E107 Masterclass with Francis Sutherland on Common Bile Duct Injuries and Cognitive Biases
Listen to this podcast on SoundCloud
Chad Ball 00:12
Welcome to the Cold Steel podcast hosted by Ameer Farooq and myself, Chad Ball. We consider it an absolute privilege to bring you guests from around the world who are truly experts in their craft. Our mission is to offer you a combination of not only master classes on clinical surgery topics, but also insights into achieving personal growth, productivity, and fulfillment as both a surgeon and perhaps more importantly, as a human.
Ameer Farooq 00:43
This week, we had a masterclass on common bile duct injuries by Dr. Francis Sutherland. Dr. Sutherland is a hepatobiliary surgeon at the University of Calgary. Dr. Sutherland talks about not just how CBD injuries happen, but why they happen and the cognitive biases that lead up to them. Please check out the show notes for videos and papers that supplement our discussion.
Francis Sutherland 01:05
I'm born in Edmonton. I don't like to tell people that, but we moved to Calgary in 1960. Dad was an ophthalmologist. I grew up here largely going to the mountains to go skiing and did my med school here and then, my surgical training here. Did a 2-year transplant fellowship. Kidney and liver in London, Ontario, with a fella named Bill Wall and of course, Dave Grant. Really got my grounding in liver and bile duct surgery there. And came back to Calgary in 1990 and started in with general surgery and a small amount of hepatobiliary, but mostly transplant. I ran the kidney transplant program here for about 8 years until I kind of burned out. Then went back to do a sabbatical in France. So, we flew the whole family over to Rennes, it's a small place in Brittany. And we did a wonderful sabbatical with a fellow named Bernard Launois, who is really a pioneer hepatobiliary surgeon. And it was a marvelous year and really got me going on HPB surgery. Which, I came back and really for the past 20 years, have been doing HPB both at the Peter Lougheed and here in Foothills. Well, that's the nutshell.
Ameer Farooq 02:41
You really have a perspective on the way that surgery has evolved, both locally in Calgary, obviously, but also more generally. And I think one of the neat, amazing things about what you just described is you going to do a sabbatical in France. So, I'm curious what that experience was like after having done, obviously, a lot of surgery for those few years. Doing transplant surgery and then deliberately going and doing a sabbatical in France, and what that experience was like. And the second thing, just to add on to that is that I think as part of that experience, you actually ended up writing a review that's in JAMA that talks about the life of Couinaud, who the liver segment system is named after. Could you talk about both of those things?
03:29
You know, I highly recommend sabbaticals for surgeons. I know it's a very difficult thing to do, because to step away from your practice and your referral base is very hard. But I had an opportunity when I stopped transplant to retool. And I got what's called a "professeur associé" position in France. And the French government puts these out every year and they basically pay people outside of France to come and learn how to do things properly. And the French have a long history of liver surgery, going back to Lortat-Jacob and the first hepatectomy and of course, Claude Couinaud. And then a whole string of, of liver surgeons, including Bernard Launois. So, it was a wonderful opportunity to take our young children and then try to learn French and try to immerse ourselves in the culture. Bernard and I would operate every day, just him and I. One case, we'd stop for lunch. It was quite an experience. I have to recommend it to anybody. In terms of Claude Couinaud, I spent a lot of my time studying anatomy. And for some reason, liver anatomy has really fascinated me, and this was an opportunity for me to sit down and read all the books. And one day, I was talking to Bernard and just saying how much I've been reading Claude Couinaud and he had a copy of his original book, Le Foie. And I asked him about him, and he said, "Oh, he's in Paris, he's still alive." And he said he would introduce me. And so, I had a friend in Rennes who I'd met, from Ottawa, and she was a historian of all things. She and I got on the train and went to Paris and interviewed Claude Couinaud in his apartment in Paris and spent 3 or 4 hours with him. Talking about his work on a liver anatomy and how he did all his casts and his life in in surgery and all the innovations that he'd done. Of course, it was all in French. She spoke perfect French, and we translated it and eventually resulted in an article, Claude Couinaud. And is really, his biography. So, it was a lifetime experience, for sure.
Ameer Farooq 06:04
I'd highly recommend any of our listeners to read that paper. It's a really fascinating read and really enjoyable. As I sort of alluded to in my previous comment, you obviously have been able to see the evolution of the way surgery has gone, particularly with regards to HPB. You've had your fingers in so many different aspects of surgery, from transplant to HPB, and obviously, you've done the full gamut of general surgery across the board here in Calgary. What do you think are the big things that have changed in your mind? Obviously, there's the technological advances, but I'm thinking more along the lines of the way that we work and the way that we practice. What are the big things that have shifted over the course of your career that you, perhaps, weren't even expecting?
Francis Sutherland 06:53
Well, I mean, who can expect, who can really predict what's going to happen in the future? Gosh, you have to really think hard to go back 30 years to how it was. And when I started my training, family doctors were still doing inguinal hernia repairs at the Foothills Hospital. And we look at how surgery has changed. Really, one of the areas that it's probably changed the most is just in terms of sub-specialization and getting everybody in to do a little narrower practice, and the resulting massive improvements in the quality of surgical care that's been delivered, I think, is probably the biggest change. We tend to be narrower, and we tend to be better at what we do now. And I think it's been a great benefit to our patients. Not that general surgeons aren't still important. But you know, I think that the idea of the generalist being able to do it all just it doesn't work anymore. And the other thing that's changed is the fact that we treat almost every patient. There's not anybody where we say, "Oh, there's nothing we can do for you." We really have extended the indications for surgery and, I think, can help a lot more people.
Chad Ball 08:18
That's an interesting perspective, being able to tell someone that you can't treat them you're right, is not something that we do often. Even in HPB, which is interesting. I was hoping that we would go deep on bile duct injuries and some of the concepts that you've really pioneered that surround it. For me, I don't just say this because you're my mentor and my partner, but I think of the titans of modern bile duct injury work, I think of Michelle Mercado in Mexico, I think of Kiefer Lumeau in the US and Steve Strasburg. I put you as the 4th member of that selective group. You've really thought about these deeply and profoundly, for a very long period of time. I'm curious to start out with them. What prompted you to think about them in such a deep way? Even more than most HPB surgeons. Why has it been such an interest for you for so long?
Francis Sutherland 09:12
Well thanks, Chad. I think, when I came back from France in 1999 and started in really hard at my HPB surgery practice. I just started to see a lot of these injuries and really got the sense of how devastating the injury is to the patients. But not just the patients, but to the surgeons themselves. I mean, it is an emotionally draining experience, a loss of confidence. And the consequences can have a profound effect on someone's career. So, there's lots of reasons to try to avoid these injuries. So, after fixing and dealing with the fallout from a lot of these injuries, that I really started to get an interest and started to read. Clearly, I went through the period of introduction of laparoscopic cholecystectomy and saw the rates go massively up and then stay up. Really, they've stayed up through my whole career. And then, starting to read and then starting to see people trying to get a handle on it. You know, Steve Strasburg's Critical View of Safety in 1995. But really, the landmark papers that got me going were, Lawrence Way's paper on the illusion of bile duct injuries and the fact that it's really not a technical error, it's an error in perception. It's this whole idea of difficulty in perception that really struck me as particularly interesting. And then after that, standing on the shoulder of giants, an Australian surgeon named Thomas Hugh has written a lot about the navigation air that bile duct injuries are, on top of the illusion. He's a guy that went over and did a full sabbatical, a full master's on bile duct injuries. And then, has written extensively on landmarking and the illusion, and a lot of the things that I've just extended the observations. And so, a lot of what I'm talking about isn't original, but it is something that I've taken up from some of these other giants in the field.
Chad Ball 09:16
Well, you're right, but you're also overly humble, I assure you of that. When I see you talk about this, especially recently, you sort of divide your grand rounds and your lectures into 2 dominant areas. The first is, you seem to talk about how these injuries happen. And the second is avoiding them, which I think makes a lot of sense. So, I was wondering if you could start us off, then, with how they happen, what's going on in that surgeon's mind, and failures of navigation and correction in particular?
Francis Sutherland 12:17
Yeah, I've tried to compartmentalize it in terms of why it happens. And really compartmentalize it into the 3 things. In terms of, how do we think? You know? And one of the things that really got me going on this was reading Daniel Kahneman's book, Thinking Fast and Thinking Slow. And then getting interested in cognitive psychology. And that really got me going in terms of thinking about trying to apply that to surgery and how we think when we operate, and how we've inherited a lot of our basic thought processes from our ancestors. And how did homosapiens really function on the African savanna? And how the thinking, how the fact that we've been mostly, all our evolution has been as big game hunters and how that process goes. And how the fact that we have to be thinking very quickly. We have to be able to process, deal with ambiguity, deal with uncertainty, and make an indefinite percept, definite, and move forward. And you see that in the way surgeons operate. We think very quickly, we use heuristics and shortcuts. And we move very quickly forward. That whole concept really gets consolidated in the idea that we operate with cognitive maps. And we place the map or the construct onto the anatomy that we find, and this allows us to move very quickly forward with making a lot of assumptions. And without dissecting everything carefully, we can basically put our map on the basis of a few landmarks and then do the dissection. So cognitive maps are really one of the things that I really started to think about a lot. There's a professor here at the University of Calgary, named Giuseppe Aria, who I've talked to and collaborated with a little bit. He is doing all kinds of original research on cognitive maps in our large-scale environment and how we use cognitive maps to navigate. And that concept of large-scale environment cognitive maps, we basically take a look at the surgeon's small-scale environment. And how we use cognitive maps to navigate through our operative field based on landmarks and knowledge that we've stored over many, many years of developing our skills. When you think about it carefully, all our training and all the work we do in terms of understanding surgery, is really just building up a library of cognitive maps. And they're schematized. And we hold them in our mind. And we bring them forward whenever the situation arises and use them in our dissections. And so, if you understand the idea of cognitive maps and how surgeons think, then you can apply that to say, "Well, what happens when it goes wrong?" And that is really a little bit about why we fail to navigate. I used to call it a failure of perception, but now I call it a failure of navigation, based on a lot of Thomas Hugh's work. And so, the concept here is that a surgeon navigates his field. And at the starting point of that operation, there's a critical moment where he uses the anatomy present and places his or her cognitive map on the area to operate. That's the concept. And so, if you get that starting point wrong in your dissection, then everything else that goes after that can be a disaster. And for cognitive maps and for the sub hepatic space, the mistake would be that, say there's some inflammation and there's no proper hepatobiliary triangle, your attention is diverted over to the central porta hepatis, you place your cognitive map by mistake in that area, and then start your dissection. What results is the division of the common hepatic duct as if it's the cystic duct. And then working your way up, making a critical view of safety, working your way up the left side of the bile duct like it is the underside of the gallbladder and then using the cautery to go right through the common hepatic duct. Or if you're really disoriented, go right through the hilar plate, and do a hilar plate injury, which is of course even more of a disaster. Now the really sinister thing about this is that, once you've divided through the bile duct, it places you back in the right plane, you take out the gallbladder, and half of these cases, the surgeons don't even recognize that what they've done is take out a chunk of gallbladder and left the bile duct, hepatic duct open. So, it's a really difficult thing to understand, but I think that a cognitive map gives us a little bit of an idea how the navigation error actually happens. The second thing that we've looked at, and we did this together, is to look at an illusion. And it was really Lawrence Way that really brought that forward that what's happening to the surgeons is an optical illusion. And that's a situation where, even quickly, our automatic thinking system misinterprets the anatomy present and even with a lot of thought and careful analysis, you still get it wrong. So, it's a very dangerous situation for a surgeon and it was Hugh that really showed a diagram where the bile duct kinks, and this is how the illusion happens. This is what brings the surgeon into the central porta hepatis triangle, looking at that kink with the pulling of the Hartmann's pouch, kinking of the common hepatic and the common bile duct. So, we did a little study where we looked and see, does this really happen? Does the bile duct really kink? And so, we took over 100 pictures and then analyzed it, and we found out that, yeah, the bile duct really can kink. And the angle that it produces can overlap with the angles of the hepatobiliary triangle. So, we thought that that really shows that indeed, an illusion may be part of this injury. So that's our failure of navigation. And then the third part of it, the third part of this triad is a failure of correction. And this really deals with why, when we start making an error, do we not find it, correct it, and then get back into the right area? This deals with cognitive biases, which are systematic errors that we all make. It's, sort of, jumping to conclusions and not fixing them. And some of them are particular, there's hundreds of them, but some of them that are particular to surgeons are privacy, so what we see first, it's difficult to get off that. Availability bias, it's hard to think of another avenue to operate in. Action bias, we all want to go forward, we want to go forward quickly. So, there's a bias to keep things moving. Confirmation bias, that's probably the granddaddy is that once we decide what we're going to do, and what the things is, everything else we see, confirms our original opinion. And lastly, overconfidence. Surgeons suffer from this, and it can get as bad as hubris. So those can all predispose to errors. And those are all, you know, inherited things that we do. So those are the 3 areas that we worked on, but cognitive maps are really the central part of, and sort of what we've taken beyond, the simple failure of perception.
Ameer Farooq 21:22
I always get so excited when someone talks about Daniel Kahneman. I just think his work has impacted so many different areas of the way we think, the way we understand the way that we think. Just this week, I was reading a paper of his, where he looked at pain that people had after having colonoscopy. And just like a simple thing that, they left the scope in at the end of the case, without moving it, so that the very end of the case was less painful. Patients had a better overall experience. There's just so many things that Kahneman has had an impact on.
Francis Sutherland 21:58
I read his book over and over. And every time I read it; I learn something new. Just the whole concept of how we learn things and how a resident operates, gets better at operating, versus somebody who is experienced. It's fascinating.
Ameer Farooq 22:20
He actually has a new book that's coming out recently, as well, which I think is also going to be equally as fascinating. I wanted to ask you, though, there's two parts. One is, I remember as a resident, you actually had done some studies and looked at actually how people use landmarking. And I remember being part of this study where you actually had us kind of, this virtual map when you were kind of going through the city and you asked participants to recreate their mental map. I'm curious what that study showed. And then the second question I have for you is, why was there an increase? What's different about laparoscopic surgery that this optical illusion happens where you think that you're dissecting on the cystic duct, but you're actually dissecting on the common bile duct?
Francis Sutherland 23:13
Really, now we're getting into the whole idea of, how do we avoid bile duct injuries? And that's where the landmarking study, and I like to say that this is my landmark study, it's the only way I'll ever say it. And Chad was obviously involved with this significantly. So, I mean, Thomas Hugh, again, one of my heroes, he published a paper in, oh, it's got to be in the 90s, looking at the sulcus of Rouviere as a landmark for navigating the cholecystectomy. And so, that really got me thinking that perhaps there are other landmarks there, that will help us set our cognitive map, set our navigation, so that we can navigate clearly with the right starting point. And so, we did a little study where we basically took pictures and looked at the subhepatic space, and about 130 consecutive laparoscopic cholecystectomies. And then we analyzed and cataloged the landmarks below the liver that could be used to orient for cholecystectomy. And, you know, there's 3 things about a landmark you have to have to make it useful. I mean, the first thing is, it has to be there in a large number of the cases. The second is, it has to be easy to identify and find. And lastly, it has to give you good relational information about the critical structures that you're either trying to find or avoid. So, we were looking for landmarks that would meet those criteria. After the review of 130 of these cases, we came up with the 5 landmarks and that are consistently there a lot and give good information on where you are in space, given that spatial disorientation is the ultimate mistake. And Chad came up with the mnemonic, B-SAFE. So, the 5 landmarks are, first of all, the bile duct, which is probably the best landmark if you're trying to avoid the bile duct, and you can identify the bile duct, that really is critical. And that's what a lot of our maneuvers are. That's what the cholangiogram is for, and the ultrasound, and all the other things that they used to prevent injury. So, we found actually that, in almost 80% of the cases, if you push the duodenal down, or you push the liver up, that you can see a portion of the bile duct and identify where it is. I think that's a useful observation in and of itself. The second landmark was the sulcus of Rouviere again, from Hugh's work. It's an excellent landmark because it is always at or below the hepatobiliary triangle. So, if you're operating below the sulcus of Rouviere, you're too low. The third one was the hepatic artery, not really recognized before, but if you look carefully, you can almost always see the pulsation of the left hepatic artery. That tells you where the left side of the porta hepatis is. The third landmark is the umbilical fissure. Again, if you're below the umbilical fissure, you're way too far to the patient's left. And the last landmark is E for enteric. And that means the duodenum. If you're close to the duodenum, you're too low. So, I mean, the navigation error is, to understand, when you're operating in the porta hepatis, you're too far to the patient's left, and you're too low. So, if you see that you use these landmarks, and you see that you're in that space, or you're under the umbilical fossa or you're under the sulcus of Rouviere, or you're on the left side of the bile duct, you know, three dimensionally, that you are in the wrong space and the flag should go up and you have to reorient. We're all talking about orienting during laparoscopic cholecystectomy. The laparoscope question? Well, it is a very interesting question. And it is interesting that in the early 90s, when bile duct injuries went crazy, that's when the laparoscope was introduced. There's several things that happen in a laparoscope that you don't get when you're open. When you're open, you really do look and understand the subhepatic space and the porta hepatis, the stomach, the markings on the liver. And when you're doing the laparoscope, you're using a laparoscope, your view becomes very much diminished, very much narrowed, and you tend to focus and get close, and you lose all of those landmarks. So, it's very much easier to become disoriented and misplace your map. And the other thing that I think is really important is that the old-time general surgeons that would do common duct explorations, and they would do maybe a few Whipples and some gastroectomies. I mean, they really understood the porta hepatis and, of course, open cholecystectomies. And the students, the kids that are coming out today, they don't have that experience. So, their cognitive map is very diminished. They don't have a full understanding anymore of this anatomy. And really, the B-SAFE landmarks to orient during laparoscopic cholecystectomy are a way for our young surgeons to expand their cognitive map, so they can orient more correctly.
Ameer Farooq 29:27
I recently listened to a podcast, and I'll link to it here in the show notes, where there was a great discussion among a bunch of different surgeons, and they were actually talking about fenestrating and subtotal gallbladders. There's one camp that said, "Well, why would you do this subtotal or fenestrating when you could open and use your hand and really try to get the gallbladder out that way?" And the other group was saying, "Well, you can get into all sorts of trouble doing that as well." It's slightly off our topic of cognitive illusions. But I'm curious, with this divide in training regimes and training experience, how you view the move of opening when you're struggling to actually find the critical view?
Francis Sutherland 30:13
Well, I think that it really talks a lot about how things have changed for surgeons. And really, I think it's really important for surgeons to know what they're capable of. I think it is one fundamental thing that really deals with patient safety. And it is unfortunate that many young surgeons really don't feel they have the capability to do an open cholecystectomy and it's hard to train to do an open cholecystectomy because you might only see them when you're doing your hip mobility, rotation. And there might only be a few. And they're done with normal gallbladders too. So, getting that experience of an open cholecystectomy with a plane gallbladder is extremely difficult. Now, the idea of a subtotal, I do them all the time. And I think it's the way to go. I do them open and I do them laparoscopic and my default, because I'm comfortable, is to go open. I think the idea that you always have to remove the gallbladder is just wrong. No gallbladder absolutely has to be removed. And we can treat these things with tubes and a radiologist can fish the stones out and crush them. So, we shouldn't ever feel pressured to take out a gallbladder. The other thing is that sometimes the gallbladder wall doesn't even exist. So, if you're trying to take out a gallbladder where it doesn't exist, you're really gonna hurt something. And the gallbladder might be fused to the common bile duct, it could be fused or nonexistent to the duodenal or liver. And more and more, I find myself taking out as much of the gallbladder as I'm comfortable with. I think the key is probably taking out all the stones and then either closing the stump or just draining it. It's the safest thing to do and, really, you can keep yourself out of trouble. It's when you try to do too much that you really can make things go badly.
Chad Ball 32:35
I think that's beautifully said, obviously, and I would point our readers again to Strasberg's classification of subtotal cholecystectomy in the Journal of the American College, I think about 2016 or so. You know, he talks about fenestrating cholecystectomy versus reconstituting cholecystectomy, under the umbrella of partial cholecystectomy. I think the classification is a little bit arbitrary, but it is well-defined. The fenestrating side of things doesn't really occlude the gallbladder, whereas your reconstitution version of it will leave a remnant gallbladder. One of the things I think that we all see as HPB surgeons, in terms of referrals, is more and more remnant cholecystitis and biliary colic as related to that. And certainly, I think your comment about removing the stones is probably critically, eh?
Francis Sutherland 33:25
Yeah, I've never had to go back and take out a stump when the surgeon's taken out the stones or I've taken out the stones. It's only when that's not done that, they can get recurrent and it's not a very fun operation to go back.
Chad Ball 33:47
No, it's true.
Francis Sutherland 33:48
I always go laparoscopic, but then some of them go open.
Chad Ball 33:53
I wanted to sneak back in, you used the sentence, but we certainly haven't explored it. And that's an intraoperative cholangiography. I think we all know that these large multinational population-based studies all show that routine intraoperative cholangiography certainly doesn't seem to be beneficial or, in particular, lower your biolect injury rate overall. But I'm curious, I think as a group, we certainly don't do very many. Why do you think that is and do you think there is a role for someone who's not an HPB surgeon and less comfortable with biliary anatomy, maybe, to do that procedure or not?
Francis Sutherland 34:38
Yeah, I always thought it was a good skill to be able to do a cholangiogram and really, with my thoughts of this being a navigation error. I'm just not sure that cutting a hole in a duct, and putting a tube in and doing an X-ray, an X-ray that you're probably not going to be able to interpret properly, is really the proper avenue for finding out where you are when you're disoriented. I think, you know, the backing up and the subtotal cholecystectomy, the limited subtotal cholecystectomy is probably a better strategy. Having said that, identifying the bile duct is one of our landmarks and, I think, apart from cholangiography, ultrasound, or indocyanine green, or some of the other technologies for identifying that landmark, I have no problem with those whatsoever. But I just don't think that cutting the bile duct open and doing a cholangiogram is a good idea.
Chad Ball 35:55
You know, obviously, I'm biased based on your education and investment in me. But I would certainly agree. It is interesting, as the technologies change, you're right. And indocyanine green is certainly pushed hard by industry, but I'm not sure it changes the equation at all, really.
Francis Sutherland 36:13
No, I think we have to rely on our operative technique and maybe a little less on technology. One of the things I wanted to say that I really haven't mentioned so far, is that this idea of the B-SAFE landmarks, I think, is something that we can add on to all the other aspects. These are not mutually exclusive. Looking for B-SAFE landmarks and the bil-wall six clip rule or the critical view of safety are all something that we can do all of these things. None of them have primacy, as far as I'm concerned. And one of the things that, when we talk about B-SAFE landmarks, we're really talking about taking a timeout. And you know, there's more written about taking a timeout now. And obviously, it's a situation where you can either slow down like Carole-Anne Moulton, slow down in a difficult critical situation. And it can go right through to stopping. Right through to stopping and getting another pair of eyes on the difficult situation. So, our idea really is to take a timeout, B-SAFE or bile duct timeout, at the beginning of the procedure and use the landmarks. It takes seconds, back the camera out, look at all the landmarks, set your map, and then go forward. And then maybe even take another timeout before you start clipping any critical structures. Timeouts are important because there is a strategy to de-bias our thinking. Take us from Kahneman's system one, automatic thinking, to the more deep, figure it out type system to thinking. That's what the safe surgery checklist is. Surgeons should be using timeouts all the time. As far as I'm concerned.
Ameer Farooq 38:13
Yeah, I mean, it's interesting to think about the fact that the critical view of safety, as sort of a schema and a way of trying to avoid this problem has been there now for, I think, almost 40 years, if I'm not mistaken. At least 30 years.
Chad Ball 38:31
1995.
Ameer Farooq 38:32
Yeah, so it's been out for a long time.
Chad Ball 38:34
Yeah, for sure.
Ameer Farooq 38:36
We still are seeing relatively stable rates of bile duct injuries. I think, not as quite as high, if I remember correctly, not quite as high as when they first came out. But certainly, stable rates. And so, I'm curious, you've talked about this idea of timeouts. But do you ever think that getting to a zero bile duct injury rate or a zero bile duct injury event, type of thing, if that's achievable and what we need to be able to get there?
Francis Sutherland 39:06
Well, no, I don't. I think there are certain limits to human endeavors, technical situations, that we can only get to be so good. Some people will argue that maybe we've reached that limit with bile duct injury rates at the .3 and .4 percent. And I'm not so sure we've arrived at the best we can do. I think we can do better. So that's why, hence the idea of a new strategy. Changing surgeon, changing human behavior, is extremely difficult and happens very slowly. You should ask yourself, why does the critical view of safety not, won't work. And I think there's a conceptual difference, the critical view of safety tells you where you should be, the B-SAFE landmarks, perhaps, tells you more where you shouldn't be. So, they're almost fundamentally different. The critical view of safety is not really a navigation strategy. Sometimes, the hepatobiliary triangle, just doesn't exist. And there's been a few papers that have shown surgeons can be convinced that they're making a critical view of safety when they're, in fact, making it in the porta hepatis triangle. So, I shouldn't say it's not, it is a good strategy, but it's not the be all and end all. I hope Steve's not listening.
Chad Ball 41:09
Yeah, exactly. In this segment in the podcast, and again, thank you for your time with it. With a question about training, I have for you, as you've talked about, you've been in this game very deep for well over three decades. And I'm curious when it comes to safe cholecystectomy, avoiding bile duct injuries and understanding biliary anatomy, in the modern training era, and you teach residents and fellows every single day, what advice would you give those trainees in terms of recruiting and obtaining that knowledge and that expertise technically, to the best that they can? Again, with the current training paradigm in mind. Yeah, you know, I think Kahneman really dealt with this in his book, a bit. I think that surgeons have a wonderful opportunity in training. In that, what we do, we receive immediate feedback. We receive feedback from our operator field, and we receive feedback from our mentors. And when you're doing something and someone is correcting you, and you see the results right away, it's a really powerful learning situation. I think that from a cognitive psychology point of view, from a cognitive map point of view, really, the idea is to explore your environment. And spend as much time as you can exploring your environment and getting feedback. So, you see residents start with basically no cognitive map whatsoever. And the only way to develop that cognitive map is to be there. And to be there over and over and over again. So, you might say, "Well, I've already seen a cholecystectomy." No, have you seen 100? Have you seen 500 cholecystectomies? Because that's how long it takes to really get good at it. And we're not just the basic anatomy. All the different variations of anatomy. And all the different tissues and how the different tissues basically behave and separate, or don't separate. It's very complicated and the only way you can be there is to get there, work hard at it, and develop your repertoire of cognitive maps that you can use throughout your whole life. Yeah, and when you're young, you can develop cognitive maps. There's a lot of evidence now that, when you get to be old, and Chad, old means more than 46. You lose the ability to create new cognitive maps and to use your maps effectively. So, there's something to think about. Well, that's perfect because I'm older than 46. I'm good. I'm bugging you. The last question we want to ask, and we try and ask everyone, as you know, having listened to some of these podcasts, is, if you were to go back and talk to a young Francis Sutherland, intern, or early junior resident, what sort of advice would you like to give yourself, back in the day?
Francis Sutherland 44:41
Yeah, I think I'd probably say to myself, don't be so hard on yourself. Let the mistakes float over you a little more easily then beating yourself up. I think sometimes, we set a bar for ourselves that is too high, and we suffer for it. I would say concentrate more on some specific areas where you can make a difference. Don't try to be all inclusive and get outside and ride your bike more often, I think.
Ameer Farooq 45:28
You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you've liked what you've been listening to, please leave us a review on iTunes. We'd love to hear your thoughts, comments or feedback. Send us an email at [email protected] or tweet at us @CanJSurg. Thanks again.