An assessment of the learning curve for laparoscopic and total laparoscopic hysterectomy

Objective To determine guidelines for an appropriate learning curve for lap aroscopic hysterectomy for novice and experienced surgeons. Design An analysis of the first year of practice, of an experienced laparos copic surgeon, with a new technique for total laparoscopic hysterectomy, an d of the initial year of training for an inexperienced laparoscopic surgeon . Subjects 33 patients (group 1) underwent total laparoscopic hysterectomy (T LH) performed by an experienced gynaecological laparoscopic surgeon (G.C.), and 21 patients (group 2) underwent laparoscopic hysterectomy (LH) perform ed by a trainee surgeon (D.R.) under the supervision of one of the experien ced surgeons. Main outcome measures Time for surgery, and peri- and postoperative complic ations were prospectively assessed and analysed as markers of completed lea rning of the techniques. Correlations between duration of surgery and uteri ne weight, patient weight, and history of previous abdominal surgery were a lso sought. Results Over the first year the time for the TLH was reduced from 145 min t o 80 min (average time 99 min). A plateau for operating time nas reached ra pidly, at around 10 cases. There were only three minor complications in thi s group, two of which occurred in the first 10 patients. The time for the t rainee surgeon was reduced from 180 min to 105 min during the first year (a verage 145 min) with complications reported in case numbers 8, 10 and 15. N o correlations between surgical time and uterine size, patient weight or hi story of previous surgery were detected. Conclusion The learning curve for laparoscopic hysterectomy for a trainee l aparoscopic surgeon was seen to improve steadily, allowing unsupervised sur gery after 16 cases, before a rise associated with unsupervised cases. This indicates a continuing reduction in operating time with supervised trainin g. With the experienced laparoscopic gynaecological surgeon, the plateau Tv as seen after about 10 procedures. We recommend any trainee or gynaecologis t to use this information as a guide to the number of supervised procedures required in order to minimize complications and ensure adequate learning.