Decision-making and technical factors account for the learning curve in complex surgery

Introduction The general public, the legal profession, patients and relatives expect best practice and have difficulty with the concept of a learning curve in surgical interventions. However, it is improbable that technical and innovative skills can be developed, or optimized, without some aspects of learning by experience and indeed 'risk taking'. Patients and Method A single surgeon experience with a novel, complex, surgical procedure for peritoneal malignancy is described and compared with recent literature reports on the surgical learning curve. In total, 100 of 242 (41%) patients referred underwent a laparotomy. The 100 were divided into three numerically equal groups of 33, 33 and 34 cases, and the proportions undergoing surgery, mortality and major morbidity rates for the three groups were analysed. Results The numbers undergoing surgery were 33/54 (61%), 33/96 (34%) and 34/92 (37%). The mortality was 6/33 (18%), 1/33 (3%) and 1/33 (3%), and the major morbidity rates were 9/33 (27%), 2/33 (6%) and 0/34 (0%) in the three groups. Conclusions The main components of the learning curve were considered to be decision-making and technical factors. A mechanism to reduce the surgical learning curve is suggested involving teamwork, and at least two experienced surgeons involved in all major surgical interventions. Decision-making and technical factors account for the learning curve in complex surgery.