title: The learning curve measured by operating times for laparoscopic and open gastric bypass: roles of surgeon's experience, institutional experience, body mass index and fellowship training.
abstract: BACKGROUND
  Surgeons must overcome a substantial learning curve before mastering laparoscopic Roux-en-Y gastric bypass (LRYGBP). This learning curve can be defined in terms of mortality, morbidity or length of surgery. The aim of this study was to compare the learning curves in terms of surgical time for the first 3 surgeons performing LRYGBP in our hospital with the length of surgery for open gastric bypass (CONTROLS).
  
  
  METHODS
  We compared 494 primary LRYGBPs performed by 3 surgeons (393 by 1st SURGEON, 57 by 2nd SURGEON and 44 by 3rd SURGEON) to 159 open vertical banded gastroplasty-Roux-en-Y gastric bypasses (CONTROLS). Data for LRYGBP patients were prospectively obtained. Factors that significantly affected the length of surgery were identified by univariate and multivariate linear regression analysis.
  
  
  RESULTS
  LRYGBP and CONTROL patients were similar in age, height, weight and BMI, although more CONTROLS were male. Median time for the 1st SURGEON performing LRYGBP dropped for each subsequent 100 operations: 1st 100 - 190 min, 2nd 100 - 135 min, 3rd 100 - 110 min and 4th 100 - 100 min. Median time for 2nd SURGEON performing LRYGBP was 120 min, 3rd SURGEON 173 min and CONTROLS 64 min. Length of surgery significantly correlated with surgical experience in terms of numbers of operations and BMI of patient. Times for 2nd SURGEON, a fellowship trained laparoscopic surgeon, started significantly faster than 1st SURGEON's, but did not significantly improve with experience. 3rd SURGEON's initial times were similar to 1st SURGEON's, but his times improved more rapidly with experience. Times for CONTROLS were significantly faster than all laparoscopic groups and did not correlate with operation number or patient BMI.
  
  
  CONCLUSIONS
  The length of surgery for LRYGBPs continued to shorten beyond 400 operations for the first surgeon performing LRYGBP in our hospital. Previous fellowship training in LRYGBP shortened surgical times during initial clinical experience as an attending for the second surgeon. The learning curve was truncated because of the already established LRYGBP program.
authors.affiliation: Bariatric Surgery Center, Hacekensack University Medical Center, Hackensack, NJ 07601, USA. ghb@lapsurgery.com
authors.forename: Garth H
authors.initials: GH
authors.lastname: Ballantyne
authors.forename: Douglas
authors.initials: D
authors.lastname: Ewing
authors.forename: Rafael F
authors.initials: RF
authors.lastname: Capella
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Capella
authors.forename: Dan
authors.initials: D
authors.lastname: Davis
authors.forename: Hans J
authors.initials: HJ
authors.lastname: Schmidt
authors.forename: Annette
authors.initials: A
authors.lastname: Wasielewski
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Davies
mesh_terms: D000328:Adult; D000704:Analysis of Variance; D015992:Body Mass Index; D016022:Case-Control Studies; D002983:Clinical Competence; D015331:Cohort Studies; D004502:Education, Medical, Continuing; D005257:Fellowships and Scholarships; D005260:Female; D015390:Gastric Bypass / Q000193:education / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D007813:Laparotomy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000175:diagnosis* / Q000601:surgery*; D011336:Probability; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D013997:Time Factors; D017749:Total Quality Management