Surgical Endoscopy

, Volume 26, Issue 9, pp 2579–2586 | Cite as

The cost of surgical training: analysis of operative time for laparoscopic cholecystectomy

  • M. von Strauss und Torney
  • S. Dell-Kuster
  • R. Mechera
  • R. Rosenthal
  • I. Langer



Duration of surgery is a main cost factor of surgical training. The purpose of this analysis of operative times for laparoscopic cholecystectomies (LC) was to quantify the extra time and related costs in regards to the surgeons’ experience in the operating room (OR).


All LC performed between January 01, 2005 and December 31, 2008 in 46 hospitals reporting to the database of the Swiss Association for Quality Management in Surgery (AQC) were analyzed (n = 10,010). Four levels of seniority were specified: resident (R), junior consultant (JC), senior consultant (SC), and attending surgeon (AS). The differences in operative time according to seniority were investigated in a multivariable log-linear and median regression analysis controlling for possible confounders. The OR costs were calculated by using a full cost rate in a teaching hospital.


A total of 9,208 LC were available for analysis; 802 had to be excluded due to missing data (n = 212) or secondary major operations (n = 590). Twenty-eight percent of the LC were performed by R as teaching operations (n = 2,591). Compared with R, the multivariable analysis of operative time showed a median difference of −2.5 min (−9.0; 4.8) for JC and −18 min (−25; −11) for SC and −28 min (−35; −10) for AS, respectively. The OR minute costs were €17.57, resulting in incremental costs of €492 (159; 615) per operation in case of tutorial assistance.


The proportion of LC performed as tutorial assistance for R remains low. Surgical training in the OR causes relevant case-related extra time and therefore costs.


Cholecystectomy Education Costs < Technical Training < Endoscopy 



The authors thank Luzi Rageth and the Swiss Association for Quality Management in Surgery (AQC) for their support in this investigation.


Drs. von Strauss, Dell-Kuster, Mechera, and Langer, and Prof. Rosenthal have no conflicts of interest or financial ties to disclose.

Supplementary material

464_2012_2236_MOESM1_ESM.doc (376 kb)
Patients’ characteristics according to the experience level of the surgeon (DOC 376 kb)


  1. 1.
    Bartowski R (2009) Problem DRG: bleibt die ärztliche Weiterbildung auf der Strecke? Swiss Knife 3:8–10Google Scholar
  2. 2.
    Bridges M, Diamond DL (1999) The financial impact of teaching surgical residents in the operating room. Am J Surg 177:28–32PubMedCrossRefGoogle Scholar
  3. 3.
    Frank S (2009) Financing graduate medical education. Nat Clin Pract Neurol 5:58–59PubMedCrossRefGoogle Scholar
  4. 4.
    Webb TP, Brasel KJ, Redlich PN, Weigelt JA (2010) Putting a price on education: hours and dollars for a general surgery curriculum. Am J Surg 199:126–130PubMedCrossRefGoogle Scholar
  5. 5.
    Glauser R (2010) Finanzierung der ärztlichen Weiterbildung. VSAO J 9:8CrossRefGoogle Scholar
  6. 6.
    Babineau TJ, Becker J, Gibbons G, Sentovich S, Hess D, Robertson S et al (2004) The “cost” of operative training for surgical residents. Arch Surg 139:366–369 discussion 369-370PubMedCrossRefGoogle Scholar
  7. 7.
    Chung RS (2005) How much time do surgical residents need to learn operative surgery? Am J Surg 190:351–353PubMedCrossRefGoogle Scholar
  8. 8.
    Deziel DJ, Millikan KW, Staren ED, Doolas A, Economou SG (1993) The impact of laparoscopic cholecystectomy on the operative experience of surgical residents. Surg Endosc 7:17–21PubMedCrossRefGoogle Scholar
  9. 9.
    Haji A, Khan A, Haq A, Ribeiro B (2009) Elective laparoscopic cholecystectomy for surgical trainees: predictive factors of operative time. Surgeon 7:207–210PubMedCrossRefGoogle Scholar
  10. 10.
    Hwang CS, Pagano CR, Wichterman KA, Dunnington GL, Alfrey EJ (2008) Resident versus no resident: a single institutional study on operative complications, mortality, and cost. Surgery 144:339–344PubMedCrossRefGoogle Scholar
  11. 11.
    Hwang CS, Wichterman KA, Alfrey EJ (2010) The cost of resident education. J Surg Res 163:18–23PubMedCrossRefGoogle Scholar
  12. 12.
    Koperna T (2004) How long do we need teaching in the operating room? The true costs of achieving surgical routine. Langenbecks Arch Surg 389:204–208PubMedCrossRefGoogle Scholar
  13. 13.
    Hutter MM, Kellogg KC, Ferguson CM, Abbott WM, Warshaw AL (2006) The impact of the 80-hour resident workweek on surgical residents and attending surgeons. Ann Surg 243:864–871 discussion 871-875PubMedCrossRefGoogle Scholar
  14. 14.
    Knapp R (2002) Financing graduate medical education and limiting resident work hours: a political assessment. Am J Surg 184:187–195PubMedCrossRefGoogle Scholar
  15. 15.
    Telser H, Leukert K (2009) Finanzierung der ärztlichen Weiterbildung aus ökonomischer Sicht. Available at: Accessed 2 May 2011
  16. 16.
    Steyerberg EW (2009) Dealing with missing values. In: Gail M, Krickeberg K, Samet J, Tsiatis A, Wong W (eds) Clinical prediction models. Springer, New York, pp 113–136CrossRefGoogle Scholar
  17. 17.
    Credit Suisse (2008) Devisendurchschnittskurse 2005–2008. Available at: Accessed 6 Jan 2011
  18. 18.
    Swiss DRG Casemix Office (2011) Available at: Accessed 23 June 2011
  19. 19.
    Kauvar DS, Braswell A, Brown BD, Harnisch M (2006) Influence of resident and attending surgeon seniority on operative performance in laparoscopic cholecystectomy. J Surg Res 132:159–163PubMedCrossRefGoogle Scholar
  20. 20.
    Z’graggen K, Wehrli H, Metzger A, Buehler M, Frei E, Klaiber C (1998) Complications of laparoscopic cholecystectomy in Switzerland. A prospective 3-year study of 10,174 patients. Swiss Association of Laparoscopic and Thoracoscopic Surgery. Surg Endosc 12:1303–1310PubMedCrossRefGoogle Scholar
  21. 21.
    Harrington DT, Roye GD, Ryder BA, Miner TJ, Richardson P, Cioffi WG (2007) A time-cost analysis of teaching a laparoscopic entero-enterostomy. J Surg Educ 64:342–345PubMedCrossRefGoogle Scholar
  22. 22.
    Sefr R, Ochmann J (1995) Our experience with early integration of laparoscopic cholecystectomy in surgical residency training. Surg Endosc 9:902–904PubMedGoogle Scholar
  23. 23.
    Shaikh IA, Sanjay P, Joga K, Yalamarthi S, Daniel T, Amin AI (2009) Are we performing enough emergency laparoscopic cholecystectomies? An experience from a district general hospital. Int J Surg 7:482–484PubMedCrossRefGoogle Scholar
  24. 24.
    Wang WN, Melkonian MG, Marshall R, Haluck RS (2001) Postgraduate year does not influence operating time in laparoscopic cholecystectomy. J Surg Res 101:1–3PubMedCrossRefGoogle Scholar
  25. 25.
    Businger A, Guller U, Oertli D (2010) Effect of the 50-hour workweek limitation on training of surgical residents in Switzerland. Arch Surg 145:558–563PubMedCrossRefGoogle Scholar
  26. 26.
    Allemann P, Schafer M, Demartines N (2010) Critical appraisal of single port access cholecystectomy. Br J Surg 97:1476–1481PubMedCrossRefGoogle Scholar
  27. 27.
    O’Shea JS (2010) Individual and social concerns in American surgical education: paying patients, prepaid health insurance, Medicare and Medicaid. Acad Med 85:854–862PubMedCrossRefGoogle Scholar
  28. 28.
    Jarman BT, Miller MR, Brown RS, Armen SB, Bozaan AG, Ho GT et al (2004) The 80-hour work week: will we have less-experienced graduating surgeons? Curr Surg 61:612–615PubMedCrossRefGoogle Scholar
  29. 29.
    Orlowa P, Siegrista M, Giger M (2007) Die wichtigsten Resultate der Umfrage 2006 bei Assistenzärztinnen und Assistenzärzten. Schweiz Ärzteztg 88:633–642Google Scholar
  30. 30.
    van der Horst K, Siegrist M, Orlow P, Giger M (2010) Residents’ reasons for specialty choice: influence of gender, time, patient and career. Med Educ 44:595–602PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • M. von Strauss und Torney
    • 1
    • 2
  • S. Dell-Kuster
    • 1
    • 3
  • R. Mechera
    • 1
    • 2
  • R. Rosenthal
    • 1
  • I. Langer
    • 4
  1. 1.Department of SurgeryBasel University HospitalBaselSwitzerland
  2. 2.Department of SurgeryCantonal Hospital BruderholzBruderholzSwitzerland
  3. 3.Institute for Clinical Epidemiology and Biostatistics, Basel University HospitalBaselSwitzerland
  4. 4.Department of SurgeryLindenhof Hospital BernBernSwitzerland

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