Learning Curve of Surgical Trainees Performing Laparoscopic Appendectomy and Effect on Patient outcome - A Register based Study

Author(s): Nathalie Young, Lennart Boström, Gabriel Sandblom, Hans Järnbert Pettersson

Background: The purpose of this study was to analyse the learning curve of a cohort of surgical trainees, to investigate if there were any impact on complication rate and potential factors influencing the learning process.

Method: The study was based on a patient cohort extracted from the local appendectomy register at Södersjukhuset, Stockholm. The register includes patient characteristics, surgical method, operation time, and 30- day complications. First-year surgical trainees attending the hospital’s trainee programme were included and followed over five years of training. Trainees who had performed less than ten procedures during the period of the study were excluded. The learning curve was described using moving average of order ten for each trainee, studying the trend in operation time with increasing volume. The cumulative sum technique was used to chart changes in complication rates of the trainees. Multivariate analysis for investigating potential factors of influence.

Results: In total 586 procedures performed by 9 surgical trainees were included, of which 97.6% were performed laparoscopically. A plateau in operation time on the learning curve was reached at 60 procedures. For three of the trainees, the 30-day complication rate decreased after completing the learning curve, whereas for two others it increased. In a multivariate analysis, operation times differed more between the trainees than it did between procedures performed early or late in the programme. Shortest versus longest mean operation time (41 min versus 89 min).

Conclusion: At least 60 procedures are required to reach sufficient proficiency in laparoscopic appendectomy and a significantly higher complication rate during the early learning curve. This highlights the importance of meticulous selection of surgical trainees, structure of training programmes, feedback and assessment.