Evaluation of the Learning Curve and Complications Related to Hand-Assisted Laparoscopic Appendectomy in Children with Acute Appendicitis

Mehrdad Hoseinpour, Masoud Nazem, Borzoo Khaledifar



Introduction: Previous studies have shown that according to the learning curve, one’s knowledge and skills increase with experience and repetition. However, no studies have yet proved that the learning curve can be generalized to medical procedures. Therefore, this study aimed to evaluate the learning curve and complications of hand assisted laparoscopic appendectomy (HALA) in children with acute appendicitis.

Materials and Methods: In a prospective randomized study in 2016, ninety patients aged 8-16 years were selected for appendectomy. The participants were then consecutively divided into three groups according to admission time. The first, second, and third groups were operated on by an attending pediatric surgeon, an attending pediatric surgeon and a pediatric surgical fellow (a surgeon who is studying the subspecialty of pediatric surgery) and in the third group only a pediatric surgical fellow, respectively. For each surgery, duration of surgery and hospitalization was determined and recorded, and the time trend of surgery was determined and compared in all three groups using the learning curve.

Results: The mean duration of surgery of the groups operated on by an attending, an attending and a fellow, and a fellow alone was 38.7±12.8, 46.9±8.8 and 48.5±11.3 respectively, with a significant difference among the three groups (p=0.002). During the surgery, duration of surgery in the fellow and attending group and the fellow group decreased over time.

Conclusion: The learning curve can be generalized to medical procedures and experiences. Duration of appendectomy for fellows can decrease over time as they become more skilled. Usually after performing 30 surgeries and gaining experience, fellows will be able to perform appendectomy nearly as fast as attending surgeons. In the meantime, the root causes of the fluctuations observed during surgery should be scientifically examined and resolved.


Learning Curve; Hand Assisted; Laparoscopic Appendectomy

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Fioretti G: From men and machines to the organizational learning curve. European Journal of Operational Research. 2007; 177: 1375-84.

Karimi Moonaghi H, Binaghi T: Teaching and learning style and the application in higher education. Mashhad: Mashhad University of Medical Sciences vice presidency for research; 2009. [In Persian].

Aizi f: Medical education: mission, vision and challenges. Tehran:Student Educational Affairs Department, Ministry of Health Medical Education;2003. [In Persian].

Oslon MH, Hergenhahn BR: An Introduction to Theories of Learning. 9th ed. NJ: Prentice-Hall; 2012.

Loukas C, Nikiteas N, Kanakis M, et al: A virtual reality simulation curriculum for intravenous cannulation training. Acad Emerg Med. 2010; 17: 1142-5.

Gettman MT, Le CQ, Rangel LJ, Slezak JM, et al: Development of a standardized curriculum for teaching cystoscopic skills using a computer-based endourologic simulator. Simul Healthc. 2009; 4(2): 92-7.

Benner P, Tanner C, Chesla C: Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics. 2 nd ed. Philadelpha: Springer Publishing Company; 2009.

Gange RM: The conditions of Learning and theory of instruction. 4th ed. Belmont, CA: Wadsworth Publishing Company; 1985.

Minne L, Varner D, Burnell A, et al: Laparoscopic vs open appendectomy. Prospective randomized study of outcomes. Arch Surg. 1997;132:708–711.

Chiu CC, Wei PL, Wang W, et al: Role of appendectomy in laparoscopic training. J Laparoendosc Adv Surg Tech A. 2006;16:113–118.

Jaffer U, Cameron AE: Laparoscopic appendectomy: a junior trainee's learning curve. JSLS.2008;12:288–291.

Kim SY1, Hong SG, Roh HR, et al: Learning curve for a laparoscopic appendectomy by a surgical trainee. J Korean Soc Coloproctol. 2010;26(5):324-8.

Liao YT, Lin TH, Lee PC, et al: Learning curve of single-port laparoscopic appendectomy for non complicated acute appendicitis: a preliminary analysis compared with conventional laparoscopic appendectomy. J Laparoendosc Adv Surg Tech A. 2013;23(5):441-6.

Lin YY1, Shabbir A, So JB: Laparoscopic appendectomy by residents: evaluating outcomes and learning curve. Surg Endosc. 2010 Jan;24(1):125-30.

DOI: https://doi.org/10.22037/irjps.v3i1.16427


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