Section Three (Bile Duct)

The third module section was labelled Bile Duct. It has eight parts with the last part marked as optional. Part one contained two MCQs (Appendix 24). The first question was a single answer MCQ about the most common cause of a bile duct injury during laparoscopic cholecystectomy, which was the surgeon’s misinterpretation of biliary anatomy. The second question required more than one answer and checked the candidates’ knowledge about intra-operative cholangiogram indications. The feedback screen expanded by explaining the hazard caused by the tenting effect. (Tenting effect happens as a result of the normal technique used to expose the field

during laparoscopic cholecystectomy. It does change the normal anatomy. However such a change should be accounted for during the operation. This is explained more in the video lecture at the end of this section (page 8)).

Part Two has one MCQ (Appendix 25). This question showed a video clip highlighting the main dissection and clipping moment in an operation and asked candidates to choose the name of the dissected and clipped structure from the list of options. The feedback screen named the structure as the common bile duct. It also prepared candidates to expect a clip from an advanced stage of the same operation (Appendix 26).

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Part Three video clip showed the full scale damage as a result of cutting the clipped duct and asks for the injury’s Bismuth-Corlette classification (see Appendix 27). It also had a warning message about the hazard caused by the low image quality in this operation (In the last two videos the overall image quality was very poor and should

be considered a risk in itself. In a modern operating theatre a much clearer image should be achieved). The feedback screen showed the injury illustration sketch

inserted by the YouTube video owner (Appendix 28). This sketch was cut off the video section used in the question, to prevent revealing the answer, also it was used as an extra illustration tool in the feedback page.

Part Four had two MCQs, questioning the reasons behind the damage presented in Part Three and the expected management plan (Appendix 29). This part teaches candidates about potential root causes of the damage and takes the message further. Rather than asking about the critical view mentioned in Section Two of the module, this question used the practical steps for creating such a view as an option to check candidates’ awareness. Dissecting the gall bladder off the liver to expose Calot’s triangle was an essential step to establish the critical view. This option was added to the other two causes for the damage: Failure to reflect the gall bladder upwards to

check behind the Calot’s triangle and Poor quality image (Appendix 30). The last

two causes should not have distracted candidates from the main safety step in this operation which was the critical view that has been stressed in Section Two. The second question in Part Four highlighted the scale of the damage caused by

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reminding candidates about the complex procedure needed to repair the resulting complication.

Part Five requested that candidates match the laparoscopic view presented in an operation video clip with the possible anatomical damaged sketches (Appendix 31). It followed a similar methodology to the matching question in Section Two part one by presenting the selected sketch below the question (Appendix 32). Once the answer was submitted by pressing the Next button the feedback page would be presented with a note describing the patient’s full recovery, following a successful repair in a tertiary centre four months after the injury (Appendix 33). This message was an indirect reminder about the need for a tertiary centre referral due to the complex nature of the procedure needed to repair such damage.

Part Six MCQ showed a video of an accessory duct (Appendix 34 and 35). The two clips used in the question and in the feedback page were extracted from a single YouTube video. This YouTube video presented a dilemma in the processing phase. It displays the name of the cystic duct and the accessory bile duct clearly in the video. After multiple attempts to split the video in various ways I found it helpful to leave the cystic duct name on screen as it would eliminate any confusion with the common bile duct injury scenario explored in the last few parts. This on-screen label worked as a signpost to tell candidates that we are switching topic. I had to cut the part showing the name of the accessory off the video clip and merge the parts before and after to create the video used in the question. The removed video part with the accessory duct’s name showing was used as feedback.

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Part Seven started with a scenario setting message (During laparoscopic

cholecystectomy the surgeon encountered some difficulty in isolating the cystic duct, forcing him to undertake retrograde dissection. The gallbladder attachment to the common bile duct is very wide (1.5 cm)). This message was followed by an operation

video clip showing the last step in gallbladder dissection with an abnormal cystic duct or rather the absence of it. This clip was followed by two questions (Appendix 36). The first question was a management MCQ question allowing more than one option and the second question asked about the eponymous name used to describe this presented pathology. Feedback followed the same principles and provided two videos (Appendix 37). The first feedback video showed the management steps taken by the surgeon in the operation and the second video showed an example of Mirizzi type I syndrome which was the other variation of Mirizzi type II syndrome presented in the operation above. This feedback video had on-screen marks and drawings to highlight anatomical elements and re-stress the importance of establishing critical view.

Part Eight was an optional part, with the ability to email links to candidates’ email addresses by a press of a button (Appendix 38). It had three extra bile duct injury video examples and two extra accessory duct video examples. They were all YouTube streaming videos with the content highlighted and the important points clearly displayed before each video. The first bile duct video was approximately eight minute long and was about bile duct injury, with possible clues to spot and avoid such danger and best injury repair approaches. The second and third videos presented the following: (the detection of bile duct iatrogenic injury, during

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laparoscopic cholecystectomy due to low dissection and the omitting of the critical view technique). The two accessory bile duct examples showed different methods of

dealing with this anatomical variation after it had been identified. Those optional videos were selected from the pool of videos that I was not able to gain permission to download and process. They stressed the message further, and provided extra

training opportunities if candidates wished to watch them. If processing those clips had been permitted they would have been included in the module essential part but they were excluded currently to keep the module time length reasonable.