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

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Abstract
Objective: To determine guidelines for an appropriate learning curve for laparoscopic hysterectomy for novice and experienced surgeons.Design: An analysis of the first year of practice, of an experienced laparoscopic surgeon, with a new technique for total laparoscopic hysterectomy, and of the initial year of training for an inexperienced laparoscopic surgeon.Subjects: 33 patients (group 1) underwent total laparoscopic hysterectomy (TLH) performed by an experienced gynaecological laparoscopic surgeon (G.C.), and 21 patients (group 2) underwent laparoscopic hysterectomy (LH) performed by a trainee surgeon (D.R.) under the supervision of one of the experienced surgeons.Main outcome measures: Time for surgery, and peri‐ and postoperative complications were prospectively assessed and analysed as markers of completed learning of the techniques. Correlations between duration of surgery and uterine weight, patient weight, and history of previous abdominal surgery were also sought.Results: Over the first year the time for the TLH was reduced from 145 min to 80 min (average time 99 min). A plateau for operating time was reached rapidly, at around 10 cases. There were only three minor complications in this group, two of which occurred in the first 10 patients. The time for the trainee surgeon was reduced from 180 min to 105 min during the first year (average 145 min) with complications reported in case numbers 8, 10 and 15. No correlations between surgical time and uterine size, patient weight or history of previous surgery were detected.Conclusion: The learning curve for laparoscopic hysterectomy for a trainee laparoscopic surgeon was seen to improve steadily, allowing unsupervised surgery after 16 cases, before a rise associated with unsupervised cases. This indicates a continuing reduction in operating time with supervised training. With the experienced laparoscopic gynaecological surgeon, the plateau was seen after about 10 procedures. We recommend any trainee or gynaecologist to use this information as a guide to the number of supervised procedures required in order to minimize complications and ensure adequate learning.