Transition from open to laparoscopic fundoplication - The learning curve

Background: Two of us (B.C.S. and C.W.D.) began performing laparoscopic fun doplication in 1992. We have always designated the resident as the operatin g surgeon. Objective: To determine the time necessary for both experienced surgeons an d residents to become proficient in laparoscopic fundoplication. Design: The medical records of 241 consecutive patients undergoing laparosc opic fundoplication were reviewed. This period started with the implementat ion of the procedure in January 1992 and ended in March 1998. For 3 consecu tive years, residents were given a questionnaire regarding their confidence in performing laparoscopic fundoplication. Results: Laparoscopic fundoplication was attempted in 241 patients and comp leted in 203 patients (84%). Comparing the first 25 attempted laparoscopic fundoplications with the secund 25, there were 14 conversions (56%) vs 4 co nversions (16%) (P < .01). Average operative times decreased from 236 to 19 9 minutes (P < .05), and the intraoperative complication rates were 5 (20%) and 1 (4%), respectively. Subsequently, the conversion rate stabilized at 2%. The operative time continued to decline to an average of 99 minutes for the last 25 laparoscopies. Senior residents and recent graduates returning the questionnaire performed an average of 112 laparoscopic procedures, inc luding 15.7 laparoscopic fundoplications. They felt comfortable with the pr ocedure after performing an average of 10.6 ope-rations. Conclusions: The learning curve is very steep for the first 25 laparoscopic Fundoplications for experienced surgeons. However, improvements, as judged by decreases in operative time, conversion rate, and intraoperative compli cations, continue to occur after 100 cases. Under supervision, residents ca n become comfortable with this procedure after about 10 to 15 procedures.