Chapter 19. Learning Curves for New Procedures – the Case of Laparoscopic Cholecystectomy

Minimal access surgery began in the early 1980s with the introduction of laparoscopic fallopian tube ligation. The first laparoscopic cholecystectomy was performed 7 years later, and was rapidly embraced as the preferred method for cholecystectomy despite a lack of evidence to support the safety of the new technique. In response to several deaths and complications associated with laparoscopic cholecystectomy, the New York State Department of Health issued guidelines for the credentialing of surgeons who wished to perform the procedure. At the same time, a National Institutes of Health Consensus conference published recommendations regarding indications for laparoscopic cholecystectomy. Clinical trials comparing the laparoscopic procedure with other approaches eventually revealed that the newer procedure to be less morbid than traditional open cholecystectomy, or even mini-laparotomy. Importantly, though, it also became clear that acquiring the skills to perform this new procedure involved a substantial surgical “learning curve.” This learning curve no longer affects patients undergoing laparoscopic cholecystectomy, as training has become a required part of all surgical residency programs, with graduating surgery residents typically having performed more than 50 laparoscopic cholecystectomies. However, the growth of laparoscopic cholecystectomy has been followed by equally rapid development and application of minimal access procedures in virtually every surgical specialty. This chapter considers the patient safety issues that arise with the diffusion of a new procedurally-based technology. It highlights the “learning curve” inherent in any new procedure, as competence invariably grows with practice (see Chapter 18). Because it is so widely performed and has the largest literature describing its record, this chapter focuses on lessons learned from the introduction of laparoscopic cholecystectomy.