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2008 Annual Meeting Abstracts

Do Learning Curves for Laparoscopic Cholecystectomy Exist in the Era of Laparoscopically-Trained Surgical Residents?
Angela K. Moss, MD1, Bram A. Nijsse2, Suzanne M. Sokal1, David L. Berger, M.D.1.
1MGH, Boston, MA, USA, 2University of Amsterdam, Amsterdam, Netherlands.

Objective: To determine if a surgeon trained in laparoscopy during residency performing laparoscopic cholecystectomies progressively improves in quality and efficiency with experience.
Design: Retrospective review (July 1997-September 2006)
Setting: tertiary referral center
Patients: 1278 consecutive patients undergoing attempted laparoscopic cholecystectomy by a single surgeon from the start of his attending career.
Interventions: none
Main Outcome Measures: rate of conversion rate to open cholecystectomy, major complications, and operative time
Results: The overall conversion rate was 5.3%. The conversion rate decreased during the first 500 cases before reaching a steady state, however, there was no statistically significant difference between the first 500 cases and the later period (6.4% vs. 4.6%, p=0.16). The overall major complication rate was 1.64%. There was no statistically significant change in the complication rate throughout the study. The overall mean operative time was 34.4 minutes (standard deviation 16.6 minutes). Operative time was analyzed by sequential cohorts of 250 patients. The first 1000 patients showed a statistically significant decrease in operative time between sequential cohorts (p=0.01). Operative times thereafter (patients 750-1278) were similar (p=0.13). There was also a significant decrease in the number of long cases (over 45 minutes) and an increase in the number of short cases (under 30 minutes).
Conclusions: No improvement in qualitative performance measures (both conversion rate and complication rate) with experience was found from the outset of the surgeon’s career, suggesting that residency training was effective in eliminating the learning curve with regard to quality metrics. However, significant improvements in efficiency continued through the first 1000 cases, suggesting there is a much longer tail for an efficiency learning curve than prior studies have shown.


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