexpected mess in there, they might have needed to convert to open surgery. My doc was old enough to have learned how to do that in medical school and has done a few since. If I'd had a younger surgeon who came up in the laparoscopic age, however, that might not have been the case.

The Decline of Open Gallbladder Surgery
A recent study in the Journal of the American College of Surgeons quantifies the decline of the open cholecystectomy. It raises the question in its title: "Who Will Be Able to Perform Open Biliary Surgery in 2025?"

Using a huge database of procedures performed at the University of Texas Health Science Center in San Antonio, researchers confirmed what they were seeing in the clinic: the disappearance of open gallbladder surgery.

They compared the use of open surgery the in the 1980s, which they call the pre-laparoscopic decade, with rates of gallbladder patients undergoing an open cholecystectomy in the 1990s (down by an average of 67%) and in 2013 (down by 92% by). Correspondingly, the average number of open cholecystectomies performed per graduating chief general surgery resident dropped from 70.4 to 22.4 and is now down to 3.6 procedures.   

Still, sometimes the open procedure is called for. UT surgeon and lead author Kenneth Sirinek, MD, says that a surgeon may need to switch from a laparoscopic to open surgery after discovering that the patient has "abnormal anatomy" or has so much inflammation from acute cholecystitis that laparoscopy is not an option.

"When we are doing the open operation, we can put our hands on structures and can feel pulses and arteries," he said. "We can do some of the dissection with our fingers. When we are doing laparoscopically, we have no feedback."

At UT, surgeons are videotaping open procedures and creating a library for those want to be more familiar with the open cholecystectomy. They also suggest the use of simulation, but note that there is a lack of simulation tools.

Tinker Ready is a contributing writer at HealthLeaders Media.

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