Skip to main content
SpringerLink
Log in

Learning curve for the surgical time of laparoscopic cholecystectomy performed by surgical trainees using the three-port method: how many cases are needed for stabilization?

  • Original Article
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

The assessment of laparoscopic cholecystectomy (LC) skills using operating times has not been well reported. We examined the total and partial operating times for LC procedures performed by surgical trainees to determine the required number of surgeries until the surgical time stabilizes.

Methods

We reviewed the video records of 514 consecutive LCs using the three-port method, performed by 16 surgical trainees. The total and partial surgical times were calculated and correlated to the surgeons’ experience.

Results

The median total surgical time for a trainee’s first LC was 112 (range 71–226) minutes. It reduced rapidly after the first 20 LCs and plateaued to its minimum after approximately 60 cases. A statistically significant time decrease was observed between the first 10 (median, range 112, 46–252 min) and the next 50–59 cases (64, 34–198 min), but not between the 50–59 and the subsequent 100–109 cases (71, 33–127 min). The total times taken by trainees who had performed > 50 operations were not significantly different from those taken by instructors during the study period. Surgery for 125 patients with acute cholecystitis took a significantly longer time (median 99 vs. 74 min with non-acute cholecystitis); however, the abovementioned time reduction findings showed similar results regardless of the patient’s acute inflammation status. The partial operating times around the cervical/cystic duct and gallbladder bed reduced uniformly between the first 10 and the following 50–59 cases. Although time variations in total and cervical/cystic duct operating times were not correlated to the surgical experience, time fluctuation of gallbladder bed procedures reduced after 60 cases.

Conclusion

The time required to perform an LC was inversely correlated with the experience of surgical trainees and halved after the first 60 cases. The surgical experience required for LC time stabilization is approximately 60 cases.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

Data availability

To protect patient information, the data from the current study are not publicly available but may be obtained from the corresponding author on reasonable request.

References

  1. Mühe E (1992) Long-term follow-up after laparoscopic cholecystectomy. Endoscopy 9:754–758

    Article  Google Scholar 

  2. Miyasaka Y, Nakamura M, Wakabayashi G (2018) Pioneers in laparoscopic hepato-biliary-pancreatic surgery. J Hepatobiliary Pancreat Sci 25:109–111

    Article  PubMed  Google Scholar 

  3. Tornqvist B, Zheng Z, Ye W, Waage A, Nilsson M (2009) Long-term effects of iatrogenic bile duct injury during cholecystectomy. Clin Gastroenterol Hepatol 7:1013–1018

    Article  PubMed  Google Scholar 

  4. Jabbar SAA, Ahmed Z, Mirza A, Nassar AHM (2019) Laparoscopic training opportunities in an emergency biliary service. J Soc Laparoendosc Surg 23(e2019):00031

    Google Scholar 

  5. Atta HM, Mohamed AA, Sewefy AM, Abdel-Fatah AS, Mohammed MM, Atiya AM (2017) Difficult laparoscopic cholecystectomy and trainees: predictors and results in an academic teaching hospital. Gastroenterol Res Pract 2017:6467814

    Article  PubMed  PubMed Central  Google Scholar 

  6. Tafazal H, Spreadborough P, Zakai D, Shastri-Hurst N, Ayaani S, Hanif M (2018) Laparoscopic cholecystectomy: a prospective cohort study assessing the impact of grade of operating surgeon on operative time and 30-day morbidity. Ann R Coll Surg Engl 100:178–184

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Reitano E, de’Angelis N, Schembari E, Carrà MC, Francone E, Gentilli S, La Greca G (2021) Learning curve for laparoscopic cholecystectomy has not been defined: a systematic review. ANZ J Surg 91:E554–E560

    Article  PubMed  PubMed Central  Google Scholar 

  8. Korol E, Johnston K, Waser N, Sifakis F, Jafri HS, Lo M, Kyaw MH (2013) A systematic review of risk factors associated with surgical site infections among surgical patients. PLoS ONE 8:e83743

    Article  PubMed  PubMed Central  Google Scholar 

  9. Childers CP, Maggard-Gibbons M (2018) Understanding costs of care in the operating room. JAMA Surg 153:e176233

    Article  PubMed  PubMed Central  Google Scholar 

  10. Cheng H, Clymer JW, Po-Han Chen B, Sadeghirad B, Ferko NC, Cameron CG, Hinoul P (2018) Prolonged operative duration is associated with complications: a systematic review and meta-analysis. J Surg Res 229:134–144

    Article  PubMed  Google Scholar 

  11. Subhas G, Gupta A, Bhullar J, Dubay L, Ferguson L, Goriel Y, Jacobs MJ, Kolachalam RB, Silapaswan S, Mittal VK (2011) Prolonged (longer than 3 hours) laparoscopic cholecystectomy: reasons and results. Am Surg 77:981–984

    Article  PubMed  Google Scholar 

  12. Ballantyne GH, Ewing D, Capella RF, Capella JF, Davis D, Schmidt HJ, Wasielewski A, Davies RJ (2005) The learning curve measured by operating times for laparoscopic and open gastric bypass: roles of surgeon’s experience, institutional experience, body mass index and fellowship training. Obes Surg 15:172–182

    Article  PubMed  Google Scholar 

  13. Pollei TR, Barrs DM, Hinni ML, Bansberg SF, Walter LC (2013) Operative time and cost of resident surgical experience: effect of instituting an otolaryngology residency program. Otolaryngol Head Neck Surg 148:912–918

    Article  PubMed  Google Scholar 

  14. Dumont GD, Cohn RM, Gross MM, Menge TJ, Battle NC, Thier ZT (2020) The learning curve in hip arthroscopy: effect on surgical times in a single-surgeon cohort. Arthroscopy 36:1293–1298

    Article  PubMed  Google Scholar 

  15. Mayumi T, Okamoto K, Takada T, Strasberg SM, Solomkin JS, Schlossberg D, Pitt HA, Yoshida M, Gomi H, Miura F, Garden OJ, Kiriyama S, Yokoe M, Endo I, Asbun HJ, Iwashita Y, Hibi T, Umezawa A, Suzuki K, Itoi T, Hata J, Han HS, Hwang TL, Dervenis C, Asai K, Mori Y, Huang WS, Belli G, Mukai S, Jagannath P, Cherqui D, Kozaka K, Baron TH, de Santibanes E, Higuchi R, Wada K, Gouma DJ, Deziel DJ, Liau KH, Wakabayashi G, Padbury R, Jonas E, Supe AN, Singh H, Gabata T, Chan ACW, Lau WY, Fan ST, Chen MF, Ker CG, Yoon YS, Choi IS, Kim MH, Yoon DS, Kitano S, Inomata M, Hirata K, Inui K, Sumiyama Y, Yamamoto M (2018) Tokyo Guidelines 2018: management bundles for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 25:96–100

    Article  PubMed  Google Scholar 

  16. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibanes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250:187–196

    Article  PubMed  Google Scholar 

  17. Kanda Y (2013) Investigation of the freely available easy-to-use software ‘EZR’ for medical statistics. Bone Marrow Transpl 48:452–458

    Article  CAS  Google Scholar 

  18. Morgenstern LWL, Berci G (1992) Twelve hundred open cholecystectomies before the laparoscopic era: a standard for comparison. Arch Surg 127:400–403

    Article  CAS  PubMed  Google Scholar 

  19. Nagral S (2005) Anatomy relevant to cholecystectomy. J Minim Access Surg 1:53–58

    Article  PubMed  PubMed Central  Google Scholar 

  20. Trichak S (2003) Three-port vs standard four-port laparoscopic cholecystectomy. Surg Endosc 17:1434–1436

    Article  CAS  PubMed  Google Scholar 

  21. Kumar M, Agrawal CS, Gupta RK (2007) Three-port versus standard four-port laparoscopic cholecystectomy: a randomized controlled clinical trial in a community-based teaching hospital in eastern Nepal. J Soc Laparoendosc Surg 11:358–362

    Google Scholar 

  22. Navez B, Ungureanu F, Michiels M, Claeys D, Muysoms F, Hubert C, Vanderveken M, Detry O, Detroz B, Closset J, Devos B, Kint M, Navez J, Zech F, Gigot JF, The Belgian Group for Endoscopic Surgery (BGES) and the Hepatobiliary and Pancreatic Section (HBPS) of the Royal Belgian Society of Surgery (2012) Surgical management of acute cholecystitis: results of a 2-year prospective multicenter survey in Belgium. Surg Endosc 26:2436–2445

    Article  PubMed  Google Scholar 

  23. Harboe KM, Bardram L (2011) The quality of cholecystectomy in Denmark: outcome and risk factors for 20,307 patients from the national database. Surg Endosc 25:1630–1641

    Article  PubMed  Google Scholar 

  24. Iwashita Y, Hibi T, Ohyama T, Umezawa A, Takada T, Strasberg SM, Asbun HJ, Pitt HA, Han HS, Hwang TL, Suzuki K, Yoon YS, Choi IS, Yoon DS, Huang WS, Yoshida M, Wakabayashi G, Miura F, Okamoto K, Endo I, de Santibanes E, Gimenez ME, Windsor JA, Garden OJ, Gouma DJ, Cherqui D, Belli G, Dervenis C, Deziel DJ, Jonas E, Jagannath P, Supe AN, Singh H, Liau KH, Chen XP, Chan ACW, Lau WY, Fan ST, Chen MF, Kim MH, Honda G, Sugioka A, Asai K, Wada K, Mori Y, Higuchi R, Misawa T, Watanabe M, Matsumura N, Rikiyama T, Sata N, Kano N, Tokumura H, Kimura T, Kitano S, Inomata M, Hirata K, Sumiyama Y, Inui K, Yamamoto M (2017) Delphi consensus on bile duct injuries during laparoscopic cholecystectomy: an evolutionary cul-de-sac or the birth pangs of a new technical framework? J Hepatobiliary Pancreat Sci 24:591–602

    Article  PubMed  Google Scholar 

  25. Cwik G, Skoczylas T, Wyroslak-Najs J, Wallner G (2013) The value of percutaneous ultrasound in predicting conversion from laparoscopic to open cholecystectomy due to acute cholecystitis. Surg Endosc 27:2561–2568

    Article  PubMed  PubMed Central  Google Scholar 

  26. Terho PM, Leppaniemi AK, Mentula PJ (2016) Laparoscopic cholecystectomy for acute calculous cholecystitis: a retrospective study assessing risk factors for conversion and complications. World J Emerg Surg 11:54

    Article  PubMed  PubMed Central  Google Scholar 

  27. Sugrue M, Coccolini F, Bucholc M, Johnston A, Contributors from WSES (2019) Intra-operative gallbladder scoring predicts conversion of laparoscopic to open cholecystectomy: a WSES prospective collaborative study. World J Emerg Surg 14:12

    Article  PubMed  PubMed Central  Google Scholar 

  28. Kaafarani HM, Smith TS, Neumayer L, Berger DH, Depalma RG, Itani KM (2010) Trends, outcomes, and predictors of open and conversion to open cholecystectomy in Veterans Health Administration hospitals. Am J Surg 200:32–40

    Article  PubMed  Google Scholar 

  29. Gholipour C, Fakhree MB, Shalchi RA, Abbasi M (2009) Prediction of conversion of laparoscopic cholecystectomy to open surgery with artificial neural networks. BMC Surg 9:13

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Funding

This study was not supported by any funding source.

Author information

Authors and Affiliations

  1. Department of Digestive Surgery, Niigata City General Hospital, Niigata, Japan

    Masaru Komatsu, Naoyuki Yokoyama, Tomohiro Katada, Daisuke Sato, Tetsuya Otani, Rina Harada, Shiori Utsumi, Motoharu Hirai, Akira Kubota & Hiroaki Uehara

Authors
  1. Masaru Komatsu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Naoyuki Yokoyama
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Tomohiro Katada
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Daisuke Sato
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Tetsuya Otani
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Rina Harada
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Shiori Utsumi
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Motoharu Hirai
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Akira Kubota
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Hiroaki Uehara
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Masaru Komatsu.

Ethics declarations

Disclosures

Masaru Komatsu, Naoyuki Yokoyama, Tomohiro Katada, Daisuke Sato, Tetsuya Otani, Rina Harada, Shiori Utsumi, Motoharu Hirai, Akira Kubota, and Hiroaki Uehara have no conflicts of interests or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Komatsu, M., Yokoyama, N., Katada, T. et al. Learning curve for the surgical time of laparoscopic cholecystectomy performed by surgical trainees using the three-port method: how many cases are needed for stabilization?. Surg Endosc 37, 1252–1261 (2023). https://doi.org/10.1007/s00464-022-09666-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-022-09666-0

Keywords

Search

Navigation