Preceptored introduction of laparoscopic techniques for cholecystectomy into a large university-affiliated medical...

Faced with the task of introducing laparoscopic techniques for cholecystectomy into the practice of a large department composed of individuals with varied backgrounds and experience, our surgical staff decided to grant provisional provileges to five surgeons, two from the full-time faculty and three from the community, who had completed a formal course in laparoscopic cholecystectomy. These five surgeons agreed to assist one another through 10 cases a piece before performing any procedures on their own or serving as preceptors for additional surgeons. Other surgeons could obtain credentials for this procedure by satisfying the same course criteria and receiving assistance from one of the five original surgeons during their first 10 cases. In the 14 months after September 1990, 250 laparoscopic cholecystectomies were performed by 19 different attending surgeons at our hospital. One death from hemorrhage (0.4%) and two bile duct injuries (0.8%) occurred in these patients. One of the bile duct injuries occurred after conversion to open cholecystectomy, as did the hemorrhage, which was from a vessel within the parenchyma of the gallbladder bed which rebled even after temporary control through open ligature technique. The second bile duct injury, the result of injudicious application of hemoclips for hemostasis, was minor in degree and the only injury to occur in a procedure conducted exclusively through the laparoscope. This experience demonstrates that laparoscopic techniques can be safely introduced into an environment involving multiple surgeons by adherence to a careful protocol of preceptored assistance.