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IMPORTANCE: Female surgeons are still in the minority worldwide, and highlighting gender differences in surgery is important in understanding and reducing inequities within the surgical specialty. Studies on different surgical procedures indicate equal results, or safer outcomes, for female surgeons, but it is still unclear whether surgical outcomes of gallstone surgery differ between female and male surgeons. OBJECTIVE: To examine the association of the surgeon's gender with surgical outcomes and operating time in elective and acute care cholecystectomies. DESIGN, SETTING, AND PARTICIPANTS: A population-based cohort study based on data from the Swedish Registry of Gallstone Surgery was performed from January 1, 2006, to December 31, 2019. The sample included all registered patients undergoing cholecystectomy in Sweden during the study period. The follow-up time was 30 days. Data analysis was performed from September 1 to September 7, 2022, and updated March 24, 2023. EXPOSURE: The surgeon's gender. MAIN OUTCOME(S) AND MEASURE(S): The association between the surgeon's gender and surgical outcomes for elective and acute care cholecystectomies was calculated with generalized estimating equations. Differences in operating time were calculated with mixed linear model analysis. RESULTS: A total of 150 509 patients, with 97 755 (64.9%) undergoing elective cholecystectomies and 52 754 (35.1%) undergoing acute care cholecystectomies, were operated on by 2553 surgeons, including 849 (33.3%) female surgeons and 1704 (67.7%) male surgeons. Female surgeons performed fewer cholecystectomies per year and were somewhat better represented at universities and private clinics. Patients operated on by male surgeons had more surgical complications (odds ratio [OR], 1.29; 95% CI, 1.19-1.40) and total complications (OR, 1.12; 95% CI, 1.06-1.19). Male surgeons had more bile duct injuries in elective surgery (OR, 1.69; 95% CI, 1.22-2.34), but no significant difference was apparent in acute

INTRODUCTION: Laparoscopic cholecystectomy is one of the most frequently performed surgical procedures worldwide, with nearly 14,000 operations per year in Sweden alone. Recurrent biliary colic or acute cholecystitis are indications for surgery. Despite being a standardized procedure, complications occur in more than 10% of all operations. This thesis includes five research papers, all of which focus on different aspects of surgical safety in gallstone surgery. PAPER 1: The recommended treatment of acute cholecystitis is acute cholecystectomy during the first hospital admission, but the optimal timing is still under discussion. The aim of the first study was to analyse whether the timing of surgery for acute cholecystitis affects complication rates. A registry-based study, based on the Swedish National Registry for Gallstone Surgery and Endoscopic Retrograde Pancreatography (GallRiks) was performed. We included 87,108 patients undergoing cholecystectomy from 2006 to 2014. Of these operations, 15,760 (18.1%) were performed due to acute cholecystitis. We analysed differences in outcomes related to timing of surgery. The results showed that intra-and postoperative complications, bile duct injuries and 30-and 90-day mortality increased with longer delays. The conclusion is that the optimal timing of surgery seems to be within two days of hospital admission. PAPER 2: Increasing hospital and surgeon volumes have been associated with better outcomes for more complicated procedures. However, it is still unknown whether the annual volume of cholecystectomies affects surgical outcomes. The aim of this study was to investigate whether the surgeon’s and hospital’s annual volume of cholecystectomies has an impact on complication rates and operating time. A registry-based study was conducted based on all cholecystectomies registered in GallRiks between 2006 and 2019. A total of 154,934 patients were analysed: 101,221 (65.3%) elective procedures and 53,713 (34.7%) acute procedures

Background: High surgical volumes are attributed to improved quality of care, especially for extensive procedures. However, it remains unknown whether high-volume surgeons and hospitals have better results in gallstone surgery. The aim of this study was to investigate whether operative volume affects outcomes in cholecystectomies. Methods: A registry-based cohort study was performed, based on the Swedish Registry of Gallstone Surgery. Cholecystectomies from 2006 to 2019 were included. Annual volumes for the surgeon and hospital were retrieved. All procedures were categorized into volume-based quartiles, with the highest group as reference. Low volume was defined as fewer than 20 operations per surgeon per year and fewer than 211 cholecystectomies per hospital per year. Differences in outcomes were analysed separately for elective and acute procedures. Results: The analysis included 154 934 cholecystectomies. Of these, 101 221 (65.3 per cent) were elective and 53 713 (34.7 per cent) were acute procedures. Surgeons with low volumes had longer operating times (P < 0.001) and higher conversion rates in elective (OR 1.35; P = 0.023) and acute (OR 2.41; P < 0.001) operations. Low-volume surgeons also caused more bile duct injuries (OR 1.41; P = 0.033) and surgical complications (OR 1.15; P = 0.033) in elective surgery, but the results were not statistically significant for acute procedures. Low-volume hospitals had more bile duct injuries in both elective (OR 1.75; P = 0.002) and acute (OR 1.96; P = 0.003) operations, and a higher mortality rate after acute surgery (OR 2.53; P = 0.007). Conclusion: This study has demonstrated that operative volumes influence outcomes in cholecystectomy. The results indicate that gallstone surgery should be performed by procedure-dedicated surgeons at hospitals with high volumes of this type of benign surgery.

BACKGROUND: High surgical volumes are attributed to improved quality of care, especially for extensive procedures. However, it remains unknown whether high-volume surgeons and hospitals have better results in gallstone surgery. The aim of this study was to investigate whether operative volume affects outcomes in cholecystectomies. METHODS: A registry-based cohort study was performed, based on the Swedish Registry of Gallstone Surgery. Cholecystectomies from 2006 to 2019 were included. Annual volumes for the surgeon and hospital were retrieved. All procedures were categorized into volume-based quartiles, with the highest group as reference. Low volume was defined as fewer than 20 operations per surgeon per year and fewer than 211 cholecystectomies per hospital per year. Differences in outcomes were analysed separately for elective and acute procedures. RESULTS: The analysis included 154 934 cholecystectomies. Of these, 101 221 (65.3 per cent) were elective and 53 713 (34.7 per cent) were acute procedures. Surgeons with low volumes had longer operating times (P < 0.001) and higher conversion rates in elective (OR 1.35; P = 0.023) and acute (OR 2.41; P < 0.001) operations. Low-volume surgeons also caused more bile duct injuries (OR 1.41; P = 0.033) and surgical complications (OR 1.15; P = 0.033) in elective surgery, but the results were not statistically significant for acute procedures. Low-volume hospitals had more bile duct injuries in both elective (OR 1.75; P = 0.002) and acute (OR 1.96; P = 0.003) operations, and a higher mortality rate after acute surgery (OR 2.53; P = 0.007). CONCLUSION: This study has demonstrated that operative volumes influence outcomes in cholecystectomy. The results indicate that gallstone surgery should be performed by procedure-dedicated surgeons at hospitals with high volumes of this type of benign surgery.

Objective: To analyse the completeness in GallRiks of the follow-up frequency in relation to the intraoperative and postoperative outcome. Design: Population-based register study. Setting: Data from the national Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (ERCP), GallRiks. Population: All cholecystectomies and ERCPs recorded in GallRiks between 1 January 2006 and 31 December 2014. Main outcome measures: Outcomes for intraprocedural as well as postprocedural adverse events between units with either a 30-day follow-up of AO% compared with those with a less frequent follow-up (<90%). Results: Between 2006 and 2014, 162 212 cholecystectomies and ERCP procedures were registered in GallRiks. After the exclusion of non-index procedures and those with incomplete data 152 827 procedures remained for final analyses. In patients having a cholecystectomy, there were no differences regarding the adverse event rates, irrespective of the follow-up frequency. However, in the more complicated endoscopic ERCP procedures, the postoperative adverse event rates were significantly higher in those with a more frequent and complete 30-day follow-up (OR 1.92; 95% Cl 1.76 to 2.11). Conclusions: Differences in the follow-up frequency in registries affect the reported outcomes as exemplified by the complicated endoscopic ERCP procedures. A high and complete follow-up rate shall serve as an additional quality indicator for surgical registries.