Proficiency-gain curve for an advanced laparoscopic procedure defined by observation clinical human reliability assessment (OCHRA)

M. Talebpour, A. Alijani, G. B. Hanna, Z. Moosa, B. Tang, Alfred Cuschieri

    Research output: Contribution to journalArticlepeer-review

    29 Citations (Scopus)


    There is no established method for defining when a surgeon reaches the proficiency plateau in performing a specific operation. The published literature refers to "learning curves" based on retrospective evaluation of operative time, conversion rates, morbidity etc., which lack objectivity and do not address individual human factors. A more useful study of the gain in proficiency by the individual surgeon for a particular operation may be obtained using observational clinical-human reliability assessment (OCHRA).

    Following an 8-month fellowship in advanced laparoscopic surgery, the surgeon M.T. performed, independently at his own hospital, a prospective series of 20 palliative bypass operations for advanced gastric or pancreatic cancer. Unedited videotapes of gastro-jejunostomy (GJ) or cholecysto-jejunostomy (CJ) were analyzed independently in the training institution by the OCHRA technique.

    For this surgeon proficiency in executing laparoscopic palliative bypass was reached after the 14th anastomosis when efficient execution (reduction in operative time) was accompanied by significant reduction in technical errors and improved economy of movement (reduction of the economy of movement index from 7-5 to 3-2). The majority of errors were enacted in component tasks associated with intracorporeal suturing. The declining incidence of these errors with experience was an integral component of the proficiency-gain curve. The important performance-shaping factors identified were: concentration lapses (n = 1,321), misjudgments (n = 209), poor camera work (n = 193), fatigue (n = 128), and impaired coordination (n = 108).

    This study has confirmed that OCHRA can describe quantitatively the proficiency-gain curve for a laparoscopic operation and indicate the plateau stage when the individual surgeon attains maximal performance in the execution of a specific procedure.

    Original languageEnglish
    Pages (from-to)869-875
    Number of pages7
    JournalSurgical Endoscopy
    Issue number4
    Publication statusPublished - Apr 2009


    • Proficiency-gain curve
    • Technical errors
    • Economy of movement index
    • OC-HRA
    • Laparoscopic surgery
    • ERRORS


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