ORIGINAL SCIENTIFIC ARTICLE

Helping the Surgeon Recover: Peer-to-Peer

Coaching after Bile Duct Injury
Alice Zhu, HBSc, Shirley Deng, BHSc, Brittany Greene, MD, Melanie Tsang, MD, MSc, FRCSC,
Vanessa N Palter, MD, PhD, FRCSC, Shiva Jayaraman, MD, MESc, FRCSC, FACS

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 ses-
sion 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 rela-
tionship 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. (J Am Coll Surg
2021;-:1e10.
2021 by the American College of Surgeons. Published by Elsevier Inc.
All rights reserved.)

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.1-5 BDI is most
commonly due to the misidentification of the cystic
duct in relation to the bile duct.6 The majority of these
injuries are preventable, especially when a structured
approach is used.7 Given the high morbidity and
Disclosure Information: Nothing to disclose.
Received March 27, 2021; Revised May 4, 2021; Accepted May 5, 2021.
From the Temerty Faculty of Medicine (Zhu, Deng, Greene, Tsang, Jayara-
man) and the Division of General Surgery (Greene, Tsang, Jayaraman),
University of Toronto; and the HPB Service, St Joseph’s Health Centre
(Tsang, Jayaraman) and the International Centre for Surgical Safety, Li
Ka Shing Knowledge Institute, St. Michael’s Hospital (Palter), Unity
Health, Toronto, Canada.
Correspondence address: Shiva Jayaraman, MD, MESc, FRCSC, FACS, St
Joseph’s Health Centre, 1600 Bloor St W, Toronto, ON M6P 1A7, Can-
ada. email: shiva.jayaraman@unityhealth.to
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 sur-
geons. It is described as a distinct entity from mentoring
and teaching, as it enables surgeons to focus on self-
identified areas of development.8 In addition, experts
argue that coaching for all surgeons is necessary to facili-
tate deliberate practice, a process thought to be essential
for technical skill mastery.9 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 sur-
geons or trainees.10-13 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.14 Expanding the
scope of surgical coaching to include skill remediation is

ª 2021 by the American College of Surgeons. Published by Elsevier Inc. https://doi.org/10.1016/j.jamcollsurg.2021.05.011

All rights reserved. 1 ISSN 1072-7515/21
2 Zhu et al Surgical Coaching after Bile Duct Injury
Abbreviations and Acronyms
ACS ¼ acute care surgery
BDI ¼ bile duct injury
HPB ¼ hepatopancreatobiliary
LC ¼ laparoscopic cholecystectomy
MIS ¼ minimally invasive surgery
SJHC ¼ St Joseph’s Health Centre
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.14
Barriers to surgical coaching and qualities of a successful
coaching program have been well described in the litera-
ture.11,15 In general, mutual respect and trust, transpar-
ency about each surgeon’s intentions, alignment of
expectations, and mutual commitment to the coaching
relationship are all critical factors of a successful and pro-
ductive coaching relationship.14,16 This is especially true
when using coaching as a tool for surgeons who have
experienced a complicationda 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 surgi-
cal coaching, their perception of BDI in LC, and their
experience and impressions of the specific surgical coach-
ing program. We hypothesized that adhering to the prin-
ciples 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 hepatopancreatobili-
ary (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 program
The coaching program consisted of 2 defined compo-
nents. First, preceding the session with the surgical coach,
videos of complicated gallbladder surgery, with a step-by-
J Am Coll Surg
step approach aligned with the safe laparoscopic cholecys-
tectomy 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 surgi-
cal coach (within 1 month of the index BDI) (Fig. 2).
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 approxi-
mate junction point between the cystic and hilar plates.
This line defines the inferior boundary of dissection dur-
ing laparoscopic cholecystectomy. By definition, all
biliary and portal structures are inferior to this line.9,10 Er-
ror traps, strategies to handle difficult situations, safety
checks, and bail-out procedures were also reviewed. On-
line resources, such as The 6-Step Program, as recommen-
ded by the Society of Gastrointestinal and Endoscopic
Surgeons (SAGES), were also reviewed.17 Second, after re-
view 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 laparos-
copy, 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 deter-
mine 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, partic-
ipants 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.
Analysis
Within 6 months of the coaching session, a member of
the research team conducted 1-on-1 semi-structured in-
terviews 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 impres-
sion of coaching in surgery, perception of complications
in surgery including questions specific to BDI in LC,
and personal experience in the coaching program
Vol. -, No. -, - 2021 Zhu et al Surgical Coaching after Bile Duct Injury 3

Figure 1. Step-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.

(eDocument 1). Due to the individualized nature of the The interviews were audio-recorded, transcribed, and
coaching program, questions were generalized and open- deidentified before analysis. One participant declined to
ended to ensure all opinions were captured. be audio-recorded; in this case, answers were explicitly
4 Zhu et al Surgical Coaching after Bile Duct Injury
Figure 2. Example 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.
transcribed during the interview. Phenomenology-based
thematic analysis was then performed, based on tran-
scripts, to categorize feedback into common themes. Phe-
nomenology is a qualitative research method that focuses
on studying the lived experiences of others.18 Inductive
reasoning was then performed to extract common themes
of each interview question, and representative quotes were
selected.
RESULTS
Demographics
Six 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).
Perception of surgical coaching
Key themes identified from surgeons’ responses to the
interview questions pertaining to their general percep-
tion 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 sur-
geons are life-long learners, and the majority (n ¼ 4)
hoped to see more surgical coaching programs offered
to staff surgeons. Four of the 6 participants noted that
J Am Coll Surg
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 individ-
ualized coaching for practicing surgeons is beneficial in
that it is more relevant, personal, empowering, and pro-
vides opportunities to learn new techniques that will
change the way they practice.
Perceptions of complications and expectations in
surgery
All 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 accept-
able. 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 ex-
pectations and acceptance of complications differ depend-
ing on the case. This applies for both patient expectations
as well as expectations from colleagues.
How surgeons experienced the coaching program
Five 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
Vol. -, No. -, - 2021
Table 1. Demographics of Surgeon Participants
Participant Time in Surgical
no. practice, y specialty LC per year, n*
1 0e4 MIS, ACS
2 10e14 Critical care,
trauma
3 5e9 MIS
4 20e24 Generaly
5 10e14 MIS
6 15e19 General
*Self-reported estimate.
y
Previous training in breast oncology, trauma, hepatopancreatobiliary,
colorectal, transplant, and thoracic surgery.
ACS, acute care surgery; LC, laparoscopic cholecystectomy; MIS, minimally
invasive surgery.
informative, and provided a nonjudgmental atmosphere
in which participants did not feel shamed, but instead,
empowered. All participants reported a positive experi-
ence overall. Of note, 2 surgeons noted that they knew
the HPB surgeon before the session and felt that this
contributed to their positive experience.
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 coach-
ing program in the future, all surgeons said yes.
Factors that made the session successful and
areas for improvement
Several key factors that made the coaching successful were
identified (Table 4). A nonjudgmental, collegial relation-
ship between the coach and participants was highlighted
as valuable. The interactive format, in which participants
were encouraged to ask questions, was also highly valued.
Zhu et al Surgical Coaching after Bile Duct Injury 5
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
~100 the session, which allowed them to prepare and attend
50 with a list of questions. The 1-on-1 targeted approach
was well received by all participants. Participants felt
>100
that the session was appropriately tailored to complex
<50
cases. The timing of the session was also an attractive
50
feature of this program. In other words, scheduling
50-100
coaching soon after the injury was believed to be
important.
To improve the coaching program, multiple surgeons
stated that they would like to have access to reference ma-
terials after the session, whether it be through a media li-
brary or handouts. Several surgeons also suggested an
increased emphasis on the emotional aspect, as complica-
tions 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.
DISCUSSION
In this study, we evaluated a novel, individualized, surgi-
cal 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 develop-
ment of practicing surgeons.16,19,20 In surveying 118 sur-
geons from 8 surgical specialties, Foley and colleagues20
found that 72.9% of the participants supported peer
coaching and identified 1-on-1 coaching in an individual-
ized setting as a useful activity for continuing professional
development. Similarly, in comparison to conventional
surgical training, Palter and associates19 demonstrated
greater learner satisfaction, as well as improvement in
technical performance and proficiency with peer
coaching.
While Mutabzic and coworkers21 found an initial pre-
dominant 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.15
Our results also highlight the importance of timing, trans-
parency, and discussion to align goals between the coach
and participants during the initial invitation to partici-
pate. 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 sur-
geon’s confidence.
6 Zhu et al Surgical Coaching after Bile Duct Injury J Am Coll Surg

Table 2. Surgeon Perception of Coaching, Expectations, and Complication

Surgeon perception, question, theme
Surgical coaching
What is your general perception of coaching in surgery?
A new concept
Informal coaching in the form of second opinions
Importance of surgical coaching
Potential limitations
Did this program change your perception of surgical
coaching?
Empowering
Who do you think benefits the most from surgical
coaching?
Surgeons as life-long learners
Benefit of coaching to practicing physicians
Complication and expectation
What are your thoughts regarding outcomes and
expectations surgeons set for themselves?
High expectations for self
Expectations for self and from patients vary by case
What are your thoughts on expectations that are set by
others?
Expectations from patients and society
Sample quotation
“Surgical coaching is a new term.”; “It is a new concept, first one-on-one,
relevant, unique in the sense that is personal.”
“Surgical coaching in the form of second opinion was very helpful and
helped me learn strategies that eventually became part of my practice.”;
“Once you are staff, there are no more checks in place, the coaching you
do get, is in the middle of a case, asking for help from a colleague.”
“It is always a good idea to ask for help, whether formal or informal. A
surgeon should not put pride in front of patient’s safety. There is no
harm to call for help.”
“We are a profession that is not very good in asking for help.”; “Personal
pride and self-perception that asking for help suggests that you are not
good enough or nor skilled enough.”; “Not everyone is lucky to have
people they can go to for advice or have access to someone who is willing
to help.”
“To have an official coaching program where you do not feel put down, but
instead empowered by, is something new.”; “It solidified my view that
coaching is crucial in surgery and every aspect of life.”
“No matter where you are in practice, you can benefit in some way.”;
“Everyone is always learning. No knowledge is too much. The College
should put more emphasis on it, it is more beneficial to the patient and to
the surgeon.”
“Fresh in practice, you are generally insecure in your approach, always
asking if there is something you missed. But having solid experience
dealing with a case and then screwing up. you become really motivated
to learn and apply new techniques that can help you avoid the same
mistake in the future.”; “Most useful to practicing surgeons, even deep in
their practice if they are open, because they are getting the least practice.”;
“I did not train in the laparoscopic era, the residency program I went
through was different than the one now, I had to learn along the way, so
it is helpful to have access to and learn from people who specialize in that
area.”
“Have very high expectations for myself and for my patients. there should
be no pain and no complication.”; “You should always aim for no
complication.”
“The expectation around complication depends on the complication. For
example, for wound infection, we take all the precautions, but we expect
people to have a wound infection, and we prepare patients to expect a
wound infection. Same with anastomotic leak. However, this (CBD
injury) is different than the other 2, because you can always leave the
gallbladder in. In general, among surgeons, it is a less acceptable
complication and less forgivable.”
“There is an unreasonable expectation put on surgeons by society as a
whole. Patients are under the expectation that surgeons should not make
mistakes and it can be difficult for patients to understand when a
(Continued)
Vol. -, No. -, - 2021
Table 2. Continued
Surgeon perception, question, theme
Expectations from colleagues may depend on the case
CBD, common bile duct.
Bile duct injuries are a dreaded complication associ-
ated with LC. There is an increasing body of evidence
examining the psychological and emotional conse-
quences of adverse outcomes on the surgeon.22-26 The re-
sults of our pilot study point to the potential of peer-
coaching in helping surgeons recover psychologically af-
ter 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.26 Institutional sup-
port, however, is often seen as inadequate, and a culture
of blame can prevail in the surgical world.24,26 Establish-
ing formal mentorship and coaching programs may
improve support for surgeons in the aftermath of major
surgical complications.
Table 3. The Experience of Coaching
Theme
Impression of the first interaction: invitation to
participate
Earlier relationship with coach helped with trust
building
Emotional aspect of the index injury
Building confidence
Knowledge, learning, and consolidation
Applying coaching feedback
Overall experience
PTSD, post-traumatic stress disorder.
Zhu et al Surgical Coaching after Bile Duct Injury 7
Sample quotation
complication arises, especially if they come with fairly benign disease.”;
“Some patients may have misplaced expectations thinking nothing will
happen, despite having explained the risks and potential complications in
advance.”; “I think patients are generally very reasonable and
understanding.”
“Colleagues are mostly supportive, but on the merit of the case.”;
“Colleagues are mostly understanding. Especially if you are generally a
cautious surgeon. But if someone is known to be a more dangerous
surgeon, it could be the straw that breaks the camel’s back.”
In a review article evaluating surgical education,
Reznick and MacRae9 advocated for the importance of
deliberate practice in the development of mastery or
expertise. Ericsson27 argued that deliberate practice in-
volves a reflection of thought processes, which is facili-
tated 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 pre-
sent at the time of operation (logistically challenging) or
the ability to video review cases. A recent study by Jung
and associates28 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 er-
rors 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
Quotation
“I thought it was a great opportunity, was more than happy to participate.”;
“Overall, I was slightly apprehensive, but I was open to the idea.”
“I knew him in advance. I knew he was a great surgeon. It enhanced the
overall experience. I trusted him.”
“There is no down time in surgery, but there was definitely a period where I
felt apprehensive. For about 6 months, it weighed heavily on me.”; “I
think it helped me to emotionally and psychologically recover from the
incident.”; “It was like PTSD, I will always be more tentative moving
forward with these surgeries.”
“Coaching is a good way to build the confidence back. It fine tunes the
systematic error in recognition. It helps you get your confidence back so
that you can do future cases in a safer manner.”
“I did not feel like I learned a new technique, because I have watched some
of the videos before and knew about the line of safety. But even so, the
coaching was helpful, it re-confirmed and consolidated my knowledge.”
“I was able to apply what I had learned the next day.”; “After the coaching, I
had 1 difficult gallbladder, where I decided not to proceed. I had learned
when to stop.”
“It was a very, very, positive experience; very happy I had the opportunity.”;
“It was expert advice and mentorship in both clinical judgement and
practice pearls, I really enjoyed the opportunity.”
8 Zhu et al Surgical Coaching after Bile Duct Injury J Am Coll Surg

Table 4. Successful Factors and Areas of the Program Needing Improvement

Factor, theme
Factors that made the session successful
Nonjudgmental, collegial
One-on-one targeted approach
Interactive format
Use of media and videos
Timing
Factors for future improvement
Availability of reference materials post-
session
Incorporate more emotional/
physiological support
Option for anonymity
Sample quotation
“The session was extremely profession and non-judgmental. It makes the person who is
doing the training feel like they have done something positive as a patient advocate in
order to improve themselves and their practice.”
“Was the first one-on-one, relevant to practice approach. It was unique in that sense and it
was personal.”
“Having an interactive format with opportunity to discuss case examples.”; “Looking at
the videos together provided an opportunity to ask questions and discuss with a
specialist.”; “Felt more like a discussion rather than formal coaching.”
“Seeing how an injury happens on video is very helpful when you are learning. Seeing a
video of someone creating an injury sticks in the mind more.”
“Being offered in a timely manner... around the time of an unwanted complication.”
“Maybe a document with highlights to look at after, or a link to the videos would be
helpful to refer to.”; “Having a video library with more videos of difficult cases and how
to approach them would be useful.”; “Continue to send difficult videos.”
“There is a lot of work that looks at feelings and emotions that surgeons go through,
which can be incorporated if the program wants to be more wholesome and complete.
Having a complication is an emotional rollercoaster so it is important to acknowledge
the feelings and emotions. It is not just about the knowledge gap; healing occurs both
ways.”
“It may appeal to more people if it was not one-on-one; some people may be more willing
to participate if anonymized, so have both options available would be ideal.”

recording of their complication, rather than BDIs in gen-
eral. 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 high-
lights the importance of mutual respect and trust in a
coaching relationship.14 Coaching can place surgeons in
a vulnerable position, wherein they may question their
identity as a competent surgeon.29 Therefore, it is imper-
ative that coaching is offered in a way that empowers the
individual, and promotes a lasting and meaningful rela-
tionship. All of our surgeons believed that by maintaining
collegiality, transparency, and a nonjudgmental attitude,
the coaching relationship became one that was empower-
ing and confidence building. This is congruent with pre-
vious studies that describe characteristics of a successful
surgical coaching program.14,16
Biliary injuries remain among the most serious compli-
cations 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 Cholecys-
tectomy 6-Step Program and didactic modules,17 as well
as the recent published consensus guidelines on preven-
tion of BDI during cholecystectomy.30 Our study suggests
that individualized coaching after a complication has
already occurred may be a complementary tool to these
programs, and might help surgeons develop a safer
approach to LC while focusing on specific areas of self-
development. Our study supports the concept that coach-
ing is beneficial regardless of the practicing surgeon’s level
of experience. Whether it is learning new approaches, or
consolidating previous knowledge, surgeons throughout
the continuum of surgical practice can benefit from
coaching. Future iterations of the coaching program
should continue to incorporate these previous works while
helping individual surgeons achieve their personal
learning goals.
As with any pilot study, there are several limitations.
First, the program targeted surgeons who had already
injured a bile duct; therefore, we cannot evaluate whether
the surgical coaching program can prevent injuries or
near-miss events. Future work to assess whether coaching
can have an impact on near miss events or errors before a
complication is critical to improving patient safety in the
operating room. Second, owing to the limited number of
participants, we were unable to study whether perceptions
were influenced by years of independent training, surgical
subspeciality training, or any demographic factors.
Expanding this pilot study to explore these factors will
allow for further refinement and individualization of
this coaching program. Third, objective evidence of how
Vol. -, No. -, - 2021
coaching affected a surgeon’s practice is difficult to assess
without long-term and consistent review. As a pilot expe-
rience, the purpose of this study was to ascertain the im-
mediate impact of the coaching intervention. Our
preliminary results, however, suggest that knowledge-
transfer from this coaching initiative will be impactful
and may be demonstrated in follow-up. Moving forward,
we plan to do interval follow-up with the participants to
see how they have incorporated the strategies and tech-
niques discussed in their practice. Likewise, we plan to
create open-access, web-based materials regarding our
safe cholecystectomy strategy, as indicated in Figure 1,
as well as disseminating links to materials such as the
SAGES 6-Steps17 and the recent guidelines on the preven-
tion of BDI.30
CONCLUSIONS
Individualized surgical coaching for safe cholecystectomy
targeted at surgeons who had injured a bile duct creates a
unique opportunity for professional development. This
work demonstrates that coaching can be used to promote
safe laparoscopic cholecystectomy and may help surgeons
regain confidence and recover psychologically in perform-
ing this common operation after a complication. Formal-
izing and expanding coaching initiatives in this context is
key to the broader effort to improve safety in laparoscopic
cholecystectomy.
Author Contributions
Study conception and design: Zhu, Tsang, Jayaraman
Acquisition of data: Zhu, Jayaraman
Analysis and interpretation of data: Zhu, Deng, Greene,
Tsang, Palter, Jayaraman
Drafting of manuscript: Zhu, Deng, Greene, Tsang,
Palter, Jayaraman
Critical revision: Zhu, Deng, Greene,Tsang, Palter,
Jayaraman
REFERENCES
1. AbdelRafee A, El-Shobari M, Askar W, et al. Long-term
follow-up of 120 patients after hepaticojejunostomy for treat-
ment of post-cholecystectomy bile duct injuries: A retrospec-
tive cohort study. Int J Surg 2015;18:205e210.
2. Pottakkat B, Vijayahari R, Prakash A, et al. Factors predicting
failure following high bilio-enteric anastomosis for post-
cholecystectomy benign biliary strictures. J Gastrointest Surg
2010;14:1389e1394.
3. Rose JB, Hawkins WG. Diagnosis and management of biliary
injuries. Curr Prob Surg 2017;54:406e435.
4. Bali MA, Pezzullo M, Pace E, Morone M. Benign biliary dis-
eases. Eur J Radiol 2017;93:217e228.
5. Gad EH, Ayoup E, Kamel Y, et al. Surgical management of
laparoscopic cholecystectomy (LC) related major bile duct in-
juries; predictors of short-and long-term outcomes in a tertiary
Zhu et al Surgical Coaching after Bile Duct Injury 9
Egyptian center- a retrospective cohort study. Ann Med Surg
(Lond) 2018;36:219e230.
6. Flum DR. Common bile duct injury during laparoscopic cho-
lecystectomy and the use of intraoperative cholangiography:
adverse outcome or preventable error? Arch Surg 2001;136:
1287.
7. Gupta V, Jain G. Safe laparoscopic cholecystectomy: Adoption
of universal culture of safety in cholecystectomy. World J Gas-
trointest Surg 2019;11:62e84.
8. Gunn E, Tambyraja A, Yule S. Personal best, could coaching
hold the key to CPD in today’s face-place workplace? Sur-
geons’ News Dec 2020:22e24.
9. Reznick RK, MacRae H. Teaching surgical skills d changes in
the wind. N Engl J Med 2006;355:2664e2669.
10. Pradarelli JC, Yule S, Lipsitz SR, et al. Surgical Coaching for
Operative Performance Enhancement (SCOPE): skill ratings
and impact on surgeons’ practice. Surg Endosc 2020 Jul 8
[Online ahead of print].
11. Greenberg CC, Klingensmith ME. The continuum of coach-
ing: opportunities for surgical improvement at all levels. Ann
Surg 2015;262:217e219.
12. Bonrath EM, Dedy NJ, Gordon LE, Grantcharov TP.
Comprehensive surgical coaching enhances surgical skill in
the operating room: a randomized controlled trial. Ann Surg
2015;262:205e212.
13. Timberlake MD, Stefanidis D, Gardner AK. Examining
the impact of surgical coaching on trainee physiologic
response and basic skill acquisition. Surg Endosc 2018;
32:4183e4190.
14. Pradarelli JC, Yule S, Panda N, et al. Optimizing the imple-
mentation of surgical coaching through feedback from prac-
ticing surgeons. JAMA Surg 2021;156:42e49.
15. Min H, Morales DR, Orgill D, et al. Systematic review of
coaching to enhance surgeons’ operative performance. Surgery
2015;158:1168e1191.
16. Beasley HL, Ghousseini HN, Wiegmann DA, et al. Strategies
for building peer surgical coaching relationships. JAMA Surg
2017;152:e165540.
17. The SAGES Safe Cholecystectomy Program - Strategies for
Minimizing Bile Duct Injuries. SAGES. Available at: https://
www.sages.org/safe-cholecystectomy-program/. Accessed April
15, 2021.
18. Neubauer BE, Witkop CT, Varpio L. How phenomenology
can help us learn from the experiences of others. Perspect
Med Educ 2019;8:90e97.
19. Palter VN, Beyfuss KA, Jokhio AR, et al. Peer coaching
to teach faculty surgeons an advanced laparoscopic skill:
A randomized controlled trial. Surgery 2016;160:
1392e1399.
20. Foley K, Granchi N, Reid J, et al. Peer coaching as a form of
performance improvement: what surgeons really think. J Surg
Educ 2021;78:525e532.
21. Mutabdzic D, Mylopoulos M, Murnaghan ML, et al. Coach-
ing surgeons: Is culture limiting our ability to improve? Ann
Surg 2015;262:213e216.
22. Luu S, Leung SOA, Moulton C. When bad things happen to
good surgeons: reactions to adverse events. Surg Clin North
Am 2012;92:153e161.
23. Luu S, Patel P, St-Martin L, et al. Waking up the next morn-
ing: surgeons’ emotional reactions to adverse events. Med Educ
2012;46:1179e1188.
10 Zhu et al Surgical Coaching after Bile Duct Injury
24. Pinto A, Faiz O, Bicknell C, Vincent C. Surgical complica-
tions and their implications for surgeons’ well-being. Br J
Surg 2013;100:1748e1755.
25. Marmon LM, Heiss K. Improving surgeon wellness: The sec-
ond victim syndrome and quality of care. Semin Pediatr Surg
2015;24:315e318.
26. Srinivasa S, Gurney J, Koea J. Potential consequences of pa-
tient complications for surgeon well-being: A systematic re-
view. JAMA Surg 2019;154:451e457.
27. Anders Ericsson K. Deliberate practice and acquisition of
expert performance: A general overview. Acad Emerg Med
2008;15:988e994.
J Am Coll Surg
28. Jung JJ, Adams-McGavin RC, Grantcharov TP. Underre-
porting of Veress needle injuries: comparing direct obser-
vation and chart review methods. J Surg Res 2019;236:
266e270.
29. Byrnes ME, Engler TA, Greenberg CC, et al. Coaching as a
mechanism to challenge surgical professional identities. Ann
Surg 2019 [Online ahead of print].
30. Brunt LM, Deziel DJ, Telem DA, et al. Safe cholecys-
tectomy multi-society practice guideline and state of
the art consensus conference on prevention of bile
duct injury during cholecystectomy. Ann Surg 2020;
272:3e23.
Vol. -, No. -, - 2021 Zhu et al Surgical Coaching after Bile Duct Injury 10.e1

eDocument 1. 5. Who do you think would benefit most from surgical

SEMI-STRUCTURED INTERVIEW
Participant: Date:
Start time: End Time
Interviewer: Location:
Recorded: Yes/No Platform
Details about participant:
- Years of practice
- Training background
- Estimated number of laparoscopic cholecystectomies
performed in a year
Description of atmosphere and platform:
Attitudes
1. What is your general impression of coaching in sur-
gery? Of this particular coaching program? Why?
2. In your opinion, did this program change your percep-
tion of surgical coaching? If so, how?
3. In your opinion, what is an acceptable rate of bile duct
injury in laparoscopic cholecystectomy?
a. Probe: Did this change over time?
b. Probe: How often do you think common bile duct
injury occurs in laparoscopic cholecystectomy?
4. What are your thoughts regarding outcomes from
laparoscopic cholecystectomy, and the expectations
that surgeons set for themselves regarding this opera-
tion or complication?
a. Probe: What are your thoughts on expectations that
are set by others? Colleagues, mentors, society etc.
coaching? For example, medical students, residents,
fellows, and/or staff surgeons.
a. Probe: Do you think years of experience is an
important factor in determining benefits from
coaching?
Experience
6. How did the coaching experience go for you?
a. Probe: How did you feel when you were first
approached to participate in this coaching session?
b. Probe: How did you feel after the coaching ses-
sion? Did this evolve over time? For example, dur-
ing the session, the next day, next week, and
months later?
7. On a scale of 0-10, how comfortable are you with
laparoscopic cholecystectomy before the coaching
session?
a. After the session?
8. On a scale of 0-10, how useful did you find this
coaching session?
a. Probe: What was the most useful aspect of this
program?
9. On a scale of 0-10, how likely are you to recommend
this surgical coaching program to a friend of
colleague? (0, not likely to recommend; 10, extremely
likely to recommend)
10. On a scale of 0-10, how likely would you do partic-
ipate in this program or something like this program
again?
11. What factors made this coaching session successful?
12. How would you change this program to make it
better?