Learning Curve For Performing Choledochotomy Bile Duct Exploration With Primary Closure After Laparoscopic Cholecystectomy

Object:To evaluate the learning curve of performing primary closure after LC+LCBDE,and investigate the independent risk factors that affect conversion to laparotomy.Method:We retrospectively identified all patients who underwent primary closure after LC+LCBDE performed by a single surgeon from January 2009 to April 2015 in our institution,and analyzed preoperative,intraoperative,and postoperative data using the cumulative sum(CUSUM)analysis to evaluate the learning curve for this procedure.Result:Overall,there were 390 patients.The total postoperative complications rate was 7.2%,including bile leakage in 9(2.3%)patients and retained common bile duct stone in 3(0.8%)patients.The CUSUM operating time(OT)learning curve was best modeled by the equation: CUSUMOT=312.209×procedure0.599× e(-0.011×pro cedure)+122.608(R2=0.96).The learning curve was composed of two phases,phase 1(the initial 54 patients)and phase 2(the remaining 336 patients).A significant decrease in the OT(116.8 ±22.4 min vs 93.8 ±17.8 min;P<0.001)and complication rate(16.7% vs 5.7%;P<0.01)including the rate of bile leakage(7.4% vs 1.5%;P<0.01)and retained stone(3.7% vs 0.3%;P<0.01)was observed between the two phases.In addition,20 patients had conversion to open surgery.Impacted stones were independently associated with conversion,as indicated by a multivariable analysis.Conclusion:The data suggest that the learning curve of this procedure was achieved in approximately 54 cases.An impacted stone was the only risk factor that affected the conversion rate.