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Learning Laparoscopic-Assisted Hysterectomy

C Altgassen, MD^*, W Michels, PhD and A Schneider, MD, MPH

From the *Department of Obstetrics and Gynecology, Campus Luebeck, University of Schleswig-Holstein, Kiel; and Department of Gynecology, Friedrich-Schiller-University, Jena, Germany.

Address reprint requests to: Chr. Altgassen, MD, Department of Obstetrics and Gynecology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany; e-mail: altgassen{at}frauenklinik.uni-luebeck.de.

OBJECTIVE: The aim of this study was to evaluate the factors considered for proficiency and to estimate the number of procedures needed to achieve competence in laparoscopic-assisted vaginal hysterectomy in a teaching hospital.

METHODS: The length of the learning curve, duration of surgery, change of hemoglobin (in grams per liter), conversion rate, and intra- and postoperative complications were evaluated. Cases were analyzed according to the order for the individual surgeon.

RESULTS: Thirty-three surgeons performed 929 laparoscopic-assisted vaginal hysterectomies during the study period. Analyzing the duration of surgery and rate of complications, we decided on a cutoff of 30 cases. Eight surgeons with more than 30 cases performed 668 laparoscopic-assisted vaginal hysterectomies. Their initial 30 cases (group A, the first 30 cases) were compared with their subsequent cases (group B, cases 31 and after). Patient age, body mass index, and uterine weight did not differ between the groups. The intraoperative complication rate dropped from 4.2% to 0.5% (P = .001), hemoglobin drop decreased from –0.8 ± 0.9 g/L to –0.5 ± 1.0 g/L (P = .002), and postoperative complications dropped from 12.9% to 7.0% (P = .017). The duration of surgery was also shorter (148.8 ± 45.4 minutes versus 125.1 ± 46.5 minutes), but this difference was taken from the results of 1 surgeon.

CONCLUSION: A learning experience of 30 laparoscopic-assisted vaginal hysterectomies was necessary in our institution to reach a low level of complications. Duration of the surgical procedure was not an adequate study endpoint to assess a learning effect.

LEVEL OF EVIDENCE: II-3

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