The Learning Curve

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Abstract
To the Editor. —In his Editorial, Mr Hatlie states that complications occur infrequently with laparoscopic cholecystectomy.1This general conclusion is based on a number of published prospective and retrospective studies that have reported morbidity and mortality rates comparable with those associated with open cholecystectomy.2However, these excellent results with laparoscopic cholecystectomy must be viewed with caution because they reflect outcomes of experienced and skilled laparoscopists. In a retrospective study of 1520 Medicare patients who underwent laparoscopic cholecystectomy between January 1, 1990, and June 30, 1991, we found complications in 15.8%. Of these, 8.8% were surgical in character, reflecting deficits in surgical skills, judgment, and technique.3In a hospital-based case review study that we conducted in New York State on 2940 Medicare and 1108 Medicaid patients who underwent laparoscopic cholecystectomy in 1991, hospitals reported complications in 11.9% of the former and 9.7% of the latter.4These very

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