title: The learning curve of laparoscopic holecystectomy in general surgery resident training: old age of the patient may be a risk factor?
abstract: A well-designed learning curve is essential for the acquisition of laparoscopic skills: but, are there risk factors that can derail the surgical method? From a review of the current literature on the learning curve in laparoscopic surgery, we identified learning curve components in video laparoscopic cholecystectomy; we suggest a learning curve model that can be applied to assess the progress of general surgical residents as they learn and master the stages of video laparoscopic cholecystectomy regardless of type of patient. Electronic databases were interrogated to better define the terms "surgeon", "specialized surgeon", and "specialist surgeon"; we surveyed the literature on surgical residency programs outside Italy to identify learning curve components, influential factors, the importance of tutoring, and the role of reference centers in residency education in surgery. From the definition of acceptable error, self-efficacy, and error classification, we devised a learning curve model that may be applied to training surgical residents in video laparoscopic cholecystectomy. Based on the criteria culled from the literature, the three surgeon categories (general, specialized, and specialist) are distinguished by years of experience, case volume, and error rate; the patients were distinguished for years and characteristics. The training model was constructed as a series of key learning steps in video laparoscopic cholecystectomy. Potential errors were identified and the difficulty of each step was graded using operation-specific characteristics. On completion of each procedure, error checklist scores on procedure-specific performance are tallied to track the learning curve and obtain performance indices of measurement that chart the trainee's progress.
  
  
  CONCLUSIONS
  The concept of the learning curve in general surgery is disputed. The use of learning steps may enable the resident surgical trainee to acquire video laparoscopic cholecystectomy skills proportional to the instructor's ability, the trainee's own skills, and the safety of the surgical environment. There were no patient characteristics that can derail the methods. With this training scheme, resident trainees may be provided the opportunity to develop their intrinsic capabilities without the loss of basic technical skills.
authors.affiliation: Department of Oncology, University of Turin, Section of General Surgery, San Luigi Gonzaga Teaching Hospital, Regione Gonzole 10, 10043 Orbassano, Turin, Italy.
authors.forename: Alessia
authors.initials: A
authors.lastname: Ferrarese
authors.affiliation: University of Turin, Department of Oncology, School of Medicine, Teaching Hospital "San Luigi Gonzaga", Section of General Surgery, Orbassano, Turin, Italy.
authors.forename: Valentina
authors.initials: V
authors.lastname: Gentile
authors.affiliation: University of Turin, Department of Oncology, School of Medicine, Teaching Hospital "San Luigi Gonzaga", Section of General Surgery, Orbassano, Turin, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Bindi
authors.affiliation: University of Turin, Department of Oncology, School of Medicine, Teaching Hospital "San Luigi Gonzaga", Section of General Surgery, Orbassano, Turin, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Rivelli
authors.affiliation: University of Turin, Department of Oncology, School of Medicine, Teaching Hospital "San Luigi Gonzaga", Section of General Surgery, Orbassano, Turin, Italy.
authors.forename: Jacopo
authors.initials: J
authors.lastname: Cumbo
authors.affiliation: University of Turin, Department of Oncology, School of Medicine, Teaching Hospital "San Luigi Gonzaga", Section of General Surgery, Orbassano, Turin, Italy.
authors.forename: Mario
authors.initials: M
authors.lastname: Solej
authors.affiliation: University of Turin, Department of Oncology, School of Medicine, Teaching Hospital "San Luigi Gonzaga", Section of General Surgery, Orbassano, Turin, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Enrico
authors.affiliation: University of Turin, Department of Oncology, School of Medicine, Teaching Hospital "San Luigi Gonzaga", Section of General Surgery, Orbassano, Turin, Italy.
authors.forename: Valter
authors.initials: V
authors.lastname: Martino
keywords: Cholecystectomy; General Surgery; Learning curve; Resident; Surgery