Introduction: This past year has born witness to the acceptance of single port laparoscopic surgery into mainstream clinical practice. Reports of surgeons’ early experience with single port laparoscopic cholecystectomy suggests the procedure is a technically feasible, safe and cosmetically superior alternative to the traditional 4-port laparoscopic cholecystectomy. To date, however, there has not been a description of the learning curve required to reach technical aptitude. This study describes a single surgeon’s experience with the single port laparoscopic cholecystectomy and delineates a learning curve for this technically demanding procedure utilizing improvements in operative time as a proxy for technical facility.
Materials and Methods: Between November 2007 and August 2009, 54 patients underwent single port laparoscopic cholecystectomies at Yale-New Haven Hospital. All procedures were performed by a single fellowship trained laparoscopic surgeon. Through a 2cm vertical transumbilical incision, three 5mm ports or SILS-Ports were placed using the Veress technique. One extracorporeal stay suture was utilized to provide cephalad retraction of the gallbladder fundus, and a reticulating instrument was used at the infundibulum to provide lateral retraction. The hilum was dissected and the cystic duct and artery were clipped and divided. One 5mm port was removed and another one was upgraded to one 10mm port to allow the introduction of a retrieval bag to facilitate the removal of the gallbladder from the abdomen. Patient demographic data, operative time, length of stay, surgical pathology and complications were recorded. Statistical analysis was performed using ANOVA and two-tailed t-tests as appropriate.
Results: 52 of 54 patients successfully underwent a single port cholecystectomies. Two patients required conversion to either a conventional laparoscopic cholecystectomy or open cholecystectomy. The average age was 41 years (18-77 years) and the average BMI, 30.2 (18.5-44.6 kg/m2). Mean operative time was 80 minutes (41-186min). Length of stay was 0.3 days (0-2days). The complication rate was 3/54 (5.5%). When patients were divided into sequential quintiles (n=10) operative times decreased significantly after the first 10 patients (p=0.0001) and then remained flat (p=0.233) (1st quintile: 110min, 2nd quintile: 73min, 3rd quintile: 71min, 4th quintile: 58min, 5th quintile: 65min) (Figure).
Conclusions: The significant improvement in operative times after the first quintile, followed by consistent results with little subsequent variability suggests the learning curve for the single port cholecystectomy, in the hands of a laparoscopic surgeon, is approximately 10 cases. This short learning curve will probably lead to further adoption of this promising new technique.
Program Number: P539