Surgeon's Learning Curve Research Articles

Learning Curve of Autologous Arteriovenous Fistula Formation for Junior Vascular Surgeons.

Autologous arteriovenous fistulas (AVFs) are considered the gold standard for hemodialysis access, with outcomes largely dependent on the surgeon's experience. Nevertheless, few studies have been conducted on the learning curve of junior vascular surgeons in AVF creation. This study aims to address this by examining the development of surgical skills among junior vascular surgeons. A retrospective analysis was conducted on 100 patients who underwent autologous AVF procedures performed by five junior surgeons between January 2018 and December 2023. To establish the cutoff number of cases for the learning curve, we examined the cubic spline curve using the hazard ratio for primary failure. The cutoff number for operation cases was 15.33, and we divided the analysis into a pre-learning curve period (≤15 cases of AVF) and a post-learning curve period (>15 cases of AVF). The 1-year primary patency rate for AVF during the post-learning curve period was 84.0%, which was higher than the 65.5% rate observed during the pre-learning curve period. In a subgroup analysis based on AVF type, the radiocephalic fistula patient group demonstrated a significant increase in 1-year primary patency in the post-learning curve period compared to that in the pre-learning curve period (80.0% vs. 43.0%, log-rank P=0.033). In contrast, there was no significant difference in the primary patency rates between the post- and pre-learning curve periods in the brachiocephalic fistula patient group (90.0% vs. 89.2%, log-rank P=0.930). Junior vascular surgeons demonstrated improved primary AVF patency beyond the learning curve benchmark in 15 patients, with particularly notable enhancements in radiocephalic fistulas.

Intra‐ and Postoperative Complications in 4565 vNOTES Hysterectomies: International Registry Cohort Study

ABSTRACTObjectiveTo present the rates of intra‐ and postoperative complications and conversions in a large cohort of unselected vNOTES hysterectomies, performed by surgeons with different levels of expertise.DesignInternational register‐based cohort study.SettingHysterectomies in the iNOTESs registry, 2015 to January 2024, performed by 201 surgeons from multiple countries.Population4565 patients undergoing vNOTES hysterectomy.MethodsDescriptive data are presented in frequencies (n) and percent (%).Main Outcome MeasureIntra‐ and postoperative complications. Conversions.ResultsIntraoperative and postoperative complication rates were 3.2% (n = 144) and 2.5% (n = 115), respectively. Conversions occurred in 1.6% (n = 72), of which 10 (0.2%) to laparotomy, and 82% of the conversions occurred within the first 50 cases of the surgeon's learning curve. The most common intraoperative complication was cystotomy, occurring in 1.3%, and almost half were performed by inexperienced surgeons. Other intraoperative organ injuries occurred in 20 cases (0.44%). Postoperatively, the most common complications were haemorrhage (n = 28), vault complications (n = 26) including 11 infected vault hematomas, cystitis (n = 18) and non‐specific infections (n = 14). The vNOTES hysterectomies were performed by 201 surgeons, of which 9.5% had performed more than 50 vNOTES cases, representing 70% of the registered cases in the registry. The remaining 30% of the hysterectomies mainly represent learning curve data from 90% of the included surgeons. The complication rate decreased with increasing surgical experience.ConclusionsThe largest study population of vNOTES hysterectomies is presented, including both learning curve data and data from experienced surgeons, with acceptable rates of intra‐ and postoperative complications. No implication was found of vNOTES being inferior to other minimally invasive methods.

Learning curve of consolers and bedside surgeons fused robotic-assisted thoracoscopic segmentectomy: insights from the initial 100 cases.

This study examined the learning curve of segmentectomy using the "fused surgery" approach. We retrospectively collected data from 100 patients who underwent segmentectomy via fused robot-assisted thoracoscopy at our institution between September 2020 and February 2024. The learning curve was evaluated using the cumulative sum of the operative times in all cases and was analyzed separately for simple and complex segmentectomies. After applying the cumulative sum method to all cases, we obtained a graph of the operative time that showed three well-differentiated phases: phase 1 (n = 23), the initial learning phase; phase 2 (n = 28), the increased competence phase; and phase 3 (n = 49), the highest skill phase. Comparing phases 1 and 2 with phase 3, we found significant differences in operative time (P < 0.001); however, no significant differences were observed in bleeding or rate of postoperative complications. We observed a significant reduction in operative time after 25 simple segmentectomies and 22 complex segmentectomies. The data suggested that the inflection point of the learning curve was achieved in 51 cases. Complex segmentectomy requires the same cases to achieve the same level of competence as simple segmentectomy.

Penile inversion vulvo-vaginoplasty with scrotal graft for trans women: surgical technique and results of initial experience.

A significant proportion of trans women is demanding for a genital gender-affirming surgery, with vulvo-vaginoplasty being the most frequently requested procedure. The gold standard for primary vaginoplasty in trans women is the penile skin inversion technique with scrotal skin graft, which allows for increased depth of the vaginal cavity. The assessment of vulvo-vaginoplasty outcomes utilizing penile skin inversion and scrotal skin graft in individuals assigned male at birth in the surgeon's learning curve involves evaluating aesthetics, functionality, and sexual aspects. A total of 76 individuals assigned male at birth were included in 2 French university hospitals from 2020 to 2022. They underwent vulvo-vaginoplasty following 8 key steps: scrotal skin excision; bilateral orchiectomy; dissection between the rectum, bladder, and prostate; penile dissection; clitoroplasty; urethroplasty; penile skin inversion with scrotal skin graft; labioplasty. The average follow-up period was 12.4months, with participants averaging 35.7years of age. Each patient was invited to complete a questionnaire during follow-up. The study's outcomes encompassed the assessment of both early and late surgical complications, postoperative sexuality, aesthetic results, and voiding satisfaction. Of the total patients, 15.8% experienced major early postoperative complications, while 3% encountered major late postoperative complications. No complication was classified 4 or 5 in Clavien-Dindo scale. Most early complications were related to issues in vulvar healing, which did not compromise long-term aesthetic results. Patients-reported satisfaction was 82% after the procedure. Vulvo-vaginoplasty utilizing penile skin inversion and scrotal skin graft for individuals assigned male at birth is a reproductive surgery procedure that can be successfully performed by experienced urologist. It achieves high patient-reported satisfaction even during the learning curve. The surgical procedures were consistent, and the sizable cohort of patients accurately reflects the learning curve of both surgeons. However, extrapolating long-term complications is challenging due to the relatively brief follow-up period. Additionally, there is a lack of self-reported sexual function data, and the scales used to assess patient-reported quality of life and urinary satisfaction are not specifically validated for transgender patients. Vulvo-vaginoplasty utilizing penile skin inversion and scrotal skin graft for individuals assigned male at birth is a complex surgical procedure. It appears to be achievable by experienced urologists during their learning curve, resulting in similar functional and surgical outcomes, along with high patient satisfaction.

A novel low-cost high-fidelity porcine model of liver metastases for simulation training in robotic parenchyma-preserving liver resection.

In the era of minimally invasive surgery (MIS), parenchyma-preserving liver resections are gaining prominence with the potential to offer improved perioperative outcomes without compromising oncological safety. The surgeon learning curve remains challenging, and simulation plays a key role in surgical training. Existing simulation models can be limited by suboptimal fidelity and high cost. We describe a novel, reproducible, high-fidelity, low-cost liver metastases model using porcine livers from adult Landrace pigs, with porcine perinephric fat used to simulate subcapsular metastases. This model was then utilised in a training session for surgical trainees performing robotic parenchyma-preserving surgery (PPS) under the guidance of expert robotic surgeons, with feedback being recorded. Trainees rated the model highly on its fidelity to human liver simulation (median score 9), tissue handling (median score 8), and overall usefulness (median score 9). Tissue handling was felt to simulate in vivo liver resection closely, while suggestions for improvement included adding simulated blood flow. This is a novel, low-cost, high-fidelity simulation model of liver metastases with high acceptability to surgical trainees, which could be readily adopted by other training centres.

Adipose tissue harvesting for microfragmented adipose tissue injection: A pilot study to evaluate safety and learning curve for orthopedic surgeons

Objectives The objective of this study is to compare the complication rate between plastic and orthopedics surgeons on harvesting adipose tissue for osteoarthritic knee mFAT injections. Methods We evaluated patients with knee osteoarthritis who were submitted to a one-stage procedure that included the harvesting of abdominal adipose fat tissue, the processing of the adipose tissue using a single-use device Lipogems®, and the injection of the processed micro fragmented adipose tissue (mFAT) into the knee. One group of patients had the adipose tissue harvested by a plastic surgeon and the other group had the procedure performed by a recently trained orthopedic surgeon. We compared the adverse effects, minor and major complications related to the adipose tissue harvesting during the procedure and after 15 days. Results Both groups showed no major complications such as fat embolism, thromboembolic event, abdominal perforation, wound infection, dehiscence or cosmetic changes. Minor complications, such as abdominal discomfort during the harvesting showed no statistical difference. Adverse effects such as abdominal ecchymosis and abdominal discomfort after the procedure were prevalent in both groups and were solved within 15 days of the procedure Conclusion For small adipose tissue volume harvesting, our study supports that low complication rates can be achieved by an orthopedic surgeon with adequate training.

Learning curve of multiple surgeons for robot-assisted radical prostatectomy using the cumulative sum method: a retrospective single-institution study.

Prostate cancer (PC) is common among men and has become a significant societal issue. Localized PC has a good prognosis with appropriate treatment. Prostatectomy, particularly robot-assisted radical prostatectomy (RARP), has become a common treatment since the da Vinci prostatectomy was approved by the FDA in 2001. The current study aimed to assess the learning curve for RARP, focusing on anastomosis time, using the cumulative sum (CUSUM) method. Data were collected from Nagoya City University Hospital between May 2011 and December 2018 and included 469 surgeries performed by experienced surgeons. Our findings indicated that, on average, 11 patients were required to complete the initial phase and 24 patients were required to complete the consolidation phase of anastomosis. Additionally, for complete resection of pT2c cases, 16 cases were required for the initial phase and 27 cases were required for the consolidation phase. The CUSUM method proved useful for visualizing trends in surgical proficiency, although the study noted potential confounding biases and limitations in evaluating surgical proficiency based solely on surgical time or positive surgical margins.

Minimalist Approach for HoLEP with A Low-Power Holmium Source: A Retrospective Study.

To assess the efficacy and safety of very low-power Holmium Laser Enucleation of the Prostate (HoLEP) on a 30-W holmium laser source. With the approval of the local ethics committee, we retrospectively analysed 60 patients treated with HoLEP. There were 30 patients in the low-power (LP) group and 30 patients in the very low-power (VLP) group. For the LP group, we used a 60-W holmium laser machine. Throughout the en bloc process, we used laser settings of 2 J and 20 Hz. We used a 30-W low-power holmium source in the VLP group. We used laser settings of 2 J and 10 Hz. All patients were operated on by an experienced surgeon. We evaluated the surgical parameters and practicality of the low-power laser vs. the very low-power laser. All patients underwent successful HoLEP in the very low-power group; it was not necessary to increase the output of the laser in any case. Mean preoperatively estimated prostate volume was 88.1 mL (range, 30-300 mL). Mean enucleation time and enucleation efficiency were 67.9 min (range, 25-150 min) and 0.99 gm/min (range, 0.8-1.8 gm/min), respectively. No patient required blood transfusion postoperatively. No stress urinary incontinence (SUI) was observed in the 3rd month postoperative follow-up. The use of a low-power laser source is encouraging for the learning curve of new surgeons who will begin HoLEP surgery; it can facilitate the adoption of HoLEP in developing countries, where the initial capital investment may be a major obstacle.

Influence of surgeon learning on outcomes in new ophthalmic procedures: quantified nationwide evidence in endothelial corneal transplantation

AimsTo investigate the impact of surgeon learning on endothelial keratoplasty (EK) procedure outcomes.MethodsA prospective nationwide registry study of EK grafts in patients aged at least 21 years with Fuchs endothelial...

Force control for the robot-assisted laparoscopic ultrasound scanning system

Laparoscopic ultrasound scanning, an acritical diagnostic imaging method for liver diseases, necessitates precise contact force control that is typically dependent on skilled physicians. Given its high mobility and controllability, the robot is anticipated to supplant physicians in performing laparoscopic ultrasound scans. Consequently, this study introduces a laparoscopic ultrasound scanning system paired with a learning-based force controller. Compared with traditional methods, our approach offers precise control over the contact force between the ultrasound probe and human organ surfaces during scanning, reducing the learning curve for surgeons in laparoscopic liver ultrasound scanning. Acknowledging the complex nonlinear mechanical model involved when the laparoscopic ultrasound probe contacts human organs and tissues, we propose a learning-based method utilizing a long short-term memory network to estimate the contact force. This method allows for the precise estimation of contact force with human organ tissues by analyzing tendon force. The results indicate that the proposed LSTM neural network can accurately fit the mechanical model of the robotic catheter, with a root mean square error of 3.44 mN. Finally, we conducted a force control experiment for ultrasound scanning on a silicone liver model. The results indicate that the proposed method can achieve relatively stable force control for laparoscopic ultrasound scanning, with a maximum error of 2.41 mN during the transient phase of system control and a maximum absolute error of 1.8 mN in the steady state.

Validating the porcine model for microsurgical perforator training: Can surgeons trained on pig perforator dissection successfully perform human DIEP flap procedures? A pilot study

Autologous breast reconstruction, especially using the deep inferior epigastric artery perforator (DIEP) flap, is increasingly seen as a reliable, safe, and long-term alternative to implant-based reconstruction. Despite the recognized advantages of the DIEP flap for breast reconstruction, successful realization demands excellent anatomical knowledge, a thorough understanding of autologous breast reconstruction concepts and advanced microsurgical skills. Given that the porcine model is widely employed in microsurgical training, our study aims to assess this model using validated outcomes, with the objective of evaluating the enhancement in a surgeon's learning curve following training with this model. Forty DIEP flaps were harvested on 20 swines by a single surgeon in "Pius Branzeu Center" (Timisoara, RO) and "Drazan Institute" (University of veterinary of Brno, CZ) laboratories for microsurgical training in 6months (January 2015-June 2015). Then we analyzed data from 40 DIEP flaps harvested by the same surgeon on first 20 consecutive patients undergoing DIEP flap breast reconstruction. Perforator dissection time, surgeon-determined dissection difficulty score (DDS) and venous congestion rate were collected for each flap in porcine model and in patients, then compared and analyzed. The mean of DDS score analysis in first and second swines group dissection resulted as statistically significant (P-value 0.0001), while it was not statistically significant between those analyzed in the second group of swines dissected and patients (P-value 0.8037). Reduction in perforator dissection time between the two swines' groups and in venous congestion rates from the first swines groups to the second to the human group resulted statistically significant too (P-value respectively 0.0001 and 0.0079). The porcine model has been used for a long time together with other animal models for microsurgical training. Our study confirms and objective by validated scores that it is a valid and reliable model, comparable to the human one and which mimics the dissection of human perforating vessels.

Feasibility, clinical outcomes, and learning curves of robotic-assisted colorectal cancer surgery in a high-volume district general hospital: a cohort study

Introduction: Robotic-assisted surgery (RAS) is one of the most influential surgical advances with widespread clinical and health-economic benefits. West Hertfordshire Teaching Hospital NHS Trust was the first in the UK to simultaneously integrate two CMR Surgical Versius robots. This study aims to investigate clinical outcomes of RAS, explore surgeon learning curves and assess the feasibility of implementation within a district general hospital (DGH). Methods: A prospective cohort study of 100 consecutive patient data were collected between July 2022 and August 2023, including demographics, operative and clinical variables, and compared with laparoscopic surgery (LS) data from the National Bowel Cancer Audit. Surgeon learning curves were analysed using sequential surgical and console times. Results: In the RAS cohort, the median age was 70 (IQR 57–78 years) and 60% were male. Retrieval of a minimum of 12 lymph nodes significantly increased in RAS compared to LS (95% vs. 88%, P=0.05). The negative mesorectal margin rate was similar between RAS and LS (97% vs. 91%, P=0.10), as well as length of stay greater than 5 days (42% vs. 39%, P=0.27). For anterior resections performed by the highest volume surgeon (n=16), surgical time was reduced over 1 year by 35% (304.9–196.9 min), whilst console time increased by 111% (63.0–132.8 min). Conclusions: Key quality performance indicators were either unchanged or improved with RAS. There is potential for improved theatre utilisation and cost-savings with increased RAS. This study demonstrates the feasibility and easy integration of robotic platforms into DGHs, offering wider training opportunities for the next generation of surgeons.

Objective performance indicators versus GEARS: an opportunity for more accurate assessment of surgical skill.

Surgical skill evaluation that relies on subjective scoring of surgical videos can be time-consuming and inconsistent across raters. We demonstrate differentiated opportunities for objective evaluation to improve surgeon training and performance. Subjective evaluation was performed using the Global evaluative assessment of robotic skills (GEARS) from both expert and crowd raters; whereas, objective evaluation used objective performance indicators (OPIs) derived from da Vinci surgical systems. Classifiers were trained for each evaluation method to distinguish between surgical expertise levels. This study includes one clinical task from a case series of robotic-assisted sleeve gastrectomy procedures performed by a single surgeon, and two training tasks performed by novice and expert surgeons, i.e., surgeons with no experience in robotic-assisted surgery (RAS) and those with more than 500 RAS procedures. When comparing expert and novice skill levels, OPI-based classifier showed significantly higher accuracy than GEARS-based classifier on the more complex dissection task (OPI 0.93 ± 0.08 vs. GEARS 0.67 ± 0.18; 95% CI, 0.16-0.37; p = 0.02), but no significant difference was shown on the simpler suturing task. For the single-surgeon case series, both classifiers performed well when differentiating between early and late group cases with smaller group sizes and larger intervals between groups (OPI 0.9 ± 0.08; GEARS 0.87 ± 0.12; 95% CI, 0.02-0.04; p = 0.67). When increasing the group size to include more cases, thereby having smaller intervals between groups, OPIs demonstrated significantly higher accuracy (OPI 0.97 ± 0.06; GEARS 0.76 ± 0.07; 95% CI, 0.12-0.28; p = 0.004) in differentiating between the early/late cases. Objective methods for skill evaluation in RAS outperform subjective methods when (1) differentiating expertise in a technically challenging training task, and (2) identifying more granular differences along early versus late phases of a surgeon learning curve within a clinical task. Objective methods offer an opportunity for more accessible and scalable skill evaluation in RAS.

Robotic-assisted versus laparoscopic-assisted extended mesorectal excision: a comprehensive meta-analysis and systematic review of perioperative and long-term outcomes.

Concurrent neoadjuvant chemo-radiation (nCRT) with total mesorectal excision (TME) alone sometimes fails to cure lateral lymph node metastasis (LLNM). Therefore, additional lateral lymph node dissection (LLND) can help in the treatment of these patients. This is what we refer to as extended total mesorectal excision (eTME). Such operations (TME alone or eTME) can be performed using conventional laparoscopic techniques and robotic-assisted techniques as well. Our meta-analysis aims to compare the results of robot-assisted (R-eTME) versus laparoscopic-assisted extended mesorectal excision (L-eTME) in terms of short- and long-term outcomes. Databases searched using title and abstract included Medline (via PubMed), Web of Science, Scopus, and Embase, up to February 20, 2024. All studies that documented robotic versus laparoscopic procedures for extended total mesorectal excision (R-eTME versus L-eTME) and reported more than two relevant outcomes, were included in the study. Our meta-analysis demonstrates four significant outcomes (operative time, urinary complications, overall recurrence, and admission days) between the laparoscopic and robotic groups. The robotic approach shows advantages over the laparoscopic approach in these outcomes except for the operative time (minute), which was longer in the robotic group compared to the laparoscopic group. The laparoscopic group is associated with a higher overall recurrence than the robotic group with an Odds Ratio of 2(95% CI, 1-4, p = 0.05). This meta-analysis study showed that the R-eTME group had a lower recurrence rate compared to the L-eTME group. Additionally, hospital admission days increased significantly in the laparoscopic group. Other long-term outcomes did not differ significantly between the two groups. Short-term outcomes were similar, except for more urinary complications in the laparoscopic group. In conclusion, the study suggests that robotic surgery may offer advantages over laparoscopic surgery for eTME. Further research and analysis could provide further insight into the potential benefits of robotic surgery in this procedure, particularly when surgeon experience, center volume, and learning curve are taken into consideration.

Predictors of Postoperative Urinary Incontinence After Holmium Laser Enucleation of the Prostate (HoLEP) for Surgeons Early in Their Experience.

To evaluate factors impacting continence recovery following holmium laser enucleation of the prostate (HoLEP) for surgeons early in their HoLEP experience. Predefined factors were evaluated from a prospectively maintained database for their impact on the recovery of continence after HoLEP. Both surgeons had performed fewer than 150 HoLEPs as attending physicians. Inclusion criteria were subjects with at least 6 months of incontinence data or documented recovery of continence. One or fewer pads per day was defined as continence. Statistical analyses were performed using R and Prism and included Spearman correlations, linear modeling, and Mantel-Cox log-rank testing as appropriate. From December 2020 to May 2023, 152 subjects met inclusion criteria with a median age of 70 (range: 51-93). The median case number was 56 (1-146). Within the study period, 144/152 (94.7%) recovered continence at a median of 1.6 months postoperatively. Linear modeling demonstrated that younger age (p = 0.01) and shorter enucleation time (p = 0.001) predicted recovery. Enucleation time less than 100 min predicted earlier continence recovery based on Mantel-Cox testing (p = 0.0004). During the surgeons' HoLEP learning curve, age, and enucleation time were predictive of the recovery of continence. Enucleation time under 100 min predicted a faster rate of continence recovery. The relationship between enucleation time and continence recovery may be demonstrative of case difficulty or may be a result of pressure on the external urethral sphincter during enucleation. These findings further our understanding of HoLEP outcomes early in a surgeon's learning curve.

Intra-operative and post-operative complications of endometriosis excision using the SOSURE approach - A single- surgeon retrospective series of 1116 procedures over 8 years.

Endometriosis surgery outcomes have been widely studied, yet heterogeneity in terminology and techniques persist. This study focuses on the perioperative outcomes of a single surgeon using the same structured approach (SOSURE: Survey & Sigmoid mobilisation, Ovarian mobilisation, Suspension of uterus and ovaries, Ureterolysis, Rectovaginal and pararectal space development, Excision of all visible disease) and adheres to the recent standardised terminology proposed by international gynaecological and endometriosis societies. A quality improvement study was conducted retrospectively from January 2015 to January 2023. Data collection involved two databases: the National British Society for Gynaecological Endoscopy (BSGE) database and a more comprehensive locally kept database. The methodology also integrated four endometriosis staging systems. Intra-operative and post-operative complication rates. Between 2015 and 2023, 1047 women underwent 1116 endometriosis procedures in various UK hospitals with S.K. as primary surgeon. Exclusions totalled 20 due to missing records and specific surgical criteria. The rate of major post-operative complications (Clavien-Dindo grade 3a and 3b) was 1.5% and minor post-operative complications (Clavien-Dindo grade 1 and 2) were seen in 13.8%. No Clavien-Dindo grade 4 or 5 complications were noted. Our study has shown a low complication rate in endometriosis surgery, despite increasing complexity of surgical cases. This is likely attributed to the surgeon's learning curve, high surgical volume and adherence to a structured approach. Our study demonstrates the learning curve of a surgeon over the course of 8 years. This series involved more than 1000 patients and to our knowledge, is the first to report the complexity of the casemix using four different endometriosis staging systems.

411.3: A prospective comparative study assessing learning curve of trainee surgeons in total laparoscopic versus hand assisted laparoscopic donor nephrectomy.

411.3: A prospective comparative study assessing learning curve of trainee surgeons in total laparoscopic versus hand assisted laparoscopic donor nephrectomy.

Six-year analysis of 30-day post-operative leaks for primary sleeve gastrectomy: a MBSAQIP database study.

Sleeve gastrectomy is the most performed bariatric surgery. Post-operative gastric sleeve leaks, although rare, are dreaded complications. This study aims to perform an updated investigation of the factors associated with sleeve leaks. This retrospective cohort study analyzed 692,554 cases from the MBSAQIP database (2016-2021) with CPT code 43,775 for primary sleeve gastrectomy. We excluded emergency operations, conversions/revisions, endoscopic interventions, patient with prior foregut surgery, and open operations. Multivariate logistic regression analysis (STATA version 15) was performed to identify factors associated with sleeve gastrectomy leaks. Out of 692,554 patients, 600,910 (86.77%) patients underwent laparoscopic sleeve gastrectomy, and 91,644 (13.23%) patients underwent robotic sleeve gastrectomy. 1179 (0.17%) developed leaks within 30days; 177(0.19%) were in the robotic group and 1002 (0.17%) in the laparoscopic group with no significant difference in leak rates between two groups on multivariate analysis. Black patients had lower odds of having leaks as compared to white patients (Odds Ratio (OR): 0.68 (0.56-0.82); p < 0.01). Hispanic patients had lower odds of having leak as compared to non-Hispanics. Factors associated with higher leak odds (p < 0.05) included hypertension, GERD, smoking, immunosuppression, increased operating time, and albumin < 3.5g/dl. Higher odds of leaks were observed in years 2016-2019 vs 2020-2021 (OR: 1.44 (1.25-1.65), p < 0.01). Higher odds of leak in operations with general surgeons compared to bariatric surgeons was found (OR: 1.46 (1.04-2.02), p = 0.02); observed only on robotic group on subgroup analysis (OR: 2.2 (1.2-4.2), p = 0.02). Staple line reinforcement, oversewing, and performance of leak test showed no differences in leak rate. Bougie size and distance from pylorus were not associated with changes in leak rate. This study provides updated insights into the factors associated with sleeve leaks, reinforcing information gained from prior studies. A higher association of leak among general surgeons could represent a learning curve for new robotic general surgeons. The overall decreasing trend for gastric sleeve leak is encouraging and may be a sign of improved techniques.

Comparative Efficacy and Safety of Robot-Assisted vs. Freehand Screw Placement in Femoral Neck Fractures: An Updated Systematic Review and Meta-Analysis.

Background: Femoral neck fractures pose significant surgical challenges with high morbidity and mortality. Traditional freehand screw placement often yields variable outcomes. Recent robotic advancements offer a promising alternative with enhanced precision. Methods: This systematic review compares the efficacy and safety of robot-assisted versus freehand techniques. A comprehensive literature search across multiple databases up to July 2024 included studies comparing both techniques. Primary outcomes were the union rate and time, functional outcomes, operative time, intraoperative parameters, and complication rates. Meta-regression analyses identified treatment response determinants. Results: Twenty-four studies (1437 patients) were included. Robot-assisted screw placement significantly improved the union rate, reduced the union time, and showed superior functional outcomes. Additionally, it resulted in shorter operative times, less intraoperative blood loss, and fewer instances of fluoroscopy and guide pin insertion. The risk of femoral neck necrosis was notably lower with robotic assistance. Meta-regression highlighted the robot type, patient age, and sample size as significant factors. Conclusions: Despite the promise of robot-assisted screw placement, limitations exist. The evidence being mainly from China raises concerns about generalizability. The lack of long-term follow-up data hinders assessment of technique durability. Unreported surgeon expertise levels and learning curves affect result validity. High initial costs and steep learning curves of robotic systems also present barriers to widespread adoption.

P253. Effect of surgeon learning curve on minimally-invasive transforaminal lumbar interbody fusion (MI-TLIF): insights from a single center retrospective comparative study

P253. Effect of surgeon learning curve on minimally-invasive transforaminal lumbar interbody fusion (MI-TLIF): insights from a single center retrospective comparative study