How to Overcome the Learning Curve of Single-incision Laparoscopic Cholecystectomy

Stephen Ky Chang, FRCS, Chee Wei Tay, MRCSEd, Iyer Shridhar Ganpathi, FRCS, Victor Tswen Wen Lee, FRCS, Krishnakumar Madhavan, FRCS. National University Health System, Singapore


Single-incision laparoscopic cholecystectomy (SILC) has been increasingly performed for benign gallbladder disease over the last few years with comparable operative results with conventional 4 ports laparoscopic cholecystectomy (CLC). As SILC is a relatively new approach to gallbladder disease, many aspects of this new technique have not been studied in detail. Majority of the concern from most surgeons are the learning curve of SILC and its potential problem and longer operating time.
Some publications suggested that learning curve of SILC by an experience HPB laparoscopic surgeon is 5- 10 cases, however other publications concluded that SILC learning curve is independent of CLC experience.

In this study, we report the SILC learning experience of a HPB unit in a university hospital. Operating time, potential problems, and ways to overcome them as well as surgical technique were included in this report. Our paper aims to facilitate other surgeons especially those who are starting to perform SILC or facing difficulty in SILC to smoothen their learning curve.

81 patients who underwent SILC by 3 HPB surgeons who routinely perform laparoscopic cholecystectomy for all benign gallbladder disease in a university hospital were studied retrospectively.

Operating time, conversion rate and reason and technical problems were recorded. Conversion is defined as adding additional port(s) at other part of the abdomen or mini-laparotomy.

81 patients who underwent SILC by 3 HPB surgeons during the period of April 2009 to March 2011 were included, 66 cases were performed by surgeon A, 9 cases were performed by surgeon B, and 6 cases were performed by surgeon C. 6 (9%) cases were acute cholecystitis, and 61 (91%) were chronic cholecystitis.

We subdivided surgeon A’s 66 cases into 4 groups in chronological order (16 cases each group). Mean opeative time of all surgeon A’s cases is 72 min (25-135, SD +/-28). Mean operative time of first, second, third and forth 16 cases was 93 min (64-135, SD +/- 22), 80 min (43 – 134, SD +/- 27), 63 min (39 – 128, SD+/- 22), 53 min (26-94, SD +/- 28) respectively. 5 (7.6%) cases need additional ports to complete the surgery.

Surgeon B has performed 9 cases with mean operative time of 120 min (51 – 182, SD +/- 50), with 1 conversion. Surgeon C has done 6 cases with mean operative time of 101 min (63 – 138, SD +/- 25) with no conversion.

No open conversion or mini laparotomy was necessary in our study.

SILC is a feasible procedure for benign gallbladder condition. About 20 cases are needed to overcome the learning curve, no significant conversion rate or longer operating time were observed after learning curve is overcome. CLC experience does not shorten the learning curve of SILC. Careful patient selection, role of assistant and appropriate equipment and technique are important at the beginning stage of performing SILC.

Session Number: Poster – Poster Presentations
Program Number: P332
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