Assessment Of Learning Curve Research Articles

BN SO59 - Learning Curve for Robotic-Assisted Cholecystectomy

Abstract Background Assessment of learning curves following the introduction of robotic-assisted technology has shown that improvement in surgical outcomes can be seen with increasing robotic experience. Method All robotic-assisted cholecystectomies performed by a single consultant upper gastrointestinal surgeon as primary operator were analysed between 6/8/21 - 6/6/24 at a UK specialist centre using the Versius robotic system (CMR surgical). We recorded set up time during cases over this period. Results 38 robotic-assisted cholecystectomies were performed within the study period. In the first 10 cases, average set up time was 8 minutes and 18 seconds. In the second 10 cases this reduced to 5 minutes and 36 seconds. No further improvement was seen after case 20. Conclusion Our results demonstrate that set up time for robotic-assisted cholecystectomy improves over the first 20 cases. This data suggests 20 cases are adequate for acquiring the skillset required to set up the Versius robotic system efficiently in real life practice.

Assessment of safety, efficacy and learning curve of intravascular lithotripsy in real world practice within a high volume calcium modification centre

Abstract Background There has been a rapid uptake in the use of intravascular lithotripsy (IVL) for calcium modification during percutaneous coronary intervention (PCI) due to its ease of use and excellent safety profile, particularly when compared to atherectomy devices. Purpose To review the adoption and safety of IVL in a high volume centre with established use of alternative calcium modification techniques Methods This was a retrospective analysis of all patients undergoing PCI from the introduction of IVL in January 2019 until December 2023. Patient demographics, comorbidity, procedure details and procedural complications were compared between IVL and non-IVL cases. Line charts were created to demonstrate the uptake and use of IVL per quarter compared with other established calcium modification strategies. A further line chart was created to compare the frequency of IVL use per quarter in more complex cases (left main intervention, ST elevation, treatment of in stent restenosis and in combination with rotational/orbital atherectomy). Results In the analysis timeframe there were 7,843 PCI cases performed, of which there were 301 IVL cases, 263 rotational/orbital atherectomy cases and 77 excimer laser atherectomy. IVL cases were older, more likely to have previous revascularisation (PCI (40.8% vs 57.1 % (p<0.001)) or bypass grafts 4.8% vs 8.0% (p=0.012)), diabetes mellitus (22.7% vs 33.6% (p<0.001)) and hypertension (45.4% vs 56.5% (p<0.001)). From a procedural perspective, treatment of left main and restenosis were more common with IVL compared with the rest of the cohort (7.0% vs 27.6% (p<0.001) and 8.3% vs 28.9% (p<0.001) respectively). IVL cases were more frequently guided by intracoronary imaging (intravascular ultrasound 35.9% vs 70.4% (p<0.001), optical coherence tomography 3.7% vs 18.9% (p<0.001)). Atherectomy was more frequent in IVL cases (excimer laser atherectomy 0.7% vs 7.3% (p<0.001) and rotational/orbital atherectomy 2.6% vs 22.9% (p<0.001)). Figure 1 shows the frequency of IVL use compared with other established calcium modification strategies per quarter and demonstrates the rapid and sustained uptake in IVL usage. Interestingly the use of other atherectomy techniques does not appear to have reduced. Figure 2 shows that IVL was quickly utilised in more complex calcification cases and again this has remained consistent since the introduction. Both figures demonstrate the short learning curve associated with IVL. Finally, there was no significant increase in perforation or slow/no reflow with IVL use (0.5% vs 0.7% (p=0.647) and 1.1% vs 1.3% (p=0.675) respectively) consistent with the published literature. There was an increase in documented coronary dissection with uncertain impact (3.4% vs 6.5% p=0.017). Conclusions IVL has become an essential tool within the calcium modification algorithm as a result of its ease of use, efficacy and excellent safety profile.Calcium modification per quarterFrequency of complex IVL cases

Comparing fourth-year medical students’ procedural surgical skill learning outcomes between third-person point-of-view video lectures and first-person point-of-view immersive virtual reality: a pilot study of surgically implanting a subdermal drain on cadavers

The use of virtual reality (VR) training in medical school education has increased over the last decade partly due to coronavirus-19 (COVID-19) and due to technology advancements in this integrative area. As medical students are being trained in new pedagogical interventions, it is important to drill-down and focus on the areas of most translational concern for assessing their competency and proficiency. Thus, the present pilot study sought to evaluate a group of fourth-year medical students’ ability to learn a modified medical school curriculum on implementing a subdermal drain by first learning how to stitch on a silicone model (i.e., proper stitching only) and then being randomly assigned to either a third-person point-of-view (TP-POV) or first-person point-of-view (FP-POV) immersive VR group to learn how to conduct the surgical procedure (i.e., conceptually and procedurally). Then, the participants’ surgical procedural motor skills were assessed on a single attempt to demonstrate their competency and proficiency on a cadaver. The results showed that the pedagogical learning differences in FP-POV immersive VR improved the cleanliness and accuracy of the surgical dissection movement and drain placement with 100% proficiency in the first attempt at implementing this surgical technique on a cadaver. Additionally, there was statistically significant improvement in the dissection movement (p < 0.05*) and the tension test (p < 0.01**) in the FP-POV group compared to the TP-POV group, even with a small sample size in the present pilot study. These findings offer unique training opportunities to be considered when designing future VR curriculum with the suggested use of repeated-measures designs on the surgical procedural motor skills to assess learning curves and their potential translations in reducing operating room errors, costs, planning and scheduling times, and surgery overlaps, thereby positively contributing to a more efficient and safer OR surgical experience by staff and patients in the near future.

Learning Curve in Two-Port Laparoscopic Gastropexy Using FlexDex.

Keyhole gastropexy is becoming increasingly popular, and the new development facilitates shorter surgical times. This paper reports on the learning curve in two-port laparoscopic gastropexy using FlexDex in a specialist's hands. FlexDex is a novel tool combining aspects of robotic surgery without requiring an expensive robot theatre setting. Cohort of 16 dogs >25 kg and at high risk of gastric volvulus and dilatation (GDV) undergoing elective laparoscopic gastropexy were enrolled in the study consecutively from 5/2022 to 9/2023. All patients were operated on by one surgeon (FM), and surgical time was recorded to assess learning curve. Competence was defined as plateauing surgical time. Detailed follow-up at 1 day, 7 days, 14 days, 2 months, 6 months, and long-term was recorded for success rate and complications. Ultrasound examination was scheduled at 4-6-month review to confirm lasting success of the gastropexy. All 16 patients were operated on successfully without any significant complications, as confirmed on the ultrasound. The surgical time of laparoscopic gastropexy reduced from 52 to 14 min (reduction of 38 min/73%) and reached plateau after the 12th case of the 16, making it a very steep learning curve in specialist hands. There were no serious complications, and success rate was 100% at the 6-month ultrasound assessment. This is the first paper to report on the learning curve with the FlexDex device in a two-port laparoscopic gastropexy setting. It effectively halves the operating time to 30 min, making the surgery safer for the patient and more cost-efficient, without compromising the result.

Towards a Standardization of Learning Curve Assessment in Minimally Invasive Liver Surgery.

The aim was to analyze the learning curves of minimal invasive liver surgery(MILS) and propose a standardized reporting. MILS offers benefits compared to open resections. For a safe introduction along the learning curve, formal training is recommended. However, definitions of learning curves and methods to assess it lack standardization. A systematic review of PubMed, Web of Science, and CENTRAL databases identified studies on learning curves in MILS. The primary outcome was the number needed to overcome the learning curve. Secondary outcomes included endpoints defining learning curves, and characterization of different learning phases(competency, proficiency and mastery). 60 articles with 12'241 patients and 102 learning curve analyses were included. The laparoscopic and robotic approach was evaluated in 71 and 18 analyses and both approaches combined in 13 analyses. Sixty-one analyses (60%) based the learning curve on statistical calculations. The most often used parameters to define learning curves were operative time (n=64), blood loss (n=54), conversion (n=42) and postoperative complications (n=38). Overall competency, proficiency and mastery were reached after 34 (IQR 19-56), 50 (IQR 24-74), 58 (IQR 24-100) procedures respectively. Intraoperative parameters improved earlier (operative time: competency to proficiency to mastery: -13%, 2%; blood loss: competency to proficiency to mastery: -33%, 0%; conversion rate (competency to proficiency to mastery; -21%, -29%), whereas postoperative complications improved later (competency to proficiency to mastery: -25%, -41%). This review summarizes the highest evidence on learning curves in MILS taking into account different definitions and confounding factors. A standardized three-phase reporting of learning phases (competency, proficiency, mastery) is proposed and should be followed.

Cumulative sum learning curve for cordocentesis among maternal-fetal medicine fellows in a low-cost simulation model.

To determine the individual learning curves for cordocentesis in a low-cost simulator for maternal-fetal medicine (MFM) fellows. This observational, descriptive, educational, and prospective study was performed from July through November 2022. After an introductory course based on a standardized technique for cordocentesis, each second-year MFM fellow who accepted to participate in the study performed this procedure using a low-cost simulation model, and experienced operators supervised the cordocenteses. Learning curves were then created using cumulative sum analysis (CUSUM). Seven second-year MFM fellows with no previous experience in cordocentesis accepted to participate in the study. A total of 2676 procedures were assessed. On average, residents performed 382 ± 70 procedures. The mean number of procedures to achieve proficiency was 369 ± 70, the overall success rate was 84.16%, and the corresponding failure rate was 15.84%. At the end of the study, all fellows were considered competent in cordocentesis. One fellow required 466 attempts to achieve competency, performing a total of 478 procedures, but the resident with the fewest attempts to reach competency required 219 procedures, completing 232 procedures. Some of the most frequent reasons for failed attempts included not reaching the indicated point for vascular access (20.99%) and being unable to retrieve the sample (69.10%). CUSUM analysis to assess learning curves, in addition to using low-cost simulation models, helped to appraise individualized learning, allowing an objective demonstration of competency for cordocentesis among MFM fellows.

Comparison of surgical times of various total knee replacement techniques and assessment of learning curve of robotic total knee replacement: a retrospective study

Background: This study aims to compare the operating times of manual, computer-assisted and robotic- assisted TKA and to calculate the learning curve for image-less robotic-assisted TKA (RATKA). Methods: This retrospective observational study, conducted at the Centre of Excellence, Bone, Joint and Spine, Meitra Hospital, Kozhikode, Kerala, India, focused on patients aged 60 and above undergoing total knee replacement for stage 4 osteoarthritis. The study included 75 consecutive cases of manual, computer- assisted, and robotic-assisted unilateral total knee arthroplasties performed between May 2021 and September 2022 (18 months). Data was collected from the hospital records. Results: The surgeon transitioned from learning to proficiency phase of RATKA after 14 cases. In the robotic learning phase, the overall operative time was 113.14 minutes (±8.96), significantly longer than the robotic proficiency phase's average of 98.24 minutes (±2.98) and that of CATKA (99.57±10.700 minutes) and manual TKAs (97.01±7.17 minutes). No statistically significant difference was observed in the global operative time between the proficiency phase RATKAs and the CATKA and manual groups (p=0.139). Conclusions: By optimizing techniques and modifying workflow, one can swiftly overcome the initial learning curve of RATKA and achieve operating times comparable to manual TKA. To enhance efficiency and productivity, the study proposes a revised workflow modifying various rate limiting surgical steps.

Learning Curve for Minimally Invasive Scoliosis Surgery in Adolescent Idiopathic Scoliosis

To evaluate the learning curve of minimally invasive scoliosis surgery (MISS) in patients with adolescent idiopathic scoliosis (AIS). A total of 76 AIS patients who underwent MISS were included from March 2015 to February 2017. The cases were divided chronologically into early period group (Group A, March 2015-February 2016, n=31) and late period group (Group B, March 2016-February 2017, n=45). Radiological parameters, operative parameters, and clinical outcomes were included in this study. The selected criteria for receiver operating characteristic analysis used to assess learning curve were mean operative time (≤389minutes) and estimated blood loss (EBL) (≤948mL). The mean operative time was 389minutes, and the EBL was 948mL. The mean operative time was significantly reduced in the late period group (360minutes) compared to the early period group (431minutes) (P<0.005). The mean EBL was significantly reduced for the late period group (798mL) compared to the early period group (1164mL)(P<0.001). Forty-six cases were required to achieve the preset criteria (area under the curve 0.858; P<0.001; sensitivity 0.778; specificity 0.796). A mild learning curve was demonstrated in MISS for AIS with significant improvement in operative times and EBL over time. Experience of more than 46 cases of MISS was required to obtain proficient surgical skills for a trained surgeon of conventional open scoliosis surgery.

Educational Scoring System in Laparoscopic Cholecystectomy: Is It the Right Time to Standardize?

Background and Objectives: Laparoscopic cholecystectomy (LC) is one of the most performed surgeries worldwide. Procedure difficulty and patient outcomes depend on several factors which are not considered in the current literature, including the learning curve, generating confusing and subjective results. This study aims to create a scoring system to calculate the learning curve of LC based on hepatobiliopancreatic (HPB) experts' opinions during an educational course. Materials and Methods: A questionnaire was submitted to the panel of experts attending the HPB course at Research Institute against Digestive Cancer-IRCAD (Strasbourg, France) from 27-29 October 2022. Experts scored the proposed variables according to their degree of importance in the learning curve using a Likert scale from 1 (not useful) to 5 (very useful). Variables were included in the composite scoring system only if more than 75% of experts ranked its relevance in the learning curve assessment ≥4. A positive or negative value was assigned to each variable based on its effect on the learning curve. Results: Fifteen experts from six different countries attended the IRCAD HPB course and filled out the questionnaire. Ten variables were finally included in the learning curve scoring system (i.e., patient body weight/BMI, patient previous open surgery, emergency setting, increased inflammatory levels, presence of anatomical bile duct variation(s), and appropriate critical view of safety (CVS) identification), which were all assigned positive values. Minor or major intraoperative injuries to the biliary tract, development of postoperative complications related to biliary injuries, and mortality were assigned negative values. Conclusions: This is the first scoring system on the learning curve of LC based on variables selected through the experts' opinions. Although the score needs to be validated through future studies, it could be a useful tool to assess its efficacy within educational programs and surgical courses.

INTRODUCTION OF ROSA ROBOTIC ARM SYSTEM FOR TOTAL KNEE ARTHROPLASTY IS ASSOCIATED WITH A MINIMAL LEARNING CURVE FOR OPERATIVE TIME

The introduction of robotics for total knee arthroplasty (TKA) into the operating theatre is often associated with a learning curve and is potentially associated with additional complications. The purpose of this study was to determine the learning curve of robotic-assisted (RA) TKA within a multi-surgeon team.This prospective cohort study included 83 consecutive conventional jig-based TKAs compared with 53 RA TKAs using the Robotic Surgical Assistant (ROSA) system (Zimmer Biomet, Warsaw, Indiana, USA) for knee osteoarthritis performed by three high-volume (&gt; 100 TKA per year) orthopaedic surgeons. Baseline characteristics including age, BMI, sex and pre-operative Kellgren-Lawrence grade were well-matched between the conventional and RA TKA groups. Cumulative summation (CUSUM) analysis was used to assess learning curves for operative times for each surgeon. Peri-operative and delayed complications were reviewed.The CUSUM analysis for operative time demonstrated an inflexion point after 5, 6 and 15 cases for each of the three surgeons, or 8.7 cases on average. There were no significant differences (p = 0.53) in operative times between the RA TKA learning (before inflexion point) and proficiency (after inflexion point) phases. Similarly, the operative times of the RA TKA group did not differ significantly (p = 0.92) from the conventional TKA group. There was no discernible learning curve for the accuracy of component planning using the RA TKA system. The average length of post-operative follow-up was 21.3 ± 9.0 months. There was no significant difference (p &gt; 0.99) in post-operative complication rates between the groups.The introduction of the RA TKA system was associated with a learning curve for operative time of 8.7 cases. Operative times between the RA TKA and conventional TKA group were similar. The short learning curve implies this RA TKA system can be adopted relatively quickly into a surgical team with minimal risks to patients.

Learning Curve for Ultrasound Assessment of Myometrial Infiltration in Endometrial Cancer Visualizing Videoclips: Potential Implications for Training.

Diagnostic accuracy for estimating myometrial infiltration by ultrasound in endometrial cancer requires experience. The objective of this study is to determine the learning curve (LC) for assessing myometrial infiltration in cases of endometrial cancer using transvaginal ultrasound (TVS). Five trainees (one staff radiologist and four fourth-year OB/GYN residents) participated in this study. All trainees had experience in performing TVS, but none of them had specific training on the assessment of myometrial infiltration. Trainees were given one specific lecture about the topic, and then they observed videoclips from 10 cases explained by the trainer. After this, all trainees visualized 45 videoclips of uterine ultrasound scans of endometrial cancer cases. The assessment of myometrial infiltration was based on the subjective impression. Definitive histology was used as a reference standard. Trainees stated whether myometrial infiltration was ≥50% or <50%. LC-CUSUM and standard CUSUM graphics were plotted to determine how many cases were needed to reach competence, allowing a mistake rate of 15%. All trainees completed the study. LC-CUSUM graphics showed that three trainees reached competence at the 33rd, 35th and 36th case, respectively. All three of them kept the process under control after reaching competence. One trainee reached competence but did not maintain it in the cumulative analysis. One trainee did not reach competence. Our study suggests that 30-40 cases would be needed to be trained for assessing myometrial infiltration by TVS by visual interpretation of videoclips by most trainees.

Attaining competency and proficiency in minimally invasive mitral valve repair: a learning curve assessment using cumulative sum analysis

ObjectiveTo evaluate the learning curve of minimally invasive mitral valvuloplasty (MVP).BackgroundMinimally invasive MVP is characterized by minimal trauma, minimal bleeding, and short postoperative recovery time. The learning curve of any new procedure needs to be evaluated for learning and replication. However, minimally invasive mitral valve technique is a wide-ranging concept, no further analysis of the outcomes and learning curve of minimally invasive Mitral valvuloplasty has been performed.MethodsOne hundred and fifty consecutive patients who underwent minimally invasive MVP alone without concurrent surgery were evaluated. Using cardiopulmonary bypass (CPB) time and aortic clamping (AC) time as evaluation variables, we visualized the learning curve for minimally invasive MVP using cumulative sum analysis. We also analyzed important postoperative variables such as postoperative drainage, duration of mechanical ventilation, ICU stay and postoperative hospital stay.ResultsThe slope of the fitted curve was negative after 75 procedures, and the learning curve could be crossed after the completion of the 75th procedure when AC and CPB time were used as evaluation variables. And as the number of surgical cases increased, CPB, AC, postoperative drainage, duration of mechanical ventilation, ICU stay and postoperative hospital stay all showed different degrees of decrease. The incidence of postoperative adverse events is similar to conventional Mitral valvuloplasty.ConclusionCompared to conventional MVP, minimally invasive MVP provides the same satisfactory surgical results and stabilization can be achieved gradually after completion of the 75th procedure.

Functional Laparoscopic Roux-en-Y Gastric Bypass with Fundectomy and Gastric Remnant Exploration (LRYGBfse): Learning Curve Assessment Using the Cumulative Sum Analysis Methodology (CUSUM)

Functional Laparoscopic Roux-en-Y Gastric Bypass with Fundectomy and Gastric Remnant Exploration (LRYGBfse): Learning Curve Assessment Using the Cumulative Sum Analysis Methodology (CUSUM)

Robotic major and minor hepatectomy: critical appraisal of learning curve and its impact on outcomes.

Robotic hepatectomy has gained increasing acceptance across the US. Although the robotic approach offers significant technical advantages, it is still bound by the individual surgeon's learning curve. Proficiency in this approach should theoretically lead to improved peri-operative outcomes. Between 2017 and 2020, data on 148 consecutive robotic hepatectomies performed by a single surgeon was retrospectively analyzed. Using cumulative sum (CUSUM) method, intraoperative blood loss (EBL) and operative time were used to assess learning curves for robotic major (n = 58) and minor (n = 90) hepatectomy patients. Perioperative outcomes were compared in regards with proficiency. Proficiency for robotic major and minor hepatectomy was achieved after 22 cases and 34 cases, respectively. No significant differences were observed in patient demographics or tumor characteristics. For robotic major hepatectomy, when compared to early experience, proficiency was associated with a significant improvement in mean EBL (242mL vs 118mL, p = 0.0004), operative time (330min vs 247min, p = 0.0002), decreased overall complication rate (23% vs 3%, p = 0.039), and length of hospital stay (5.7days vs 4.1days, p = 0.004). No difference in conversion rate, mortality or 30day readmission was seen. For robotic minor hepatectomy, proficiency was associated with significantly decreased mean EBL (115mL vs 54mL, p = 0.005), operative time (168 vs 125min, p = 0.014), and length of hospital stay (2.8days vs 2.1days, p = 0.021). No difference was observed in conversion rate, overall complications, mortality or 30day readmission. In the modern era, robotic hepatectomy offers a safe approach with excellent perioperative outcomes. Post learning curve proficiency is associated with significant improvements in perioperative outcomes in both major and minor hepatectomy. Results from our study can serve as a guide to surgeons and programs looking to adopt this technique.

Video grading of the pancreatic anastomosis during robotic pancreatoduodenectomy to assess learning curve and risk of pancreatic fistula

Video grading of the pancreatic anastomosis during robotic pancreatoduodenectomy to assess learning curve and risk of pancreatic fistula

Surgeon-conducted color Doppler ultrasound deep inferior epigastric artery perforator mapping: A cohort study and learning curve assessment

Perforator mapping using diagnostic methods facilitates deep inferior epigastric perforator (DIEP) flap planning. Computed tomographic angiography (CTA) is a well-proven tool for perforator mapping. However, the benefits of color Doppler ultrasonography (CDU) are as follows: 1) CDU involves dynamic real-time examination and 2) does not use radiation. Comparing the accuracies of both methods in a cohort of patients, this study aimed to evaluate the learning curve of surgeon-conducted CDU perforator mapping. Twenty patients undergoing DIEP flap breast reconstruction were enrolled in a cohort study. All patients underwent CTA perforator mapping preoperatively. XY coordinates of significant perforators were subtracted by a radiologist. A single surgeon (sonographer) with minimal experience with CDU performed CDU perforator mapping, including XY coordinates subtraction. The sonographer was blinded to the CTA data. The reference coordinates of dissected perforators were measured during surgery. Deviations from reference coordinates for both methods were compared, and CDU mapping learning curve was assessed using Joinpoint Regression. We included 20 women (32 DIEP flaps and 59 dissected perforators). The mean deviation between mapped and reference coordinates was 1.00 (0.50-1.12) cm for CDU and 0.71 (0.50-1.12) cm for CTA. The learning curve of CDU mapping showed the breaking point after the seventh patient (≈ 21 localized perforators). After the breaking point, no significant differences between the deviations of both methods were found (p=0.980). A limited number of examinations were needed for the surgeon to learn CDU DIEA perforator mapping with accuracy similar to that of CTA mapping.

Assessment of learning curves on a simulated neurosurgical task using metrics selected by artificial intelligence.

Understanding the variation of learning curves of experts and trainees for a given surgical procedure is important in implementing formative learning paradigms to accelerate mastery. The study objectives were to use artificial intelligence (AI)-derived metrics to determine the learning curves of participants in 4 groups with different expertise levels who performed a series of identical virtual reality (VR) subpial resection tasks and to identify learning curve differences among the 4 groups. A total of 50 individuals participated, 14 neurosurgeons, 4 neurosurgical fellows and 10 senior residents (seniors), 10 junior residents (juniors), and 12 medical students. All participants performed 5 repetitions of a subpial tumor resection on the NeuroVR (CAE Healthcare) platform, and 6 a priori-derived metrics selected using the K-nearest neighbors machine learning algorithm were used to assess participant learning curves. Group learning curves were plotted over the 5 trials for each metric. A mixed, repeated-measures ANOVA was performed between the first and fifth trial. For significant interactions (p < 0.05), post hoc Tukey's HSD analysis was conducted to determine the location of the significance. Overall, 5 of the 6 metrics assessed had a significant interaction (p < 0.05). The 4 groups, neurosurgeons, seniors, juniors, and medical students, showed an improvement between the first and fifth trial on at least one of the 6 metrics evaluated. Learning curves generated using AI-derived metrics provided novel insights into technical skill acquisition, based on expertise level, during repeated VR-simulated subpial tumor resections, which will allow educators to develop more focused formative educational paradigms for neurosurgical trainees.

281. COMPETENCY ASSESSMENT TOOL FOR MINIMALLY INVASIVE ESOPHAGECTOMY: DEVELOPMENT, CONSTRUCT VALIDITY, RELIABILITY AND VERSION 2

Abstract Minimally invasive esophagectomy (MIE) is a complex and technically demanding procedure and implementation is associated with substantial learning curves. In other complex minimally invasive procedures suboptimal surgical performance, assessed by video-based peer reviewing, has convincingly been related to less favorable patient outcomes. A validated procedure-specific competency assessment tool (CAT) for MIE could provide structured feedback to evaluate surgical performance and be used for training, safe implementation, learning curve assessment, research and to improve patient outcome. Based on key steps from a Delphi study and validated CATs, the MIE-CAT was composed. Final content was approved by eighteen independent international MIE experts (&amp;gt; 120 MIEs performed). These experts assessed 32 MIE videos from the same surgical team (2010–2020) with the MIE-CAT. For construct validity, videos were divided into groups based on the surgical team’s experience (novice, intermediate, advanced and expert). For reliability assessment, inter- and intra-rater reliability was determined. Based on discrepancies in MIE-CAT’s scores and a focus group, the MIE-CAT 2.0 was composed. MIE-CAT 2.0’s reliability was analyzed based on four experts assessing five videos each. The MIE-CAT contains eight procedural phases. Per phase four quality components are scored on a 1–4 Likert scale, with a total score between [32–128]. Eighty-four assessments were used for analysis. Median MIE-CAT scores were 80 [IQR 75–94], 91 [85–107], 101 [91–106] and 101 [96–106] for respectively novice, intermediate, advanced and expert group. Intra-rater reliability of 0.75 (ICC, 95% CI 0.64–0.83) and inter-rater reliability of 0.52 (ICC, 95% CI 0.38–0.65) was observed. Expert opinions from a utility questionnaire highlighted a useful and practical feedback tool. Results from the MIE-CAT 2.0 are expected in May 2022. The MIE-CAT was developed and validated in this study. Results indicate good reliability within observers and moderate reliability between observers. The MIE-CAT can be used for clinical, training and research purposes. Future work will focus on optimizing the MIE-CAT to increase inter-rater reliability and clinical validation by correlating MIE-CAT scores to patient outcomes.

Introduction of ROSA robotic-arm system for total knee arthroplasty is associated with a minimal learning curve for operative time

PurposeThe introduction of robotics for total knee arthroplasty (TKA) into the operating theatre is often associated with a learning curve and is potentially associated with additional complications. The purpose of this study was to determine the learning curve of robotic-assisted (RA) TKA within a multi-surgeon team.MethodsThis prospective cohort study included 83 consecutive conventional jig-based TKAs compared with 53 RA TKAs using the Robotic Surgical Assistant (ROSA) system (Zimmer Biomet, Warsaw, Indiana, USA) for knee osteoarthritis performed by three high-volume (> 100 TKA per year) orthopaedic surgeons. Baseline characteristics including age, BMI, sex and pre-operative Kellgren-Lawrence graded and Hip-Knee-Ankle Axis were well-matched between the conventional and RA TKA groups. Cumulative summation (CUSUM) analysis was used to assess learning curves for operative times for each surgeon. Peri-operative and delayed complications (infection, periprosthetic fracture, thromboembolism, and compromised wound healing) and revisions were reviewed.ResultsThe CUSUM analysis for operative time demonstrated an inflexion point after 5, 6 and 15 cases for each of the three surgeons, or 8.7 cases on average. There were no significant differences (p = 0.53) in operative times between the RA TKA learning (before inflexion point) and proficiency (after inflexion point) phases. Similarly, the operative times of the RA TKA group did not differ significantly (p = 0.92) from the conventional TKA group. There was no discernible learning curve for the accuracy of component planning using the RA TKA system. The average length of post-operative follow-up was 21.3 ± 9.0 months. There was one revision for instability in the conventional TKA group and none in the RA TKA group. There were no significant difference (p > 0.99) in post-operative complication rates between the conventional TKA and RA TKA groups.ConclusionsThe introduction of the RA TKA system was associated with a learning curve for operative time of 8.7 cases. Operative times between the RA TKA and conventional TKA group were similar. The short learning curve implies this RA TKA system can be adopted relatively quickly into a surgical team with minimal risks to patients.

Learning curve for magnetic resonance imaging/ultrasound fusion prostate biopsy in detecting prostate cancer using cumulative sum analysis.

Targeted magnetic resonance (MR) with ultrasound (US) fusion-guided biopsy has been shown to improve detection of prostate cancer. The implementation of this approach requires integration of skills from radiologists and urologists. Objective methods for assessment of learning curves, such as cumulative sum (CUSUM) analysis, may be helpful in identifying the presence and duration of a learning curve. The aim of this study is to determine the learning curve for MR/US fusion-guided biopsy in detecting clinically significant prostate cancer using CUSUM analysis. Retrospective analysis was performed in this institutional review board-approved study. Two urologists implemented an MR/US fusion-guided prostate biopsy program between March 2015 and September 2017. The primary outcome measure was cancer detection rate (CDR) stratified by Prostate Imaging Reporting and Data System (PI-RADS) scores assigned on the MR imaging. Cumulative sum analysis quantified actual cancer detection versus a predetermined target satisfactory CDR of MR/US fusion biopsies in a sequential case-by-case basis. For this analysis, satisfactory performance was defined as >80% CDR in patients with PI-RADS 5, >50% in PI-RADS 4, and <20% in PI-RADS 1-3. Complete data were available for MR/US fusion-guided biopsies performed on 107 patients. The CUSUM learning curve analysis demonstrated intermittent underperformance until approximately 50 cases. After this inflection point, there was consistently good performance, evidence that no further learning curve was being encountered. At a new center implementing MR/US fusion-guided prostate biopsy, the learning curve was approximately 50 cases before a consistently high performance for prostate cancer detection.