Surgeon's Learning Curve Research Articles

Consensus and operating guidelines of Chinese experts on transanal endoscopic surgery (2023 edition)

Although transanal endoscopic surgery has been developed for more than 40 years, it remains relatively unknown to most domestic colleagues. In 2019, the Chinese Society of Transanal Total Mesorectal Excision (CSTa) and the Chinese Society of Colon and Rectal Surgeons (CSCRS) organized domestic experts to write and publish the "Chinese Expert Consensus on Transanal Endoscopic Surgery (2019 Edition)", which elaborated on the definition, surgical methods, indications, contraindications, basic principles, key issues and complications of transanal endoscopic surgery, and provided a certain theoretical foundation for the development of transanal endoscopic surgery in China. In the past four years, the scope of application of transanal endoscopic techniques has been expanded, and many prospective and retrospective clinical research have provided more evidence-based medical evidence. Therefore, the Chinese Society of Transanal Total Mesorectal Excision (CSTa) once again organized domestic experts to write the "Expert Consensus and Operation Guidelines for Transanal Endoscopic Surgery in China (2023 Edition)", updating the expert consensus opinions on the definition, indications, complications and learning curve of transanal endoscopic surgery and adding operation guidelines. The aim is to promote the standardized practices in transanal endoscopic surgery and facilitate a shorter learning curve for surgeons.

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

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

Vesicourethral Anastomosis in Transvesical Single-Port Robotic Radical Prostatectomy: A Technical Description and Perioperative Outcomes.

Objective: To describe the technical evolution and perioperative outcomes of vesicourethral anastomosis (VUA) in transvesical (TV) single-port robot-assisted radical prostatectomy (SP-RARP). Materials and Methods: A retrospective review was performed on 189 patients who underwent TV SP-RARP by a single surgeon using the purpose-built SP robotic platform. VUA was completed from within the bladder using two unidirectional V-loc sutures in a continuous, semicircular manner with greater emphasis posteriorly. The most recent 20 cases of TV SP-RARP were selected to evaluate the anastomosis technique and to compare the perioperative outcomes with the first 20 cases of TV SP-RARP performed at our institution. Demographic and clinical data were collected from the prospectively maintained database and statistical analysis was performed. Results: VUA was effectively completed in all cases using the aforementioned technique without any suture breaks, need for conversion, or evidence of intraoperative complication, including urine leak. Marked improvement in the learning curve was observed, which translated to significant reduction in the number of VUA sutures (median: 13 vs 15, p < 0.05) and faster anastomosis time (median: 19.1 vs 33.5 minutes, p < 0.05). The number of anastomotic sutures did not correlate with the prostatectomy specimen weight or volume, especially with both being significantly greater in the latest cases (median weight: 45.1 vs 37.6 g, p < 0.05; median volume: 40.9 vs 36.2 mL, p < 0.05). Postoperative outcomes were favorable with immediate continence achieved in 51.3% of our total cohort and with no patients demonstrating evidence of bladder neck contracture. Conclusion: We provided a detailed technical description of VUA in TV SP-RARP. The improved maneuverability of the SP robotic platform allowed for unique movements to facilitate suture placements from within the confined space of the bladder. The learning curve of a single surgeon was shown in our study, which resulted in notable reduction in the number of sutures, faster anastomosis time, and improved perioperative outcomes.

National learning curves among robotic thoracic surgeons in the United States: Quantifying the impact of procedural experience on efficiency and productivity gains

ObjectiveThis study aims to characterize the aggregate learning curves of US surgeons for robotic thoracic procedures and to quantify the impact on productivity. MethodsNational average console times relative to cumulative case number were extracted from the My Intuitive application (Version 1.7.0). Intuitive da Vinci robotic system data for 56,668 lung resections performed by 870 individual surgeons between 2021 and 2022 were reviewed. Console time and hourly productivity (work relative value units/hour) were analyzed using linear regression models. ResultsAverage console times improved for all robotic procedures with cumulative case experience (P = .003). Segmentectomy and thymectomy had the steepest initial learning curves with a 33% and 34% reduction of the average console time for proficient (51-100 cases) relative to novice surgeons (1-10 cases), respectively. The hourly productivity increase for proficient surgeons ranged from 11.4 work relative value units/hour (+26%) for lobectomy to 17.0 work relative value units/hour (+50%) for segmentectomy. At the expert level (101+ cases), average console times continued to decrease significantly for esophagectomy (−18%) and lobectomy (−23%), but only minimally for wedge resections (−1%) (P = .003). The work relative value units/hour increase at the expert level reached 50% for lobectomy and 40% for esophagectomy. Surgeon experience level, dual console use, system model, and robotic stapler use were factors independently associated with console time for robotic lobectomy. ConclusionsThe aggregate learning curve for robotic thoracic surgeons in the United States varies significantly by procedure type and demonstrate continued improvements in efficiency beyond 100 cases for lobectomy and esophagectomy. Improvements in efficiency with growing experiences translate to substantial productivity gains.

Biportal endoscopic surgery for lumbar spine herniated discs: a narrative review of its clinical application and outcomes.

Lumbar disk herniation (LDH) is a common condition affecting millions worldwide. The management of LDH has evolved over the years, with the development of newer surgical techniques that aim to provide better outcomes with minimal invasiveness. One promising emerging technique is biportal endoscopic spinal surgery (BESS), which utilizes specialized endoscopic equipment to treat LDH through two small incisions. This review aims to assess the effectiveness of BESS as a management option for LDH by analyzing the available literature on surgical outcomes and potential complications associated with the technique. Our review shows that BESS is associated with favorable postoperative results as judged by clinical scoring systems, such as visual analog scale, Oswestry disability index, and MacNab criteria. BESS has several advantages over traditional open surgery, including minimized blood loss, a shorter duration of hospitalization, and an expedited healing process. However, the technique has limitations, such as a steep learning curve and practical challenges for surgeons. Our review offers recommendations for the optimal use of BESS in clinical practice, and provides a foundation for future research and development in this field, aiming to improve patient outcomes and quality of life.

Retrospective Evaluation of a Single Surgeon's Learning Curve of Robot-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion via Ileal Conduit.

Robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) is increasingly being performed instead of open surgery. A criticism of this technique is the long learning curve, but limited data are available on this topic. At our center, the transition from open radical cystectomy (ORC) to iRARC began in May 2017. A retrospective analysis was conducted on the initial 53 cases of robot-assisted cystectomy with intracorporeal urinary diversion via ileal conduit, which were performed by one single surgeon. The patients were divided into four consecutive groups according to the surgeon's increasing experience, and perioperative parameters were analyzed as a surrogate for the learning curve. Over the course of the learning curve, a decline in median operation time from 415 to 361 min (p = 0.02), blood loss from 400 to 200 mL (p = 0.01), and minor complications from 71% to 15% (p = 0.02) was observed. No significant difference in overall and major complications, length of hospital stay, and total lymph node yield was shown. During the initial period of the learning curve, only the less complex cases were operated on using robotic surgery, while the more challenging ones were handled through open surgery. After experience with 28 cases, no more cystectomies were performed through open surgery. This led to an increase in operation time and length of hospital stay, as well as a higher incidence of both minor and overall complications among cases 28-40. After 40 cases, a significant decrease in these parameters was observed again. Our analysis demonstrated that operation time, blood loss, and minor complications decrease with increasing surgical experience in iRARC, while suggesting that technically challenging cases should be operated on after experience with 40 robotic cystectomies.

Unveiling the Economic Toll of Surgical Learning Curve in Elderly Hip Fractures.

Can the financial impact of implant choice during the learning curve of inexperienced surgeons in hip fracture surgery be quantified? Hip fractures in the elderly are a significant medical concern, often requiring surgical interventions performed by orthopedic surgery residents. As healthcare costs rise, exploring cost reduction opportunities within the healthcare system becomes crucial. In this prospective analysis, we examined the financial implications of implant choices encountered by residents during their learning curve in hip fracture surgery. Our study included 278 surgically treated pertrochanteric fractures using the same locking cephalomedullary nail. Data on patients, surgeons (including their experience and seniority), and all implants charged by the hospital were collected. This encompassed documentation of any nail-related equipment that was opened on the operating table and whether it was subsequently used by the end of the procedure. By calculating the number and cost of these implants, we assessed the financial burden associated with suboptimal choices made during the learning curve. Our findings revealed that in 16.18% of surgeries, instances of suboptimal implant utilization occurred, highlighting the complexities of the learning process. Importantly, the rate of these challenges was not influenced by surgeon seniority or patient characteristics. The mean additional cost per surgery was determined to be USD 65.69 ± 157.63 for surgeries with suboptimal implant utilization, compared to USD 56.55 ± 139.13 for surgeries without such challenges. Although there was a trend towards higher implant-related costs in resident-led surgeries, the difference did not reach statistical significance. These findings underscore the feasibility of enabling residents to autonomously perform intramedullary nailing surgeries, even without specialist supervision, while incurring minimal additional expenses during the learning curve. By acknowledging the financial implications associated with the learning curve in the management of hip fractures, we can strive to optimize healthcare costs, thus addressing an important aspect of this issue.

Assessment of laparoscopic intracorporeal intestinal anastomosis training using simulation-based 3D printed models: exploring surgical performance and learning curves.

Intestinal anastomosis is a clinical procedure widely used to reconstruct the digestive tract, but authentic laparoscopic intracorporeal intestinal anastomosis（LIIA） models are lacking. However, three-dimensional (3D) printing can enable authentic and reusable models. In this paper, a novel cost-effective 3D-printing training model of LIIA is designed and the authenticity and validity of the model are tested. An FDM 3D printing and assembled lab model were built to test LIIA. Fifteen surgeons were required to perform LIIA, and their operation score and time were recorded and analyzed. Five experts were invited to assess the face and content validity of the models. A study was also performed to further evaluate and validate the learning curve of surgeons. The difference in Modified anastomosis objective structured assessment of technical skills (MAOSATS) scores between the expert, intermediate and novice groups were significant (64.1±1.8: 48.5±1.7: 29.5±3.1, P < 0.001). In addition, the operation time of the procedure was statistically different for all three groups (21.5±1.9: 30.6±2.8:70.7±4.0, P < 0.001). The five experts rated the face and content validity of the model very highly, with the median being four out of five. Surgeons who underwent repeated training program showed improved surgical performance. After eight training, the novices' performance was similar to that of the average level of untrained intermediates, while the operation scores of the intermediates were close to that of the average level of experts. In this study, it is found that the LIIA model exhibits excellent face, content and construct validity, repeated simulation training of the LIIA training program improved the surgeon's operative performance, so the model is considered one of the effective methods for LIIA training and assessment of surgical quality in the future and for reducing healthcare costs.

CUSUM learning curves: what they can and can't tell us.

There has been increased interest in assessing the surgeon learning curve for new skill acquisition. While there is no consensus around the best methodology, one of the most frequently used learning curve assessments in the surgical literature is the cumulative sum curve (CUSUM) of operative time. To demonstrate the limitations of this methodology, we assessed the CUSUM of console time across cohorts of surgeons with differing case acquisition rates while varying the total number of cases used to calculate the CUSUM. We compared the CUSUM curves of the average console times of surgeons who completed their first 20 robotic-assisted (RAS) cases in 13, 26, 39, and 52weeks, respectively, for their first 50 and 100 cases, respectively. This analysis was performed for prostatectomy (1094 surgeons), malignant hysterectomy (737 surgeons), and inguinal hernia (1486 surgeons). In all procedures, the CUSUM curve of the cohort of surgeons who completed their first 20 procedures in 13weeks demonstrated a lower slope than cohorts of surgeons with slower case acquisition rates. The case number at which the peak of the CUSUM curve occurs uniformly increases when the total number of cases used in generation of the CUSUM chart changes from 50 to 100 cases. The CUSUM analyses of these three procedures suggests that surgeons with fast initial case acquisition rates have less variability in their operative times over the course of their learning curve. The peak of the CUSUM curve, which is often used in surgical learning curve literature to denote "proficiency" is predictably influenced by the total number of procedures evaluated, suggesting that defining the peak as the point at which a surgeon has overcome the learning curve is subject to routine bias. The CUSUM peak, by itself, is an insufficient measure of "conquering the learning curve."

Four-Year Outcome of XEN 45 Gel Stent Implantation in a Swedish Population.

To report the long-time success rate of XEN 45 gel stent implantation in a Scandinavian population. This was a retrospective single-center analysis of all patients undergoing XEN 45 stent surgery between December 2015 and May 2017. The main outcome was success rate according to several definitions of success. Subgroup analysis was performed. Secondary outcomes were change in intraocular pressure (IOP) and number of IOP-lowering agents. Need for secondary glaucoma surgery, needling rate and complications were recorded. A total of 103 eyes could be evaluated after four years. Mean age was 70.6 years. Primary open-angle glaucoma (POAG) accounted for 46.6% and exfoliative glaucoma (PEXG) for 39.8%. Mean IOP dropped from 24.0 to 15.9 mmHg (p<0.001) and IOP-lowering agents from 3.5 to 1.5 (p<0.001). The success rate with individual target pressures after four years was 43.7%. Secondary glaucoma surgery was performed in 45 (43.7%) of cases. Combined cases (n=12) were not statistically different to stand-alone procedures (p=0.28). No difference between PEXG and POAG could be detected (p=0.44). During the learning curve, stent misplacement was common and resulted in worse outcome for less experienced surgeons. The overall success rate of XEN 45 gel stent surgery in the present cohort is relatively low in a long-time follow-up under the given circumstances if all initial patients are included to follow-up. The influence of the surgeon's learning curve is obvious, and improvement in success can be expected when used by experienced and high-volume surgeons. No significant differences were found in PEXG compared to POAG or in XEN surgery combined with cataract surgery compared to stand-alone.

Dry Wrist Arthroscopy: Technique and Rationale

Wrist arthroscopy has been established as a useful, minimally invasive tool for diagnosing and treating many different wrist conditions. The standard portals are located on the dorsum of the hand and wrist and are named for their relation to the extensor compartments. They include the radiocarpal and midcarpal portals. The radiocarpal portals are 3-4, 4-5, 6R, 6U, and 1-2. The midcarpal portals are STT (scaphotrapeziotrapezoidal), MCR (midcarpal radial), and MCU (midcarpal ulnar). Traditionally, wrist arthroscopy is performed with constant inflow of saline solution for joint insufflation and visualization. Dry wrist arthroscopy (DWA) is a technique that allows for arthroscopic exploration and instrumentation without infusing any fluid into the joints. Some advantages of DWA include lack of fluid extravasation, less obstruction by floating synovial villi, decreased risk of compartment syndrome, and the ability to perform concomitant open procedures more easily than with a wet technique. Additionally, the risk of fluid displacing carefully laid bone graft is much less without constant flow. DWA can be used in the assessment and management of triangular fibrocartilage complex (TFCC) and scapholunate interosseous ligament tears and other ligamentous injuries. DWA can also be used in fracture fixation to assist with reduction and restoration of articular surfaces. Moreover, it is used in more chronic settings to diagnose scaphoid nonunions. DWA does have its disadvantages such as generation of heat through the use of burrs and shavers and clogging of these instruments during debridement of tissue. DWA is a technique that can be used to manage multiple orthopaedic conditions including soft-tissue and osseous injuries. With a minimal learning curve for surgeons who already perform wrist arthroscopy, DWA can be a useful addition to their practice.

A novel training program: laparoscopic versus robotic-assisted low anterior resection for rectal cancer can be trained simultaneously.

Current expectations are that surgeons should be technically proficient in minimally invasive low anterior resection (LAR)-both laparoscopic and robotic-assisted surgery. However, methods to effectively train surgeons for both approaches are under-explored. We aimed to compare two different training programs for minimally invasive LAR, focusing on the learning curve and perioperative outcomes of two trainee surgeons. We reviewed 272 consecutive patients undergoing laparoscopic or robotic LAR by surgeons A and B, who were novices in conducting minimally invasive colorectal surgery. Surgeon A was trained by first operating on 80 cases by laparoscopy and then 56 cases by robotic-assisted surgery. Surgeon B was trained by simultaneously performing 80 cases by laparoscopy and 56 by robotic-assisted surgery. The cumulative sum (CUSUM) method was used to evaluate the learning curves of operative time and surgical failure. For laparoscopic surgery, the CUSUM plots showed a longer learning process for surgeon A than surgeon B (47 vs. 32 cases) for operative time, but a similar trend in surgical failure (23 vs. 19 cases). For robotic surgery, the plots of the two surgeons showed similar trends for both operative times (23 vs. 25 cases) and surgical failure (17 vs. 19 cases). Therefore, the learning curves of surgeons A and B were respectively divided into two phases at the 47th and 32nd cases for laparoscopic surgery and at the 23rd and 25th cases for robotic surgery. The clinicopathological outcomes of the two surgeons were similar in each phase of the learning curve for each surgery. For surgeons with rich experience in open colorectal resections, simultaneous training for laparoscopic and robotic-assisted LAR of rectal cancer is safe, effective, and associated with accelerated learning curves.

Safety and feasibility of three-dimensional McKeown minimally invasive esophagectomy.

To compare the perioperative outcomes from McKeown minimally invasive esophagectomy (MIE) when performed in three-dimensional versus two-dimensional visualization system, and investigate the learning curve of a single surgeon who implemented three-dimensional McKeown MIE. A total of 335 consecutive cases (three-dimensional or two-dimensional) were identified. Perioperative clinical parameters were compared and cumulative sum learning curve was plotted. Propensity score matching was used to reduce selection bias from confounding factors. Patients in three-dimensional group were associated with more chronic obstructive pulmonary disease (23.9% vs 3.0%, p < 0.01). After propensity score matching (108 matched patients in each groups), this finding was no longer statistically significant. Comparing to two-dimensional group, significant improvement in total retrieved lymph nodes (28 vs 33, p = 0.003) was observed in three-dimensional group. In addition, more lymph nodes around the right recurrent laryngeal nerve were harvested in three-dimensional group than that in two-dimensional group (p = 0.045). However, there were no significantly differences were found between the two groups in terms of other intraoperative parameters (e.g., operative time) and postoperative relevant outcomes (e.g., lung infection). Furthermore, the change point in the cumulative sum learning curves for intraoperative blood loss and thoracic procedure time was 33 procedures, respectively. Three-dimensional visualization system appears to be superior in performing lymphadenectomy during McKeown MIE to that of a two-dimensional technique. For surgeons proficient in performing two-dimensional McKeown MIE, the learning curve for a three-dimensional procedure appears to begin near proficiency after more than 33 cases.

Pediatric Mini-Invasive Splenectomy Comparing Laparoscopy With or Without Robotic Approach-A Single-Center Study.

Background: The introduction of splenectomy in pediatric robotic surgery programs remains controversial. The aim of this study is to evaluate the feasibility and safety of robotic assisted splenectomy (RAS) in children and compare its outcomes with the laparoscopic splenectomy (LAS). Method: A single institution retrospective study was performed (2011-2020). We used the minimally invasive splenectomy score described by Giza et al. to measure the level of technical difficulty. The data collected for each procedure included its duration, the need for blood transfusion, complications, analgesic use, and the length of hospital stay. A standard univariate analysis is applied. Results: We recorded 41 cases (26 LAS and 15 RAS). The mean age was 11 years [7.00; 13.5]. The operating time was 97 minutes [85.5-108] for LAS and 223 minutes [190-280] for RAS (P < .001). The length of stay was 6.50 days [5.00-8.00] for LAS and 5 days [5.00-5.50] for RAS (P = .055). The cumulative use of level III analgesic was not statically different (P = .29). Two cases of difficult splenectomy were found in each group with comparable performances. In the RAS, we demonstrated the improved outcomes with the progression of the learning curve of a single surgeon. Conclusions: In our experience (as in the literature), RAS remains safe, but offers no additional advantage compared to laparoscopy as the cost and the operating time are higher. Our study has the advantages of having a 9 years long evolving experience, including broad indications in comparison to other pediatric studies.

Flattening the Curve and Cutting Corners-Pearls and Pitfalls Facial Gender Affirming Surgery.

This is an experiential article based on the past 6years experience of providing facial gender confirmation surgery (fGAS) at an academic medical center. While trainees are getting increasing exposure to aspects of facial gender affirming surgery (fGAS), the gap between trained providers and patients who can access care is currently still widening. A handful of fellowships across the country have emerged that include fGAS in their curriculum, but it will take another decade before the principles of affirming care and surgeries are systematically taught. Fortunately, the surgical principles and techniques required to perform fGAS are part of the skill set of any specialty surgeon trained in adult craniofacial trauma and esthetic facial surgery/rhinoplasty. It is the aim of this article to provide directly applicable knowledge with the goal to assist surgeons who consider offering fGAS in flattening the learning curve and hopefully contribute to increasing the quality of care provided for the transgender and gender diverse population. We hope to provide the reader with a very tangible article with the aims to 1) provide a simple systematic framework for an affirming consultation and preoperative assessment and 2) provide translatable surgical pearls and pitfalls for forehead feminization and gonial angle resection. The frontal sinus set back and gonial angle resection in our opinion are the most unique aspect to fGAS as rhinoplasty, genioplasty and other associated procedures (e.g., fat grafting) follow well established principles. We hope that the value of this article lies in the translatability of the presented principle to any practice setting without the need for VSP, special surgical instruments or technology beyond basic craniofacial tools. This is an experiential article based on the senior authors 6year experience offering fGAS in an academic setting. The article is structured to outline both pearls and pittfalls and is supplemented by photographs and a surgical video. A total of 19 pearls and pitfalls are outlined in the article. Facial gender affirming surgery mostly follows established craniofacial and esthetic surgery principles. Forehead feminization and gonial angle feminization are the 2 components that diverge most from established surgical techniques and this article hopefully provides guidance to shorten the learning curve of surgeons.

Transforaminal endoscopic lumbar discectomy: learning curve of a single surgeon.

Transforaminal endoscopic lumbar discectomy (TELD) has well-recognized advantages and disadvantages in the literature. Some of the mentioned disadvantages are insufficient discectomy, higher recurrence rate and long learning curve (LC). The objective of this study is to describe the LC and analyze the survival rate of patients operated through TELD. Retrospective study of 41 cases operated through TELD by the same surgeon from June 2013 to January 2020, with a minimum follow-up of 6 months. Demographic data and information on operative time (OT), complications, hospital stay, hernia recurrence and reoperations were collected. LC of the TELD was analyzed using a cumulative sum (CUSUM) test for parameter stability for linear regression coefficients, using the CUSUM from recursive residuals. Thirty-nine patients, 24 men (61.54%) and 15 women (38.46%), were included in the present cohort, and a total of 41 TELD were performed. The average OT was 96 minutes (SD =30) and the CUSUM of the recursive residuals shows learning of the TELD in the case 20. The mean OT in the first 20 cases was 114 minutes (SD =30) versus 80 minutes (SD =17) in the last 21 cases (P=0.0001). The rates of recurrent Dh were 17%, and 12% need reoperation. We consider that the LC of TELD requires operating 20 cases to perform the procedure with a significant reduction in OT, with minimal rates of reoperation and complications.

A292 Learning curve of gastric cancer expert surgeon in bariatric surgery : Analysis of 85 consecutive laparoscopic sleeve gastrectomy cases

A292 Learning curve of gastric cancer expert surgeon in bariatric surgery : Analysis of 85 consecutive laparoscopic sleeve gastrectomy cases

"Double Grooves-Double Rings" technique of transurethral Thulium laser enucleation of the prostate: learning curve of single surgeon

Objective: To evaluate the learning curve of the "Double Grooves-Double Rings" (DGDR) technique of transurethral Thulium laser enucleation of the prostate (ThuLEP) for benign prostatic hyperplasia (BPH) by a single surgeon. From June 2021 to July 2022, 84 patients mean age (69.0±8.0) years,preoperative prostate volume (90.9±40.3)ml with BPH underwent ThuLEP in the Department of Urology, Peking University First Hospital.Performed by a single surgeon who had no experience of transurethral resection of prostate (TURP) and any laser surgeries. The case scatter plots with the best fitting line were drawn to analyze the learning curve. According to the date of the surgeries, the patients were equally divided into three learning stages (28 patients for each group). The T-PSA,prostate volume,operative time,enucleation time, enucleation efficiency,catheter indwelling time, hemoglobin drop and perioperative complications (including re-TURP, blood transfusion, stress incontinence≥3 months and urethral stricture) were compared among the groups. The learning curve was divided into three stages, and the cutting point was shown on the 14th case. Except the prostate volume [stage1 (75.7±30.7) ml, stage2 (93.40±39.6)ml, stage3 (103.5±46.2) ml, P<0.05], there was no significant difference of the baseline data between three groups (P>0.05). Compared with those of stage 1(100.6±24.7) min,(0.55±0.22) g/min, a statistically significant improvement was observed in both of the operative time and the enucleation efficiency among stage 2[(84.5±36.6) min, (0.87±0.33) g/min and stage 3 (71.2±26.3) min, (1.27±0.45) g/min, P<0.05]. The learning curve of the DGDR technique for ThuLEP can be divided into three stages. A ThuLEP beginner can preliminarily master this technique after completing 14 cases.

Evaluation of the safety, radiographic and resident training results of thoracic pedicle screws placement using resection of the transverse process

Objective This study aimed at the evaluation and assessment of a simple method, the transverse process resection (TPR) technique, for freehand thoracic pedicle screw placement and the learning curve for trainee surgeons. Methods In the TPR technique, the tip of the thoracic transverse process (TP) is removed to create an entry point in the cancellous bone of the TP, and the thoracic pedicle is cannulated from the TP. We retrospectively evaluated the safety and radiographic results of the TPR technique and compared with that of conventional pedicle screws. The training performance of seven neurosurgical residents with TPR techniques were evaluated. Results Among 46 patients, a total of 322 thoracic screws were analyzed, including 178 screws placed using the TPR technique and 144 screws using the conventional straight-forward (SF) technique. TPR screws had greater medial angulations in all levels from T2 to T12 compared to SF screws (p < 0.001). The incidence of pedicle breach was lower in the TPR screws compared to SF screws (6.2% vs. 21.5%, p < 0.001), especially for screws placed by residents (6.7% vs. 29.6%, p < 0.001). Residents had improved performance following a cadaveric training course on the TPR technique (p = 0.001). Conclusion This study demonstrated the safety of the TPR technique for thoracic pedicle screw placement and its short learning curve for trainee surgeons.

BiZact™ tonsillectomy: Predictive factors for post-tonsillectomy haemorrhage from a 1717 case series.

To determine primary and secondary post-tonsillectomy haemorrhage (PTH) rates and identify predictive factors in a cohort of consecutive adult and paediatric BiZact™ tonsillectomy cases. Retrospective cohort study. Patients from Flinders Medical Centre, Noarlunga Hospital and private otolaryngology practices who underwent BiZact™ tonsillectomy from 2017 to 2020. patient age, indication for tonsillectomy, surgeon experience, time and severity of PTH, including return to theatre. Each secondary PTH was graded using the Stammberger classification. Logistic regression was utilised to identify predictors of secondary PTH. One thousand seven hundred and seventeen patient medical records were assessed (658 adults and 1059 children). The primary PTH rate was 0.1%, and secondary PTH rate was 5.9%. The majority of secondary PTH cases were Stammberger grade A (80/102, 78.4%) requiring observation only. Few secondary PTH required medical intervention (grade B; 9/102, 8.8%), return to theatre (grade C; 12/102, 11.8%), or blood transfusion (grade D; 1/102, 1.0%), with no death reported (grade E; 0/102, 0.0%). Recurrent secondary PTH occurred in 8 patients (0.5%). Predictive factors of secondary PTH in children were surgeon experience with trainees having greater chance of PTH (OR 2.502, 95% CI 1.345-4.654; p = .004) and age of child (OR 1.095, 95% CI 1.025-1.170; p = .007). Surgeon experience was a predictive factor for adults (OR 3.804, 95% CI 2.139-6.674; p < .001). BiZact™ tonsillectomy has a low primary PTH rate, with a secondary PTH rate comparable to other 'hot tonsillectomy' techniques. The majority of PTH events were minor and self-reported. There appears to be a learning curve for trainee surgeons.