Original article

Surgeon experience and trends in intraoperative complications

in laparoscopic cholecystectomy
M. S. Hobbs1 , Q. Mai1 , M. W. Knuiman1 , D. R. Fletcher2 and S. C. Ridout1
1
School of Population Health, University of Western Australia, Crawley, and 2 School of Surgery and Pathology, Fremantle Hospital and University of
Western Australia, Fremantle, Western Australia, Australia
Correspondence to: Professor M. S. Hobbs, School of Population Health, University of Western Australia, 35 Stirling Highway, Crawley, Western Australia
6907, Australia (e-mail: mikeh@dph.uwa.edu.au)

Background: Intraoperative complications, particularly bile duct injuries (BDIs), have increased since
the introduction of laparoscopic cholecystectomy (LC). This excess risk is expected to decline as surgeon
experience in laparoscopic surgery increases.
Methods: This was a population-based study of trends in intraoperative injuries in 33 309
cholecystectomies carried out in Western Australia between 1988 and 1998, based on hospital discharge
abstracts. Endpoints were identified from diagnostic and procedure codes in index or postoperative
readmissions, or a register of endoscopic retrograde cholangiopancreatography procedures, and validated
using hospital records. Multivariate analysis was used to estimate the risk of complications associated
with potential risk factors.
Results: Following the introduction of LC in 1991, the prevalence of all complications doubled by
1994 then stabilized, whereas that of BDI declined after 1994. The risk of complications increased with
age, was higher in men, teaching and country hospitals, and was higher for LC and more complicated
operations. It was lower when intraoperative cholangiography was performed and with increasing surgeon
experience. Approximately 20 per cent of all complications and 30 per cent of BDIs were attributable to
surgeons who had performed 200 or fewer cholecystectomies in the previous 5 years.
Conclusion: The risk of intraoperative complications declined with increasing surgical experience and
use of intraoperative cholangiography.

Paper accepted 7 April 2006

Published online 2 May 2006 in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.5333

Introduction A previous population-based study of cholecystectomy

The risk of intraoperative injury during laparoscopic
cholecystectomy (LC) is higher than that in open
cholecystectomy (OC)1 – 14 . It has been anticipated that
this will diminish with increasing surgeon experience
in the use of LC15 – 17 . The interpretation of trends
in intraoperative complications associated with LC or
OC is, however, complicated by changes in case
selection for LC, as surgeons become more expert
in laparoscopic surgery and fewer patients undergo a
primary open procedure. Furthermore, surgeons who had
extensive previous experience of OC may exercise greater
judgement about which patients should be considered
for initial OC rather than LC, and may be better
equipped to deal with laparoscopic procedures that require
conversion.
in Western Australia found a marked increase in
intraoperative injuries and other major complications
during the first 4 years of uptake of LC (1991–1994)
compared with the previous 3 years11 . A strong negative
association with intraoperative cholangiography (IOC) was
also noted. This study has now been extended for a further
4 years, with the primary aim of testing the hypothesis
that intraoperative injuries would decline with time and
increasing experience of individual surgeons.
Patients and methods
The study was set in Western Australia, which had a
population of approximately 1·8 million in 1998. Most of
the population (72 per cent) lives in the capital city Perth,

Copyright  2006 British Journal of Surgery Society Ltd British Journal of Surgery 2006; 93: 844–853
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Complications of laparoscopic cholecystectomy
in which all tertiary hospital services are located. The
remainder is dispersed in small country towns of no more
than 30 000 persons.
The study was based on an electronic file of all hospital
admissions and death records for patients admitted to
hospital for biliary disease between 1980 and 1999 from
the Western Australian Data Linkage System maintained
by the State Department of Health18 . The records of all
individuals who underwent cholecystectomy in 1988–1998
were selected, excluding patients with selected neoplasms
(cancer of the duodenum, biliary tract, pancreas or
secondary cancer of the liver (International Classification
of Diseases (ICD) 9/ICD-9-CM codes 152·0, 156, 157 and
197·7 respectively) and patients with obstructive jaundice
or cholangitis (576·1, 576·2, 574·31–574·51) associated
with any other malignancy (140–208) in admissions before
or after cholecystectomy. The study period included the
3 years before the introduction of LC and 8 years during
which LC rapidly became the main procedure used. LC
was first performed in Western Australia in 1990, but
only 34 procedures were performed in that year. For the
purposes of this study, 1991 has been designated as the year
in which LC was introduced. The linked file was also used
to identify patients with previous admissions for biliary
disease or those who were admitted for postoperative
complications, and to measure the cumulative experience
in cholecystectomy of individual surgeons in the 5 years
before each index procedure in the study period. This study
was conducted with the approval of the Human Research
Ethics Committee of the University of Western Australia
and the Confidentiality of Health Information Committee
of the Department of Health of Western Australia.
The endpoints of the study were bile duct injuries
(BDIs), bowel or blood vessel injuries, postoperative
haemorrhage and other major bile leaks detected during
either the index (operative) admission or a readmission
within 30 days. BDIs were defined as injuries to the
common bile duct (CBD) or hepatic ducts as a
result of surgery. Bowel and vascular injuries included
those documented in the operation notes or requiring
reintervention such as laparotomy. Other major bile leaks
were those that did not involve injury of bile ducts but
were of sufficient severity to require further surgical
or endoscopic reintervention. Similarly, postoperative
haemorrhage was defined as bleeding from the operative
site sufficient to warrant further surgery. Minor bile
leaks treated with drainage or drains left in situ after
surgery were excluded. Selected diagnostic and procedure
codes in operative or postoperative readmissions recorded
in hospital separation abstracts were used to identify
patients with possible intraoperative complications, as
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845
described in detail previously19 . In addition, a register
of all endoscopic retrograde cholangiopancreatographies
(ERCPs) performed in Western Australia since 1990 was
used to identify patients in whom ERCP was performed
because of suspected injury of the CBD. From these
sources 1870 patients with suspected complications were
identified from a total of 33 309 patients meeting the
study selection criteria. The relevant hospital medical
records (including those for preoperative and postoperative
admissions) of patients with suspected injuries were then
reviewed using a standard data collection form to confirm
the occurrence of a complication, and to collect relevant
clinical information including reasons for surgery, type
of procedure (including conversion to OC), operating
surgeon, diagnostic procedures, location and type of
injury, time of detection of the injury and subsequent
management.
A four-point, hierarchical classification of surgical
complexity, based on selected ICD-9-CM diagnostic codes
or admissions for biliary disease before the index admission,
was constructed. Complicated operations included those
for a diagnosis of acute pancreatitis (577·0), cholangitis
(576·1) or obstructive jaundice (576·2, 574·31–574·51)
during the index or previous admission. Acute operations
were those undertaken for acute cholecystitis during the
index or a previous admission (574·0, 574·3, 575·0).
Operations were considered to be potentially complicated
if the patient had one preoperative admission for biliary
disease (574, 575, 576), but did not fall into either of the
previous two categories, and were classed as simple for
all remaining patients. Surgery was further graded as non-
complex (simple operations) or complex (any of other three
categories defined above).
In teaching hospitals with trainee surgeons, the
operating surgeon was identified from the operating
theatre registers or computer-based operating theatre
information system (18·2 per cent of patients). For the
remaining procedures (performed in private hospitals or
non-teaching public hospitals that in general do not have
trainee surgeons) the operating surgeon was identified
from a specific code (present in 62·6 per cent of records)
or, if this was missing, the code for ‘responsible doctor’,
providing that the doctor had a surgical qualification
(15·1 per cent). This resulted in exclusion of 537 patients
(1·6 per cent) because relevant codes were missing from the
hospital inpatient statistical system. A further 557 patients
(1·7 per cent) were excluded from the analysis because the
‘responsible doctor’ was not a surgeon and performed only
one cholecystectomy in the entire study period. It is likely
that these patients were admitted for medical reasons and
were subsequently transferred for surgery.
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846
Surgeon experience was defined as the number
of previous cholecystectomies (open or laparoscopic)
performed by individual surgeons in the 5 years before
each index procedure, determined by record linkage. Total
experience with LC was similarly determined by counting
laparoscopic procedures performed in the previous 5 years.
Surgeon experience was divided into categories 1–50,
51–100, 101–200, 201–300 and more than 300 previous
cholecystectomies.
Statistical analysis
The data were analysed with logistic regression using
the SAS statistical analysis software package (SAS
Institute, Cary, North Carolina, USA). Because the
numbers of each complication were too small for reliable
individual multivariate analysis, all complications (bile duct
injuries, vascular injuries, bowel injuries, postoperative
haemorrhage and major bile leaks) were combined. The
dependent variable was the occurrence or otherwise of
a complication. Independent variables included sex, age,
hospital type, type of cholecystectomy, surgical complexity,
time interval, IOC and surgeon experience. Laparoscopic
procedures converted to open surgery were analysed
as LCs.
Risk factors were assessed individually (univariate
analysis) and also after adjustment for age, sex, hospital
type, surgical complexity and time interval (multivariate
analysis). For categorical variables, each level was compared
to a reference level and odds ratios (ORs) and χ2 P values
presented. For quantitative/trend variables, the OR for a
change in value of one unit or level was calculated, together
with the trend χ2 P value. Statistical significance was taken
at the 5 per cent level.
The proportions of all complications and BDIs
associated with relative surgical inexperience (fewer than
200 cholecystectomies in the previous 5 years) were
estimated using standard methodology for estimating
population-attributable proportions20 .
Results
Between 1988 and 1998, 34 625 cholecystectomies were
performed in Western Australia. After exclusion of 1316
patients with malignant neoplasms, 33 309 patients were
eligible for the study. Of these, 13 895 underwent OC and
19 414 underwent LC (including 1339 conversions). One-
fifth of procedures were performed in teaching (tertiary)
hospitals, one-fifth in country hospitals and the remainder
in non-teaching hospitals in Perth.
Following the general introduction of LC in 1991,
rates of cholecystectomy rose by approximately 25 per cent
Copyright  2006 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
M. S. Hobbs, Q. Mai, M. W. Knuiman, D. R. Fletcher and S. C. Ridout
in both men and women and then remained steady.
The proportion of all cholecystectomies performed
laparoscopically increased rapidly from 44·3 per cent
in 1991–1992 to 78·5 per cent in 1993–1994 and to
85·0 per cent in 1997–1998 (79·8 per cent in men and
86·8 per cent in women). The use of IOC declined from
71·2 per cent in 1988–1990 to 47·0 per cent in 1993–1994
before rising to 62·7 per cent in 1997–1998 (Fig. 1).
Trends in use of IOC were different for OC and LC. Use
of IOC in open procedures declined from 71·4 per cent
in 1988–1990 to 49·0 per cent in 1993–1994 and then
stabilized, whereas that in LC increased steadily with time.
The proportion of patients undergoing IOC did not vary
greatly with surgical complexity, being 55·0 per cent in
acute operations, 59·3 per cent in potentially complicated,
59·7 per cent in simple and 64·7 per cent in complicated
operations. These relative differences in use of IOC did
not change over the study period.
There was a gradual increase in the percentage of
patients with complex conditions over the course of the
study (Fig. 2). This was particularly marked in the case
80
70
60
Use of IOC (%)
50
40
30 Open
Laparoscopic
20 All procedures
10
0
1988–1990 1991–1992 1993–1994 1995–1996 1997 – 1998
Fig. 1Trends with time in the use of intraoperative
cholangiography (IOC) by type of procedure
Patients with complex conditions (%)
60
Open
50 Laparoscopic
All procedures
40
30
20
10
0
1988–1990 1991–1992 1993–1994 1995–1996 1997 – 1998
Trends with time in the proportion of patients with
Fig. 2
complex conditions undergoing cholecystectomy by operation
type
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Complications of laparoscopic cholecystectomy 847

of open procedures. The proportion of patients with
complex conditions selected for LC also increased and
by 1997–1998 LC was performed on most patients with
complex conditions (78·8 per cent).
The proportion of all procedures resulting in
BDI increased from 0·18 per cent in 1988–1990 to
0·35 per cent in 1993–1994 and then declined to
0·14 per cent in 1997–1998 (Table 1). The proportion of
procedures resulting in other injuries or major bile leaks
also increased from 1988–1990 to 1993–1994 but did not
decline thereafter.
Table 2 shows the unadjusted prevalence and ORs
for all complications combined, stratified according to
various risk factors. The risk of complications increased
progressively with age and was also higher in men, in
teaching and country hospitals compared with other non-
teaching hospitals in Perth, in LC and with increasing
surgical complexity. It decreased with use of IOC and
increasing surgeon experience. The risk of complications
increased steeply from 1988–1990 to 1993–1994 and
then stabilized. Multivariate analysis yielded similar results
(Table 3).
The number of patients with BDI (22·8 per cent of
all complications) was too small for detailed multivariate
analysis, but an abbreviated version of the model in Table 3
that included age, sex, surgical complexity (complex or
simple), IOC, procedure type and surgeon experience
was developed with BDI as the outcome. There was
a significant trend for the risk of BDI to decline with
increasing surgeon experience (P = 0·018). Surgeons who
had performed 1–50 operations were 2·40 ((95 per cent
confidence interval (c.i.) 1·09 to 5·29); P = 0·029) times
more likely to create a BDI than those who had performed
over 300 procedures in the previous 5 years. The only
other factor associated with a significant variation in the
risk of BDI was surgical complexity (OR 1·65 (95 per cent
c.i. 1·05 to 2·69); P = 0·032). Although not significant, the
risk was greater during LC (OR 1·64 (95 per cent c.i. 0·99
to 2·72); P = 0·053) and lower when IOC was performed
(OR 0·68 (95 per cent c.i. 0·42 to 1·03); P = 0·066).
To determine whether the negative association between
IOC and all complications was a general correlation or
related specifically to BDI, the analysis in Table 3 was
repeated after omission of patients with BDI. A strong
and significant negative association between the risk of
complications and IOC remained. There were, however,
no significant interactions between IOC and the remaining
variables.
Results of multivariate analysis of risk of intraoperative
complications for LC alone are shown in Table 4. Surgeon
experience was again based on all cholecystectomies (OC
and LC combined) performed in the previous 5 years,
but an alternative statistical model, in which previous
experience of LC only and total experience at the time
of first LC was substituted for any previous procedures,
provided similar results. This was not unexpected, given

Table 1 Trends in intraoperative complications in cholecystectomy by type of procedure 1988–1998

Bile duct injuries Other injuries* Major bile leaks All complications Procedures

Open
1988–1990 12 (0·17) 5 (0·07) 20 (0·28) 37 (0·52) 7 063
1991–1992 6 (0·19) 1 (0·03) 6 (0·19) 13 (0·40) 3 214
1993–1994 5 (0·36) 1 (0·07) 9 (0·64) 15 (1·07) 1 403
1995–1996 3 (0·26) 6 (0·53) 17 (1·49) 26 (2·28) 1 138
1997–1998 2 (0·19) 3 (0·28) 8 (0·74) 13 (1·21) 1 077
Total 28 (0·20) 16 (0·12) 60 (0·43) 104 (0·75) 13 895
Laparoscopic
1988–1990† 1 (3) 0 (0) 1 (3) 2 (6) 34
1991–1992 8 (0·31) 3 (0·12) 8 (0·31) 19 (0·74) 2 552
1993–1994 18 (0·35) 21 (0·41) 29 (0·57) 68 (1·33) 5 123
1995–1996 15 (0·27) 20 (0·36) 41 (0·73) 76 (1·35) 5 623
1997–1998 8 (0·13) 22 (0·36) 43 (0·71) 73 (1·20) 6 082
Total 50 (0·26) 66 (0·34) 122 (0·63) 238 (1·23) 19 414
Total
1988–1990† 13 (0·18) 5 (0·07) 21 (0·30) 39 (0·55) 7 097
1991–1992 14 (0·24) 4 (0·07) 14 (0·24) 32 (0·55) 5 766
1993–1994 23 (0·35) 22 (0·34) 38 (0·58) 83 (1·27) 6 526
1995–1996 18 (0·27) 26 (0·38) 58 (0·86) 102 (1·51) 6 761
1997–1998 10 (0·14) 25 (0·35) 51 (0·71) 86 (1·20) 7 159
Total 78 (0·23) 82 (0·25) 182 (0·55) 342 (1·03) 33 309

Values in parentheses are percentages. *Vascular injuries, bowel injuries and haemorrhage. †Laparoscopic cholecystectomy was introduced into Western
Australia in late 1990.

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848 M. S. Hobbs, Q. Mai, M. W. Knuiman, D. R. Fletcher and S. C. Ridout

Table 2 Distribution of all cholecystectomies and prevalence of intraoperative complications by level of risk with univariate odds ratios

No. of
procedures All complications* Odds ratio† P

Sex
M 8 969 128 (1·43) 1·63 (1·31, 2·04) < 0·001
F 24 340 214 (0·88) 1·00
Age (per year) 33 309 342 (1·03) 1·01 (1·00, 1·02) 0·003
Age (years)
< 55 19 172 175 (0·91) 1·00
55–64 6 097 58 (0·95) 1·04 (0·77, 1·41) 0·783
65–74 5 376 70 (1·30) 1·43 (1·08, 1·89) 0·012
≥ 75 2 664 39 (1·46) 1·61 (1·14, 2·29) 0·006
Hospital type
Teaching 6 716 106 (1·58) 2·14 (1·67, 2·74) < 0·001
Non teaching-metropolitan 20 276 151 (0·74) 1·00
Country 6 317 82 (1·30) 1·75 (1·34, 2·30) < 0·001
Cholecystectomy
Laparoscopic 19 414 238 (1·23) 1·65 (1·31, 2·07) < 0·001
Open 13 895 104 (0·75) 1·00
Surgical complexity
Simple 23 157 190 (0·82) 1·00
Potentially complicated 4 112 58 (1·41) 1·59 (1·18, 2·04) 0·024
Acute cholecystectomy 4 074 56 (1·37) 1·66 (1·23, 2·24) 0·010
Complicated 1 966 38 (1·93) 3·13 (2·20, 4·45) < 0·001
Previous biliary admission
Yes 7 283 104 (1·43) 1·57 (1·25, 1·98) < 0·001
No 26 026 238 (0·91) 1·00
Time (per year) 33 309 342 (1·03) 1·12 (1·08, 1·16) < 0·001
Interval
1988–1990 7 097 39 (0·55) 1·00
1991–1992 5 766 32 (0·55) 1·01 (0·63, 1·61) 0·966
1993–1994 6 526 83 (1·27) 2·33 (1·59, 3·41) < 0·001
1995–1996 6 761 102 (1·51) 2·77 (1·91, 4·02) < 0·001
1997–1998 7 159 86 (1·20) 2·20 (1·51, 3·22) < 0·001
Intraoperative cholangiography
Yes 13 552 175 (1·29) 0·65 (0·53, 0·81) < 0·001
No 19 757 167 (0·85) 1·00
Surgeon experience‡ 0·010
1–50 4 482 69 (1·37) 1·72 (1·21, 2·46) 0·003
51–100 3 801 46 (1·21) 1·52 (1·03, 2·25) 0·036
101–200 8 350 90 (1·08) 1·35 (0·97, 1·89) 0·076
201–300 8 565 75 (0·88) 1·10 (0·78, 1·55) 0·598
> 300 7 017 56 (0·80) 1·00

Values in parentheses are *percentages or †95 per cent confidence intervals. ‡Surgeon experience was the cumulative number of all cholecystectomies
performed by individual surgeons in the past 5 years; 1094 procedures (including six patients with complications) with an incorrect or missing ‘responsible
surgeon’ code were excluded.

the high degree of correlation between previous total
experience in cholecystectomy and total experience of LC
for individual surgeons (Pearson correlation 0·88, P <
0·001). The patterns of variation in risk of complications
during LC were similar to those for all cholecystectomies,
although there were marginal differences in ORs for some
categories (see Tables 3 and 4).
The use of IOC did not vary with surgical experience, but
surgical complexity was inversely related to past surgical
experience. Approximately 40 per cent of procedures
performed by surgeons who had performed 100 or fewer
cholecystectomies were classified as complex, compared
with approximately 25 per cent in the case of surgeons
who had performed over 200 cholecystectomies (Fig. 3).
This result was related to hospital type. Teaching and
country hospitals admitted a higher proportion of patients
with complex disease (52·3 and 35·6 per cent respectively)
than non-teaching metropolitan hospitals (21·2 per cent)
and, as shown in Fig. 4, it was in these hospitals that
surgeons with the least experience were more likely
to operate. In contrast, surgeons with the greatest
experience operated mainly in non-teaching metropolitan

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Complications of laparoscopic cholecystectomy 849

70 Table 3 Multivariate analysis of the risk of intraoperative

% of ccholecystectomies

60
complications by levels of risk factors (all cholecystectomies)

50 Odds ratio P†
40
Sex
30
M 1·46 (1·16, 1·84) 0·001
20 Use of IOC
F 1·00
Complex conditions
10 Age (per year) 1·01 (1·00, 1·01) 0·067
Hospital type
0 Teaching 1·58 (1·19, 2·10) 0·002
1 – 50 51–100 101–200 201–300 >300
Non teaching-metropolitan 1·00
Surgeon experience (cholecystectomies in past 5years)
Country 1·48 (1·10, 1·98) 0·010
Cholecystectomy
Fig. 3Relationship between surgeon experience, and use of Laparoscopic 1·51 (1·11, 2·04) 0·008
intraoperative cholangiography (IOC) and proportion of patients Open 1·00
with complex conditions Surgical complexity < 0·001
Simple 1·00
Potentially complicated 1·20 (0·88, 1·65)
(predominately private) hospitals, in which 60·9 per cent of Acute cholecystitis 1·28 (0·93, 1·75)
Complicated 2·28 (1·56, 3·32)
all cholecystectomies were performed. Within each type of Interval 0·001
hospital however, there was no clear relationship between 1988–1990 1·20 (0·73, 1·98)
surgical complexity and surgeon experience. 1991–1992 1·00
The proportions of total complications and BDIs 1993–1994 1·98 (1·29, 3·04)
1995–1996 2·48 (1·63, 3·77)
attributable to relative lack of surgeon experience were 1997–1998 2·00 (1·30, 3·08)
estimated from the multivariate model in Table 3. The Intraoperative cholangiography
higher risk of complications in surgeons who had Yes 0·70 (0·56, 0·88) 0·002
No 1·00
performed 1–50 or 51–200 cholecystectomies compared
Surgeon experience* 0·007
with those who had performed over 200 procedures 1–50 1·67 (1·13, 2·46)
accounted for 8·4 and 14·1 per cent of all complications 51–100 1·51 (0·99, 2·30)
respectively. From an alternative model in which BDI was 101–200 1·40 (0·97, 2·00)
201–300 1·21 (0·85, 1·73)
the outcome, the respective proportions were 14·7 and > 300 1·00
16·0 per cent (total 30·7 per cent).
The incidence of BDI peaked in 1993–1994 and then Values in parentheses are 95 per cent confidence intervals. *Cumulative
declined (Table 1). Table 5 shows changes in severity of number of all cholecystectomies performed by individual surgeons in the
BDI in the broad intervals corresponding to the period past 5 years; 1094 procedures with an incorrect or missing ‘responsible
surgeon’ code were excluded. †Logistic regression.
immediately before the introduction of LC (1988–1990),
the period of rapid dissemination (1991–1994) and the
period of consolidation (1995–1998). In 1991–1994, there 1995–1998 than in 1991–1994, and incisions were located
were proportionately more major BDIs such as transec- mainly at or below the level of the cystic duct, so could
tions, excisions or strictures (0·15 per cent), compared relatively easily be dealt with by the use of stents or external
with 0·11 per cent in 1988–1990 and 0·05 per cent in drainage.
1995–1998. For all BDIs the respective figures were Increasing age, male sex, teaching hospitals, country
0·29, 0·18 and 0·21 per cent. Most lesions in the inter- hospitals, surgical complexity and LC were associated with
val 1995–1998 (20 of 29) were incisions (side holes) a significantly increased risk of complications, whereas use
at or below the junction of the CBD and cystic of IOC and increasing surgical experience were associated
duct. with a reduced risk. The excess risk associated with LC
compared with OC was, however, weaker than noted
Discussion previously (OR 2·50 (95 per cent c.i. 1·53 to 4·22) for
the period 1988–1994)11 . Comparisons between the risk
After increasing during the first 4 years of LC, the overall of complications in open and laparoscopic procedures
excess risk of intraoperative complications appeared to have become increasingly difficult to interpret because
stabilize. The prevalence and severity of BDI appeared to of the declining use of OC and increased selection of
decrease after reaching a peak in 1993–1994. There were complex cases for LC. Under these circumstances, trends in
relatively fewer transections or excisions of the CBD in complications over time occurring in all cholecystectomies

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850 M. S. Hobbs, Q. Mai, M. W. Knuiman, D. R. Fletcher and S. C. Ridout

100

90
Hospital type (% of procedures)

80
Country
70 hospital
60 Other metropolitan
hospital
50 Teaching
hospital
40

30

20

10

0
1–50 51–100 101–200 201–300 ≥300
Surgeon experience (previous cholecystectomies)

Fig. 4 Relationship between surgeon experience and type of hospital

Table 4 Multivariate analysis of risk of intraoperative As in the authors’ previous study11 , IOC was associated
complications by levels of risk factors in laparoscopic with a 30 per cent lower risk of all intraoperative
cholecystectomies
complications. This is consistent with the results of other
Odds ratio P† population-based studies that examined the relationship
between IOC and CBD injury21,22 . The use of IOC varied
Sex
M 1·66 (1·26, 2·19) 0·001
during the course of the study, initially declining to its
F 1·00 lowest level in 1993–1994 but then increasing to earlier
Age (per year) 1·00 (1·00, 1·01) 0·293 levels in the later years of the study in laparoscopic but
Hospital type
not open procedures. This temporal variation in IOC is
Teaching 1·59 (1·13, 2·23) 0·007
Non-teaching metropolitan 1·00 consistent with the pattern of increase (but not necessarily
Country 1·22 (0·85, 1·77) 0·284 causally related to) the rise and subsequent fall in rate of
Surgical complexity < 0·001
intraoperative complications.
Simple 1·00
Potentially complicated 1·14 (0·78, 1·65) A similar, but non-significant reduction in risk with use
Acute cholecystitis 1·24 (0·84, 1·82) of IOC was also found with BDI as the outcome. This
Complicated 1·95 (1·20, 3·19) apparently protective effect of IOC was, however, also
Interval 0·103
1991–1992 1·00 found for other adverse outcomes (on which it should
1993–1994 1·67 (1·00, 2·80) logically have no bearing) after exclusion of BDI from
1995–1996 1·92 (1·15, 3·21) the analysis, suggesting that the observed benefit of IOC
1997–1998 1·72 (1·02, 2·89)
Intraoperative cholangiography
may be at least partly related to an indirect association
Yes 0·72 (0·55, 0·93) 0·009 between use of IOC by individual surgeons and other
No 1·00 surgical attributes that reduce the risk of complications.
Surgeon experience* < 0·001
1–50 1·69 (1·06, 2·68)
For example, surgeons with good bimanual skills who
51–100 1·60 (0·95, 2·67) are less likely to incur intraoperative complications may
101–200 1·66 (1·11, 2·48) be more likely to use IOC irrespective of case severity
201–300 1·33 (0·90, 1·96)
or level of personal experience. In acute cholecystitis, in
> 300 1·00
which the CBD is often difficult to visualize, IOC may
Values in parentheses are 95 per cent confidence intervals. *Cumulative be particularly valuable but is paradoxically less likely to
number of all cholecystectomies performed by individual surgeons in the be performed than in other complex conditions because of
past 5 years; 225 procedures with an incorrect or missing ‘responsible difficulty in visualizing the cystic duct in the presence of
surgeon’ code were excluded. †Logistic regression.
acute inflammation23 . Without IOC, the problem of poor
definition of anatomy in acute cholecystitis is compounded
in a defined population provide a more meaningful measure in LC by poor spatial orientation owing to monocular
of surgical outcomes. vision.

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Complications of laparoscopic cholecystectomy
Table 5 Bile duct injuries by site and location of lesion and interval
1988–1990
Type of lesion (n = 7097)
Transection or excision 7 (0·10)
Stricture 1 (0·01)
All major bile duct injuries 8 (0·11)
Incision (side hole) 5 (0·07)
Above origin of cystic duct 1 6
At origin of cystic duct 2 8
Below origin of cystic duct 2 3
Unknown 0 1
All injuries 13 (0·18)
Values in parentheses are percentages.
An alternative explanation for a possible indirect
association between use of IOC and intraoperative
complications was proposed by the authors of a major
study of LC based on 1·5 million cholecystectomies in
Medicare recipients in the USA22 . It was found that the
frequency of complications in LC declined with increasing
average use of IOC in patients in which IOC was performed
but, paradoxically, the reverse was true in patients of the
same surgeons in whom IOC was not performed. The
authors suggested that some surgeons who rely on IOC
are less confident or adept when this is not performed22 .
The present study did not have sufficient power to test this
relationship.
Consistent with previous findings21,22,24 , the present
study showed an inverse relationship between the previous
number of cholecystectomies performed by individual
surgeons at the time of each index procedure and the risk of
intraoperative complications. After adjustment for surgical
complexity and hospital type, approximately 20 per cent of
all complications and 30 per cent of BDIs were attributable
to the relative inexperience in surgeons who had performed
up to 200 cholecystectomies in the previous 5 years. About
half of the excess of total complications and BDIs associated
with relative inexperience was attributable to surgeons
who had performed between one and 50 procedures,
and who collectively performed 13·9 per cent of all
cholecystectomies. Reduction in the risk of complications
by careful mentoring of least experienced surgeons might
thus have a measurable impact on overall rates of
complications.
With regard to other risk factors for intraoperative
complications, no relationship was found between surgeon
experience and the proportion of cholecystectomies in
which IOC was performed. An unexpected finding was
an inverse relationship between surgeon experience and
the percentage of complex procedures performed. This
was because the least experienced surgeons performed
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Published by John Wiley & Sons Ltd
851
1991–1994 1995–1998 1988–1998
(n = 12 292) (n = 13 920) (n = 33 309)
13 (0·11) 6 (0·04) 26 (0·08)
5 (0·04) 1 (0·01) 7 (0·02)
18 (0·15) 7 (0·05) 33 (0·10)
17 (0·14) 20 (0·14) 42 (0·13)
9 16
10 20
1 6
2 3
36 (0·29) 29 (0·21) 78 (0·23)
relatively more operations in teaching and country
hospitals, both of which admitted a higher proportion
of complex cases. Both teaching and country hospitals
had a substantially higher risk of complications than
non-teaching hospitals even after adjustment for surgical
complexity. The fact that trainees in teaching hospitals
are operating on patients with relatively more complex
conditions than experienced surgeons highlights the need
for vigilance in the supervision of surgical training
programmes.
In the case of surgeons working in country hospitals,
lower levels of experience may simply reflect small
numbers of patients presenting with biliary disease, whereas
other patients may elect to have surgery in metropolitan
hospitals, underlining the difficulty that these surgeons
face in maintaining surgical skills. In remote locations
where surgeons are required to turn their hands to many
procedures, OC might be a safer option if regular rotations
to major centres for experience in LC and other common
procedures cannot be arranged.
Although rates of BDI have improved, the occurrence
of other intraoperative injuries, haemorrhage and major
leaks has not diminished, suggesting the existence of
technical problems that need to be resolved. The majority
of bile leaks are from the cystic duct, indicating that
clips are not always of adequate size or closure, or both.
In selected patients in whom the cystic duct is wide
owing to obstruction or inflammation, either large clips
or ligation should be undertaken. The latter is a skill that
all laparoscopic surgeons should possess.
This study has several limitations. When LC was
introduced initially, it had no specific code and its
identification required use of the code for endoscopic
laparoscopy in association with that for cholecystectomy.
If this rule was not applied consistently, the total number
of LCs would have been underestimated, resulting in an
overestimation of the risk of adverse outcomes associated
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852
with LC in the interval 1991–1992. Similarly, there was
no specific code for laparoscopic procedures converted to
OC. Although it was possible to correct the coding of
procedures and other relevant information in the records
of patients with suspected complications, the study did not
have the resources to validate the coding in the records of
all patients undergoing cholecystectomy. It is possible that
some converted laparoscopic procedures without suspected
complications were misclassified as OC, also leading to
overestimation of the risk of IOC associated with LC.
Because the proportion of LCs converted to open surgery
was relatively small (6·3 per cent in 1993–1994), this effect
was unlikely to be large. As noted in other major studies25 ,
it was not always possible to identify patients in whom IOC
was performed because of a complication during surgery,
rather than as an initial procedure to display anatomy
or exclude CBD stones before the dissection had started.
The beneficial effect of IOC might therefore have been
underestimated.
A further concern relating to the consistency of coding
was that surgical complexity, based on diagnostic codes
for acute cholecystitis, obstructive jaundice, cholangitis or
previous pancreatic disease, increased to a greater extent
than could be reasonably explained by real trends in the
underlying pathology in the general population. This may
have resulted from changes in disease coding following
the introduction of case-mix funding in some hospitals in
Western Australia in the early 1990s. This could have led
to overestimation of the decline in risk of complications
in the later years of the study, but no evidence of this
was found when surgical complexity was omitted from
multivariate analysis. An alternative explanation is that
improved access to cholecystectomy since the introduction
of LC might have led to altered selection of patients with
complex conditions for surgery.
In teaching hospitals, the surgeon coded as being
responsible for a patient may not necessarily be the
operating surgeon, particularly when trainees are involved.
Operating theatre registers were examined to correctly
identify the operating surgeon. It is nevertheless arguable
whether operations undertaken by trainees should be
attributed to the trainee or the supervising surgeon.
A further shortcoming is that the measure of surgeon
experience used in the study was based on operations
performed in Western Australia only, so that the experience
of surgeons who had migrated into Western Australia or
returned after surgical training elsewhere would have been
underestimated. Finally, in approximately 3 per cent of
patients, the operating surgeon could not be determined
because the relevant fields had not been completed or
the ‘responsible’ doctors were attributed with only one
Copyright  2006 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
M. S. Hobbs, Q. Mai, M. W. Knuiman, D. R. Fletcher and S. C. Ridout
cholecystectomy in the study period and were not surgeons.
In the latter group (half of the omitted cases) it is likely
that in most instances a transfer of the patient to surgical
care after admission was not recognized by coders. The
prevalence of complications in these patients (0·4 per cent)
was less than the overall prevalence of 1·03 per cent for the
entire study. Their omission is therefore unlikely to have
biased the results.
Despite these caveats, the authors believe that the
increased risk of complications associated with the advent
of LC has stabilized and, more importantly, there has
been a decline in both the prevalence and severity of BDI
despite increasing use of LC for complex cases. Increasing
surgeon experience and rising rates of IOC are likely to
have contributed to this improvement.
Acknowledgements
This study was supported by grants from the National
Health and Medical Research Council of Australia and the
Department of Health of Western Australia (M.S.H. and
S.C.R.). The authors thank the Health Information Centre
of the Department of Health of Western Australia for
providing access to the linked hospital discharge abstracts
included in the study.
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