Surgical Endoscopy

, Volume 26, Issue 9, pp 2403–2415 | Cite as

Development and evaluation of a laparoscopic common bile duct exploration simulator and procedural rating scale

  • Byron F. Santos
  • Taylor J. Reif
  • Nathaniel J. Soper
  • Alexander P. Nagle
  • Deborah M. Rooney
  • Eric S. Hungness



Laparoscopic common bile duct exploration (LCBDE) is an effective, single-stage treatment for choledocholithiasis. However, LCBDE requires specific cognitive and technical skills, is infrequently performed by residents, and currently lacks suitable training and assessment modalities outside of the operating room. To address this gap in training, a simulator model for transcystic and transcholedochal LCBDE was developed and evaluated.


A procedure algorithm incorporating essential cognitive and technical steps of LCBDE was developed, along with a physical model to allow performance of a simulated procedure. Modified Objective Structured Assessment of Technical Skills (OSATS) rating scales were developed to assess performance on the model. Construct validity was assessed by comparing the performance of novices (residents and surgeons without LCBDE experience) versus experienced subjects (surgeons with previous LCBDE experience). Concurrent validity was assessed by comparing scores from the LCBDE scales to those from the standard OSATS scale. Internal consistency and interrater reliability were assessed by comparing performance scores assigned by three independent raters.


Sixteen novices and five experienced subjects performed simulated procedures, with novices scoring lower than experienced subjects on both transcystic (20 ± 3 vs. 33 ± 2 [possible score range, 0–45], p < 0.001) and transcholedochal (25 ± 8 vs. 42 ± 3 [possible score range, 0–53], p < 0.001) rating scales. Scores on the rating scales correlated significantly with scores from the standard OSATS scale. Internal consistency and interrater reliability of the LCBDE rating scales were favorable.


The LCBDE simulator is a low-cost yet realistic physical model that allows performance and evaluation of technical skills required for LCBDE. The LCBDE rating scales show evidence of construct validity, concurrent validity, internal consistency, and interrater reliability. Use of the LCBDE model and associated rating scales allows procedure-specific feedback for trainees and could be used to improve current training.


Laparoscopic Common bile duct exploration Simulation Education Validation 


  1. 1.
    Tranter SE, Thompson MH (2003) Spontaneous passage of bile duct stones: frequency of occurrence and relation to clinical presentation. Ann R Coll Surg Engl 85:174–177PubMedCrossRefGoogle Scholar
  2. 2.
    Rhodes M, Sussman L, Cohen L, Lewis MP (1998) Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones. Lancet 351:159–161PubMedCrossRefGoogle Scholar
  3. 3.
    Tranter SE, Thompson MH (2002) Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct. Br J Surg 89:1495–1504PubMedCrossRefGoogle Scholar
  4. 4.
    Christensen M, Matzen P, Schulze S, Rosenberg J (2004) Complications of ERCP: a prospective study. Gastrointest Endosc 60:721–731PubMedCrossRefGoogle Scholar
  5. 5.
    Martin DJ, Vernon DR, Toouli J (2006) Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev:CD003327Google Scholar
  6. 6.
    Poulose BK, Arbogast PG, Holzman MD (2006) National analysis of in-hospital resource utilization in choledocholithiasis management using propensity scores. Surg Endosc 20:186–190PubMedCrossRefGoogle Scholar
  7. 7.
    Bell RH Jr, Biester TW, Tabuenca A, Rhodes RS, Cofer JB, Britt LD, Lewis FR Jr (2009) Operative experience of residents in U.S. general surgery programs: a gap between expectation and experience. Ann Surg 249:719–724PubMedCrossRefGoogle Scholar
  8. 8.
    Chung R, Pham Q, Wojtasik L, Chari V, Chen P (2003) The laparoscopic experience of surgical graduates in the United States. Surg Endosc 17:1792–1795PubMedCrossRefGoogle Scholar
  9. 9.
    Ponsky JL (2010) Laparoscopic biliary surgery: will we ever learn? Surg Endosc 24:2367PubMedCrossRefGoogle Scholar
  10. 10.
    Doraiswamy A, Phillips EH (2009) Surgery of the extrahepatic bile ducts. In: Swanstrom LL, Eubanks WS, Soper NJ (eds) Mastery of endoscopic and laparoscopic surgery. Lippincott Williams & Wilkins, PhiladelphiaGoogle Scholar
  11. 11.
    Reznick R, Regehr G, MacRae H, Martin J, McCulloch W (1997) Testing technical skill via an innovative “bench station” examination. Am J Surg 173:226–230PubMedCrossRefGoogle Scholar
  12. 12.
    Watson MJ (2004) Laparoscopic CBDE. SAGES Top 14: procedures every practicing surgeon should know, Cine-Med, Inc., WoodburyGoogle Scholar
  13. 13.
    Scott DJ, Dunnington GL (2008) The new ACS/APDS skills curriculum: moving the learning curve out of the operating room. J Gastrointest Surg 12:213–221PubMedCrossRefGoogle Scholar
  14. 14.
    Scott DJ, Watson MJ. American College of Surgeons: Division of Education: Surgical Skills Curriculum InformationGoogle Scholar
  15. 15.
    Martin IJ, Bailey IS, Rhodes M, O’Rourke N, Nathanson L, Fielding G (1998) Towards T-tube free laparoscopic bile duct exploration: a methodologic evolution during 300 consecutive procedures. Ann Surg 228:29–34PubMedCrossRefGoogle Scholar
  16. 16.
    Lyass S, Phillips EH (2006) Laparoscopic transcystic duct common bile duct exploration. Surg Endosc 20(Suppl 2):S441–S445PubMedCrossRefGoogle Scholar
  17. 17.
    Fanelli RD, Gersin KS (2001) Laparoscopic endobiliary stenting: a simplified approach to the management of occult common bile duct stones. J Gastrointest Surg 5:74–80PubMedCrossRefGoogle Scholar
  18. 18.
    Cameron BH, O’Regan PJ, Anderson DL (1994) A pig model for advanced laparoscopic biliary procedures. Surg Endosc 8:1423–1424PubMedCrossRefGoogle Scholar
  19. 19.
    Crist DW, Davoudi MM, Parrino PE, Gadacz TR (1994) An experimental model for laparoscopic common bile duct exploration. Surg Laparosc Endosc 4:336–339PubMedCrossRefGoogle Scholar
  20. 20.
    Watson DI, Treacy PJ, Williams JA (1995) Developing a training model for laparoscopic common bile duct surgery. Surg Endosc 9:1116–1118PubMedGoogle Scholar
  21. 21.
    Common Bile Duct Exploration Model | Practice Common Bile Duct Exploration | Simulab CorporationGoogle Scholar
  22. 22.
    Bittner JG, Mellinger JD, Imam T, Schade RR, Macfadyen BV Jr (2010) Face and construct validity of a computer-based virtual reality simulator for ERCP. Gastrointest Endosc 71:357–364PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Byron F. Santos
    • 1
  • Taylor J. Reif
    • 1
  • Nathaniel J. Soper
    • 1
  • Alexander P. Nagle
    • 1
  • Deborah M. Rooney
    • 1
  • Eric S. Hungness
    • 1
  1. 1.Department of SurgeryNorthwestern University, Feinberg School of MedicineChicagoUSA

Personalised recommendations