An Old-school Surgical Procedure Faces Obsolescence, Raising Questions

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.

Not So Dire
Still, it's not like there's a clamor for this training. Sirinek and other surgeons I talked to make a few points that should calm hospitals administrators who will read the above and think, "lawsuit":

• If you've learned the basics of surgery and know how to remove a gallbladder, you can probably pull off an open cholecystectomy with a little practice.
• If a surgeon has to convert from laparoscopic to open surgery, he or she have time to call for help from an older or more experienced surgeon.
• Younger surgeons know how to handle complications laparoscopically, so demand for the open cholecystectomy will continue to drop.

H. David Reines, MD, was going over the case logs for his chief residents this week and says the shift is clear. A surgeon and director of CME for Inova Fairfax Hospital in Virginia, Reines says his residents remove about 100 gallbladders laparoscopically each year, compared to performing between three and eight open procedures.

But he says he worries a lot less about the shift than he once did. Now 69, Reines learned open surgery during his training because that was the only option.

Even after doctors started using the laparoscope, the thinking was to switch to open surgery at any sign of trouble. That is no longer true, in part, because younger doctors have gotten better at handling complications with the scope. Reines says, "Now a lot of people feel more secure continuing on laparoscopically."

What they are uncomfortable doing, he says, is open surgery. In those cases, he and others say surgeons have plenty of time to call for help.

"If you feel you are in danger of taking a piece of the liver or getting into the common duct, you can close the patient up and go ahead and send them to a hepatobiliary surgeon," he said.

Teaching Procedures vs. Principles
Douglas Smink, MD, is a surgeon at Brigham and Women's Hospital in Boston who works with both surgical residents and the hospital's STRATUS Center for Medical Simulation. He says the question of competency comes up regularly around multiple surgical procedures that are performed less and have become almost obsolete.

Open gallbladder surgery is one of them. Still, Smink doesn't think that simulation and more training is the answer. Laparoscopy is a technique. The concept surgeons need to master is removal of the gallbladder, which is sometime done during other surgical procedures, he says.

"Some of what we teach are procedures and some of what we teach are principles," he said. "So even if somebody doesn't do many open cholecystectomies in their training, they still do a fair number of (laparoscopic) cholecystectomies and they still do a fair amount of surgery."

He feels comfortable that his trainees are still getting the skills they need to be able to put those skills together if they need to do open surgery.

The fate of open biliary surgery in 2025 is better framed this way: In the push for evidence-based medicine, lots of overused or outdated treatments will emerge; some devices and procedures will fall into disuse and eventually become extinct.

The key to good outcomes and patient safety will be to ensure that doctors have the skills and tools they need to do their jobs, even as their tools and skills are changing.