Total laparoscopic hysterectomy – Learning curve and its impact on surgical outcome of 773 case series from a single center

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Abstract Study Objective: The objective of this study was to assess the learning curve of total laparoscopic hysterectomy (TLH) and its impact on surgical outcome of 773 consecutive cases between two decades. Design: This was a retrospective observational comparative study of 773 consecutive cases of TLH. Setting: This study was conducted at ILS Hospital, Kolkata, India, a private tertiary referral center for endoscopic surgery. Patients: Total 773 women with benign pelvic pathologies from 2000 to 2019 having similar demographic characteristics irrespective of uterus size and previous surgery were included while patients with malignancy and second-degree uterus prolapse were excluded. Interventions: TLH by ipsilateral technique. Materials and Methods: The study period was divided into two decades with 386 and 387 surgeries of TLH in the first and second decades, respectively, maintaining homogeneity within the periods. The CUmulative SUMmation (CUSUM) technique was used to construct a learning curve of operative time where learning point. Results: Learning Point was found at the 118th surgery. Overall complications decreased from 4.39% to 1.33% (P = 0.0096) between two decades, and major and minor complications decreased from 3.36% to 0.52% (P = 0.0042) and from 1.03% to 0.78% (P = 0.1416), respectively. No major vessel injury occurred. Five ureter injuries occurred in the first decade and none in the second decade. In-spite of significant increase in uterus size and double the number of Lower Uterine Caesarian Section (LUCS) in 2nd decade (P<0.00001), bladder injuries occurred in 1st decade & 2nd decade was 7 (1.81%) and 1 (0.26%) respectively (P=0.033). Total 56 conversions (7.56%) occurred: the first decade was 27 (6.97%) and the second decade 29 (7.51%) (P = 0.7814). Conclusion: Laparoscopic hysterectomy can be safely done by ipsilateral technique with low complication if one achieves a learning curve under supervised training. In our study, gained experience helped us to decrease major bladder, bowel, and ureteric injuries drastically by 90.91% in spite of increased complexity of cases in the second decade.