Single-stage laparoscopic management of choledocholithiasis: An analysis after implementation of a mastery learning resident curriculum

Background

Laparoscopic common bile duct exploration is an underutilized treatment for choledocholithiasis. We sought to evaluate the impact of a simulation-based mastery-learning curriculum for surgical residents on laparoscopic common bile duct exploration utilization and to compare outcomes for patients treated with laparoscopic common bile duct exploration versus endoscopic retrograde cholangiopancreatography (ERCP).

Methods

The number of laparoscopic common bile duct explorations performed before and after curriculum implementation was reviewed and outcomes were compared between patients with choledocholithiasis managed with laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography. Based on cost savings from increased utilization of laparoscopic common bile duct exploration, the annual return on investment associated with the curriculum was calculated.

Results

Twenty-two residents completed the curriculum. In the pre-curriculum period, an average of 1.7 laparoscopic common bile duct explorations was performed yearly, which increased to 8.4 cases per year after curriculum implementation (P?<?.05). Identified were 155 patients with choledocholithiasis: 31 underwent laparoscopic common bile duct exploration plus laparoscopic cholecystectomy and 124 underwent endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. The laparoscopic common bile duct exploration and laparoscopic cholecystectomy group had a reduced duration of stay (2.5?±?1.8 days versus 4.3?±?2.2 days, P?<?.0001) and costs ($12,987?±?$3,286 versus $15,022?±?$4,613, P?=?.01) compared with endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. Rates of readmission and reoperation were equivalent between groups. Cost savings were more than $38,000, resulting in a 3.8 to 1 return on investment from curriculum implementation.

Conclusion

A simulation-based mastery-learning curriculum increased institutional utilization of laparoscopic common bile duct exploration and adoption of the curriculum resulted in positive return on investment.