The Rapid Acquisition of Competence for the Single Incision Laparoscopic Cholecystectomy

Gary B Deutsch, MD MPH, Vikraman Gunabushanam, MD, Nitin Mishra, MD, Jonathan D S Klein, MD, Gary Gecelter, MD, Harry Zemon, MD, George Denoto, MD, Eugene Rubach, MD. North Shore University Hospital, North Shore — Long Island Jewish Health System, Manhasset, NY; St. Francis Hospital/ Catholic Health System of Long Island, Roslyn, NY

INTRODUCTION
Once primarily performed by open technique, the cholecystectomy has been transformed into a standard laparoscopic procedure over the last two decades. This phenomenon can be attributed to the overwhelming data supporting the superiority of laparoscopy – reduction of postoperative pain, shorter recovery time, and improved cosmesis – while maintaining an acceptable complication rate. Within the last few years, there has been a push for an even more minimally invasive approach to biliary disease with the adoption of the single-incision laparoscopic cholecystectomy (SILC). Many believe that by reducing the total incision length, surgeons can attain equivalent results with improved postoperative pain and patient satisfaction. So far, the preliminary experience is quite promising. One of the major barriers to entry is the learning curve thought to accompany the implementation of any new modality, specifically the modified instruments in an operative field with limited degrees of freedom. Recent studies have attempted to quantitatively assess the number of cases needed to achieve proficiency. However, they are limited to individual operator reports. We set out to compare four individual surgeon experiences in order to define whether there exists a learning curve in single-incision surgery.

METHODS AND PROCEDURES
A retrospective review was performed of approximately 270 single-incision laparoscopic cholecystectomies by a group of laparoscopic fellowship-trained general surgeons at three institutions between May 2008 and September 2010. The procedure times were recorded for each SILC, ordered chronologically for each surgeon, entered into a spreadsheet and subsequently plotted on a graph. The patients were also split into cohorts of five and ten cases to further evaluate for signs of improvement in operative efficiency. Descriptive statistics and univariate analyses using the chi-square test or Fisher’s exact test as deemed appropriate for categorical variables and the t-test or Mann-Whitney test for continuous data were used.

RESULTS
Of the four surgeons involved in the study, only two (Surgeons 2 and 4) confirmed the presence of a learning curve, reaching proficiency within the first five cases performed. The most experienced surgeon of the group (Surgeon 1) reached steady state immediately; whereas only one (Surgeon 3) had more variable procedure times that did not show a distinct trend. When breaking the cases into cohorts of five and ten cases, the latter surgeon appeared to improve markedly between cases five and fifteen.

CONCLUSION
Previous studies have indicated a five or ten case learning curve with single-incision laparoscopic cholecystectomies. Our results indicate that in laparoscopic fellowship-trained general surgeons, there does not seem to be a significant learning curve when transitioning to single incision laparoscopic cholecystectomy. While the most experienced surgeon in the group, Surgeon 1, achieved the best operative times, the other laparoscopists reached their baseline performance almost immediately. In order to confirm these results and avoid potential biases, prospective randomized studies at resident-independent institutions are required.