Defining a Learning Curve for Laparoscopic Cardiomyotomy

BACKGROUND: This study was designed to determine whether there is a learning curve for laparoscopic cardiomyotomy for the treatment of achalasia. METHODS: All patients who underwent a primary laparoscopic cardiomyotomy for achalasia between 1992 and 2006 in our hospitals were identified from a prospective database. The institutional and the individual surgeon's learning experiences were assessed based on operative and clinical outcome parameters. The outcomes of cardiomyotomies performed by consultant surgeons versus supervised trainees also were compared. RESULTS: A total of 186 patients met the inclusion criteria; 144 procedures were undertaken by consultant surgeons and 42 by a surgical trainee. The length of operation decreased after the first ten cases in both the institutional and each individual experience. The rate of conversion to open surgery also was significantly higher in the first 20 cases performed. Intraoperative complications, overall satisfaction with the outcome, reoperation rate, and postoperative dysphagia were not associated with the institutional or the surgeon's operative experience. Although the length of the operation was greater for surgical trainees (93 versus 79 minutes; p < 0.01), no differences in outcome between the operations performed by consultant surgeons and surgical trainees were detected. CONCLUSION: An institutional (20 cases) and an individual (10 cases) learning curve for laparoscopic cardiomyotomy for achalasia can be defined. The clinical outcome for laparoscopic cardiomyotomy does not differ between supervised surgical trainees and consultant surgeons.     

Learning Curve for Laparoscopic Pancreaticoduodenectomy: a CUSUM Analysis

Background

Laparoscopic pancreaticoduodenectomy (LPD), an advanced minimally invasive technique, has demonstrated advantages to open pancreaticoduodenectomy (OPD). However, this complex procedure requires a relatively long training period to ensure technical proficiency. This study was therefore designed to analyze the learning curve for LPD.

Methods

From October 2010 to September 2015, 63 standard pancreaticoduodenectomy procedures were to be performed laparoscopically by a single surgeon at the Department of Pancreatic Surgery, West China Hospital, Sichuan University, China. After applying the inclusion and exclusion criteria, a total of 57 patients were included in the study. Data for all the patients, including preoperative, intraoperative, and postoperative variables, were prospectively collected and analyzed. The learning curve for LPD was evaluated using both cumulative sum (CUSUM) and risk-adjusted CUSUM (RA-CUSUM) methods. All of the variables among the learning curve phases were compared.

Results

Based on the CUSUM and the RA-CUSUM analyses, the learning curve for LPD was grouped into three phases: phase I was the initial learning period (cases 1–11), phase II represented the technical competence period (cases 12–38), and phase III was regarded as the challenging period (cases 39–57). The operative time, intraoperative blood loss, and postoperative ICU demand significantly decreased with the learning curve. More lymph nodes were collected after the initial learning period. There were no significant differences in terms of postoperative complications or the 30-day mortality among the three phases. More challenging cases were encountered in phase III.

Conclusions

According to this study, the learning curve for LPD consisted of three phases. Conservatively, to attain technical competence for performing LPD, a minimum of 40 cases are required for laparoscopic surgeons with a degree of laparoscopic experience.

     

Defining the Learning Curve for Robotic-assisted Esophagogastrectomy

Introduction

The expansion of robotic-assisted surgery is occurring quickly, though little is generally known about the “learning curve” for the technology with utilization for complex esophageal procedures. The purpose of this study is to define the learning curve for robotic-assisted esophagogastrectomy with respect to operative time, conversion rates, and patient safety.

Methods

We have prospectively followed all patients undergoing robotic-assisted esophagogastrectomy and compared operations performed at our institutions by a single surgeon in successive cohorts of 10 patients. Our measures of proficiency included: operative times, conversion rates, and complications. Statistical analyses were undertaken utilizing Spearman regression analysis and Mann–Whitney U test. Significance was accepted with 95 % confidence.

Results

Fifty-two patients (41 male: 11 female) of mean age 66.2?±?8.8 years underwent robotic-assisted esophagogastrectomies for malignant esophageal disease. Neoadjuvant chemoradiation was administered to 30 (61 %) patients. A significant reduction in operative times (p <0.005) following completion of 20 procedures was identified (514?±?106 vs. 397?±?71.9). No conversions to open thoracotomy were required. Complication rates were low and not significantly different between any 10-patient cohort; however, no complications occurred in the final 10-patient cohort. There were no in-hospital mortalities.

Conclusions

For surgeons proficient in performing minimally-invasive esophagogastrectomies, the learning curve for a robotic-assisted procedure appears to begin near proficiency after 20 cases. Operative complications and conversions were infrequent and unchanged across successive 10-patient cohorts.     

腹腔镜前列腺根治性切除术的学习曲线

目的探讨腹腔镜前列腺根治性切除术的学习曲线。方法回顾分析2004年1月～2011年5月我院由同一医师完成的180例腹腔镜前列腺根治性切除术的临床资料。按手术先后顺序分为4组（A、B、C、D组）,每组45例,比较各组手术时间、出血量、切缘阳性率、输血率、术后住院时间、并发症发生率。结果中转开放率为1.1%（2/180）,均发生在A组。A组手术时间为（284.5±67.7）min,显著长于B组（213.7±42.6）min（q=9.491,P〈0.05）,C组（229.7±40.9）min（q=7.346,P〈0.05）和D组（235.4±42.6）min（q=6.582,P〈0.05）。输血率由A组的18.6%（8/43）,下降至B组4.4%（2/45）,C组6.7%（3/45）和D组2.2%（1/45）（χ2=9.637,P=0.022）。A组术后住院时间中位数12 d（5～60 d）,显著长于B组9 d（5～36 d）,C组10 d（6～60 d）和D组10 d（4～38 d）（Z值分别为-2.600,-1.993,-2.112,P值分别为0.009,0.046,0.035）。A组出血量为中位数300 ml（100～3000 ml）,显著多于B组200 ml（50～1200 ml）（Z=-3.050,P=0.002）和D组150 ml（30～700 ml）（Z=-4.060,P=0.001）。4组切缘阳性率及并发症发生率并无显著差异（χ2=0.907,P=0.824;χ2=0.270,P=0.966）。结论腹腔镜前列腺根治性切除术的学习曲线大致为45例。     

Total Laparoscopic Pancreaticoduodenectomy

Introduction:

Total laparoscopic pancreaticoduodenectomy (TLPD) remains one of the most advanced laparoscopic procedures. Owing to the evolution in laparoscopic technology and instrumentation within the past decade, laparoscopic pancreaticoduodenectomy is beginning to gain wider acceptance.

Methods:

Data were collected for all patients who underwent a TLPD at our institution. Preoperative evaluation consisted of computed tomography scan with pancreatic protocol and selective use of magnetic resonance imaging and/or endoscopic ultrasonography. The TLPD was done with 6 ports on 3 patients and 5 ports in 2 patients and included a celiac, periportal, peripancreatic, and periduodenal lymphadenectomy. Pancreatic stents were used in all 5 cases, and intestinal continuity was re-established by intracorporeal anastomoses.

Results:

Five patients underwent a TLPD for suspicion of a periampullary tumor. There were 3 women and 2 men with a mean age of 60 years and a mean body mass index of 32.8. Intraoperatively, the mean operative time was 9 hours 48 minutes, with a mean blood loss of 136 mL. Postoperatively, there were no complications and a mean length of stay of 6.6 days. There was no lymph node involvement in 4 out of 5 specimens. The pathological results included intraductal papillary mucinous neoplasm in 2 patients, pancreatic adenocarcinoma in 1 patient (R0 resection), benign 4-cm periampullary adenoma in 1 patient, and a somatostatin neuroendocrine carcinoma in 1 patient (R0, N1).

Conclusion:

TLPD is a viable alternative to the standard Whipple procedure. Our early experience suggests decreased length of stay, quicker recovery, and improved quality of life. Complication rates appear to be improved or equivalent.     

How To Reduce the Laparoscopic Colorectal Learning Curve

Background:

The laparoscopic approach for colorectal pathologies is becoming more widely used, and surgeons have had to learn how to perform this new technique. The purpose of this work is to study the indicators of the learning curve for laparoscopic colectomy in a community hospital and to find when the group begins to improve.

Methodology:

From January 1 2005 to December 31 2012, 313 consecutive laparoscopic colorectal surgeries were performed (105 rectal and 208 colonic) by at least 60% of the same surgical team (6 members) in each operation. We evaluate the learning curve by moving averages and cumulative sums (CUSUM) for different variables related to the surgery outcomes.

Results:

Moving average curves for postoperative stay, fasting, and second step analgesia show a stabilizing trend toward improvement as we get more experience. However, intensive care unit stay, number of lymph nodes achieved, and operating time did not show a clear decreasing tendency. CUSUM curves of conversion, specimens <12 lymph nodes, and complications all show a clear turning point marked on all the charts around the procedure 60, accumulating a positive trend toward improvement. The CUSUM curve of the “learning variable” shows this improvement point at procedure 70.

Conclusions:

The laparoscopic colectomy learning curve accelerates with a collective team involvement in each procedure. The CUSUM and moving average curves are useful for initial and ongoing monitoring of new surgical procedures. The markers of the learning curve evidenced in our study are the conversion rate, postoperative surgical morbidity, and the number of patients with a lymph node count <12.

What is new in this paper?

The significance of this study is the evaluation of the learning curve, in laparoscopic colorectal surgery, of a surgical team in a community hospital, using moving average and CUSUM curves. This study demonstrated that the number of patients needed to achieve skilful practice decreased when there is collective team involvement in each procedure.     

Laparoscopic Colorectal Surgery: Ascending the Learning Curve

n = 5), hemorrhage ( n = 6), intraabdominal abscess ( n = 4), prolonged ileus ( n = 4), wound infection ( n = 2), anastomotic leak ( n = 1), aspiration ( n = 1), cardiac arrhythmia ( n = 1), upper intestinal bleeding ( n = 1), and postoperative small bowel obstruction ( n = 1). There were no deaths. When divided into three equal, consecutive groups, the patients in the early ( n = 33) and intermediate ( n = 33) groups had a significantly higher complication rate (42% and 27%, respectively), than those in the late group ( n = 34, 12%; p < 0.05). The complication rate in each group was also directly related to the number of TACs performed (18 in the early, 13 in the intermediate, and 5 in the late group). The overall complication rate in TAC cases was significantly higher (42%) when compared to that of all other procedures (segmental resection 9%, nonresectional 12%; p < 0.01). The mean operating time was 4 hours (2.5–6.5 hours) for TAC, 2.5 hours (1.5–5.5 hours) for segmental colonic resection, and 1.6 hours (1.0–2.5 hours) for the nonresectional procedures. The length of ileus was 3.5 days (2–7 days) after TAC, 3 days (2–7 days) after the segmental resections, and 2 days (1–4 days) after the nonresectional procedures. The mean hospital stay was 7.3 days (2–40 days): 8.4 (5–40), 7.0 (4–12), and 6.8 (2–11) days for the TAC, segmental resection, and nonresectional procedures, respectively. We conclude that the feasibility of laparoscopic colorectal surgery has been well established. The morbidity associated with laparoscopic colorectal surgery correlates with a steep learning curve but is also related to the type of procedure. TAC is associated with a higher complication rate than are other laparoscopic colorectal procedures.     

腹腔镜结直肠癌手术学习曲线

目的探讨腹腔镜结直肠癌手术的学习曲线。方法回顾性分析2008年10月-2011年6月同一组医师连续开展的60例腹腔镜结直肠癌手术,按手术先后次序分为A、B、C3组,每组20例,3组年龄、性别、Dukes分期和手术方式等方面有可比性。比较各组的手术时间、出血量、淋巴结清扫数目、肠蠕动恢复时间、并发症、中转开腹率和术后住院时间。结果A、B组的手术时间分别为（242±32）min、（236±28）min,显著长于c组（212±30）min（F;5．58,P=0．006）;A、B组的出血量分别为（126±23）ml、（129±30）ml,显著多于c组（105±18）ml（F=5．85,P=0．005）。中转开腹率由A组的20％（4／20）、B组的15％（3／20）下降到c组的5％（1／20）（,=2．019,P=0．364）。3组淋巴结清扫数目、肠蠕动恢复时间、并发症发生率和术后住院时间差异无显著性（P〉0．05）。结论腹腔镜结直肠癌手术的学习曲线大致为40例。     

腹腔镜胃癌根治手术的学习曲线

目的探讨腹腔镜胃癌根治手术的学习曲线。方法回顾分析2004年3月~2006年2月由同一组医师完成的100例腹腔镜胃癌根治手术的临床资料。按手术先后次序分为4组(A、B、C、D),每组25例,比较各组的手术时间、出血量、淋巴结清扫总数、中转开腹率、并发症。A组手术在8个月内完成,平均每月3.1例,B组平均每月4.2例,C组平均每月6.3例,D组平均每月8.3例。结果4组病例在年龄、性别、病理分期和手术方式等方面有可比性。A、B组的手术时间分别为(230±45)min、(210±42)min,显著长于C组(180±38)min和D组(165±34)min(P<0.05);A、B组的出血量分别为(328±150)ml、(278±137)ml,显著多于C组(150±90)ml和D组(140±83)ml(P<0.05)。中转开腹率由A组的24%(6/25)、B组的20%(5/25)下降到C组的8%(2/25)、D组的4%(1/25)(χ2=5.446,P=0.155)。4组淋巴结清扫个数、并发症发生率无显著差异。结论腹腔镜胃癌根治手术的学习曲线大致为50例。     

腹腔镜精索静脉高位结扎术的学习曲线研究

目的 分析腹腔镜精索静脉高位结扎术的学习曲线.方法 回顾性分析我中心2010年1月至2011年11月行腹腔镜精索静脉高位结扎术患者的手术相关资料.入组标准:①患者的手术目的为改善精液质量;②双侧精索静脉曲张患者;③自同一医师进行的第一例按照标准方法进行的腹腔镜双侧精索静脉高位结扎术为起始患者.按照手术顺序构建手术时间和术中估计失血量曲线.观察手术时间曲线,根据曲线平台期情况,将所有病例分为A、B、C三组,A组12例;B组16例;C组30例.应用Wilcoxon秩和检验分别比较A组与B+C组及B组与C组手术时间的统计学差异.并应用独立样本t检验比较A组与B+C组及B组与C组术中估计失血量的统计学差异.结果 符合入组标准病例58例,无中转开放病例,无术中输血病例.A组12例患者的平均手术时间为96.67±9.85分钟;B组16例患者的平均手术时间为75±10.49分钟;C组30例患者的平均手术时间为64.33±10.23分钟.A组12名患者的手术时间与B组及C组的46例患者的手术时间差异具有统计学意义(P =0.00001);B组16例患者与C组的30例患者的手术时间差异具有统计学意义(P=0.0001).A、B及C三组患者的平均术中估计失血量分别为12.92±3.96 ml、11.88±5.44 ml及15.67±5.68 ml,三组术中估计失血量数据符合正态分布(P均＞0.05),应用独立样本t检验示三组间术中估计失血量无统计学差异(P＞0.05).结论 腹腔镜精索静脉高位结扎术的学习曲线为12例.     

Impact of Fellowship Training on the Learning Curve for Laparoscopic Gastric Bypass

Background: We have previously shown that the learning curve for laparoscopic Roux-en-Y gastric bypass (LRYGBP) is approximately 75 cases. Patients have worse outcomes during the learning curve. Our aim was to evaluate the impact of fellowship training on outcomes during a surgeon's early experience with LRYGBP. Methods: The study population consisted of the first 75 consecutive LRYGBP operations attempted by two laparoscopic surgeons, one with laparoscopic gastric bypass fellowship training (Group A) and one without laparoscopic bypass fellowship training (Group B). Outcome parameters included mortality, major perioperative complications, operative time, and conversion to an open operation. Results: Age, BMI, and gender distribution were similar in both groups. Operative time was significantly longer in Group B (189 min. vs 122 min., P <0.05). Conversion to an open procedure occurred uncommonly in both groups (3%). Major complications occurred more frequently in Group B (13% vs 8%, P =NS). In addition, the complications in Group B were more severe, resulting in 2 deaths. No deaths occurred in Group A. Conclusion: Laparoscopic gastric bypass fellowship training improves perioperative outcomes during a surgeon's early experience with LRYGBP.     

Multidimensional Analysis of the Learning Curve for Laparoscopic Resection in Rectal cancer

Background  We attempted to assess the learning curve for laparoscopic resection for rectal cancer. Method  We included 381 patients who underwent laparoscopic resection for rectal cancer between December 2002 and December 2007. The operative experience was divided into four periods according to numbers of operations and significant changes in main surgical results. Results  Operative time decreased significantly after 90 operations. The overall anastomotic leakage rate was 3.7%; 14.6% for the first 50 patients and 5.4% for the following 40 patients. The overall conversion rate was 2.9%, 4–6% during the first and second periods, but decreasing thereafter. The number of harvested lymph nodes and distal resection margin was within an acceptable range during the entire period. For the patients with stage I–III tumors, the local recurrence rate was 4.4% and the overall recurrence rate was 22.9%. The local recurrence rate was 8.9% initially and decreasing to 1.4% after the second period. The cumulative incidence of local recurrence decreased to less than 7% after 120 patients and to less than 5% after 180 cases. Conclusion  The learning curve for laparoscopic surgery for rectal cancer changed over time. Moreover, the learning curve for oncological safety was longer than that for operative safety.     

从腹腔镜到机器人辅助肾部分切除术的过渡:一个资深腹腔镜外科医生的学习曲线

背景腹腔镜肾部分切除术的高难度和挑战性使许多腹腔镜外科医生采用机器人辅助肾部分切除术治疗肾脏小肿瘤。从腹腔镜肾部分切除术到机器人辅助肾部分切除术的过渡期我们评估一个资深腹腔镜外科医生的学习曲线。方法我们比较同一外科医生施行的早期20例机器人辅助肾部分切除术和最近18例腹腔镜肾部分切除术的围术期结果。所有手术是在2005年4月～2009年7月间完成的。既往该医生成功施行100余例腹腔镜肾部分切除术和100余例机器人辅助手术。2组手术步骤相同,在镜下充分游离肾动静脉后,完整游离肿瘤表面,利用术中超声来界定肿瘤边界,哈巴狗血管阻断钳控制肾动脉,在热缺血状态下切除肿瘤,2-0可吸收线连续缝合肾实质,如果集合系统切开后也予以缝合。学习曲线的定义指能熟练地在较短的手术时间和热缺血时间内完成机器人辅助肾部分切除术的例数。利用散点图显示机器人辅助肾部分切除术的学习曲线,用以比较2种术式的手术时间和热缺血时间。结果 2组患者术前临床资料和肿瘤病理学结果的比较无统计学差异。2组均无切缘阳性病例。2组手术并发症也无统计学差异。在机器人辅助肾部分切除术的学习曲线(图1)中,手术时间和热缺血时间均呈下降趋势。经过早期5例手术后,机器人辅助肾部分切除术的平均手术时间即可接近最近18例腹腔镜肾部分切除术的平均手术时间。前5例机器人辅助肾部分切除术的平均手术时间是242.8 min,远远长于后15例机器人辅助肾部分切除术平均手术时间171.3 min(P=0.011)。结论 一个资深腹腔镜外科医生从腹腔镜到机器人辅助肾部分切除术过渡是一个非常迅速的过程。2组热缺血时间、术中估计出血量和住院时间均无统计学差异。经过前5例机器人辅助肾部分切除术后,一个资深腔镜外科医生行机器人辅助和腹腔镜肾部分切除术的手术时间大致相同。     

腹腔镜下猪胰肠吻合的学习曲线分析

目的：评价腹腔镜下猪胰肠吻合的手术效果，探讨其学习曲线。方法2012年9月～2013年2月我科由同一手术团队完成40头家猪腹腔镜下胰肠吻合手术，按家猪实验的时间顺序分为4组（Ⅰ、Ⅱ、Ⅲ、Ⅳ组），每组10例，比较4组手术时间、吻合效果。结果40头家猪腹腔镜下胰肠吻合手术均成功完成。4组手术时间有统计学差异，其中Ⅳ组手术时间（112．7±8．3）min显著短于Ⅰ组（145．1±16．6）min（q＝9．154，P＜0．05）、Ⅱ组（133．0±8．7）min（q＝5．735，P＜0．05）、Ⅲ组（137．2±9．0）min（q＝6．922，P＜0．05），Ⅱ组与Ⅰ组手术时间无统计学差异（q＝3．419，P＞0．05），其他各组间手术时间无统计学差异，表明腹腔镜下猪胰肠吻合的学习曲线约为30例，手术频数约为6．7例／月。4组吻合效果无统计学差异（χ2＝0．586，P＝0．900）。结论腹腔镜下猪胰肠吻合动物实验是可行的，学习曲线约为30例。     

Laparoscopic Varicocelectomy: Virtual Reality Training and Learning Curve

Objectives:

To explore the role that virtual reality training might play in the learning curve of laparoscopic varicocelectomy.

Methods:

A total of 1326 laparoscopic varicocelectomy cases performed by 16 participants from July 2005 to June 2012 were retrospectively analyzed. The participants were divided into 2 groups: group A was trained by laparoscopic trainer boxes; group B was trained by a virtual reality training course preoperatively. The operation time curves were drafted, and the learning, improving, and platform stages were divided and statistically confirmed. The operation time and number of cases in the learning and improving stages of both groups were compared. Testicular artery sparing failure and postoperative hydroceles rate were statistically analyzed for the confirmation of the learning curve.

Results:

The learning curve of laparoscopic varicocelectomy was 15 cases, and with 14 cases more, it came into the platform stage. The number of cases for the learning stages of both groups showed no statistical difference (P = .49), but the operation time of group B for the learning stage was less than that of group A (P < .00001). The number of cases of group B for the improving stage was significantly less than that of group A (P = .005), but the operation time of both groups in the improving stage showed no difference (P = .30). The difference of testicular artery sparing failure rates among these 3 stages was proved significant (P < .0001), the postoperative hydroceles rate showed no statistical difference (P = .60).

Conclusions:

The virtual reality training shortened the operation time in the learning stage and hastened the trainees'' steps in the improving stage, but did not shorten the learning curve as expected to.     

达芬奇机器人直肠癌根治术的学习曲线

目的探讨达芬奇机器人直肠癌根治术的学习曲线。方法回顾分析我院微创胃肠外科中心2010年3月～2012年5月完成的60例达芬奇机器人直肠癌根治术的临床资料,按手术先后顺序分成A、B、C3组,每组20例,比较各组机器人安装时间、手术时间、出血量、淋巴结清扫数目、并发症、术后住院时间。结果A组机器人安装时间（66±6）min,显著长于B组（35±5）min和c组（32±4）min（q=27．365,P〈0．05;q=30．013,P〈0．05）,B、C2组无统计学差异（q=2.648,P〉0．05）。3组手术时间无统计学差异（F=1．28,P=0．286）,总手术时间差异（F=8．82,P=0．000）主要由于机器人安装时间差异,机器人直肠癌根治术学习曲线为20例。3组出血量、淋巴结清扫数目、并发症、术后住院时间无显著性差异（P〉0．05）。结论对于熟练掌握腹腔镜直肠癌根治术的外科医生,达芬奇机器人直肠癌根治术学习曲线约为20例。