Background

Bile duct injury sustained during laparoscopic cholecystectomy is associated with high morbidity and mortality, and can be a devastating complication for a general surgeon. We introduce a novel, individualized surgical coaching program for surgeons who recently injured a bile duct in laparoscopic cholecystectomy. We aim to explore the perception of coaching among these surgeons and to assess surgeons' experiences in the coaching program.

Study design

Six general surgeons who injured a bile duct at an emergency laparoscopic cholecystectomy participated in a 1-on-1 coaching session with a hepatopancreatobiliary surgeon. The session focused on debriefing the index case with video feedback, and discussion of strategies for safe laparoscopic cholecystectomy. The pilot program ran from March to November 2020. Exit interviews were then conducted. Themes covering perception of surgical training, perception of complications, and experience in the coaching program were explored.

Results

Surgeons were generally accepting of the coaching program, especially when the goals aligned with their self-identified areas of development. One-on-1 sessions with a local expert in the area, and the use of video feedback created a unique and interactive coaching opportunity. Peer coaching was identified as a valuable resource in helping surgeons regain confidence and maintain well-being after a bile duct injury. Maintaining a collegial, nonjudgmental relationship is critical in establishing positive coaching experiences.

Conclusions

An individualized surgical coaching program creates a unique opportunity for professional development and may help promote safe laparoscopic cholecystectomy.

Graphical abstractAbbreviations and Acronyms: ACS (acute care surgery), BDI (bile duct injury), HPB (hepatopancreatobiliary), LC (laparoscopic cholecystectomy), MIS (minimally invasive surgery), SJHC (St Joseph's Health Centre)Laparoscopic cholecystectomy (LC) is one of the most frequently performed operations by general surgeons. Bile duct injury (BDI) is a serious complication of LC and occurs in 0.1% to 1.5% of cases.1AbdelRafee A. El-Shobari M. Askar W. et al.Long-term follow-up of 120 patients after hepaticojejunostomy for treatment of post-cholecystectomy bile duct injuries: A retrospective cohort study., 2Pottakkat B. Vijayahari R. Prakash A. et al.Factors predicting failure following high bilio-enteric anastomosis for post-cholecystectomy benign biliary strictures., 3Diagnosis and management of biliary injuries., 4Bali M.A. Pezzullo M. Pace E. Morone M. , 5Gad E.H. Ayoup E. Kamel Y. et al.Surgical management of laparoscopic cholecystectomy (LC) related major bile duct injuries; predictors of short-and long-term outcomes in a tertiary Egyptian center- a retrospective cohort study. BDI is most commonly due to the misidentification of the cystic duct in relation to the bile duct.6Common bile duct injury during laparoscopic cholecystectomy and the use of intraoperative cholangiography: adverse outcome or preventable error?. The majority of these injuries are preventable, especially when a structured approach is used.7Safe laparoscopic cholecystectomy: Adoption of universal culture of safety in cholecystectomy. Given the high morbidity and mortality of these injuries, the importance of performing safe cholecystectomies cannot be overstated.Surgical coaching is a growing concept in the field of continuous professional development for practicing surgeons. It is described as a distinct entity from mentoring and teaching, as it enables surgeons to focus on self-identified areas of development.8Gunn E. Tambyraja A. Yule S. Personal best, could coaching hold the key to CPD in today’s face-place workplace?. In addition, experts argue that coaching for all surgeons is necessary to facilitate deliberate practice, a process thought to be essential for technical skill mastery.9Teaching surgical skills — changes in the wind. Over the past few years, several successful coaching initiatives have been described in the literature. The majority of these, however, focus on teaching new skills or new procedures to practicing surgeons or trainees.10Pradarelli J.C. Yule S. Lipsitz S.R. et al.Surgical Coaching for Operative Performance Enhancement (SCOPE): skill ratings and impact on surgeons’ practice., 11Greenberg C.C. Klingensmith M.E. The continuum of coaching: opportunities for surgical improvement at all levels., 12Bonrath E.M. Dedy N.J. Gordon L.E. Grantcharov T.P. Comprehensive surgical coaching enhances surgical skill in the operating room: a randomized controlled trial., 13Timberlake M.D. Stefanidis D. Gardner A.K. Examining the impact of surgical coaching on trainee physiologic response and basic skill acquisition. Although coaching has been shown to assist surgeons with new skill development, to date, there has been a lack of attention on understanding how coaching can assist surgeons who have experienced intraoperative errors or complications.14Pradarelli J.C. Yule S. Panda N. et al.Optimizing the implementation of surgical coaching through feedback from practicing surgeons. Expanding the scope of surgical coaching to include skill remediation is important not only for professional development, but also to improve patient safety in the operating room.Implementation of coaching programs in ways that align with surgical culture has also been challenging.14Pradarelli J.C. Yule S. Panda N. et al.Optimizing the implementation of surgical coaching through feedback from practicing surgeons. Barriers to surgical coaching and qualities of a successful coaching program have been well described in the literature.11Greenberg C.C. Klingensmith M.E. The continuum of coaching: opportunities for surgical improvement at all levels.,15Min H. Morales D.R. Orgill D. et al.Systematic review of coaching to enhance surgeons’ operative performance. In general, mutual respect and trust, transparency about each surgeon's intentions, alignment of expectations, and mutual commitment to the coaching relationship are all critical factors of a successful and productive coaching relationship.14Pradarelli J.C. Yule S. Panda N. et al.Optimizing the implementation of surgical coaching through feedback from practicing surgeons.,16Beasley H.L. Ghousseini H.N. Wiegmann D.A. et al.Strategies for building peer surgical coaching relationships. This is especially true when using coaching as a tool for surgeons who have experienced a complication—a particularly vulnerable group.

In this qualitative pilot study, we evaluated a novel individualized surgical coaching program for practicing surgeons who injured a bile duct during LC. The study objectives were to assess these surgeons' opinions of surgical coaching, their perception of BDI in LC, and their experience and impressions of the specific surgical coaching program. We hypothesized that adhering to the principles of deliberate practice, and the qualities necessary for a productive surgical coaching relationship, would ensure acceptability of this novel coaching program among the study participants.

Methods Participants

Study participants were staff surgeons who injured a bile duct during LC, and whose cases were referred to St Joseph's Health Centre (SJHC) during the study period (May 2020 to November 2020). All coaching sessions were led by 1 coach, an experienced hepatopancreatobiliary (HPB) surgeon at SJHC, a designated HPB Centre of Excellence in Ontario, Canada. Approval from Unity Health Toronto Research Ethics Board was obtained (REB# 21-023C).

 The coaching programThe coaching program consisted of 2 defined components. First, preceding the session with the surgical coach, videos of complicated gallbladder surgery, with a step-by-step approach aligned with the safe laparoscopic cholecystectomy strategy designed by the HPB team at SJHC, were sent to the participants (Fig. 1). Second, a 1-hour, 1-on-1 video conference session took place with the surgical coach (within 1 month of the index BDI) (Fig. 2).

Figure 1Step-by-step approach for a safe laparoscopic cholecystectomy. (1) Landmarking and operative planning, (2) is it safe to fire clips? IOC, intraoperative cholangiography; NIRF-C, near-infrared fluorescent cholangiography.

Figure 2Example of a videoconference screenshot from a coaching session illustrating the location of the injury relative to important surgical landmarks such as the Sulcus of Rouviere and the line of safety defining the inferior boundary for safe dissection. CBD, common bile duct.

The coaching session consisted of 2 parts. First, the coach reviewed the safe laparoscopic cholecystectomy concept with the surgeon. This included a review of the critical view of safety, as well as a landmarking technique called the line of safety. The line of safety is defined by an imaginary line through Rouviere's sulcus to the approximate junction point between the cystic and hilar plates. This line defines the inferior boundary of dissection during laparoscopic cholecystectomy. By definition, all biliary and portal structures are inferior to this line.9Teaching surgical skills — changes in the wind.,10Pradarelli J.C. Yule S. Lipsitz S.R. et al.Surgical Coaching for Operative Performance Enhancement (SCOPE): skill ratings and impact on surgeons’ practice. Error traps, strategies to handle difficult situations, safety checks, and bail-out procedures were also reviewed. Online resources, such as The 6-Step Program, as recommended by the Society of Gastrointestinal and Endoscopic Surgeons (SAGES), were also reviewed.17The SAGES Safe Cholecystectomy Program - Strategies for Minimizing Bile Duct Injuries. SAGES. Second, after review of strategies for safe LC, video of the laparoscopic re-exploration was analyzed with the index surgeon. At SJHC, surgical management of BDI begins with laparoscopy, to ascertain whether an injury has, in fact, occurred, perform a cholangiogram if possible, obtain optimal source control of the bile leak and peritonitis, and determine the best strategy and timing for definitive repair or endoscopic intervention. This initial laparoscopic assessment is recorded as part of standard practice at the institution. The recorded video was used to frame a general discussion of the thought process during the index case and to reflect on how the injury may have been prevented. At the end of the individualized review, participants had the opportunity to ask questions. The video was also used to highlight the location of landmarks like the line of safety as a means of reinforcing the value of landmarking as a tool to prevent bile duct injury. After the session, participants had direct e-mail and telephone access to the HPB surgeon, in case they had further questions. AnalysisWithin 6 months of the coaching session, a member of the research team conducted 1-on-1 semi-structured interviews over the telephone with participating surgeons to understand their experience in the surgical coaching program, as well as their broader perception of coaching in surgery. Each interview was 30 to 45 minutes in length. Questions were grouped into 3 domains: general impression of coaching in surgery, perception of complications in surgery including questions specific to BDI in LC, and personal experience in the coaching program (eDocument 1). Due to the individualized nature of the coaching program, questions were generalized and open-ended to ensure all opinions were captured.The interviews were audio-recorded, transcribed, and deidentified before analysis. One participant declined to be audio-recorded; in this case, answers were explicitly transcribed during the interview. Phenomenology-based thematic analysis was then performed, based on transcripts, to categorize feedback into common themes. Phenomenology is a qualitative research method that focuses on studying the lived experiences of others.18Neubauer B.E. Witkop C.T. Varpio L. How phenomenology can help us learn from the experiences of others. Inductive reasoning was then performed to extract common themes of each interview question, and representative quotes were selected.Results DemographicsSix of 6 surgeons who injured a bile duct during the study period consented to participate in the coaching program. In addition, all 6 agreed to be subsequently interviewed. Five out of the 6 surgeons had additional fellowship training, including minimally invasive surgery and acute care surgery. Length of independent practice ranged from 2 to 24 years (Table 1).

Table 1Demographics of Surgeon Participants

ACS, acute care surgery; LC, laparoscopic cholecystectomy; MIS, minimally invasive surgery.

 Perception of surgical coachingKey themes identified from surgeons' responses to the interview questions pertaining to their general perception of surgical coaching included the importance of coaching in surgery, informal coaching in the form of second opinions, and the new concept of individualized 1-to-1 surgical coaching and potential limitations to surgical coaching (Table 2). Participants agreed that surgeons are life-long learners, and the majority (n = 4) hoped to see more surgical coaching programs offered to staff surgeons. Four of the 6 participants noted that while everyone (medical students, residents, fellows, and staff) can benefit from coaching in different ways, depending on their level of training, staff surgeons are likely to benefit the most. Surgeons agreed that individualized coaching for practicing surgeons is beneficial in that it is more relevant, personal, empowering, and provides opportunities to learn new techniques that will change the way they practice.

Table 2Surgeon Perception of Coaching, Expectations, and Complication

 Perceptions of complications and expectations in surgeryAll surgeons expressed that they have high expectations for themselves, where they aim for complication rates lower than those reported in the literature (Table 2). Two surgeons stated that BDIs in LC are never acceptable. There is some disagreement regarding the perceived expectation of surgeons from patients and society. Although some surgeons state that patients can have very high expectations for surgeons, others believe they are generally reasonable. It is agreed, however, that the expectations and acceptance of complications differ depending on the case. This applies for both patient expectations as well as expectations from colleagues. How surgeons experienced the coaching programFive of the 6 surgeons reported having positive feelings (ie eager, excited, happy) when first approached to partake in the coaching (Table 3). One surgeon recalled feeling slightly apprehensive when first approached, but stated that the feeling quickly dissipated once the session began. There was consensus that the session was informal, very informative, and provided a nonjudgmental atmosphere in which participants did not feel shamed, but instead, empowered. All participants reported a positive experience overall. Of note, 2 surgeons noted that they knew the HPB surgeon before the session and felt that this contributed to their positive experience.

Table 3The Experience of Coaching

PTSD, post-traumatic stress disorder.

Five of the surgeons recalled a decline in their self-confidence immediately after the BDI. Four of these surgeons believed that the session helped them regain some of their confidence, while 1 surgeon expressed that they will always be more tentative moving forward. Four of the surgeons commented on the emotional aspect of the BDI, explaining that coaching played a role in their emotional recovery. Three of the 6 surgeons revealed that they learned something new in the session, while the other 3 stated that the session reinforced and helped consolidate their knowledge. There was consensus that coaching helped the surgeons refine their approach for future LC. The specifics of how it has changed their practice, however, differed among surgeons. For instance, while 1 surgeon noted that he now takes more time outs, another noted that he is less hesitant to ask for help.

All surgeons (6/6) maintained a relationship with the coach after the session. All 6 surgeons found the session useful (average rating 9.3/10) and would recommend it to a friend or colleague (average rating 10/10). When asked if they would consider partaking in a similar coaching program in the future, all surgeons said yes.

 Factors that made the session successful and areas for improvementSeveral key factors that made the coaching successful were identified (Table 4). A nonjudgmental, collegial relationship between the coach and participants was highlighted as valuable. The interactive format, in which participants were encouraged to ask questions, was also highly valued. Reviewing videos of complicated LC with the coach was among the most well received features of the program. Participants also enjoyed having materials to review before the session, which allowed them to prepare and attend with a list of questions. The 1-on-1 targeted approach was well received by all participants. Participants felt that the session was appropriately tailored to complex cases. The timing of the session was also an attractive feature of this program. In other words, scheduling coaching soon after the injury was believed to be important.

Table 4Successful Factors and Areas of the Program Needing Improvement

To improve the coaching program, multiple surgeons stated that they would like to have access to reference materials after the session, whether it be through a media library or handouts. Several surgeons also suggested an increased emphasis on the emotional aspect, as complications such as BDI can have a major impact on a surgeon's well-being. Another surgeon suggested adding an option for group coaching and anonymization of participants.

DiscussionIn this study, we evaluated a novel, individualized, surgical peer-coaching program designed for surgeons who injured a bile duct during LC. Consistent with previous literature, our findings support the utility of a peer-coaching program in the continuing professional development of practicing surgeons.16Beasley H.L. Ghousseini H.N. Wiegmann D.A. et al.Strategies for building peer surgical coaching relationships.,19Palter V.N. Beyfuss K.A. Jokhio A.R. et al.Peer coaching to teach faculty surgeons an advanced laparoscopic skill: A randomized controlled trial.,20Foley K. Granchi N. Reid J. et al.Peer coaching as a form of performance improvement: what surgeons really think. In surveying 118 surgeons from 8 surgical specialties, Foley and colleagues20Foley K. Granchi N. Reid J. et al.Peer coaching as a form of performance improvement: what surgeons really think. found that 72.9% of the participants supported peer coaching and identified 1-on-1 coaching in an individualized setting as a useful activity for continuing professional development. Similarly, in comparison to conventional surgical training, Palter and associates19Palter V.N. Beyfuss K.A. Jokhio A.R. et al.Peer coaching to teach faculty surgeons an advanced laparoscopic skill: A randomized controlled trial. demonstrated greater learner satisfaction, as well as improvement in technical performance and proficiency with peer coaching.While Mutabzic and coworkers21Mutabdzic D. Mylopoulos M. Murnaghan M.L. et al.Coaching surgeons: Is culture limiting our ability to improve?. found an initial predominant resistance to coaching in surgery, our results demonstrate that surgeons are generally accepting of coaching opportunities, especially when it aligns with their specific learning goals. This is in line with recent studies that suggest successful coaching revolves around the learner's self-identification of areas of development.15Min H. Morales D.R. Orgill D. et al.Systematic review of coaching to enhance surgeons’ operative performance. Our results also highlight the importance of timing, transparency, and discussion to align goals between the coach and participants during the initial invitation to participate. After a BDI, the surgeons in this program expressed a temporary state of decreased confidence. This coaching program provided an opportunity to review the case with an HPB expert, which, in return, helped rebuild the surgeon's confidence.Bile duct injuries are a dreaded complication associated with LC. There is an increasing body of evidence examining the psychological and emotional consequences of adverse outcomes on the surgeon.22Luu S. Leung S.O.A. Moulton C. When bad things happen to good surgeons: reactions to adverse events., 23Luu S. Patel P. St-Martin L. et al.Waking up the next morning: surgeons’ emotional reactions to adverse events., 24Pinto A. Faiz O. Bicknell C. Vincent C. Surgical complications and their implications for surgeons’ well-being., 25Improving surgeon wellness: The second victim syndrome and quality of care., 26Srinivasa S. Gurney J. Koea J. Potential consequences of patient complications for surgeon well-being: A systematic review. The results of our pilot study point to the potential of peer-coaching in helping surgeons recover psychologically after a devastating complication. This is in line with a recent systematic review evaluating the surgeon's well-being after a complication, where genuine mentorship from seniors and peers was identified as a valuable resource in the surgeon's recovery.26Srinivasa S. Gurney J. Koea J. Potential consequences of patient complications for surgeon well-being: A systematic review. Institutional support, however, is often seen as inadequate, and a culture of blame can prevail in the surgical world.24Pinto A. Faiz O. Bicknell C. Vincent C. Surgical complications and their implications for surgeons’ well-being.,26Srinivasa S. Gurney J. Koea J. Potential consequences of patient complications for surgeon well-being: A systematic review. Establishing formal mentorship and coaching programs may improve support for surgeons in the aftermath of major surgical complications.In a review article evaluating surgical education, Reznick and MacRae9Teaching surgical skills — changes in the wind. advocated for the importance of deliberate practice in the development of mastery or expertise. Ericsson27Deliberate practice and acquisition of expert performance: A general overview. argued that deliberate practice involves a reflection of thought processes, which is facilitated by feedback and training/coaching. One of the challenges with deliberate practice in surgery is that focused, directed practice can occur only with a coach present at the time of operation (logistically challenging) or the ability to video review cases. A recent study by Jung and associates28Jung J.J. Adams-McGavin R.C. Grantcharov T.P. Underreporting of Veress needle injuries: comparing direct observation and chart review methods. effectively illustrated that a surgeon's memory or recall of a particular case is limited, and that without video review, a significant number of surgical errors or near miss events are missed. The coaching program described in this study is unique in that the participants were provided with the opportunity to review the video recording of their complication, rather than BDIs in general. This 1-on-1, personalized approach and the use of individualized personal video footage created an open, interactive learning environment conducive to immediate feedback and reflection on the decision making process of the specific case, all principles essential to the concept of deliberate practice and the creation of expertise.This study is also consistent with literature that highlights the importance of mutual respect and trust in a coaching relationship.14Pradarelli J.C. Yule S. Panda N. et al.Optimizing the implementation of surgical coaching through feedback from practicing surgeons. Coaching can place surgeons in a vulnerable position, wherein they may question their identity as a competent surgeon.29Byrnes M.E. Engler T.A. Greenberg C.C. et al.Coaching as a mechanism to challenge surgical professional identities. Therefore, it is imperative that coaching is offered in a way that empowers the individual, and promotes a lasting and meaningful relationship. All of our surgeons believed that by maintaining collegiality, transparency, and a nonjudgmental attitude, the coaching relationship became one that was empowering and confidence building. This is congruent with previous studies that describe characteristics of a successful surgical coaching program.14Pradarelli J.C. Yule S. Panda N. et al.Optimizing the implementation of surgical coaching through feedback from practicing surgeons.,16Beasley H.L. Ghousseini H.N. Wiegmann D.A. et al.Strategies for building peer surgical coaching relationships.Biliary injuries remain among the most serious complications of LC, and considerable work has been done to attempt to reduce its incidence in recent years. These include, but are not limited to, the SAGES Safe Cholecystectomy 6-Step Program and didactic modules,17The SAGES Safe Cholecystectomy Program - Strategies for Minimizing Bile Duct Injuries. SAGES. as well as the recent published consensus guidelines on prevention of BDI during cholecystectomy.30