HPB P62 Is it time to introduce intraoperative ultrasound into surgical training?
Authors: Holmes Matthew , Aroori Somaiah 
Published: December 2022

Abstract

Background
Gallstone disease is one of the most common causes of abdominal pain and emergency hospital admissions in the UK. Those patients that have symptomatic gallstones in the gallbladder will be offered a laparoscopic cholecystectomy (LC) as treatment and therefore reduce the risk of developing further complications. Confirmation of bile duct stones before or at the time of LC is essential in order to prevent complications.
There are three main ways to identify bile duct stones intraoperatively: x-ray cholangiography, fluoroscopic cholangiography and intraoperative ultrasound (IOUS). X-ray cholangiography is the most commonly used method intraoperatively as it is effective in identifying biliary anatomy and bile duct stones, can be repeated and has good deep tissue penetration. However, it is an invasive procedure that requires the use of ionising radiation. IOUS on the other hand is non-invasive, does not involve ionising radiation, is able to detect vascular anatomy and arguably has a shorter learning curve compared to the other two methods.

Methods
IOUS is not currently taught on the surgical curriculum. In response to this, we have set up the Laparoscopic Hands-on Intra-operative Ultrasound (L-HOUS) course which takes place over a two-day period.
The first day is delivered through interactive seminars and practice on phantom models. The topics covered are: the basic principles of the technique; the relevant anatomy; the role of IOUS in gallstone disease; and the role of IOUS in biliary surgery and various other non-HPB conditions. The afternoon is dedicated to demonstrating how to set up the equipment, the step-wise approach to IOUS of the biliary system, and hands-on practice using phantom models.
The second day takes place in the operating theatre and offers delegates the opportunity to perform IOUS of the bile duct in real clinical cases. Delegates rotate around to practice their IOUS skills under the supervision of the operating surgeon, while un-scrubbed delegates are able to watch the surgery via a video link from the seminar room.

Results
The course has been run on four occasions and attracted 21 delegates since its inception in 2017. The vast majority of delegates have been senior general surgical trainees or post-CCT fellows, in addition to one consultant. The feedback received was overwhelmingly positive and the course has evolved at each iteration to reflect the comments from delegates.

Conclusions
This is the only course in Europe that offers delegates hands-on experience in developing IOUS skills under specialist guidance. Crucially, hands-on experience has been shown to have better outcomes in relation to ultrasound training when compared to simulation or classroom-based methods. This concept fits in unity with Edgar Dale's pyramid of learning whereby students are more likely to retain information that they have practiced ‘doing’ compared to other visual or auditory methods of teaching.
Given the benefits of IOUS in terms of cost, and reduction in additional procedures or investigations, we argue that the technique should be included in the surgical training curriculum. One of the main reasons for poor uptake of a one-stage approach to bile duct stones using IOUS is lack of formal training. Given there will likely be an increase in the adoption of the IOUS technique in coming years, it is vital to equip current trainees with the necessary skills within their training pathway. However, prior to this it is imperative that trainees have access to high-fidelity training opportunities to develop skills that will be used routinely in future practice.