title: Does concentration of surgical expertise improve outcomes for laparoscopic cholecystectomy? 9 year audit cycle.
abstract: BACKGROUND
  Evidence from surgery shows that high volume is often associated with better outcomes. The aim of this study was to investigate this principle related to elective laparoscopic cholecystectomy practice.
  
  
  METHODS
  A retrospective analysis of all conversions and complications for patients undergoing elective laparoscopic cholecystectomy was performed. Data was collected and then repeated after restrictions were implemented to concentrate practice. Hospital databases and patient notes were used to collect data.
  
  
  RESULTS
  Between January 1999 and March 2004, 1605 laparoscopic cholecystectomies were performed by 8 surgeons. Case load varied from an average of <1 to 104 procedures per annum. Only 1 surgeon was an upper gastrointestinal specialist. Overall rates for conversion to open surgery were 4.9%, common bile duct injury was 0.31%, bile leak 0.75%, bowel injury 0.25%, haemorrhage 0.44% and death 0.06%, which met guidelines. Significant correlation between conversion and procedure number was identified (p=0.033) Between April 2006 and March 2010, 1820 laparoscopic cholecystectomies were performed by 4 surgeons. Case load varied from 23 to 268 procedures per annum, 2 surgeons were upper gastrointestinal specialists. Overall rates for conversion to open surgery were 3.5%, common bile duct injury 0.1%, bile leak 0.9%, bowel injury 0.21%, haemorrhage 0.16% and death 0.1%. Conversion rates were significantly lower in re-audit data (p=0.027), but remained lowest for the highest volume sub-specialist surgeons (p=0.016).
  
  
  CONCLUSIONS
  Concentrating expertise to those surgeons with interest and commitment to laparoscopic cholecystectomy service led to standardisation and reduction in conversion rates. There is correlation between volume of surgery and outcomes.
authors.affiliation: Royal Devon and Exeter Foundation Trust, Barrack Road, Exeter, Devon EX2 5DW, UK. Electronic address: stuart.andrews76@btinternet.com.
authors.forename: S
authors.initials: S
authors.lastname: Andrews
mesh_terms: D017081:Cholecystectomy, Laparoscopic / Q000379:methods* / Q000706:statistics & numerical data*; D054869:Clinical Audit; D002983:Clinical Competence; D017558:Elective Surgical Procedures; D005705:Gallbladder Diseases / Q000601:surgery*; D006801:Humans; D015994:Incidence; D007902:Length of Stay; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D013043:Specialties, Surgical / Q000592:standards*; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome; D006113:United Kingdom / Q000453:epidemiology
keywords: Laparoscopic Cholecystectomy; Outcome; Volume