Early Learning Curve Research Articles

Evaluating robotic assistance on the learning curve and efficiency of mandibular angle ostectomy: an animal model study.

This study evaluated the efficacy and learning curve of a maxillofacial surgical robotic system (MSRS) guided by electromagnetic navigation for mandibular angle ostectomy (MAO), compared to traditional surgical methods. The study utilized a controlled experiment involving thirty rabbits, paired divided into experimental and control groups. The experimental group underwent MAO using the MSRS, while the control group was treated with conventional surgical techniques. The surgeons performing the procedures were inexperienced in robotic surgery and MAO to assess the learning curve and the impact of robotic assistance. Key parameters measured included the accuracy of ostectomy, setup time, and ostectomy efficiency, with data analyzed through a paired-t test to compare the performance between the two groups. The study indicated a significant reduction in ostectomy time for the experimental group, with improved accuracy and efficiency in ostectomy. The study found that robotic assistance could decrease the risk of complications and enhance surgical outcomes. It also highlighted the presence of an initial learning curve when adopting new robotic technologies, which could be mitigated through adequate training and simulation practices. Using MSRS for MAO could lead to faster early learning curves and increased ostectomy efficiency compared to traditional surgical methods. It demonstrated the potential benefits of integrating robotic systems into craniofacial surgery, suggesting a promising direction for future surgical practices.

The early learning curve of the bipolar enucleation of the prostate: a multicenter cohort study

ObjectivesTo evaluate the early learning curve of BipolEP (Bipolar Enucleation of the Prostate).Subjects/patients and methodsWe conducted a retrospective, multicenter analysis of surgical and functional outcomes of patients treated with BipolEp for BPO (benign prostatic obstruction). We evaluated the first 20 cases of BipolEp performed by four different surgeons in three different countries. The following baseline parameters were obtained: age, IPSS, indwelling catheter, transrectal measured prostate volume, post void residual volume (PVR) and uroflowmetry. The learning curve was analysed based on perioperative parameters and the influence of perioperative parameters was correlated with the sequence of BipolEp cases.Results84 BipolEp operations performed by 4 different surgeons in their early learning curve were studied. Mean prostate volume was 75 ml, 39% of cases had an indwelling catheter and the average operating time was 101 min. Three out of four surgeons performed at least 50% of successful operations according to Trifecta (complete enucleation and morcellation < 90 min., no conversion to TUR-P). Conversion rate to TURP was 11.9% in total which however was driven by a single surgeon with an almost 50% conversion rate. Mean enucleated prostate was 33.3 gr (18-54.5). Intraoperative complications and reported stress incontinence ranged from 0 to 38.1%. At six-weeks review, the IPPS improved by 12.5 (8–16) points and Qmax by 208% (109.8-266.7). Uroflowmetry outcomes correlated with the sequence of cases with a linear improvement during 20 consecutive cases (p = 0.018) in all centres. Major complications (Clavien Dindo ≥ 3) were rare (4.8%) and comparable between the groups.ConclusionSurgeons starting to learn BipolEp can expect to be able to achieve a linear improvement in Uroflow at the six-week postoperative evaluation after 20 consecutive cases. BipolEp can be successfully performed during the early learning curve with an acceptable rate of conversion to standard TUR-P.

Saliva stress biomarkers in ERCP trainees before and after familiarisation with ERCP on a virtual simulator.

Stress during the early ERCP learning curve may interfere with acquisition of skills during training. The purpose of this study was to compare stress biomarkers in the saliva of trainees before and after familiarisation with ERCP exercises on a virtual simulator. Altogether 26 endoscopists under training, 14 women and 12 men, completed the three phases of this study: Phase 1. Three different ERCP procedures were performed on the simulator. Saliva for α-amylase (sAA), Chromogranin A (sCgA), and Cortisol (sC) were collected before (baseline), halfway through the exercise (ex.), and 10 min after completion of the exercise (comp.); Phase 2. A three-week familiarisation period where at least 30 different cases were performed on the virtual ERCP simulator; and Phase 3. Identical to Phase 1 where saliva samples were once again collected at baseline, during, and after the exercise. Percentage differences in biomarker levels between baseline and exercise (Diffex) and between baseline and completion (Diffcomp) during Phase 1 and Phase 3 were calculated for each stress marker. Mean % changes, Diffex and Diffcomp, were significantly positive (p < 0.05) for all markers in both Phase 1 and Phase 3. Diffex in Phase 1 was significantly greater than Diffex in Phase 3 (p < 0.05) for sAA and sCgA. Diffcomp for sAA in Phase 1 was significantly greater than Diffcomp in Phase 3 (p < 0.05). No significant differences were found in sC concentration between Phases 1 and 3. This study shows that familiarisation with the ERCP simulator greatly reduced stress as measured by the three saliva stress biomarkers used with sAA being the best. It also suggests that familiarisation with an ERCP simulator might reduce stress in the clinical setting.

Shaping the curve from the microscopic transsphenoidal to the endoscopic endonasal approach for the sellar region.

This study aimed to investigate the limitations, barriers, and complications in the early transition from the microscopic transsphenoidal approach (MTA) to the endonasal endoscopic approach (EEA) to the skull base in our institution. Technical challenges, as well as clinical features and complications, were compared between MTA, EEA, and mixed cases during the early surgical curve. The period from the early learning curve was 1 year until the EEA protocol was used routinely. A total of 34 patients registered a resection using a transsphenoidal approach. Eighteen patients underwent EEA, 11 underwent MTA, and five underwent a mixed endonasal and microscopic approach. Non-significant differences were found in endocrine outcomes between the three groups. Patients with unchanged or improved visual function were higher in the EEA group (p = 0.147). Non-significant differences were found in terms of the extent of resection (EOR) between groups (p = 0.369). Only 1 (2.9%) patient in the whole series developed a post-operative CSF leaking that resolved with medical management, belonging to the EEA group (5.5%). The early phase of the learning curve did not affect our series significantly in terms of the EOR, endocrine status, and visual outcomes.

Perioperative Complications of Single-Port and Multiport Robotic Radical Prostatectomy: A Single Institutional Comparison Analysis.

Background: Following its introduction in 2018, the Single-Port (SP) robotic platform has been increasingly utilized for various approaches of robotic radical prostatectomy (RARP). Despite the demonstrable benefits in enhancing postoperative outcomes, there has been limited evidence on its perioperative morbidity, especially when compared to the gold-standard multiport (MP). This study sought to compare the perioperative morbidity between SP and MP-RARP. Methods: A retrospective review was performed on 911 patients who underwent RARP between January 2015 and May 2023. At our institution, SP-RARP has been performed since October 2018 with Extraperitoneal and Transvesical (TV) techniques. To reduce the risk of selection bias, only MP-RARP cases performed before October 2018 were included. Baseline clinicodemographic and perioperative parameters were collected. Perioperative complications were classified in accordance to the Clavien-Dindo system with postoperative complications and readmission reported within 90 days of surgery. Statistical analysis was performed with R Packages for Statistical Computing with descriptive statistics as presented. Results: Of the 484 SP and 322 MP-RARP cases included in our analysis, one intraoperative complication was reported, which pertained to a small enterotomy during TV SP-RARP. Postoperative complications were identified in 14.5% and 14.6% of SP and MP-RARP cases (p = 0.989), respectively. Major complication represents 4.1% of the SP and 3.4% of MP cohorts. The 90-day rates of hospital readmission following SP and MP-RARP were 5.6% and 4.9%, respectively (p = 0.717). Limitations of this study included the retrospective single surgeon, single institution nature of our series that also included the early learning curve experience associated with the novel SP platform. Conclusion: This comparative study provided evidence highlighting the low rates of perioperative complication and readmission following SP-RARP that were comparable to the Transperitoneal MP approach. The low morbidity associated with SP-RARP supports its wider application as an addition to the contemporary minimally invasive surgical armamentariums for prostate cancer.

Thirty versus 60-Watt thulium laser enucleation of prostate: Toward the development of low-power anatomical enucleation of the prostate.

We aimed to study whether using 30 W versus 60 W thulium enucleation of the prostate (ThuLEP) would affect postoperative outcomes in patients with benign prostatic hyperplasia (BPH). We prospectively identified male patients with moderate or severe lower urinary tract symptoms due to BPH. We randomized patients into 30 W (Group 1) or 60 W (Group 2) thulium yag laser with a 550 μm laser fiber and a 26 Fr continuous flow resectoscope. We collected data related to prostate size, enucleation time, morcellation time, laser time, perioperative complications, and 1-year functional outcomes. A total of 120 patients were included, with a mean age of 67 years and a mean prostate size of 105 g. The preoperative characteristics were similar across both groups. The mean operative time was shorter in the 60 W group, 74 ± 27 vs. 91 ± 33 min in the 30 W group (P = 0.001), and the mean laser time was 55 ± 20 in 60 W versus 71 ± 25 in 30 W (P = 0.0001). The mean hospital stay was 1 day in both groups and at 1-year follow-up; there was a similar improvement in mean Qmax and International Prostate Symptom Score symptom scores. Both 30 and 60 W ThuLEP provided a safe and comparable outcome with a relatively shorter operative time for the 60 W groups. Perhaps using a 30-W setting would be beneficial in the early learning curve or cases with more bleeding capsular perforators; besides, the financial benefit of manufacturing low-cost low-power devices that may help in the widespread of AEEP.

Artificial intelligence-based analysis of associations between learning curve and clinical outcomes in endoscopic and microsurgical lumbar decompression surgery.

A common spine surgery procedure involves decompression of the lumbar spine. The impact of the surgeon's learning curve on relevant clinical outcomes is currently not well examined in the literature. A variety of machine learning algorithms have been investigated in this study to determine how a surgeon's learning curve and other clinical parameters will influence prolonged lengths of stay (LOS), extended operating times (OT), and complications, as well as whether these clinical parameters can be reliably predicted. A retrospective monocentric cohort study of patients with lumbar spinal stenosis treated with microsurgical (MSD) and full-endoscopic (FED) decompression was conducted. The study included 206 patients with lumbar spinal stenosis who underwent FED (63; 30.6%) and MSD (118; 57.3%). Prolonged LOS and OT were defined as those exceeding the 75th percentile of the cohort. Furthermore, complications were assessed as a dependent variable. Using unsupervised learning, clusters were identified in the data, which helped distinguish between the early learning curve (ELC) and the late learning curve (LLC). From 15 algorithms, the top five algorithms that best fit the data were selected for each prediction task. We calculated the accuracy of prediction (Acc) and the area under the curve (AUC). The most significant predictors were determined using a feature importance analysis. For the FED group, the median number of surgeries with case surgery type at the time of surgery was 72 in the ELC group and 274 in the LLC group. FED patients did not significantly differ in outcome variables (LOS, OT, complication rate) between the ELC and LLC group. The random forest model demonstrated the highest mean accuracy and AUC across all folds for each classification task. For OT, it achieved an accuracy of 76.08% and an AUC of 0.89. For LOS, the model reached an accuracy of 83.83% and an AUC of 0.91. Lastly, in predicting complications, the random forest model attained the highest accuracy of 89.90% and an AUC of 0.94. Feature importance analysis indicated that LOS, OT, and complications were more significantly affected by patient characteristics than the surgical technique (FED versus MSD) or the surgeon's learning curve. A median of 72 cases of FED surgeries led to comparable clinical outcomes in the early learning curve phase compared to experienced surgeons. These outcomes seem to be more significantly affected by patient characteristics than the learning curve or the surgical technique. Several study variables, including the learning curve, can be used to predict whether lumbar decompression surgery will result in an increased LOS, OT, or complications. To introduce the provided prediction tools into clinics, the algorithms need to be implemented into open-source software and externally validated through large-scale randomized controlled trials.

Postoperative results, learning curve, and outcomes of pancreatectomy with arterial resection: a single-center retrospective cohort study on 236 procedures

Background: Newer chemotherapy regimens are reviving the role of pancreatectomy with arterial resection (PAR) in locally advanced pancreatic cancer. However, concerns about the early outcomes and learning curve of PAR remain. This study aimed to define the postoperative results and learning curve of PAR and provide preliminary data on oncologic outcomes. Materials and methods: A single center’s experiences (1993–2023) were retrospectively analyzed to define the postoperative outcomes and learning curve of PAR. Oncologic results were also reported. Results: During the study period 236 patients underwent PAR. Eighty PAR (33.9%) were performed until 2012, and 156 were performed thereafter (66.1%). Pancreatic cancer was diagnosed histologically in 183 patients (77.5%). Induction therapy was delivered to 18 of these patients (31.0%) in the early experience and to 101 patients (80.8%) in the last decade (P&lt;0.0001). The superior mesenteric artery (PAR-SMA), celiac trunk/hepatic artery (PAR-CT/HA), superior mesenteric/portal vein, and inferior vena cava were resected in 95 (40.7%), 138 (59.2%), 189 (80.1%), and 9 (3.8%) patients, respectively. Total gastrectomy was performed in 35 (18.5%) patients. The thirty-day mortality rate was 7.2% and ninety-day mortality rate was 9.7%. The learning curve for mortality was 106 PAR (16.0% vs. 4.6%; odds ratio, OR=0.25 [0.10–0.67], P=0.0055). Comparison between the PAR-SMA and PAR-CT/HA groups showed no differences in severe postoperative complications (25.3% vs. 20.6%), 90-day mortality (12.6% vs. 7.8%), and median overall survival. Vascular invasion was confirmed in 123 patients (67.2%). The median number (interquartile range) of examined lymph nodes was 60.5 (41.3–83) and rate of R0 resection was 66.1% (121/183). Median overall survival for PAR was 20.9 (12.5–42.8) months, for PAR-SMA was 20.2 (14.4–44) months, and for PAR-CT/HA was 20.2 (11.4–42.7). Long-term prognosis improved by study decade (1993–2002: 12.0 [5.4–25.9] months, 2003–2012: 15.1 [9.8–23.4] months, and 2013–present: 26.2 [14.3-51.5] months; P&lt;0.0001). Conclusions: In recent times, PAR is associated with improved outcomes despite a steep learning curve. Pancreatic surgeons should be prepared to face the technical challenge posed by PAR.

The Unilateral Biportal Endoscopic Technique for Treatment of Lumbar Spinal Stenosis: Early Surgical Results

Objective: Minimally invasive (MI) surgery for the treatment of spinal stenosis is currently a topic of substantial interest. One such technique is the unilateral biportal endoscopic (UBE) method, becoming popular among spine surgeons as a MI alternative to decompressive lumbar laminectomy without fusion. The purpose of this study was to present a description of the surgical technique and early clinical and radiological outcomes following the author's adoption of the UBE surgical technique for decompression of spinal stenosis.Methods: Between 2019 and 2021, surgery was performed on 47 patients with lumbar spinal stenosis. Clinical and radiological data were retrospectively analyzed through electronic medical records and imaging software reviews. Questionnaires and radiologic images were prospectively collected at scheduled times. The surgical technique used two corridors: one for endoscopic viewing and the other for handling surgical instruments during the procedure. Clinical outcomes were measured using the visual analogue scale (VAS) and the Oswestry Disability Index (ODI), while radiological outcomes were evaluated using X-rays to assess instability. Outcomes after UBE surgery were evaluated in terms of changes in clinical and radiological parameters from the baseline. A mixed-effects model with random effects for patients and surgical levels was used to test for differences in repeatedly measured clinical and radiological parameters.Results: During the early postoperative period, there were few complications, and all patients had a smooth recovery. Patients reported minimal postoperative wound discomfort. Back and leg VAS scores improved significantly in the early postoperative period (at 3, 6, and 12 months) compared to the baseline preoperative scores (p&lt;0.001). The ODI also showed significant improvement post-operatively (p&lt;0.001). The X-ray parameters were well maintained and did not show any progression of instability during the follow-up period.Conclusion: UBE surgery is a safe and effective MI technique for treating lumbar stenosis, with good early results and few complications during the early learning curve period.

Conventional versus underwater endoscopic resection for superficial non-ampullary duodenal epithelial tumours.

Several endoscopic resection methods have been developed as less invasive treatments for superficial non-ampullary duodenal epithelial tumours. This study aimed to compare outcomes of conventional endoscopic mucosal resection and underwater endoscopic mucosal resection for superficial non-ampullary duodenal epithelial tumours, including resection depth and rate of the muscularis mucosa contained under the lesion. This single-centre retrospective cohort study conducted from January 2009 to December 2021 enrolled patients who underwent conventional endoscopic mucosal resection and underwater endoscopic mucosal resection for superficial non-ampullary duodenal epithelial tumours and investigated their clinicopathological outcomes using propensity score matching. Of the 285 superficial non-ampullary duodenal epithelial tumours, 98 conventional endoscopic mucosal resections and 187 underwater endoscopic mucosal resections were included. After propensity score matching, 64 conventional endoscopic mucosal resections and 64 underwater endoscopic mucosal resections were analysed. The R0 resection rate was significantly higher in underwater endoscopic mucosal resection cases than in conventional endoscopic mucosal resection cases (70.3% vs. 50.0%; P=0.030). In the multivariate analysis, a lesion diameter> 10mm (odds ratio 7.246; P=0.001), being in the 1st-50th treatment period (odds ratio 3.405; P=0.008), and undergoing conventional endoscopic mucosal resection (odds ratio 3.617; P=0.016) were associated with RX/R1 resection. Furthermore, in underwater endoscopic mucosal resection cases, the R0 rate was significantly higher for lesions diameter≤10mm than >10mm, and was significantly higher in the 51st-treatment period than in the 1st-50th period. Conventional endoscopic mucosal resection and underwater endoscopic mucosal resection cases showed no significant difference in resection depth and muscularis mucosa containing rate. Underwater endoscopic mucosal resection may be more acceptable than conventional endoscopic mucosal resection for superficial non-ampullary duodenal epithelial tumours ≤ 10mm. A steep early learning curve may be acquired for underwater endoscopic mucosal resection. Large multicentre prospective studies need to be conducted to confirm the effectiveness of underwater endoscopic mucosal resection.

Effect of Metrics-Based Simulation Training to Proficiency on Procedure Quality and Errors Among Novice Cardiac Device Implanters

In cardiac device implant training, there is no common system to objectively assess trainees' ability to perform tasks at predetermined performance levels before in vivo practice; therefore, patients are potentially exposed to risks related to operators' early learning curve. To assess the effect on implant performance quality of novel metrics-based simulation training to proficiency (proficiency-based progression [PBP]) vs traditional simulation-based training (SBT). In this prospective randomized trial, conducted between March 8, 2022 and November 24, 2022, novice implanters were randomized (blinded) 1:1 to participate in an SBT curriculum (procedural knowledge e-learning and in-person simulation training) at an international skills training center, with proficiency demonstration requirements at each training stage for advancing (PBP approach) or without the requirements. Ultimately, trainees performed a cardiac resynchronization therapy (CRT) implant using virtual reality simulation. The procedure was video-recorded and subsequently scored using previously validated metrics by 2 independent assessors blinded to group. Physicians who had already implanted more than 20 pacemakers or defibrillators and fewer than 200 CRT systems as the first operator were eligible. Thirty-two implanters from 10 countries voluntarily enrolled in the training program and were randomized; 30 (15 per group) started and completed training. Data analysis was performed from November 27 to December 22, 2022. Training with PBP vs SBT. The primary outcome comprised 4 objectively assessed performance metrics derived from the video-recordings: number of procedural steps completed, errors, critical errors, and all errors combined. Baseline experience of the 30 participants (19 [63%] male; mean [SD] number of years in implant practice, 2.0 [1.8]; median [IQR] number of implanted pacemakers or defibrillators, 47.5 [30.0-115.0]; median [IQR] number of implanted CRT systems, 3.0 [1.25-10.0]) was similar between study groups. Compared with the SBT group, the PBP group completed 27% more procedural steps (median [IQR], 31 [30-32] vs 24 [22-27]; P < .001) and made 73% fewer errors (median [IQR], 2 [1-3] vs 7 [5-8]; P < .001), 84% fewer critical errors (median [IQR], 1 [0-1] vs 3 [3-5]; P < .001), and 77% fewer all errors combined (errors plus critical errors) (median [IQR], 3 [1-3] vs 11 [8-12]; P < .001); 14 of the 15 PBP trainees (93%) demonstrated the predefined target performance level vs 0 of the 15 SBT trainees. In this randomized trial, the PBP approach to novice implanter training generated superior objectively assessed performance vs SBT. If implemented broadly and systematically, PBP training may ensure safe and effective performance standards before trainees proceed to (supervised) in vivo practice. Future studies are needed to verify implications on procedure-related patient complications. ClinicalTrials.gov Identifier: NCT05952908.

Evaluation of Early &amp; Late Hypocalcemia Post Total Thyroidectomy in the Early Learning Curve Retrospective Study

Abstract Background Hypocalcemia post total thyroidectomy, is one of the most common complications observed in patients who undergo bilateral thyroid resection. Although hypocalcemia is self-limiting in most patients and does not require treatment, symptomatic hypocalcemia is of particular concern. We aimed to evaluate the incidence of hypocalcemia post total thyroidectomy with an evaluation of serum calcium levels as a cheap and available method so we can identify patients at risk of postoperative hypocalcemia who require supplementation treatment, and those not at risk who can be safely discharged without any supplementation treatment. Aim of the Work To analyze the data of post total thyroidectomy regarding calcium level temporary and permanent in the early learning curve and compare it with the standard incidence of developing hypocalcemia with total thyroidectomy in the literature. Patients and Methods Retrospective analysis of 120 patients undergoing total thyroidectomy. Preservation of parathyroid glands and their blood supply was attempted in all cases. The patients were assessed for manifestations of hypocalcaemia after thyroidectomy. The assessment was done through (1) monitoring the total and ionized calcium level 24 hours postoperatively, (2) Total and ionized calcium level was measured in the third week postoperative, (3) clinical examination and detection of symptoms and signs of hypocalcaemia, (4) In resistant cases assessment of total and ionized calcium and PTH at 3 and 6 months. Results The study included 103 females and 17 males, 37 was the mean age; 15 patients developed symptoms of hypocalcaemia all of them recovered from hypocalcaemia except 1 patient. Conclusion There is no difference between the incidence of temporary and permanent hypocalcemia in the early learning curve and the standard incidence of temporary and permanent hypocalcemia post total thyroidectomy

FTP4.7 A stitch in time; Surgeon learning curve in Robotic Assisted Colorectal Cancer Resection Operating Times

Abstract Aims We began performing Robotic Assisted (RAS) colorectal cancer (CRC) resections in our hospital in 2022. In order to understand whether we could demonstrate a surgeon learning curve, we assessed for any difference in median length of operating time (OT) in RAS CRC resections from their implementation to present time. Method We performed a retrospective review of theatre logs for RAS CRC resections from 2nd May 2022 until 17th January 2023. We recorded ‘knife to skin’ and ‘close’ time for each case alongside resection type. We included the 4 highest volume resection types and identified the median OT for the first half of cases, from which we subtracted the median OT from the second half of cases performed. We then calculated median time difference between the sets. Results As table 1 demonstrates, the median OT decreased for all included RAS CRC resections (n=51) from the first data set to the second. The median time saved over all resection types was 26.5 minutes. Discussion In surgery, demonstrating a learning curve involves looking at a marker of progress (such as operating time) and assessing it against exposure to, for example, a new technique or instrument. RAS represents a unique opportunity for this. We were able to demonstrate an early surgeon learning curve with a decrease in median OT across our highest volume RAS CRC resections within 8 months of their implementation at our centre.

Consecutive Experience with Left Bundle Branch Area Pacing in a High-Volume Australian Centre.

Left-bundle branch area pacing (LBBAP) is a relatively new technique for conduction system pacing. Australian safety and efficacy data is currently lacking. We aim to evaluate the learning curve, medium-term safety, and lead performance in a high-volume Australian setting. We performed a retrospective cohort study of 200 consecutive LBBAP procedures performed by a single operator at two centres between January 2019 and May 2020. Left bundle branch area pacing was performed predominantly via left subclavian access using a 69 cm Medtronic SelectSecure 3830 pacing lead and a preformed non-steerable C315-His sheath. Procedural success was defined as evidence of left septal or left bundle branch area capture as evidenced by a right bundle branch block-like paced morphology. Procedural characteristics, and follow-up (including lead performance) data were collected. Procedural efficiency over time, as well as safety data, were collected. Median age was 78.26 years (interquartile range [IQR] 71-85), 37% were female. Atrial fibrillation was present in 22%. The left ventricular ejection fraction <50% in 24%, atrioventricular (AV) block was present in 43.5%, left bundle branch block in 22.5% and right bundle branch block in 24.5%. Acute procedural success was 91.5%. Implant threshold was 0.6V @ 0.5 ms, and 0.75V @ 0.5 ms at 11.9 months of follow-up. The QRS was significant reduced (baseline 134 ms vs implant 114 ms, p<0.001) There was a reduction in procedural time and X-ray dose over the course of the study. There were no complications specific toLBBAP. LBBAP appears to be a safe and effective pacing strategy. The QRS duration was significantly reduced compared to baseline. There appears to be an early learning curve with LBBAP.

Impact of ERCP simulator training on early ERCP learning curves of novice trainees: a cohort study.

Background and study aim Simulator-based training has been extensively studied in training gastroduodenoscopy and colonoscopy and shown to significantly improve learning curves of novices. Data on simulator-based training in endoscopic retrograde cholangiopancreatography (ERCP) are scarce. We aimed to determine the impact of 2-day intensive hands-on simulator training on the course of the learning curve of novice trainees. Methods We conducted a prospective cohort study using a validated mechanical ERCP simulator (Boškoski-Costamagna ERCP Trainer). Six trainees were allocated to the simulation course program (SG). Each of these trainees were paired with an endoscopy trainee starting regular ERCP training at the same center who had no exposure to a simulation course program (control group; CG). The course included lectures, live ERCP demonstrations, and hands-on ERCP training to educate trainees in basic techniques related to cannulation, stent placement, stone extraction and stricture management. After the course, both the SG and CG started formal ERCP training in their respective centers. The Rotterdam Assessment Form for ERCP was used to register each performed ERCP. Simple moving average was applied to create learning curves based on successful common bile duct (CBD) cannulation. Outcomes were plotted against a historical cohort (HC). Results Thirteen trainees were included, six trainees in the SG and seven trainees in the CG, with a total of 717 ERCPs. Mean successful ERCP cannulation rate was higher for the simulator group at baseline compared to both CG and HC, 64% versus 43% and 42%, respectively. Differences became less explicit after 40 ERCPs, but persisted until a median of 75 ERCPs. Conclusions We demonstrate that 2-day hands-on simulator-based ERCP training course has a positive effect on the learning curves of ERCP trainees and should be considered an integral part of the training curricula for ERCP to develop skills prior to patient-based training.

Adequate Mentorship Program for Holmium Laser Enucleation of the Prostate (HoLEP) Leads to Satisfactory Short-Term Outcomes in the Early Learning Curve of Young Urologists: First-Year Outcomes of a Newly Established Mentorship Training in Mexico.

Introduction Benign prostatic hyperplasia (BPH) is one of the most common causes of lower urinary tract symptoms in men. Holmium Laser Enucleation of the Prostate (HoLEP) has been recommended by international guidelines as an alternative to transurethral resection of the prostate (TURP). HoLEP's learning curve and the lack of adequate mentorship remains an obstacle for the worldwide adoption of this technique. Objective To report the first-year learning curve of a newly established mentorship program in young urologists without any previous HoLEPexperience. Methods We report a cohort of patients with BPH, with prostate size ≥70 grams, treated with HoLEP, analyzed for perioperative data and complications, and short-term postoperative complications and functional outcomes, at three and six months after surgery. Results A total of 47 patients were managed with HoLEP. Mean total operative time was 149.8 ± 42.9 minutes. We experienced five (10.6%) intraoperative complications, including one intravesical resection of the prostate with bipolar energy, three conversions to TURP and one conversion to open prostatectomy. We experienced four postoperative complications, all of them Clavien-Dindo ≤2. Median International Prostate Symptom Score (IPSS) decrease at six months was -17 points from baseline. Mean post-void residual volume and prostate-specific antigen significantlydecreased by the third postoperative month. Multiple linear regression showed that prostate size is directly related to increased surgical time during the early learning curve. Discussion Our experience adequately reflects the importance of HoLEP mentorship in young urologists seeking training in this technique. Both surgeons had perioperative and postoperative outcomes deemed satisfactory based on previously published learning curves. Conclusions HoLEP is a technically difficult procedure, however, adequate mentorship leads to satisfying short-term outcomes since the early stages of the learning curve in young urologists with no previous training on this technique.

Towards identifying a learning curve for robotic abdominal wall reconstruction: a cumulative sum analysis.

Over the past decade, an increase has been seen in robotics used for hernia repair, specifically robotic abdominal wall reconstruction (rAWR). However, the learning curve for rAWR can be steep and presently, little is understood regarding the optimal case volume required to achieve proficiency. The aim of our study was to review skill acquisition and describe the learning curve for rAWR. A retrospective, single-surgeon case series of consecutive patients who underwent rAWR from 2018 to 2022. The primary outcome was operative time, obtained from console time identified through the MyIntutive application. A one-sided cumulative sum analysis (CUSUM) curve for the total operative time was derived based on the mean operative time of chronological procedures (207min). 185 patients underwent rAWR between 2018 and 2022. These patients were more likely to be female, Caucasian, and have undergone two previous hernia repairs. ASA complexity increased over time with ASA 3 being predominant from 2020 onwards. The median hernia length was 15.0cm and the median width was 7cm. Average operative time was 207.8min and decreased over time. The CUSUM analysis identified four phases of skill acquisition with the following case volumes: Initial Learning Curve (0-20), Stabilization Phase (21-55), Second Learning Curve (56-70), 4) Skill Proficiency (> 70). In the early learning curve of rAWR, operative time decreased consistently after 70 cases, with an initial inflection after 20 cases. We identified varying stages of skill acquisition that are likely typical of a surgeon as they would progress through the learning curve of advanced robotic surgery. Future studies are needed to confirm the optimal case volume for determining the skill level for the performance of rAWR.

Radical Vaginal Hysterectomy, Type B: An Educational Video, Cadaver Model.

The radical vaginal hysterectomy popularized by Schauta1 has been virtually abandoned due to painful perineal incision, high rate of urinary dysfunction, and inability to perform lymph node assessment. However, this approach is still used and taught in a few centers outside its Austrian birthplace. In addition, a combined vaginal and laparoscopic approach, overcoming the flaws of the pure vaginal technique, was developed in the 1990s by French and German surgeons.2 After the publication of the Laparoscopic Approach to Cervical Cancer trial,3 the radical vaginal approach has found a very timely application with the closure of the vaginal cuff, aiming at avoiding cancer cell spillage.4 In addition, it is the basis to perform radical vaginal trachelectomy, or Dargent's operation, the best documented approach for the fertility-sparing management of stage IB1 cervical cancers. Today, the main obstacle to the rebirth of radical vaginal surgical surgery is the lack of teaching centers and the need of a specific learning curve that requires performing 20-50 surgeries.5,6 This educational video demonstrates that training is possible using a fresh cadaver model. A type B approach according to the Querleu-Morrow7 classification of radical vaginal hysterectomy, adapted according to surgeon's choice to stage IB1 or IB2 cervical cancer, is shown. Key specific steps such as the creation of a vaginal cuff and the identification of the ureter within the bladder pillar are highlighted. Fresh cadaver model is a method that spares the patients the risks of early learning curve while allowing the surgeon to acquire skills and keep offering the patient the benefit of the most specifically gynecological approach in cervical cancer surgery.

Introducing robotic oesophagectomy into an Australian practice: an assessment of the early procedural outcomes and learning curve

Robotic oesophagectomy (RAMIO) is a novel procedure in Australia and New Zealand. We aimed to report the early operative and clinical outcomes achieved during the introduction of RAMIO into the practice of a single Australian surgeon and benchmark these against outcomes of patients receiving conventional minimally invasive oesophagectomy (MIO) by the same surgeon. Data on all patients undergoing RAMIO, performed by a single high-volume Australian surgeon, were collected from a prospectively maintained database. Operative, clinical and surgical quality outcomes were benchmarked on a univariable basis against those of patients receiving MIO. Learning curves were computed using quadratic and linear regression of operating times on case-numbers and compared using Cox regression modelling. 290 patients (237 MIO, 53 RAMIO (47% Ivor-Lewis, 53% McKeon oesophagectomy)) were included. Compared with MIO, the median thoracic operating time was 20 min longer for RAMIO (P = 0.03). Following RAMIO, there was less blood loss (P < 0.01) and a shorter length of stay (P < 0.01).There were no differences in morbidity and quality of surgery following RAMIO compared with MIO. There were no deaths following RAMIO. Having progressed from MIO, the operating times for RAMIO improved after 22 cases compared with MIO (110 cases) (HR 0.70 (0.51-0.93), P = 0.01). With careful implementation, RAMIO may be safely performed within the Australian setting and is associated with a modest increase in procedure duration, but less blood loss and shorter length of stay compared with conventional MIO.

A retrospective review of single-position prone lateral lumbar interbody fusion cases: early learning curve and perioperative outcomes

PurposeThe objective of this study was to discuss our experience performing LLIF in the prone position and report our complications.MethodsA retrospective chart review was conducted that included all patients who underwent single- or multi-level single-position pLLIF alone or as part of a concomitant procedure by the same surgeon from May 2019 to November 2022.ResultsA total of 155 patients and 250 levels were included in this study. Surgery was most commonly performed at the L4–L5 level (n = 100, 40%). The most common preoperative diagnosis was spondylolisthesis (n = 74, 47.7%). In the first 30 cases, 3 surgeries were aborted to an MIS TLIF. Complications included 3 unintentional ALL ruptures (n = 3/250, 1.2%), and 1 malpositioned implant impinging on the contralateral foramen requiring revision (n = 1/250, 0.4%), which all occurred within the first 30 cases. Out of 147 patients with more than 6-week follow-ups, there were 3 cases of femoral nerve palsy (n = 3/147, 2.0%). Two cases of femoral nerve palsy improved to preoperative strength by the 6th week postoperatively, while one improved to 4/5 preoperative strength by 1 year. There were no cases of bowel perforation or vascular injury.ConclusionOur single-surgeon experience demonstrates the initial learning curve when adopting pLLIF. Thereafter, we experienced reproducibility in our technique and large improvements in our operative times, and complication profile. We experienced no technical complications after the 30th case. Further studies will include long-term clinical and radiographic outcomes to understand the complete utility of this approach.