Learning Curve For Laparoscopic Surgery Research Articles

Learning Curve of Laparoscopic Surgery for Colorectal Cancer at a New Regional State Hospital: A Single-Surgeon Experience Of 106 Consecutive Cases Without Supervision.

Laparoscopic surgery for colorectal cancer is mostly performed in university hospitals or experienced centers. This study aimed at determining the learning curve of laparoscopic surgery for colorectal cancer at a new regional state hospital. Clinico-pathological data of 106 consecutive patients who underwent laparoscopic surgery for colorectal cancer at a new regional state hospital between August 2018 and September 2021 were prospectively recorded and analyzed. All surgeries were performed by a single inexperienced surgeon without supervision. The primary outcome of the study was the operative time, which was used for a Cumulative Sum (CUSUM) analysis of the learning curve. The secondary outcomes included a comparison of preoperative, intraoperative, and postoperative outcomes during the learning curve period. According to the CUSUM analysis, the learning curve consisted of three unique phases: phase 1 [the initial learning period (cases 1-53)], phase 2 [the consolidation period (cases 54-68)], and phase 3 [the experienced period (cases 69-106)]. Of the intraoperative outcomes, operative time and estimated blood loss were significantly reduced from phase 1 to phase 3 (p<0.001). Of the postoperative outcomes, time to pass stool (p<0.05), time to oral feeding (p=0.001), drain removal time (p<0.001), and length of hospital stay (p=0.042) were shorter in phase 3 compared to phases 1 and 2. Of the histopathological results, the specimen length and the number of harvested lymph nodes increased with experience (p=0.001). The present results suggest that a surgeon at a new regional state hospital must experience 53-68 cases to achieve competence in laparoscopic colorectal cancer surgery.

Comparative Study Of Clinical Outcome Of Laparoscopic Total Extraperitoneal Repair Vs Lichtenstein Repair In 50 Cases Of Inguinal Hernia

INTRODUCTIONAbdominal hernia includes groin hernia (70%), umbilical hernia (15%), epigastric hernia (7%) and incisional hernia (9%). After Bassini’s published paper on the techniques of tissue repair, numerous modifications like use of prosthetic material by Usher and open preperitoneal mesh repair introduced by Stoppa but these were associated with significant postoperative pain and morbidity. The concept of Tension free open mesh repair was first introduced by Lichtenstein. Totally extra peritoneal hernia repair (TEP) is a relatively new technique of repairing inguinal hernias laparoscopically where the dissection and repair are carried out without violating the peritoneal cavity laparoscopically. This study compares the results of laparoscopic hernioplasty by Total Extra-Peritoneal (TEP) technique and Lichtenstein tension free repair hernioplasty technique by open method and determine if the relative advantages achieved could be put in practice in large scale and also identify criteria which may help to choose the patient to a particular type of repair to obtain encouraging results for that particular patient.METHODS AND MATERIALS:The present study was carried out with 50 patients admitted in the department of general surgery at our hospital from period May 2018 to December 2019.Inclusion criteria: Patient aged 18 years and above giving written valid consent. Patients diagnosed as having unilateral incomplete inguinal hernia. Patients medically fit to undergo the procedure. Exclusion criteria:Single or multiple previous lower abdominal surgeries;Complicated inguinal hernia, i.e., irreducible, obstructed, or strangulated;Uncorrected coagulopathies;Patients unfit for general anaesthesiaRESULTIn our prospective Comparative study of laparoscopic and open inguinal hernioplasty, we studied 50 patients with unilateral direct inguinal hernia. Average operative time in open repair was 48 minutes and 70 minutes in laparoscopic repair. In TEP, complications such as difficulty in dissection was seen in 3 patients (12%), accidental opening of peritoneum in 2 patients (8%), and inadequate/inability to insufflate was seen in 1 patient (4%). On postoperative day 7, 8 patients (32%) have mild pain and 3 patients (12%) have moderate pain after open hernia repair. And rest 14(56%) patients experienced no pain. After laparoscopic hernia repair 16 patients (64%) have no pain and 7 patients (28%) have mild pain and 2 patients (8%) had moderate pain. Duration of hospital stay in open (3.5 days) is more compared to laparoscopic repair (2.5 days). Return to normal routine activities in open repair (15.3 days) is delayed than laparoscopic repair (12.92 days). CONCLUSION Here, we have done prospective comparative study of clinical outcome of laparoscopic TEP Vs Lichtenstein open inguinal repair in 50 cases of inguinal hernia. We have reached to following conclusion in our study. Incidence of wound infection and scrotal edema are more in open repair then TEP. TEP is less painful in the early postoperative period leading to earlier ambulation than open repair. TEP results in significantly earlier return to work and better cosmetic results. TEP results in decreased hospital stay and faster recovery than open repair. Average operative repair in TEP is more (70 mins) compared to open repair (48mins) Issue of steep learning curve for laparoscopic surgery should be addressed with better supervision and standardization of training in laparoscopy

Evaluation of a remote-controlled laparoscopic camera holder for basic laparoscopic skills acquisition: a randomized controlled trial

BackgroundUnsteady camera movement and poor visualization contribute to a difficult learning curve for laparoscopic surgery. Remote-controlled camera holders (RCHs) aim to mitigate these factors and may be used to overcome barriers to learning. Our aim was to evaluate performance benefits to laparoscopic skill acquisition in novices using a RCH.MethodsNovices were randomized into groups using a human camera assistant (HCA) or the FreeHand v1.0 RCH and trained in the (E-BLUS) curriculum. After completing training, a surgical workload questionnaire (SURG-TLX) was issued to participants.ResultsForty volunteers naïve in laparoscopic skill were randomized into control and intervention groups (n = 20) with intention-to-treat analysis. Each participant received up to 10 training sessions using the E-BLUS curriculum. Competency was reached in the peg transfer task in 5.5 and 7.6 sessions for the ACH and HCA groups, respectively (P = 0.015), and 3.6 and 6.8 sessions for the laparoscopic suturing task (P = 0.0004). No significance differences were achieved in the circle cutting (P = 0.18) or needle guidance tasks (P = 0.32). The RCH group experienced significantly lower workload (P = 0.014) due to lower levels of distraction (P = 0.047).ConclusionsRemote-controlled camera holders have demonstrated the potential to significantly benefit intra-operative performance and surgical experience where camera movement is minimal. Future high-quality studies are needed to evaluate RCHs in clinical practice.Trial registrationISRCTN 83733979

3D laparoscopic common bile duct exploration is safe and feasible

Introduction: 10-15% of patients with gallstones have common bile duct stones. Pre-operative endoscopic retrograde cholangiopancreaticography (ERCP), followed by laparoscopic cholecystectomy (LC) is the common treatment approach. However, recent studies showed that one stage laparoscopic common bile duct exploration (LCBDE) is also feasible though more technically demanding. Three-dimensional (3D) laparoscopy enhances depth perception, facilitates intra-corporeal suturing and is reported to reduce learning curve in laparoscopic surgery. There is no report of application of 3D technology to LCBDE. We report first case series of 3D LCBDE. Materials and Methods: We describe a case series of first 13 consecutive 3D LCBDE. Magnetic resonance cholangiopancreatography (MRCP) is liberally done for patients with deranged liver function test (LFT) and ERCP is reserved only for therapeutic intentions. CBD explorations are done through choledochotomy with 5mm choledochoscope and primarily repaired with absorbable suture without a stent. Clinical profile of patients, intraoperative details and outcomes were reported. Results: Mean age of patients was 70.6 (range 44 – 91) years. 7 patients (53.8%) were male. The indications for surgery were choledocholithasis 69.2% (n=9), cholangitis 15.4% (n=2) and gallstone pancreatitis 15.4% (n=2). More than half of the patients (53.1%, n=7) had pre-operative ERCP. 23% (n=3) had pre-operative biliary stent. The median American Society of Anaesthesiology (ASA) score was 2 (range 2-3) and the commonest comorbidity was hypertension (n=9, 69%). Pre-operative MRCP was done in majority of patients. (n=9,69%) and mean diameter of CBD was 14.6 mm (range 7-30). Median operative time was 125 (range 80 -265) minutes. 69% (n=9) had intra-operative drain inserted and this was removed at a median of 3 (range 3-4) days. There was no open conversion, bile leak and post-operative LFT were normal at one month. There was no mortality. Conclusion: 3D surgery provides binocular vision with depth perception which facilitates intra-corporeal suturing. 3D LCBDE is safe and feasible.

Learning curve for laparoscopic transabdominal preperitoneal repair: A single-surgeon experience of consecutive 105 procedures.

Based on previously published papers, the learning curve for laparoscopic groin hernia repair is controversial. The purpose of the present study was to evaluate the learning curve for laparoscopic surgery for groin hernia in a local hospital setting. We analyzed 100 consecutive cases of laparoscopic transabdominal preperitoneal repair performed by a single surgeon at a single facility from April 2013 to December 2015. The total operative time was divided into three parts: (a) preparing the peritoneal flap, (b) unfolding the mesh, and (c) suturing the peritoneum. A cumulative sum method for the total operative time and duration of the three parts was used to determine the learning curve. The learning curve was overcome after 75 cases based on cumulative sum analysis of the total operative time. The cumulative sum analysis of the times to unfold mesh and to suture the peritoneum indicated that the learning curve was overcome after 22 and 32 cases, respectively. The learning curve for preparing the peritoneal space was correlated with that for the entire procedure. No cases of recurrence were encountered. At least 75 cases were needed to overcome the learning curve for laparoscopic transabdominal preperitoneal repair.

Strategies and technical skills of teamwork in lymphadenectomy of laparoscopic radical gastrectomy for gastric cancer

The application of laparoscopic gastrectomy for gastric cancer has more than 20 years, more and more medical centers carry out this technique for gastric cancer. Due to the wide range of lymph node dissection for radical gastrectomy, it is required to perform lymphadenectomy in multiple layers and spaces, in addition, there is a learning curve for laparoscopic surgery, so a well-matched surgical team is particularly important, which enables the surgeons to get through the learning curve faster, increases the confidence of the operation, and also improves the quality of the operation. A high-quality laparoscopic radical gastrectomy requests an experienced and skilled surgeon, a functional assistant who can perform a good exposure and separation, as well as a mirror assistant who provides a high-quality view. Familiar with the anatomy and variation of the perivascular vessels, choosing the appropriate surgical approach, and using programmed surgical procedures and coordination make the surgeon achieve a better minimally invasive surgery, which also benefits to the patients. Key words: Gastric neoplasms; Gastric cancer; Radical resection; Lymphadenectomy; Laparoscopy

Learning curve and surgical outcomes for laparoscopic surgery, including pelvic lymphadenectomy, for early stage endometrial cancer.

The purpose of this study was to determine the learning curve of laparoscopic surgery for the treatment of early endometrial cancer and report the surgical outcomes. Patients: Data were retrospectively extracted from the medical charts of patients who underwent laparoscopic surgery. Laparoscopic surgery, including pelvic lymphadenectomy, was performed using the same technique and instruments for all patients. The learning curve for the surgical technique, characterized by the operative time, number of lymph nodes removed, and volume of intra-operative blood loss, was analyzed. Over the period of observation, 82 patients were enrolled. For analysis, cases were classified into four groups, based on their surgery date. Between-group comparisons identified a significant decrease in operative time and volume of blood loss between Groups 1 and 4 (P < 0.05). However, the number of lymph nodes removed, and the length of hospital stay were not influenced by learning. The operative time and the amount of blood loss significantly decreased with an increase in the surgeon's experience but with no effect of learning on the number of lymph nodes removed and length of hospital stay.

No-cable and smartphone/tablet: A functional laparoscopic training box "Fu-Lap T-Box".

Because of the long and variable learning curve of laparoscopic surgery, before its actual application, a well-designed practical simulating instruments like laparoscopic training boxes are needed. But because of unfavourable cost-effectiveness and huge sizes of these boxes, surgeons hardly procure, and carry them. We aimed to design a new, cheap, light and handy laparoscopic training box. Our training box is made of aluminium and used with smartphone or tablet. There is no need for a power unit. Our foldable box has dimensions of 52×38×4 cm, and weighs 2.8 kg and foldable. There are 5 working ports in it. Compared to its alternatives "Fu-Lap T-Box" is much cheaper, lighter and more comfortable. In our opinion it is possible to design and use a new cheaper and portable simulator to gain more hands-on experience before the real surgery.

3D laparoscopy versus 2D laparoscopy : An up to date evaluation

The 3D laparoscopy is currently under intensive discussion. At the moment the majority of newly acquired laparoscopy systems include the 3D technique. New 4K systems, which will be offered in combination with 3D, are complicating the decision-making when buying new laparoscopic systems. The aim of the article is to show the advantages and possible limitations of 3D laparoscopy. Furthermore, the position of 3D laparoscopy in the current video market is evaluated. This study was based on an up to date literature search in PubMed. Concerning the question whether the 3D is replacing the 2D laparoscopy, observations from the industry and apersonal evaluation were included in the analysis. The current studies show clear advantages of 3D laparoscopy concerning operation time, efficiency and workload. Amajor proportion of the studies were conducted on simulation trainers; however, some clinical trials also confirmed these results. The learning curve in laparoscopic surgery is clearly improved with the 3D technique and 3D also seems be useful for operations by experts. The limitation is that not every surgeon can see three dimensionally. Furthermore, the set-up in the operation room needs to be optimized so that a 3D system can be successfully implemented with the nursing staff and side effects, such as exhaustion, dizziness or headache can be prevented. The choice of video system will depend on the personal interest of the surgeon and the ability to see 3D. It can be assumed that the majority of the systems will include 3D laparoscopy but 2D laparoscopy will not be completely replaced. Adynamic development of 3D in association with 4K and robotics can be expected.

Secrets for successful antireflux surgery: learning curve

The field of surgery is a complex environment of constant innovation. With persistent advancement in technique and tools, there also comes the need for proper surgical education in order to maximize technical proficiency in a short period of time. In recent times, the concept of a learning curve has been the focus of surgical education. A learning curve is essentially a positive curvilinear relation of performance and experience; this curve is par-ticularly steep in antireflux laparoscopic surgery. There are, however, certain fundamental secrets that allow any individual to efficiently and successfully adapt to such an arduous learning curve. In order to identify these secrets, we conducted a thorough search on PubMed and systematically reviewed relevant literature on the learning curve of laparoscopic surgery, with a focus on antireflux surgery, from 1995 to 2016. The following key words were used in our search: “Learning Curve”, “Anti-Reflux Surgery” and “Surgery Education”. Based on our review of literature, the authors of this perspective manuscript propose three key fundamental secrets to successful adaption of the steep learning curve of laparoscopic surgery.

Reply: Factors Favorable to Reducing the Learning Curve of Laparoscopic Gastrectomy for Gastric Cancer.

To the Editor: We appreciate the interest and comments from Kong et al. o n our recent manuscript, Short-Term Outcomes of Laparoscopic Total Gastrectomy Performed by a Single Surgeon Experienced in Open Gastrectomy: Review of Initial Experience (doi: http://dx.doi.org/10.5230/jgc.2015.15.3.159).1 We agree with their opinions and would like to add some comments on the learning curve of laparoscopic total gastrectomy. The surgeon in the study1 was trained as a gastrointestinal surgery fellow and has worked in a high volume hospital, where over 1,000 gastrectomies for gastric cancer have been performed per year. Thus, this surgeon has been exposed to a large number of cases of laparoscopic gastrectomy for gastric cancer, within a short period of time, which may result in a more favorable learning curve and low morbidity and mortality.2 According to the United States (US) Graduate Medical Education General Surgery Report, a US general surgery residency graduate only experiences an average of five cases of gastrectomy for gastric cancer (including 0.9 cases of total gastrectomy); thus, it would be difficult to generalize the present results to the situation itnhe US.3 Standard surgery is important in the prognosis of patients with gastric cancer.4 Despite past arguments that laparoscopic surgery is not adequate for gastric cancer because it does not achieve appropriate lymph node dissection, brave and innovativ e surgeons have further developed and propagated laparoscopic techniques.5 Laparoscopic surgical techniques have evolved from laparoscopic-assisted to fully laparoscopic gastrectomy as well as from circular staplers to linear staplers for anastomosis.6,7 Although experienced surgeons have their own knowledge base when performing laparoscopic gastrectomy for gastric cancer, laparoscopic procedures have been standardized because of the efforts of the first generation of laparoscopic surgeons and surgical societies including the Korean Gastric Cancer Association. Thus, this technically mature laparoscopic procedure may allow easier learning curves for recently trained surgeons and the next generation. One advantage that could reduce the learning curve of laparoscopic gastrectomy for gastric cancer is that laparoscopic procedures are easy to record and share compared to open surgery. Surgeons can record video and review their own procedure after the operation, to aid self-examination of their surgical technique. Furthermore, young surgeons can learn from video recordings of operations performed by experts and can adapt techniques for their own use. The popularity of general laparoscopic surgical procedures is another factor that is favorable to reduce the learning curve of laparoscopic surgery for gastric cancer. Recently, relatively simple surgeries such as appendecotmy, herniorrhaphy, and cholecystectomy have been performed by laparoscopic procedures; thus, surgeons are more familiar with laparoscopic instruments compared to surgeons in the past. Taken together, the recent environment is favorable for allowing surgeons to improve and refine their surgical skills, which helps to reduce the learning curve for laparoscopic surgery for gastric cancer. Lastly, as Kong et al. commented, it is difficult to define the learning curve of laparoscopic total gastrectomy by a single parameter. The operative time, complication rate, and number of retrieved lymph nodes have been used as parameters to measure the learning curve of laparoscopic surgery for gastric cancer.8,9 However, these factors are not only influenced by the surgeon's ability, but also by the assistant surgeon's experience and ability, as well as patient factors. Thus, no single parameter can be used to measure the learning curve of this surgery. Additionally, increasing popularity and interest in proximal gastrectomy for gastric cancer make it difficult to determine the learning cuerv of laparoscopic total gastrectomy. Thus, a new statistical model that can consider and integrate these complicated factors is required to quantify the learning curve for surgical procedures.

The learning curve of laparoscopic holecystectomy in general surgery resident training: old age of the patient may be a risk factor?

A well-designed learning curve is essential for the acquisition of laparoscopic skills: but, are there risk factors that can derail the surgical method? From a review of the current literature on the learning curve in laparoscopic surgery, we identified learning curve components in video laparoscopic cholecystectomy; we suggest a learning curve model that can be applied to assess the progress of general surgical residents as they learn and master the stages of video laparoscopic cholecystectomy regardless of type of patient.Electronic databases were interrogated to better define the terms “surgeon”, “specialized surgeon”, and “specialist surgeon”; we surveyed the literature on surgical residency programs outside Italy to identify learning curve components, influential factors, the importance of tutoring, and the role of reference centers in residency education in surgery. From the definition of acceptable error, self-efficacy, and error classification, we devised a learning curve model that may be applied to training surgical residents in video laparoscopic cholecystectomy.Based on the criteria culled from the literature, the three surgeon categories (general, specialized, and specialist) are distinguished by years of experience, case volume, and error rate; the patients were distinguished for years and characteristics. The training model was constructed as a series of key learning steps in video laparoscopic cholecystectomy. Potential errors were identified and the difficulty of each step was graded using operation-specific characteristics. On completion of each procedure, error checklist scores on procedure-specific performance are tallied to track the learning curve and obtain performance indices of measurement that chart the trainee’s progress.Conclusions. The concept of the learning curve in general surgery is disputed. The use of learning steps may enable the resident surgical trainee to acquire video laparoscopic cholecystectomy skills proportional to the instructor’s ability, the trainee’s own skills, and the safety of the surgical environment. There were no patient characteristics that can derail the methods. With this training scheme, resident trainees may be provided the opportunity to develop their intrinsic capabilities without the loss of basic technical skills.

Intersphincteric resection for very low rectal cancer: clinical outcomes of open versus laparoscopic approach and multidimensional analysis of the learning curve for laparoscopic surgery

BackgroundLaparoscopic rectal cancer surgery is regarded as more complex because of its technical difficulties in pelvic exposure, dissection, and sphincter preservation. This study therefore aimed to investigate the feasibility of laparoscopic resection for low rectal cancer using intersphincteric resection (ISR) and to assess its short-term oncological outcomes. Further, we intended to analyze the learning curve for laparoscopic surgery and identify the factors influencing the learning curve. MethodsPatients with low rectal cancer who received open or laparoscopic ISR were retrospectively chart reviewed. The surgical and oncological outcomes were evaluated. Comparisons of operating time, estimated blood loss, surgical outcomes, and histopathologic status were analyzed. Also, operating time was used as a technical indicator for learning curve analysis. ResultsThe mean estimated blood loss was 265 mL (range, 100–800 mL) in the open group and 104 mL (range, 30–250 mL) in the laparoscopic group. There was a significant difference between these two groups (P < 0.001). Operative experience analysis showed that the mean operating time was 402.1 min (range, 210–570 min) in the first stage and 331.4 min (range, 210–450 min) in the second stage, and on pathologic examination the mean number of lymph nodes harvested was 11.1 (range, 5–21) in the first stage and 18.3 (range, 11–31) in the second stage, with statistical differences between these two stages (P = 0.034 and P = 0.004, respectively). Multifactorial analysis showed that operating time was associated with surgeons’ experience (<18 or ≥18 cases) (odds ratio = 2.918, 95% CI 1.078–7.902). Protective stoma creation was also associated with surgeons’ experience (odds ratio = 3.999, 95% CI 1.153–13.86). ConclusionsOur data show that laparoscopic ISR for low rectal cancer is feasible and safe. Surgeons’ experience improved operating time and postoperative complications.

Future perspectives in robotic surgery

• Robotics of the current day have advanced significantly from early computer-aided design/manufacturing systems to modern master-slave robotic systems that replicate the surgeon's exact movements onto robotic instruments in the patient. • Globally >300,000 robotic procedures were completed in 2010, including ≈98,000 robot-assisted radical prostatectomies. • Broadening applications of robotics for urological procedures are being investigated in both adult and paediatric urology. • The use of the current robotic system continues to be further refined. Increasing experience has optimized port placement reducing arm collisions to allow for more expedient surgery. Improved three-dimensional camera magnification provides improved intraoperative identification of structures. • Robotics has probably improved the learning curve of laparoscopic surgery while still maintaining its patient recovery advantages and outcomes. • The future of robotic surgery will take this current platform forward by improving haptic (touch) feedback, improving vision beyond even the magnified eye, improving robot accessibility with a reduction of entry ports and miniaturizing the slave robot. • Here, we focus on the possible advancements that may change the future landscape of robotic surgery.

How Do Young Residents Practice Laparoscopic Surgical Skills?

To investigate whether a training system using a dry box is feasible for training young urologists. Despite laparoscopic surgery being widely indicated for several urological diseases, a laparoscopic training system for young urologists has not been fully established yet. However, the learning curve for laparoscopic surgery has not yet been ascertained. We continued to test 11 sixth-year residents (postgraduate year: PGY6) and third-year residents (PGY3) in our department in terms of surgical skills using a dry box. We gave them several tasks (cutting and suturing) and let them practice until task completion. We continued to test all participants by these tasks for 16 weeks. At the beginning of the present study, the PGY6 residents achieved significantly better scores than the PGY3 residents. However, the difference between the 2 groups became insignificant over time. Furthermore, statistical analysis revealed that a practice time of 100 minutes per week was the only significant factor affecting the last test score. For the final test, the mean practice time for all participants was 79.1 minutes per week. These results suggest that laparoscopic surgical skills can definitely be polished by adequate voluntary practice.

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

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

Learning curve of laparoscopic surgery for gastric cancer, a laparoscopic distal gastrectomy-based analysis

The application of laparoscopic gastrectomy in management of gastric cancer is being propagated rapidly. Training and education play important role during this process. The purpose of this study is to define the learning curve of laparoscopic gastrectomy to obtain an insight into this training process. All 362 cases of laparoscopic gastrectomy from January 1998 to July 2007 were enrolled and divided into 12 groups of 30 cases each in time sequence. The learning curve was defined with the split group method. Laparoscopic distal gastrectomy was extracted from the 12 groups and the means of operation time and intraoperative blood loss were compared to define the learning curve. Then general data and variables including occurrence of systematic inflammatory response syndrome (SIRS), complications, and conversion to open surgery were compared among the phases of learning curve. A three-phase learning curve of laparoscopic gastrectomy was defined from the laparoscopic distal gastrectomy-based analysis, which included a training phase for the first 120 cases of operation, an intermediate phase for the following 90 cases, and a well-developed phase for the last 152 cases. Learning was considered to be complete after 60-90 operations in the training phase. For most variables, the differences among three phases were statistically significant except for the rate of complications. There was a significant learning curve, composed of three phases. Experience of about 60-90 cases of operation was required for completion of learning.

Learning curves for laparoscopic sigmoidectomy used to manage curable sigmoid colon cancer: single-institute, three-surgeon experience

Laparoscopic surgery demands mastery of a steep learning curve. Defining a learning curve in laparoscopic surgery is useful for planning training programs or clinical trials. This study aimed to define the learning curves for laparoscopic sigmoidectomy used to manage curable sigmoid colon cancer by evaluating early surgical outcome data from three colorectal surgeons. This study analyzed data from 138 consecutive patients undergoing laparoscopic sigmoidectomy for curable sigmoid colon cancer performed by three colorectal surgeons between May 2001 and November 2006. The learning curve for each surgeon were generated using the moving average method to assess changes in operation time and cumulative sum (CUSUM) analysis to assess changes in failure rates [(failure = conversion to open surgery, major perioperative complication, or failure to harvest an adequate number of lymph nodes (<12 nodes)]. Learning curves generated with the moving average method indicated that the operation time reached a steady state after 42 cases for surgeon A, 35 cases for surgeon B, and 30 cases for surgeon C. The overall open conversion rate was 2.9%. There was only one laparoscopy-related perioperative major complication (0.7%). An inadequate number of lymph nodes was harvested in 10 cases (7.2%): 6 (10.5%) for surgeon A, 1 (2.4%) for surgeon B, and 3 (7.7%) for surgeon C. Learning curves generated using CUSUM analysis based on a 90% success rate showed that adequate learning occurred after 10 cases for surgeon A, 17 cases for surgeon B, and 5 cases for surgeon C. Pertinent learning curves for laparoscopic sigmoidectomy used to manage curable sigmoid colon cancer can be generated using the moving average method and CUSUM analysis. These results are likely to be useful in designing laparoscopic training programs and clinical trials aimed at investigating outcomes of laparoscopic colorectal cancer surgery.

The Impact of the Learning Curve in Laparoscopic Surgery

TP Wright originally introduced the concept of a learningcurve in aircraft manufacturing in 1936.1 He described a basic theoryfor costing the repetitive production of airplane assemblies. The termwas introduced to medicine in the 1980s after the advent of minimalaccess surgery. It also caught the attention of the public and the legalprofession when a surgeon told a public enquiry in Britain that a highdeath rate was inevitable while surgeons were on a learning curve.2Recently it has been labeled as a dangerous curve3 with a morbidity,mortality and unproven outcomes. Yet there is no standardization ofwhat the term means. In an endeavor to help laparoscopic surgeonstowards evidence based practices this commentary will define anddescribe the learning curve, its drawing followed by a discussion of thefactors affecting it, statistical evaluation, effect on randomized controlledtrials and clinical implications for both practice and training, thelimitations and pitfalls, ethical dilemmas and some thoughts to pavethe way ahead.

Preliminary results of laparoscopic colorectal resections: Does surgeon's age influences outcomes?

Several randomized controlled trials demonstrated that laparoscopic colon resection is a safe and effective technique for colon and rectum diseases. In fact mini-invasive procedure required an adequate learning curve to safely perform it. Many studies confirm there is a comparatively long learning curve in laparoscopic surgery, with demonstrable decrease in conversion and complication rates with increasing experience. In this study we want to demonstrate feasibility of laparoscopic colon resection performed by a junior surgeon, referring to short-term outcomes as primary end point. A total of 163 patients underwent colorectal resections of whom 88 were enrolled in the laparoscopic (LCR) and 75 in the open group, respectively. The mean operative time was 183.4 min in the LCR group and 151.2 min in the open group. The mean number of lymph nodes collected was 21.3 in the LCR group and 22.1 in the open group. 10.5% who underwent LCR developed postoperative complications compared with 16% of open group; this difference was statistically significant. Postoperative death occurred in one patient for each group. Our study demonstrate that results obtained by an under 35-year-old surgeon, fully trained in laparoscopic surgery but with limited overall experience in colorectal resections, can be at least as good as the ones obtained in open surgery. This seems to be true both in term of intra-postoperative complications as well as for oncological results.