Improvement In Operative Time Research Articles

Learning curve for the open Latarjet procedure: a single-surgeon study.

The popularity of the Latarjet procedure (LP) for the treatment of anterior shoulder instability continues to rise. However, LP is technically demanding and associated with complications. This study aims to determine the learning curve for the open LP (oLP) and the threshold for proficiency. This was a retrospective study of all oLPs performed by a single surgeon in a single institution from 2016 to 2021. Operative time, defined as time from incision to closure, was the primary outcome of this study, and 1-year postoperative complications were the secondary outcome. After listing oLP cases in chronological order, they were classified into groups of 15, and the average operative time for each group was determined. Demographics, operative duration, and postoperative complications were compared across groups. Seventy-five oLPs were included in this study, and operative times decreased after the first 15 procedures. While operative times continued to decrease with increasing case number, the learning curve began to plateau after 30 procedures. After 75 procedures, there was a total decrease in average operative time of 31.5 minutes relative to that of the first 15 cases. There were no differences in complication or revision rates among procedure groups. Establishing learning curves provides important insight into the complexity of surgical procedures. Our study demonstrates that the oLP has a steep learning curve with significant improvement in operative time after the first 15 cases. Operative time plateaus after 30 cases, indicating proficiency in this procedure. Level of evidence: IV.

Systematic review and meta-analysis of ROSA vs. conventional therapy for intracerebral hemorrhage.

The purpose of this systematic review and meta-analysis was to evaluate the perioperative and short-term results of the Robot of Stereotactic Assistance (ROSA) compared to traditional approaches in individuals with intracerebral hemorrhage (ICH). We will perform a comprehensive computerized search of PubMed, CNKI, Embase, and Google Scholar to identify relevant literature on ROSA vs. conventional therapy for intracerebral hemorrhage, covering publications from the inception of each database until July 2024. This study will include both English and Chinese language studies. Literature screening will adhere strictly to inclusion and exclusion criteria, focusing on randomized controlled trials (RCTs) and cohort studies. The ROBINS-I tool is utilized for evaluating bias risk in non-RCTs. Analysis of the data from the studies included will be conducted with Review Manager 5.4.1. The final analysis included 7 retrospective cohort studies and 1 randomized controlled study, involving a total of 844 patients. Among these, 433 patients underwent ROSA, while 411 received conventional treatment (conservative treatment, conventional craniotomy, or stereotactic frame-assisted surgery). Compared to conventional therapy, patients treated with ROSA showed improvements in operative time, postoperative rebleeding, postoperative extubation time, and intracranial infection. Nonetheless, there was no notable contrast in mortality or central hyperthermia outcomes between the two treatments. ROSA is a safe and viable option for treating patients with cerebral hemorrhage, showing significant advantages in terms of surgery duration, postoperative rebleeding, time to remove the breathing tube, and intracranial infection compared to conservative treatment, traditional craniotomy, or stereotactic surgery.

The long-term learning curve of holmium laser enucleation of the prostate (HoLEP) in the en-bloc technique: a single surgeon series of 500 consecutive cases

PurposeTo evaluate perioperative parameters, clinical outcomes, and the learning curve of holmium laser enucleation of the prostate (HoLEP) of a single surgeon in 500 consecutive cases.MethodsDemographic parameters, outcomes, and adverse events were evaluated. The learning curve for HoLEP in en-bloc technique of the first 500 consecutive patients was analyzed in clusters of 100 (clusters 1–5) using the Wilcoxen rank test, Chi² test and Kruskal Wallis test.ResultsEnucleation weight was similar in the clusters 1,2,3, and 5 (62 g, 63 g, 61 g, 61 g), in cluster 4 it was slightly higher at 73 g. There was a significant reduction in operating time from 67 min (cluster 1) to 57 min (cluster 2), 46 min (cluster 3), 53 min (cluster 4), and 43 min (cluster 5), p < 0.001. Enucleation efficiency (g/min) showed a steady increase (1.72, 2.24, 2.79, 2.92 vs. 2.99, p < 0.001). Laser energy efficiency also improved (2.17 vs. 2.12 vs. 1.71 vs. 1.65 vs. 1.55; p < 0.001). There was no measurable learning curve regarding the length of hospital stay (mean 2.5 days), catheterization time (1.9 days), hemoglobin drop (approx. 1 g/dl) or complications (p > 0.1).ConclusionsHoLEP using the en-bloc technique is a safe and highly effective method. Over time, a slight but steady learning curve and improvement in operation time, enucleation efficiency and laser energy efficiency were shown even for an experienced surgeon - after 500 cases, still no plateau was reached. There was no measurable learning curve regarding blood loss, complications, length of hospital stay, and catheterization time.

Evaluating a Single Surgeon's Learning Curve for Laparoscopic Totally Extraperitoneal Repair of Inguinal Hernia with Telescopic Dissection: A Cumulative Sum Control Chart Analysis.

Background: Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair (IHR) reduces risk of injury to intraperitoneal structures. Balloon dissection is more costly and has theoretical risk of injury to the surrounding structures compared with telescopic dissection (TD). This study aims to evaluate the learning curve (LC) for TEP IHR with TD of a single surgeon. Methods: This is a 3-year retrospective cohort study from January 2020 to December 2022 on patients who underwent elective laparoscopic TEP unilateral IHR with TD. Exclusion criteria were recurrent inguinal hernia. Cumulative sum (CUSUM) analysis was performed to evaluate the number of cases required to surmount the LC, that is, NLC for operating time (OT) and open conversion. One way analysis of variance was used to perform groupwise comparison. Results: There were 69 patients who underwent laparoscopic TEP unilateral IHR with TD. The median age was 58.0 years (range 24.0-80.0) and body mass index was 23.0 (range 18.6-30.0). Majority of the hernia was indirect (n = 48, 69.6%). The median OT was 70 minutes (range 35-210). Three cases (4.3%) had open conversion. One-year recurrence was 4.2% (n = 1/24). CUSUM analysis showed improvement in OT after the eighth case. However, this was followed by multiple inflection points with no apparent stabilization in OT. Pairwise comparison showed a decrease in OT between cases 18-36 and cases 37-54. There was no incidence of open conversion until the 56th case. Conclusion: Laparoscopic TEP IHR using TD is safe in the absence of a practor. A minimum of 36 cases is required to surmount the initial LC.

Learning curve of robotic-assisted splenic vessel-preserving spleen-preserving distal pancreatectomy by one single surgeon: a retrospective cohort study

AimSplenic vessel-preserving spleen-preserving distal pancreatectomy (SVP-SPDP) has a lower risk of splenic infarction than the splenicvessel-sacrificing SPDP, but it is more technically demanding. Learning curve of robotic-assisted SVP-SPDP (RSVP-SPDP) remains unreported. This study sought to analyze the perioperative outcomes and learning curve of RSVP-SPDP by one single surgeon.MethodsSeventy-four patients who were intended to receive RSVP-SPDP at the First Affiliated Hospital of Sun Yat-sen University between May 2015 and January 2023 were included. The learning curve were retrospectively analyzed by using cumulative sum (CUSUM) analyses.ResultsSixty-two patients underwent RSVP-SPDP (spleen preservation rate: 83.8%). According to CUSUM curve, the operation time (median, 318 vs. 220 min; P < 0.001) and intraoperative blood loss (median, 50 vs. 50 mL; P = 0.012) was improved significantly after 16 cases. Blood transfusion rate (12.5% vs. 3.4%; P = 0.202), postoperative major morbidity rate (6.3% vs. 3.4%; P = 0.524), and postoperative length-of-stay (median, 10 vs. 8 days; P = 0.120) improved after 16 cases but did not reach statistical difference. None of the patients had splenic infarction or abscess postoperatively.ConclusionRSVP-SPDP was a safe and feasible approach for selected patients after learning curve. The improvement of operation time and intraoperative blood loss was achieved after 16 cases.

A Comparison of Three-Dimensional Visualization Systems and Two-Dimensional Visualization Systems During Laparoscopic Cholecystectomy: A Narrative Review.

Background: Laparoscopic cholecystectomy is a common procedure for the definitive treatment for cholecystitis and symptomatic cholelithiasis. One advancement in minimally invasive surgery has been the development of three-dimensional (3D) visualization systems to provide stereopsis. It is yet to be determined whether this innovation is beneficial to the surgeon or simply just a gimmick. This narrative review aims to answer the following research question, what is the impact of 3D visualization systems on surgical efficiency compared with two-dimensional visualization systems in laparoscopic cholecystectomy? Methods: Through a broad literature search it was determined that operative time and intraoperative errors have been used in published research to assess intraoperative efficiency. Results: Studies published to date have used operative time, intraoperative errors, and intraoperative bleeding as current measures for intraoperative efficiency. Previous meta-analysis have shown a slight improvement in operative time for 3D visualization systems; however, subsequent randomized control trials have not shown a significant difference in operative time. Reporting of intraoperative errors has been quite subjective and a difference between visualisation modality has not been shown. Conclusion: 3D visualization systems have shown a minor improvement in operative time compared with traditional laparoscopic systems and it is unlikely to be of any clinical significance. Studies that measure intraoperative error vary greatly in what they report, and which assessment tool is used. Across existing literature, studies do not control for surgeon's experience, elective/emergent cases, and grade of gallbladder/difficulty. Further research is required, using novel tools for assessment in laparoscopic cholecystectomy to determine intraoperative differences through objective and quantitative variables.

Learning curve for endoscopic posterior cervical foraminotomy.

While anterior cervical discectomy and fusion as well as cervical disk arthroplasty are gold standard treatments for the surgical treatment of cervical radiculopathy, posterior endoscopic cervical foraminotomy (PECF) as a substitute procedure is gaining popularity. To date, studies investigating the number of surgeries needed to achieve proficiency in this procedure are lacking. The purpose of the study is to examine the learning curve for PECF. The learning curve in operative time for two fellowship-trained spine surgeons at independent institutions was retrospectively assessed for 90 uniportal PECF procedures (PBD: n = 26, CPH: n = 64) performed from 2015 to 2022. Operative time was assessed across consecutive cases using a nonparametric monotone regression, and a plateau in operative time was used as a proxy to define the learning curve. Secondary outcomes assessing achievement of endoscopic prowess before and after the initial learning curve included number of fluoroscopy images, visual analog scale (VAS) for neck and arm, Neck Disability Index (NDI), and the need for reoperation. There was no significant difference in operative time between surgeons (p = 0.420). The start of a plateau for Surgeon 1 occurred at 9 cases and 111.6min. The start of a plateau for Surgeon 2 occurred at 29 cases and 114.7min. A second plateau for Surgeon 2 occurred at 49 cases and 91.8min. Fluoroscopy use did not significantly change before and after surmounting the learning curve. The majority of patients achieved minimally clinically important differences in VAS and NDI after PECF, but postoperative VAS and NDI did not significantly differ before and after achieving the learning curve. There were no significant differences in revisions or postoperative cervical injections before and after reaching a steady state in the learning curve. PECF is an advanced endoscopic technique with an initial improvement in operative time that occurred after as few as 8 cases to as many as 28 cases in this series. A second learning curve may occur with additional cases. Patient-reported outcomes improve following surgery, and these outcomes are independent of the surgeon's position on the learning curve. Fluoroscopy use does not change significantly along the learning curve. PECF is a safe and effective technique that current and future spine surgeons should consider as part of their armamentarium.

The feasibility of robot-assisted radical cystectomy: an experimental study.

To investigate the feasibility of the avatera system for performing robot-assisted radical cystectomy (RARC) followed by intracorporeal reconstruction of ileal neobladder. Six anesthetized female pigs were used to perform RARC and formation of the intracorporeal orthotopic ileal neobladder. Three surgeons with different level of expertise in the use of robotic systems performed RARC after a short instructional lecture and a 2-h hands-on training. The urinary diversion phase was performed only by the experienced surgeon. The successful completion of the procedure, operative time for demolitive and reconstructive phases, intraoperative blood loss and malfunction of the robotic system were evaluated. An improvement of the operative time was observed for each surgeon. The experienced surgeon, the fellow and the resident improved their time by 11, 15, and 22min, respectively, between the first and the second RARC performed. The most significant time difference was demonstrated by the resident, who had no previous experience in using robotic systems. The time difference between the first and the last orthotopic ileal neobladder creation for the experienced surgeon was 51min. The feasibility of avatera system for performing complex surgical procedure such as RARC with intracorporeal neobladder formation was demonstrated by this experimental study. No major bleeding or severe malfunctions were observed during the procedures. Significant improvement in operative time was demonstrated with the increasing experience from 1st to 6th case.

The Efficacy and Safety of HoLEP for Benign Prostatic Hyperplasia With Large Volume: A Systematic Review and Meta-Analysis

This meta-analysis was to evaluate the efficacy and safety of holmium laser enucleation of prostate (HoLEP) in the treatment of benign prostatic hyperplasia (BPH) with large volume. PubMed, Embase, and Cochrane Library databases (until March 2022) were used to search related randomized controlled trials. A total of 11 studies including 1,258 patients were involved. HoLEP could significantly decrease the length of hospital stay and accelerate recovery. In subanalysis, HoLEP had better perioperative outcomes than bipolar transurethral resection of the prostate (B-TURP) and bipolar transurethral enucleation of the prostate (BPEP). The improvement in operative time and enucleation time was better in thulium laser enucleation of the prostate (ThuLEP) than HoLEP. In the follow-up period, the HoLEP decreased post-void residual urine (PVR) in short-term intervals and improved patients’ maximum flow rate (Qmax) and prostate-specific antigen (PSA) in mid- and long-term intervals. In subanalysis, HoLEP presented significant improvements in Qmax, PSA, and quality of life (QoL) than B-TURP, and HoLEP could also improve Qmax than ThuLEP after 6 months of surgery. The HoLEP reduced the risk of postoperative bleeding compared with other surgeries in safety. In our study, we confirmed the advantages of HoLEP in treating BPH when the prostate size was larger than 80 mL, which indicated that HoLEP could be the best choice for treatment of large volume of prostate.

PERCUTANEOUS NEPHROLITHOTRIPSY PRACTICE IN VIETNAM: A SYSTEMATIC SCOPING REVIEW

Introduction: Percutaneous nephrolithotripsy is safe and effective for managing renal calculi but complex and expensive. Different institutions with different resource readiness as well as approaches might show differences in outcomes. Our systematic scoping review aimed to map the evidence body as well as review effectiveness of the technique in national scale in over three decades of practice. Methods: This research was carried out with studies on percutaneous nephrolithotripsy in Vietnam by searching full text articles via following databases as well as search engines: PubMed/MEDLINE, Cochrane Library, Embase, Google Scholar, http://lienthuvien.yte.gov.vn/ - an online library run by Vietnam’s Ministry of Health; and by searching directly in the library of Hanoi Medical University. Study selection process followed the PRISMA flow chart of study search and selection. The data from selected studies were extracted with double check before summarizing and charting the data. Results: Preliminary data analysis from 30 selected studies showed that approximately 20 years from the first performance, percutaneous nephrolithotripsy gradually transferred from more resource readiness centers to lesser counterparts. The transference was accomplished to some extent, reflecting on improvement in operation time, surgical conversion rate, stone free rate, as well as on a decrease in the rate of severe complications. Conclusion: This systematic scoping review mapped evidence body in national range regarding percutaneous nephrolithotripsy. It suggests that a more homogeneous research design should be obtained for more precisely picturing clinical practice.

Learning Curve and Associated Prognosis of Minimally Invasive McKeown Esophagectomy

BackgroundThe implementation of McKeown minimally invasive esophagectomy (MIE) is associated with a steep learning curve. However, there is no consensus on the number of cases required before effective and safe McKeown MIE can be achieved. MethodsData on consecutive patients with esophageal carcinoma who underwent esophagectomy performed by a single surgeon in the Department of Thoracic Surgery at Daping Hospital in Chongqing, China from September 2009 to June 2019 were collected. The cumulative sum learning curve was plotted on the basis of the learning associated parameters. Propensity score matching was used to reduce selection bias from confounding factors. The Kaplan-Meier method was used to assess the survival differences. ResultsThe learning curve was divided into the ascending period (cases 1-197), the plateau period (198-314), and the descending period (315-onward). After 197 cases, significant improvements in operative time (300 minutes vs 210minutes; P < .001), retrieved lymph nodes (17 vs 20; P = .004), hospital length of stay (18 days vs 13 days; P = .001), major postoperative complications (38.6% vs 32.5%; P < .001), vocal cord palsy (6.1% vs 0.9%; P = .04), and pulmonary complications (31.5% vs 17.1%; P = .005) were observed. In addition, after 314 cases, significant decreases in blood loss (200 mL vs 100 mL; P < .001), anastomotic leak (24.8% vs 14.8%; P = .02), and chylothorax (4.3% vs 0%; P = .001) were observed. After propensity score matching, the overall and disease-free survival rates were significantly improved during the experienced period (P = .02 and .03, respectively). ConclusionsThe initial learning phase of McKeown MIE consisted of 197 procedures in 51 months. Moreover, the surgeon’s experience did have a direct impact on the long-term outcomes in patients with esophageal carcinoma.

P-BN03 A systematic review of pre-operative low-calorie diets for laparoscopic cholecystectomy

Abstract Background Laparoscopic cholecystectomy is the fourth most common procedure in the UK. Increased liver adiposity, commonly encountered in obesity, anecdotally may increase technical difficulty and surgical risk. Pre-operative low-calorie diets are well-established in bariatric surgery to reduce liver bulk, thereby ameliorating difficulty and risk. Similar diets are often used before laparoscopic cholecystectomy, however, the supporting evidence base is unclear; we performed the first systematic review on their use in this context. Methods PubMed, Embase and Cochrane Central Register of Controlled Trials databases were searched in February 2021. We included English language clinical studies describing pre-operative low-calorie diet for laparoscopic cholecystectomy. Data were extracted for specifics of / adherence to diet, weight change, operative time / difficulty, complications and length of stay. Study quality was qualified using Scottish Intercollegiate Guidelines Network criteria and Jadad score. Results One randomised controlled trial (RCT) and one prospective observational study were identified. Both utilised a pre-operative very low-calorie diet of &amp;lt; 800 kcal/day. Overall weight loss was greater in patients deemed compliant with the intervention. Both demonstrated tendency towards reduced operative difficulty with the intervention. Only the RCT found improvement in operative time. Conclusions Pre-operative very low-calorie diets (&amp;lt; 800 kcal/day for two weeks) may aid weight loss and reduce operative difficulty in laparoscopic cholecystectomy, although evidence supporting their continued use is limited. Further RCTs are warranted to fully evaluate their role in clinical and cost-effectiveness.

Learning Curve for a Dual Attending Surgeon Strategy in Posterior Spinal Fusion (PSF): An Analysis of 105 Severe Adolescent Idiopathic Scoliosis Patients (Cobb Angle ≥90°).

Retrospective study. To assess the learning curve of a dual attending surgeon strategy in severe adolescent idiopathic scoliosis patients. The advantages of a dual attending surgeon strategy in improving the perioperative outcome in scoliosis surgery had been reported. However, the learning curve of this strategy in severe scoliosis had not been widely studied. A total of 105 patients with adolescent idiopathic scoliosis with Cobb angle of 90° or greater, who underwent posterior spinal fusion using a dual attending surgeon strategy were recruited. Primary outcomes were operative time, total blood loss, allogeneic blood transfusion requirement, length of hospital stay from time of operation and perioperative complications. Cases were sorted chronologically into group 1: cases 1 to 35, group 2: cases 36 to 70, and group 3: case 71 to 105. Mean operative time (≤193.3 min), total blood loss (≤1612.2 mL), combination of both and allogeneic blood transfusion were the selected criteria for receiver operating characteristic analysis of the learning curve. The mean Cobb angle was 104.5° ± 12.3°. The operative time, total blood loss, and allogeneic blood transfusion requirement reduced significantly for group 1 (220.6 ± 54.8 min; 2011.3 ± 881.8 mL; 12 cases) versus group 2 (183.6 ± 36.7 min; 1481.6 ± 1035.5 mL; 3 cases) and group 1 versus group 3 (175.6 ± 38.4 min; 1343.7 ± 477.8 mL; 3 cases) (P < 0.05). There were six perioperative complications. Fifty-seven cases were required to achieve the preset criteria (mean operative time and mean total blood loss) (area under the curve 0.740; P < 0.001; sensitivity 0.675; specificity 0.662). There was significant improvement in operative time and total blood loss when comparing group 1 versus group 2 and group 1 versus group 3. The cut-off point for the learning curve was 57 cases when the preset criteria were fulfilled (≤193.3 min operative time and ≤1612.2 mL of total blood loss).Level of Evidence: 4.

Robotic Assisted Laparoscopic Tubal Anastomosis: Single Institution Analysis

Study Objective To study operative time and cost of robotic assisted laparoscopic tubal anastomosis beyond the learning curve. Secondary objective was to assess pregnancy rate. Design Retrospective Cohort Study. Setting University-affiliated hospital. Patients or Participants All patients who underwent robotic assisted laparoscopic tubal anastomosis from April 2013 to December 2018, performed by a single surgeon at a university-affiliated hospital. Interventions Robotic assisted laparoscopic tubal anastomosis surgery. Measurements and Main Results 109 patients were identified who underwent robotic tubal reversal. Retrospective analysis of EMR was performed. Phone survey was conducted. Operative times were evaluated for 106 cases. Age ranged from 27 to 46 (median 36 ± 4.7), BMI ranged from 18 to 47 (median 29 ± 5.8). Previous ligations included excisional (63%), cautery (13%), and mechanical obstruction (24%). 60% of patients had previous laparotomy. Mean operative time decreased with experience. In 2013, the average operative time was 140.7 ± 27.0 minutes. Average operative time in 2018 was 60.0 ± 9.1 minutes. Downward trend in operative time was highly significant (p The average cost of the surgery was $7,153.46 ± $1,484.41. Direct cost was $4798.25. Follow up information regarding pregnancy outcome was available in 59 patients. Mean follow up time was 37.5 months. 36 patients conceived spontaneously and 23 had not conceived (61%). 75% of patients under 37 became pregnant (n=24), whereas the pregnancy rate was 44% and 45% in the age groups 37-39 (n=7) and >40 years (n=5) respectively. Conclusion There is significant improvement in operative time for robotic assisted tubal anastomosis over time. The operative time of robotic assisted tubal anastomosis beyond the learning curve compares favorably, and may even surpass that of the laparoscopic approach, in our experience. Additionally, this is a cost-effective procedure in our institution when compared to laparoscopic approach.

Robotic-assisted laparoscopic tubal anastomosis: Single institution analysis.

Tubal anastomosis has similar pregnancy rates regardless of approach. Historically, robotic anastomosis has been associated with increased cost and operative time. We sought to perform a contemporary study of these metrics. One hundred and nine patients were identified who underwent robotic-assisted laparoscopic tubal anastomosis. Retrospective analysis of medical records was performed. Phone survey was conducted. The mean operative time decreased from 140.7 ± 27.0 min in 2013 to 60.0 ± 9.1 min in 2018, with significant downward trend (p < 0.001). The mean cost was $7153.46 ± $1484.41. The pregnancy rate was 59% (35/59), and tubal patency rate was 81% (42/52). Seventy-two percent of patients under 37 years became pregnant. There is significant improvement in operative time of robotic-assisted tubal anastomosis with surgical experience. Robotic tubal anastomosis outperformed historical metrics of laparoscopy and laparotomy with regard to operative time and cost in this series.

Assessment of Quality Outcomes and Learning Curve for Robot-Assisted Minimally Invasive McKeown Esophagectomy.

This study aimed to identify the results of the quality assessment and the learning curve of robot-assisted minimally invasive McKeown esophagectomy (RAMIE-MK). The study retrospectively reviewed the data of 400 consecutive patients with esophageal cancer who underwent RAMIE-MK by a single surgeon from November 2015 to March 2019. Cumulative summation analysis of the learning curve was performed. The patients were divided into decile cohorts of 40 cases to minimize demographic deviations and to maximize the power of detecting statistically significant changes in performance. The 90-day mortality rate for all the patients was 0.5% (2 cases). The authors' experience was divided into the ascending phase (40 cases), the plateau phase (175 cases), and the descending phase (185 cases). After 40 cases, significant improvements in operative time (328 vs. 251min; P = 0.019), estimated blood loss (350 vs. 200ml; P = 0.031), and conversion rates (12.5% vs. 2.5%; P < 0.001) were observed. After 80 cases, a decrease in the rates of anastomotic leakage (22.5% vs. 8.1%; P = 0.001) and vocal cord palsy (31.3% vs. 18.4%; P = 0.024) was observed. The number of harvested lymph nodes increased after 40 cases (13 vs. 23; P < 0.001), especially for lymph nodes along the recurrent laryngeal nerve (3.0 vs. 6.0; P < 0.001). The learning phase of RAMIE-MK consists of 40 cases, and quality outcomes can be improved after 80 procedures. Several turning points related to the optimization of surgical outcomes can be used as benchmarks for surgeons performing RAMIE-MK.

Subxiphoid uniportal video-assisted thoracoscopic pulmonary segmentectomy: effect of learning curve and future perspectives.

Subxiphoid uniportal video-assisted thoracoscopic segmentectomy (SU-VATs) has been widely adopted because it is associated with better postoperative pain scores. Nevertheless, it also has had some limitations that have gradually been decreasing. Therefore, our goal was to evaluate the change in perioperative results with SU-VATs as the learning curve developed to outline the current status and the points that should be of future concern. Three hundred patients who underwent SU-VATs from September 2014 to May 2018 were divided chronologically into 2 groups; group 1 comprised the first 150 cases and group 2 comprised the last 150 cases. Different perioperative variables were analysed and compared between the 2 groups. In addition, the cumulative sum analysis and multivariable logistic regression were conducted to identify the cut-off point and predictors of significant improvement in operative time. The cumulative sum analysis showed significant improvement in the operative time after the 148th case. Group 2 showed a statistically significant decrease in operative time (104.3 ± 36.7 vs 132 ± 43.1 min; P < 0.001), amount of operative blood loss [50 (80 ml) vs 100 (50 ml); P < 0.001], chest drain duration (2.6 ± 1.6 vs 3.2 ± 1.4 days; P = 0.004) and hospital stay (3.7 ± 1.7 vs 4.2 ± 1.7 days; P = 0.008). The number of dissected lymph nodes was significantly higher in the second group [11 (4) vs 9 (4); P < 0.001]. Limitations of SU-VATs are being overcome by the improvement in the learning curve and in the expertise of the surgeons. Our future concerns should focus on examining the long-term survival rate, the oncological efficacy and the effect on quality of life.

A Systematic Review of Learning Curves in Plastic and Reconstructive Surgery Procedures.

Surgical learning curves reflect the trainee's rate of progress in gaining skills and competence for new procedures. Complex interventions such as free tissue transfers, with various linked skills and competences, transferred to one procedure are likely to have steep learning curves. This work aimed to report influence of learning curves on outcomes such as success rate, operative time, and complication rates in plastic surgery procedures. The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic database literature search (PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trails) was performed. Articles were included when reporting effects of learning curves on outcomes in plastic surgery procedures. Twenty-nine articles focusing on learning curves in plastic surgery procedures were included. Studies reported on non-free flap breast reconstruction, mastectomy, and free flap reconstruction in general and for breast reconstruction and did not allow for pooling of the data because of heterogeneity. Most common outcomes for measuring improvements were success rate, operation time, and complication rate, which demonstrated improvements in almost all studies. Plateaus were reached in 45 to 100 cases for breast reconstructions and were not reported for other procedures. Only 2 studies did not find associations between surgical experience and clinical outcomes. There are sparse data on learning curves in plastic surgery. Existing studies draw a heterogeneous picture, but especially free flap breast reconstructions seem to undergo learning curves with improvements in operative time, complication rates, and success rates. However, well-designed studies with clearly defined outcomes and comparison between surgeons of different levels over time should be performed.Systematic review registration: PROSPERO: CRD42018108634.

Learning curve of robot-assisted middle pancreatectomy (RMP): experience of the first 100 cases from a high-volume pancreatic center in China.

Middle pancreatectomy (MP) is safe and feasible in patients with benign or low-grade malignant tumors located at the neck or proximal body of the pancreas. As a tissue-sparing operation, MP can preserve normal pancreatic function and reduce the risk of postoperative endocrine and exocrine insufficiency. However, the morbidity, especially the postoperative pancreatic fistula (POPF) rate, remains high. A robot-assisted surgical system may provide patients with less trauma; however, there are few reports on robot-assisted middle pancreatectomy (RMP). We describe the experience of RMP at our center to illustrate the learning curve (LC). From August 2010 to July 2017, 100 patients underwent RMP in the Pancreatic Disease Center of Shanghai Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine. Patient characteristics, operative outcomes, and oncological outcomes were collected and analyzed. The CUSUM curve was analyzed according to operative time and estimated blood loss (EBL) and was used to describe the LC and identify the flexion points. Among the 100 patients who underwent RMP in our hospital, the mean age was 47.5 ± 14.2years, and 69 patients were female. From the CUSUM curve, we found two flexion points: cases 12 and 44. After 44 cases, the rate of improvement was much faster. We separated the patients into two groups based on the LC (cases 1-44 and cases 45-100). There were significant improvements in operative time (173.1 ± 44.7min vs. 137.3 ± 30.1min, p < 0.001) and EBL (103.4 ± 90.0ml vs. 69.3 ± 53.9ml, p = 0.021). The overall POPF rate was 32% (32/100), while the incidence rate of biochemical leakage was 14% (14/100). However, there was no significant difference in the risk of POPF or other complications between the two groups. The postoperative length of stay (LOS) was also not different. The 90-day mortality rate was 1%. From our long-term follow-up, pancreatic function was preserved in most patients, with only three cases of endocrine insufficiency and two cases of exocrine insufficiency. RMP was helpful and a good choice for the selected patients. PF was the main complication and has not been improved until now. There were two flexion points in the LC at cases 12 and 44. More cases are needed to gain more experience. A larger sample size and prospective studies are needed to verify the advantage of RMP.

Modified equipment for facilitating the transoral vestibular approach to endoscopic thyroidectomy.

Objectives:The objectives of the study were to investigate the improvement in operation time for thyroid surgery gained using a modified endobag and suture and to accelerate the learning process for novice endoscopic surgeons.Materials and Methods:A retrospective study was conducted between 2 June 2015 and 1 November 2018. Medical records of patients who underwent transoral endoscopic thyroidectomy vestibular approach (TOETVA) were retrieved and analysed. Comparisons of operative time with or without the use of modified equipment were calculated by the unequal variance t-test in lobectomy and isthmectomy groups.Results:Medical records of 102 patients (mean age: 39.1 years) were analysed. The size of thyroid nodule averaged 4.0 cm (range: 1.0–13.0 cm). TOETVA was applied for right lobectomy (57.8%), left lobectomy (34.3%), isthmectomy (3.9%) and total thyroidectomy (3.9%). Early in our experience, TOETVA required 168 min, whereas following the introduction of the modified endobag and extracorporeal suture, operative time was reduced to 30 min (P > 0.05).Conclusions:The use of modified equipment permitted shorter operation times. The time difference was not statistically significant but does represent a significant time-saving. The use of the modified equipment will simplify and speed up the learning process for novice endoscopic surgeons.