When can I be proficient in laparoscopic surgery? A systematic review of the evidence

Purpose: The aim of this study was to quantify the learning curve in laparoscopic surgery. Methods: A systematic review of the evidence using a defined search strategy (PubMed, Medline, OVID, Embase, ERIC, Cochrane databases) was performed. Studies without statistical evaluation of the learning curve and opinion articles were excluded. The authors analysed 7 common laparoscopic procedures: cholecystectomy, fundoplication, colectomy, hemiorrhaphy, splenectomy, appendicectomy, and pyloromyotomy. The "initial" and "late" stages of experience were compared with regards to the following outcome measures: operating time, conversion rate, complication rate, and length of stay in hospital. Results: A total of 3,641 articles were reviewed, of which, 37 (25,777 patients) fulfilled the entry criteria (5 in children). In all articles, the definition of proficiency was subjective, and the number of operations required to reach it was highly variable. There were improvements in all 4 outcome measures for cholecystectomy, fundoplication, colectomy, hemiorrhaphy, and splenectomy between the "initial" and "late" experience. No data were available for the learning curves in appendicectomy or pyloromyotomy. Conclusions: The number of procedures required to reach proficiency in laparoscopic surgery has not been defined clearly. These findings are important for training, ethical and medico-legal issues.