10
11
12
13
6
7
8
9
SUPPLEMENTARY APPENDIX
SEARCH STRATEGY
Search strategy
Databases: Ovid MEDLINE(R) <1948 to February Week 1 2013>
Embase <1980 to 2012 Week 06>
AMED
PsycINFO
<1985 to February 2012>
<1987 to February Week 1 2013>
2
3
4
5
Search Strategy via Ovid SP Interface:
-----------------------------------------------------------------------------------------------------
1 surgical skill$.ti,ab,sh. surgical performance.ti,ab,sh. surgical training.ti,ab,sh. surgical education.ti,ab,sh. surgical competenc$.ti,ab,sh. surgical proficiency.ti,ab,sh. surgical ability.ti,ab,sh. surgical expertise.ti,ab,sh.
(surgeon$ adj4 performance).ti,ab.
(surgeon$ adj4 experience$).ti,ab.
(surgeon$ adj4 assess$).ti,ab.
(surgeon$ adj4 skill$).ti,ab.
(surgeon$ adj4 individual).ti,ab.
18
19
20
21
14
15
16
17 exp Specialties, surgical/mt, st exp Surgical procedures, operative/st or/1-15 individual.ti,ab. learning curve$.ti,ab. learning.sh. exp Employee Performance Appraisal/mt, st, sn exp Process Assessment/mt
22
23 exp "Outcome Assessment (Health Care)"/mt or/17-22
24
25
16 and 23 limit 24 to english language
-----------------------------------------------------------------------------------------------------
Database: Cochrane Database of Systematic Reviews <2000 to 2013>
Search Strategy via PubMed Interface:
-----------------------------------------------------------------------------------------------------
1 Cochrane Database Syst Rev[Journal] AND (Surgery OR Surgeon OR Surgical) AND (Training OR
Performance OR Skill OR Skills OR Education OR Competence OR Competency OR Proficiency OR Ability OR
Expertise OR Learning Curve)
-----------------------------------------------------------------------------------------------------

Year
TABLE A: DATA EXTRACTION
DOMAIN
Year
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
1986-1990
1991-1995
1996-2000
1993
1994
1995
1996
1997
1998
1999
CATEGORY
1986
1987
1988
1989
1990
1991
1992
NUMBER
(n)
0
0
3
1
2
6
2
1
0
0
1
1
0
1
4
12
2
2
3
1
3
4
0
3
1
0
0
4
3
4
11
PERCENTAGE
(%)
0
0
5.3
1.8
3.5
10.5
3.5
1.8
0
0
1.8
1.8
0
1.8
0
5.3
1.75
0
0
7.0
3.5
5.3
1.75
5.3
7.0
7.0
21.1
3.5
5.3
7.0
19.3

Country
Aim
Design
Continent
Design
Design
2001-2005
2006-2010
2011-2014
Australia
Canada
China
Finland
France
Germany
Greece
Korea
Netherlands
New Zealand
South Korea
Taiwan
UK
USA
Europe
Americas
Asia
Oceania
Determinants of a surgical outcome
Determinants of a learning curve
Learning curve for acquiring a new procedure
Routine monitoring of performance
Prospective
Retrospective
Experimental
Observational
Cross-sectional
Longitudinal
23
24
8
2
15
42
2
55
5
52
8
13
18
2
4
28
1
2
1
1
1
1
6
2
1
2
5
14
34
7
2
26.3
73.7
3.5
96.5
8.8
91.2
24.6
59.6
12.3
3.5
40.4
42.1
14.0
3.5
14.0
22.8
31.6
1.8
3.5
1.8
1.8
1.8
3.5
7.0
49.1
1.8
10.5
3.5
1.8
3.5
8.8

Multicentre status
Setting
Specialty (1)
Specialty (2)
Surgical procedure
Yes
No
Hospital
Specialist
Hospital, specialist
Hospital (National Health Service and private)
Bariatric surgery
Breast surgery
Cardiothoracic
Colorectal
Ear, nose, throat (ENT)
Endocrine
Gastrointestinal (GI) surgery
Oncology
Ophthalmology
Orthopedics
Plastics
Thyroid surgery
Upper GI surgery
Urology
Vascular
Vascular/thoracic
Breast
Cardiothoracic
Digestive
ENT
Endocrine
Ophthalmology
Orthopedic
Plastics
Urology
Vascular
Artificial urinary sphincter procedures
Carotid endarterectomy
1
2
4
12
1
1
1
1
1
3
11
7
1
1
2
8
3
2
12
7
1
5
22
1
3
1
32
25
51
4
1
1
1
6
56.1
43.9
89.5
7.0
1.8
1.8
1.8
3.5
7.0
21.1
1.8
1.8
1.8
1.8
1.8
5.3
1.8
3.5
14.0
19.3
12.3
1.8
1.8
8.8
38.6
1.8
5.3
1.8
5.3
3.5
21.1
12.3
1.8
10.5

Unit of analysis
Number of units
Cholecystectomy
Colectomy
Coronary artery bypass
Endoscopic extraperitoneal radical prostatectomy
Endovascular aortic repair
Ileo-anal pouch anastamosis
Kidney transplant
Laparascopic colorectal resections
Laparoscopic cardiomyotomy
Laparoscopic cholecystectomy
Laparoscopic colectomy
Laparoscopic inguinal herniorrhaphy
Laparoscopic Nissen fundoplication
Laparoscopic prostatectomy
Laparoscopic radical prostatecomy
Laparoscopic Sleeve Gastrectomy
Lobectomy
Open radical prostatectomy
Palatoplasty
Pancreaticoduodenectomy
Radical prostatectomy
Resection for breast cancer
Right and left sided resections
Robot-Assisted Laparoscopic Prostatectomy
Robot-Assisted Radical Prostatectomy and laparoscopic radical prostate
Roux-en-Y gastric bypass
Scleral buckling or primary vitrectomy
Septomeatoplasty
Thyroid surgery
Thyroidectomy
Total Gastrectomy with lymph node dissection
Total Hip Arthoplasty
Patients
Procedures
50
2
1
1
1
2
3
1
1
1
1
1
2
1
2
3
1
2
1
1
1
1
2
5
2
1
1
1
1
1
2
1
3
36
21
1
1.8
1.8
1.8
1.8
1.8
3.5
1.8
5.3
63.2
36.8
3.5
1.8
1.8
1.8
3.5
5.3
1.8
1.8
1.8
1.8
3.5
5.3
1.8
1.8
3.5
3.5
8.8
3.5
1.8
3.5
1.8
1.8
1.8
1.8
1.8

1003
1031
1068
1194
1302
1600
1629
1965
2200
3574
3645
3794
650
653
683
750
900
904
927
225
300
375
392
401
461
614
644
67
75
100
102
110
120
150
185
186
198
200
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
3.5
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
3.5
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1

Number of units
Number of teams
3997
4524
4702
8032
8774
9739
9895
12861
22128
22461
25091
28207
34803
57187
65602
709483
0-100
101-200
201-300
301-400
1
2
3
5
7
13
16
401-500
501-750
751-1000
1001-2500
2501-5000
5000-10000
10000-50000
50000-100000
100000+
2
6
3
9
7
4
5
8
2
2
6
2
1
30
1
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
8.8
14.0
3.5
3.5
3.5
10.5
5.3
15.8
12.3
7.0
10.5
3.5
1.8
52.6
1.8
5.3
5.3
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8

Number of surgeons
28
29
52
61
86
104
114
131
180
212
226
316
329
9
12
18
19
20
2
3
4
5
7
8
23
30
32
46
50
67
90
96
153
169
250
253
N/A
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
14.0
10.5
8.8
3.5
3.5
3.5
1.8
1.8
1.8
3.5
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
8.8
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
8
6
5
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
5

Number of surgeons
Data source
Data source
Experience measure
Experience type
Adjusted outcome
462
477
494
812
821
2052
2322
8497
N/A
1-20
21-50
51-100
100-250
250-500
500+
N/A
Query administrative
Administrative
Clinical data
Clinical data (might be some administrative)
Clinical data / administrative
Research
Research
Routine
Number of cases
Years-of-experience
Both
Categorical
Continuous
Both
Yes
No
31
2
3
6
5
5
5
2
3
36
1
2
13
1
1
1
1
1
5
1
1
1
16
41
45
6
6
25
6
26
25
32
28.1
72.0
78.9
10.5
10.5
54.4
3.5
5.3
10.5
8.8
8.8
8.8
3.5
5.3
63.2
1.8
3.5
22.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
8.8
43.9
10.5
45.6
43.9
56.1

Adjusted age
Adjusted sex
Adjusted BMI (body mass index)
Adjusted comorbidities
Adjusted complexity
Adjusted emergency
Adjusted other
Number of case-mix adjusters
Adjusted provider
Surgical residency
Surgeon age
5
6
7
0
1
2
3
4
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
33
8
2
4
5
2
2
1
10
47
2
55
11
46
10
47
4
53
18
39
4
16
41
11
46
6
51
28.1
71.9
19.3
80.7
10.5
89.5
19.3
80.7
17.5
82.5
7.0
93.0
31.6
68.4
57.9
14.0
3.5
7.0
8.8
3.5
3.5
1.8
17.5
82.5
3.5
96.5
7.0

Surgeon length of experience
Clustering considered
Outcome - operation duration
Outcome - mortality
Outcome - reoperation
Outcome - specific complication
Outcome - composite of complications
Outcome - complication hemorrhage
Outcome - satisfaction
Outcome - other
Outcome - technical success
Outcome - length of stay
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
24
33
12
45
15
42
16
41
53
9
48
8
49
25
32
8
49
1
56
15
42
2
55
11
46
93.0
15.8
84.2
14.0
86.0
43.9
56.1
42.1
57.9
21.1
78.9
26.3
73.7
28.1
71.9
14.0
86.0
1.8
98.2
26.3
73.7
3.5
96.5
19.3
80.7

Outcome - warm ischemia time
Outcome - graft survival
Outcome - surgeon comfort
Outcome - catheterization
Outcome - transfusion
Outcome - visual acuity
Outcome - dysphagia improvement
Outcome - continence
Complication - reoperation
Complication - hemorrhage
Complication - ileus
Complication - infection
Complication - laceration
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1
56
1
56
1
56
3
54
1
56
1
56
1
56
3
54
15
42
25
32
1
56
3
54
14
43
1.8
98.2
1.8
98.2
1.8
98.2
5.3
94.7
1.8
98.2
1.8
98.2
1.8
98.2
1.8
98.2
5.3
94.7
24.6
75.4
5.3
94.7
26.3
73.7
43.9
56.1

Complication - urinary retention
Complication - respiratory
Complication - thromboembolism
Complication - cardiovascular
Complication - gastrointestinal
Complication - transfusions
Complication - mortality
Complication - renal failure
Complication - liver failure
Complication - hyperparathyroidism
Complication - hypocalcemia
Feedback delivered
Yes
No
Yes
No
Yes
No
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Yes
No
Yes, implemented
Yes, discussed
No
1
56
1
56
1
56
1
56
4
5
48
2
55
4
53
5
51
3
54
1
56
3
54
2
55
5.3
94.7
1.8
98.2
5.3
94.7
3.5
96.5
1.8
98.2
1.8
98.2
1.8
98.2
1.8
98.2
7.0
8.8
84.2
3.5
96.5
7.0
93.0
10.5
89.5

PRISMA CHECKLIST
Section/topic
TITLE
Title
ABSTRACT
Structured summary
INTRODUCTION
Rationale
Objectives
METHODS
Protocol and registration
Eligibility criteria
Information sources
Search
Study selection
Data collection process
Data items
Risk of bias in individual studies
Summary measures
# Checklist item
1 Identify the report as a systematic review, meta-analysis, or both.
2 Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number.
Reported on page #
0
Abstract
3 Describe the rationale for the review in the context of what is already known.
4 Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).
2
2
5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registration number.
6 Specify study characteristics (e.g., PICOS, length of follow up) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale.
7 Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched.
8 Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated.
9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta analysis).
10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.
11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.
12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis.
13 State the principal summary measures (e.g., risk ratio, difference in means). n/a
3
3
3
3
3
3
3
4

Synthesis of results 14 Describe the methods of handling data and combining results of studies, if done, including measures of consistency
(e.g., I 2
) for each meta analysis.
Risk of bias across studies
Additional analyses
15 Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective reporting within studies).
16 Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre specified.
RESULTS
Study selection 17 Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.
Study characteristics 18 For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations.
19 Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12). Risk of bias within studies
Results of individual studies 20 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.
Synthesis of results
Risk of bias across studies
21 Present results of each meta-analysis done, including confidence intervals and measures of consistency.
22 Present results of any assessment of risk of bias across studies (see Item 15).
Additional analysis 23 Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item 16]). n/a
4 n/a
4, Fig
4, 5
4, 5
Appendix
DISCUSSION
Summary of evidence
Limitations
24 Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers).
25 Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias).
26 Provide a general interpretation of the results in the context of other evidence, and implications for future research. n/a n/a n/a
9, 10, 11
11
Conclusions 12
FUNDING
Funding 27 Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the systematic review. n/a
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097

STUDIES SELECTED FOR REVIEW
Ballantyne, G. H., Ewing, D., Capella, R. F., Capella, J. F., Davis, D., Schmidt, H. J., Wasielewski, A. & Davies,
R. J. (2005) The learning curve measured by operating times for laparoscopic and open gastric bypass: roles of surgeon's experience, institutional experience, body mass index and fellowship training. Obesity Surgery. 15 (2),
172-182.
Bartlett, A. & Parry, B. (2001) Cusum analysis of trends in operative selection and conversion rates for laparoscopic cholecystectomy. ANZ Journal of Surgery. 71 (8), 453-456.
Bennett, C. L., Stryker, S. J., Ferreira, M. R., Adams, J. & Beart Jr, R. W. (1997) The learning curve for laparoscopic colorectal surgery: preliminary results from a prospective analysis of 1194 laparoscopic-assisted colectomies. Archives of Surgery. 132 (1), 41.
Blana, A., Straub, M., Wild, P. J., Lunz, J. C., Bach, T., Wieland, W. F. & Ganzer, R. (2007) Approach to endoscopic extraperitoneal radical prostatectomy (EERPE): the impact of previous laparoscopic experience on the learning curve. BMC Urology. 7 (1), 11.
Brook, R. H., Park, R. E., Chassin, M. R., Kosecoff, J., Keesey, J. & Solomon, D. H. (1990) Carotid endarterectomy for elderly patients: predicting complications. Annals of Internal Medicine . 113 (10), 747-53.
Budäus, L., Abdollah, F., Sun, M., Morgan, M., Johal, R., Thuret, R., Zorn, K. C., Isbarn, H., Shariat, S. F. &
Montorsi, F. (2010) Annual surgical caseload and open radical prostatectomy outcomes: improving temporal trends. The Journal of Urology. 184 (6), 2285-2290.
Carty, M. J., Chan, R., Huckman, R., Snow, D. & Orgill, D. P. (2009) A detailed analysis of the reduction mammaplasty learning curve: a statistical process model for approaching surgical performance improvement.
Plastic and Reconstructive Surgery. 124 (3), 706-714.
Chen, G., Liu, Z., Han, P., Li, J. & Cui, B. (2013) The Learning Curve for the Laparoscopic Approach for
Colorectal Cancer: A Single Institution's Experience. Journal of Laparoendoscopic & Advanced Surgical
Techniques. 23 (1), 17-21.
Duclos, A., Carty, M. J., Peix, J., Colin, C., Lipsitz, S. R., Kraimps, J., Menegaux, F., Pattou, F., Sebag, F. &
Voirin, N. (2012) Development of a charting method to monitor the individual performance of surgeons at the beginning of their career. PloS One. 7 (7), e41944.
Duclos, A., Peix, J., Colin, C., Kraimps, J., Menegaux, F., Pattou, F., Sebag, F., Touzet, S., Bourdy, S. & Voirin, N.
(2012) Influence of experience on performance of individual surgeons in thyroid surgery: prospective cross sectional multicentre study. BMJ: British Medical Journal. 344, d8041.
Fechner, G., Seifert, I., Hauser, S. & Müller, S. C. (2012) Impact of a learning curve model in kidney transplantation on functional outcome and surgical complications in a small volume centre: does size really matter?
International Urology and Nephrology. 44 (5), 1411-1415.
Feinberg, E. J., Agaba, E., Feinberg, M. L., Camacho, D. & Vemulapalli, P. (2012) Single-incision laparoscopic cholecystectomy learning curve experience seen in a single institution. Surgical Laparoscopy Endoscopy &
Percutaneous Techniques. 22 (2), 114-117.
Forbes, T. L., Chu, M. W., Lawlor, D. K., DeRose, G. & Harris, K. A. (2007) Learning curve analysis of thoracic endovascular aortic repair in relation to credentialing guidelines. Journal of Vascular Surgery. 46 (2), 218-222.
Grotenhuis, B. A., Wijnhoven, B. P., Jamieson, G. G., Devitt, P. G., Bessell, J. R. & Watson, D. I. (2008) Defining a learning curve for laparoscopic cardiomyotomy. World Journal of Surgery. 32 (8), 1689-1694.
Han, H. J., Choi, S. B., Park, M. S., Lee, J. S., Kim, W. B., Song, T. J. & Choi, S. Y. (2011) Learning curve of single port laparoscopic cholecystectomy determined using the non-linear ordinary least squares method based on a non-linear regression model. Journal of Hepato-Biliary-Pancreatic Sciences. 18 (4), 510-515.

Hannan, E. L., O'Donnell, J. F., Kilburn, H. Jr., Bernard, H. R. & Yazici, A. (1989) Investigation of the relationship between volume and mortality for surgical procedures performed in New York State hospitals. The Journal of the
American Medical Association . 262 (4), 503-10.
Hannan, E. L., Kilburn, H. Jr., O'Donnell, J. F., Bernard, H. R., Shields, E. P., Lindsey, M. L. & Yazici, A. (1992)
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