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Zeng B, Lin H, Deng W, Zhou R, Wu T, Liu B. Learning curve in mandibular reconstruction with vascularized iliac crest free flap: a cumulative sum analysis. Int J Oral Maxillofac Surg 2025; 54:322-328. [PMID: 39721907 DOI: 10.1016/j.ijom.2024.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 12/02/2024] [Accepted: 12/05/2024] [Indexed: 12/28/2024]
Abstract
The repair of mandibular defects is challenging due to the functional and structural complexity of the mandible. The aim of this study was to evaluate the learning curve of mandibular reconstruction using a vascularized iliac crest free flap (ICFF) performed by a single surgeon. This retrospective study used the cumulative sum (CUSUM) method to analyse the operation times of 60 patients who underwent mandibular reconstruction surgery with an ICFF between 2013 and 2022. The results showed that the learning curve could be divided into two phases according to the turning point: phase 1 comprised cases 1-17 and phase 2 comprised cases 18-60. The operation time and length of hospital stay were significantly longer in phase 1 than in phase 2, while there was no significant difference in the flap failure rate or follow-up outcomes between the two phases. In summary, the learning curve of mandibular reconstruction with an ICFF stabilized after approximately 17 cases.
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Affiliation(s)
- B Zeng
- State Key Laboratory of Oral and Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - H Lin
- State Key Laboratory of Oral and Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - W Deng
- State Key Laboratory of Oral and Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School and Hospital of Stomatology, Wuhan University, Wuhan, China; Department of Oral and Maxillofacial Head Neck Oncology, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - R Zhou
- State Key Laboratory of Oral and Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - T Wu
- State Key Laboratory of Oral and Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School and Hospital of Stomatology, Wuhan University, Wuhan, China; Department of Oral and Maxillofacial Head Neck Oncology, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - B Liu
- State Key Laboratory of Oral and Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School and Hospital of Stomatology, Wuhan University, Wuhan, China; Department of Oral and Maxillofacial Head Neck Oncology, School and Hospital of Stomatology, Wuhan University, Wuhan, China.
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Mathew J, Bansod YK, Yadav N, Murugan J, Reddy KB, Kazi M, DeSouza A, Saklani A. Laparoscopic Versus Robotic Lateral Pelvic Lymph Node Dissection in Locally-Advanced Rectal Cancer: A Cohort Study Comparing Perioperative Morbidity and Short-Term Oncological Outcomes. Cancer Rep (Hoboken) 2025; 8:e70174. [PMID: 40052270 PMCID: PMC11886407 DOI: 10.1002/cnr2.70174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2024] [Revised: 02/12/2025] [Accepted: 02/20/2025] [Indexed: 03/09/2025] Open
Abstract
BACKGROUND Robotic surgery has been associated with superior short-term outcomes in patients undergoing total mesorectal excision (TME) for organ-confined rectal cancer. However, whether this approach offers an additional benefit over laparoscopy when performing lateral pelvic lymph node dissection (LPLND) with TME or extended TME (e-TME) in locally advanced rectal cancer (LARC) is not known. AIMS This study was conducted to evaluate the outcomes of robotic and laparoscopic LPLND in patients with lateral pelvic node-positive LARC with reference to intraoperative safety, postoperative morbidity, pathological indices including nodal yield and node positivity rates, lateral pelvic recurrence rates, and short term event-free and overall survival. METHODS AND RESULTS In this retrospective single-center study, consecutive patients with non-metastatic histologically proven LARC and clinically significant lateral pelvic lymphadenopathy who had undergone laparoscopic or robotic LPLND with TME or e-TME between 2014 and 2023 were included, all procedures having been performed by minimal-access colorectal surgeons who were beyond the learning curve for either surgical approach. Of the 115 patients evaluated, 98.3% received neoadjuvant chemoradiotherapy, following which 27 (23.5%) underwent robotic and 88 (76.5%) laparoscopic LPLND with TME or e-TME. The baseline clinicodemographic features, treatment-related characteristics, and proportion of patients undergoing extended resections for persistent circumferential resection margin-positive rectal cancer (22.7% vs. 18.5%, respectively) were statistically similar in both groups. When comparing robotic with laparoscopic resections, no significant difference was observed in intraoperative parameters including procedure-associated blood loss (median 250 mL vs. 400 mL) and on-table adverse events or conversion rates (none in either group), postoperative outcomes comprising clinically significant early (14.8% vs. 9.1%), intermediate (5.3% vs. 1.9%) and late (5.3% vs. 2.0%) surgical morbidity, re-exploration rates (7.4% vs. 3.4%) and duration of hospital stay (median 6 days in both groups), or the pathological quality indices of margin involvement (7.4% vs. 2.3%), nodal yield (median 4 vs. 7 nodes) and lateral node positivity (22.2% vs. 26.1%), respectively. At a median 11 months follow-up, oncological outcomes in terms of lateral pelvic recurrence rates (3.7% vs. 4.5%), 2-year event-free survival (78.7% vs. 79.3%) and 2-year overall survival (83.1% vs. 93.8%) were also comparable. CONCLUSION Surgical competence in laparoscopy may offset the potential benefits extended by robotic platforms. In a high-volume setup with experienced minimal-access surgeons, the clinical, pathological, and short-term oncological outcomes associated with both approaches may be considered equivalent.
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Affiliation(s)
- Joseph Mathew
- Department of GI Surgical Oncology and Minimal Access SurgeryHealthCare Global Enterprises Ltd. (HCG)BangaloreIndia
| | - Yogesh Kisan Bansod
- Division of Colorectal Oncology, Department of Surgical OncologyTata Memorial CentreMumbaiIndia
| | - Nishant Yadav
- Department of Surgical OncologyMPMMCC Tata Memorial CentreVaranasiIndia
| | - Janesh Murugan
- Division of Colorectal Oncology, Department of Surgical OncologyTata Memorial CentreMumbaiIndia
| | - Kovvuru Bhaskar Reddy
- Division of Colorectal Oncology, Department of Surgical OncologyTata Memorial CentreMumbaiIndia
| | - Mufaddal Kazi
- Division of Colorectal Oncology, Department of Surgical OncologyTata Memorial CentreMumbaiIndia
| | - Ashwin DeSouza
- Division of Colorectal Oncology, Department of Surgical OncologyTata Memorial CentreMumbaiIndia
| | - Avanish Saklani
- Division of Colorectal Oncology, Department of Surgical OncologyTata Memorial CentreMumbaiIndia
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Toba T, Ishii T, Sato N, Nogami A, Hojo A, Shimizu R, Fujimoto A, Matsuda T. Effectiveness of a novel ex vivo training model for gastric endoscopic submucosal dissection training: a prospective observational study conducted at a single center in Japan. Clin Endosc 2025; 58:94-101. [PMID: 39489604 PMCID: PMC11837555 DOI: 10.5946/ce.2024.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/01/2024] [Accepted: 06/03/2024] [Indexed: 11/05/2024] Open
Abstract
BACKGROUND/AIMS The efficacy of endoscopic submucosal dissection (ESD) for early-stage gastric cancer is well established. However, its acquisition is challenging owing to its complexity. In Japan, G-Master is a novel ex vivo gastric ESD training model. The effectiveness of training using G-Master is unknown. This study evaluated the efficacy of gastric ESD training using the G-Master to evaluate trainees' learning curves and performance. METHODS Four trainees completed 30 ESD training sessions using the G-Master, and procedure time, resection area, resection completion, en-bloc resection requirement, and perforation occurrence were measured. Resection speed was the primary endpoint, and learning curves were evaluated using the Cumulative Sum (CUSUM) method. RESULTS All trainees completed the resection and en-bloc resection of the lesion without any intraoperative perforations. The learning curves covered three phases: initial growth, plateau, and late growth. The transition from phase 1 to phase 2 required a median of 10 sessions. Each trainee completed 30 training sessions in approximately 4 months. CONCLUSIONS Gastric ESD training using the G-Master is a simple, fast, and effective method for pre-ESD training in clinical practice. It is recommended that at least 10 training sessions be conducted.
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Affiliation(s)
- Takahito Toba
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Tsuyoshi Ishii
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Nobuyuki Sato
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Akira Nogami
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Aya Hojo
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Ryo Shimizu
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Ai Fujimoto
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Takahisa Matsuda
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
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Samà L, Kumar S, Ruspi L, Sicoli F, D'Amato V, Mintemur Ö, Renne SL, Quagliuolo VL, Cananzi FC. Learning curve in retroperitoneal sarcoma surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108612. [PMID: 39180973 DOI: 10.1016/j.ejso.2024.108612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 07/11/2024] [Accepted: 08/18/2024] [Indexed: 08/27/2024]
Abstract
INTRODUCTION Retroperitoneal sarcoma (RPS) surgery poses unique challenges. This retrospective study aimed to analyze the learning curve (LC) in RPS surgery, assessing the relationship between surgical experience and outcomes. MATERIALS AND METHODS Cumulative sum (CUSUM) analysis was used to analyze 62 RPS surgeries performed by a single surgeon between 2016 and 2022 at our center. RESULTS The number of cases where the surgeon acted as first operator increased from 3 in 2016 to 13 in 2022. The surgeon operated with his mentor in 66.7 % of cases in 2016, whereas in 7.7 % of cases in 2022. LC consisted of 3 phases. Phase 1 (16 cases), with a negative slope, represented shorter operative time (OT) and fewer number of resected organs (RO). Phase 2 (30 cases) was the plateau phase. Phase 3 (16 cases), with a positive slope, indicated longer OT and more RO. Statistically significant differences were observed in terms of size (p = 0.003), presentation (p = 0.048), number of resected organs (p = 0.046), pattern of resection (p = 0.033), OT (p = 0.006), and length of stay (p = 0.026) between the three phases. CONCLUSION This study focused on the critical role of LC in RPS surgery, emphasizing its influence on outcomes. We identified three phases, highlighting the surgeon's evolution. This offers a framework for educating sarcoma surgeons and ensuring exposure to increasing surgical complexity. In discussions on sarcoma referral centers and the correlation between case volume and outcomes, this study underlines the importance of evaluating LC to distinguish surgeons qualified to manage sarcoma cases within a referral center.
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Affiliation(s)
- Laura Samà
- Sarcoma, Melanoma and Rare Tumors Surgery Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Sonia Kumar
- Sarcoma, Melanoma and Rare Tumors Surgery Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Laura Ruspi
- Sarcoma, Melanoma and Rare Tumors Surgery Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Federico Sicoli
- Sarcoma, Melanoma and Rare Tumors Surgery Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Vittoria D'Amato
- Sarcoma, Melanoma and Rare Tumors Surgery Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Ömer Mintemur
- Department of Pathology, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Salvatore L Renne
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy; Department of Pathology, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Vittorio L Quagliuolo
- Sarcoma, Melanoma and Rare Tumors Surgery Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Ferdinando Cm Cananzi
- Sarcoma, Melanoma and Rare Tumors Surgery Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
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Ciftci Y, Radomski SN, Johnson BA, Johnston FM, Greer JB. Triphasic Learning Curve of Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2024; 31:7987-7997. [PMID: 39230850 DOI: 10.1245/s10434-024-15945-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 07/17/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an effective but costly procedure for select patients with peritoneal malignancies. The impact of progression along a learning curve on the cost of these procedures is unknown. PATIENTS AND METHODS We performed a retrospective cohort study of patients undergoing CRS-HIPEC from 2016 to 2022 at a single quaternary center. Our study cohort was temporally divided into four equally sized volume quartiles (A, B, C, and D). We utilized cumulative sum plots and split-group analysis to characterize the institutional learning curve based on cost, operative time, length of stay, and morbidity. Multivariable linear regression was performed to estimate costs after adjusting for covariates. Bivariate analysis was performed using a Kruskal-Wallis test to compare continuous variables and a χ2 test to compare categorical variables. RESULTS Of 201 patients, the median age [interquartile range (IQR)] was 57 (47-65) years, 113 (56%) patients were female, 143 (71%) were white, and 107 (53%) had private insurance. Median operating room charge [US$42,639 (US$32,477-54,872), p < 0.001] varied between volume quartiles, peaking in quartile C. Stabilization was achieved for 86 cases for operating room cost, 88 cases for routine cost, 96 cases for length of stay, 103 cases for operative time, 120 cases for intensive care unit length of stay, and 150 cases for overall and serious morbidity. The actual operating room and routine costs were similar to predicted costs at the end of the study period. CONCLUSIONS The CRS-HIPEC learning curve is triphasic, with cost stability achieved relatively early compared with other markers of surgical proficiency.
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Affiliation(s)
- Yusuf Ciftci
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shannon N Radomski
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Blake A Johnson
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabian M Johnston
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan B Greer
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Lopez MPJ, Viray BAG, Onglao MAS, Tampo MMT, Monroy HJ. Outcomes of Robotic versus Laparoscopic versus Open Resection for Rectal Cancer in a Center with a Beginning Robotic Colorectal Surgery Program. ACTA MEDICA PHILIPPINA 2024; 58:74-82. [PMID: 39600666 PMCID: PMC11586283 DOI: 10.47895/amp.vi0.7081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2024]
Abstract
Background and Objective Robotic surgery for rectal malignancies in the Philippines is emerging. Evidence has shown promising results for robot-assisted (R) rectal surgery when compared to the laparoscopic (L) and open (O) approach. This study discussed the clinicopathologic outcomes of the first robotic rectal resections versus laparoscopic and open rectal resections at the Philippine General Hospital (PGH). Methods This was a retrospective cohort of 45 consecutive surgical resections for rectal malignancy done at the PGH from March 2019 to October 2019 that compared the outcomes of the first 15 robotic procedures done at the institution versus laparoscopic (n=15) and open (n=15) operations performed during the same time period. One-way ANOVA was done to determine significant differences among variables, while Bonferonni multiple comparison test was done to analyze differences among means. Results The 45 patients in the study had a mean age of 56.04 ± 13.45 years. The patients were mostly male (60%). Most of the tumors were located in the low rectum (27/45; 60%). Most of the patients had locally-advanced (at least Stage IIIB) disease (27/45; 60%), and warranted neoadjuvant treatment (41/45; 91.11%). Most patients underwent a sphincter-saving procedure (34/45; 75.56%). All three groups had comparable baseline characteristics. The R-group had the longest operative time (438.07 ± 124.57; p value <0.0001). Blood loss was significantly highest in the R-group (399 ± 133.07 cc; p value - 0.0020) as well, while no statistical difference was observed between the O- and L-groups (p value - 0.75). No conversion to open was noted in the R- and L-groups. Most of the patients had well-differentiated adenocarcinoma (22/45; 48.49%). All patients in the L- and O-groups had an R0 resection There were two R1 resections in the R-group. All patients who underwent an open surgery had a negative circumferential resection margin (CRM); L-group 93.99%, R-group 69.23%. All patients had adequate proximal and distal resection margins. Those who underwent an open surgery had the shortest post-operative length of stay (LOS) (p value - 0.0002). Post-operative ileus (7/45; 15.56%) was the most commonly encountered morbidity, and was seen mostly in the R-group (3/15; 20%). One patient in the R-group underwent a transanal repair of an anastomotic dehiscence and was discharged three days after re-operation. There was no reported mortality. Conclusion Our institution with a beginning robotic colorectal surgery program showed promise as its initial outcomes for rectal cancer were compared to the more often-performed open and laparoscopic procedures. The authors expect more favorable clinicopathological outcomes as our staff overcome the prescribed learning curve for robotic surgery.
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Affiliation(s)
- Marc Paul J. Lopez
- Division of Colorectal Surgery, Department of Surgery, Philippine General Hospital, University of the Philippines Manila
| | - Brent Andrew G. Viray
- Department of Surgery, Philippine General Hospital, University of the Philippines Manila
| | - Marc Augustine S. Onglao
- Division of Colorectal Surgery, Department of Surgery, Philippine General Hospital, University of the Philippines Manila
| | - Mayou Martin T. Tampo
- Division of Colorectal Surgery, Department of Surgery, Philippine General Hospital, University of the Philippines Manila
| | - Hermogenes J. Monroy
- Division of Colorectal Surgery, Department of Surgery, Philippine General Hospital, University of the Philippines Manila
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Wong NW, Teo NZ, Ngu JCY. Learning Curve for Robotic Colorectal Surgery. Cancers (Basel) 2024; 16:3420. [PMID: 39410039 PMCID: PMC11475096 DOI: 10.3390/cancers16193420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2024] [Revised: 10/01/2024] [Accepted: 10/02/2024] [Indexed: 10/20/2024] Open
Abstract
With the increasing adoption of robotic surgery in clinical practice, institutions intending to adopt this technology should understand the learning curve in order to develop strategies to help its surgeons and operating theater teams overcome it in a safe manner without compromising on patient care. Various statistical methods exist for the analysis of learning curves, of which a cumulative sum (CUSUM) analysis is more commonly described in the literature. Variables used for analysis can be classified into measures of the surgical process (e.g., operative time and pathological quality) and measures of patient outcome (e.g., postoperative complications). Heterogeneity exists in how performance thresholds are defined during the interpretation of learning curves. Factors that influence the learning curve include prior surgical experience in colorectal surgery, being in a mature robotic surgical unit, case mix and case complexity, robotic surgical simulation, spending time as a bedside first assistant, and being in a structured training program with proctorship.
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Affiliation(s)
- Neng Wei Wong
- Department of Surgery, Changi General Hospital, Singapore 529889, Singapore; (N.Z.T.); (J.C.-Y.N.)
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Massias S, Vadhwana B, Arjomandi Rad A, Hollingshead J, Patel V. Feasibility, clinical outcomes, and learning curves of robotic-assisted colorectal cancer surgery in a high-volume district general hospital: a cohort study. Ann Med Surg (Lond) 2024; 86:5744-5749. [PMID: 39359778 PMCID: PMC11444557 DOI: 10.1097/ms9.0000000000002545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Accepted: 08/25/2024] [Indexed: 10/04/2024] Open
Abstract
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.
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Affiliation(s)
- Samuel Massias
- Department of Surgery, West Hertfordshire Teaching Hospitals NHS Trust, Watford General Hospital
| | - Bhamini Vadhwana
- Department of Surgery, West Hertfordshire Teaching Hospitals NHS Trust, Watford General Hospital
- Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital, London
| | - Arian Arjomandi Rad
- Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford, UK
| | - James Hollingshead
- Department of Surgery, West Hertfordshire Teaching Hospitals NHS Trust, Watford General Hospital
| | - Vanash Patel
- Department of Surgery, West Hertfordshire Teaching Hospitals NHS Trust, Watford General Hospital
- Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital, London
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Miyoshi H, Kamiya S, Ikeda T, Narasaki S, Kondo T, Syourin D, Sumii A, Kido K, Otsuki S, Kato T, Nakamura R, Tsutsumi YM. Impact of proficiency in the transcatheter aortic valve implantation procedure on clinical outcomes: a single center retrospective study. BMC Anesthesiol 2024; 24:209. [PMID: 38907200 PMCID: PMC11191309 DOI: 10.1186/s12871-024-02594-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 06/10/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND We used transcatheter aortic valve implantation (TAVI) procedure time to investigate the association between surgical team maturity and outcome. METHODS Among patients who underwent TAVI between October 2015 and November 2019, those who had Sapien™ implanted with the transfemoral artery approach were included in the analysis. We used TAVI procedure time and surgery number to draw a learning curve. Then, we divided the patients into two groups before and after the number of cases where the sigmoid curve reaches a plateau. We compared the two groups regarding the surveyed factors and investigated the correlation between the TAVI procedure time and survey factors. RESULTS Ninety-nine of 149 patients were analysed. The sigmoid curve had an inflection point in 23.2 cases and reached a plateau in 43.0 cases. Patients in the Late group had a shorter operating time, less contrast media, less radiation exposure, and less myocardial escape enzymes than the Early group. Surgical procedure time showed the strongest correlation with the surgical case number. CONCLUSION The number of cases required for surgeon proficiency for isolated Sapien™ valve implantation was 43. This number may serve as a guideline for switching the anesthesia management of TAVI from general to local anesthesia.
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Affiliation(s)
- Hirotsugu Miyoshi
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan.
| | - Satoshi Kamiya
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Tsuyoshi Ikeda
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Soshi Narasaki
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Takashi Kondo
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Daiki Syourin
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Ayako Sumii
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Kenshiro Kido
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Sachiko Otsuki
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Takahiro Kato
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Ryuji Nakamura
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Yasuo M Tsutsumi
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
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Sun H, Lu H, Xiao Q, Ding Z, Luo Z, Zhou Z. The learning curve of a novel seven-axis robot-assisted total hip arthroplasty system: a randomized controlled trial. BMC Musculoskelet Disord 2024; 25:342. [PMID: 38689270 PMCID: PMC11061987 DOI: 10.1186/s12891-024-07474-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 04/24/2024] [Indexed: 05/02/2024] Open
Abstract
BACGROUND The aim of this study was to assess the learning curve of a novel seven-axis robot-assisted total hip arthroplasty (RaTHA) system. METHODS A total of 59 patients who underwent unilateral total hip arthroplasty at our institution from June 2022 to September 2022 were prospectively included in the study. In this randomized controlled clinical trial, robot-assisted THA (RaTHA) and Conventional THA (CoTHA) were performed using cumulative sum (CUSUM) analysis to evaluate the learning curve of the RaTHA system. The demographic data, preopera1tive clinical data, duration of operation, postoperative Harris Hip Score (HHS), postoperative Western Ontario and McMaster Universities Arthritis Index (WOMAC) score, and duration of operation between the learning stage and the proficiency stage of the RaTHA group were compared between the two groups. RESULTS The average duration of operation of the RaTHA group was increased by 34.73 min compared with the CoTHA group (104.26 ± 19.33 vs. 69.53 ± 18.38 min, p < 0.01). The learning curve of the RaTHA system can be divided into learning stage and proficiency stage, and the former consists of the first 13 cases by CUSUM analysis. In the RaTHA group, the duration of operation decreased by 29.75 min in the proficiency stage compared to the learning stage (121.12 ± 12.84 vs.91.37 ± 12.92, p < 0.01). CONCLUSIONS This study demonstrated that the surgical team required a learning curve of 13 cases to become proficient using the RaTHA system. The duration of operation, total blood loss, and drainage gradually shortened (decreased) with the learning curve stage, and the differences were statistically significant. TRIAL REGISTRATION Number: ChiCTR2200061630, Date: 29/06/2022.
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Affiliation(s)
- Haocheng Sun
- Department of Orthopedics, West China Hospital, Orthopedic Research Institute, Sichuan University, Chengdu, China
| | - Hanpeng Lu
- Department of Orthopedics, West China Hospital, Orthopedic Research Institute, Sichuan University, Chengdu, China
| | - Qiang Xiao
- Department of Orthopedics, Chengdu Second People's Hospital, Chengdu, China
| | - Zichuan Ding
- Department of Orthopedics, West China Hospital, Orthopedic Research Institute, Sichuan University, Chengdu, China
| | - Zeyu Luo
- Department of Orthopedics, West China Hospital, Orthopedic Research Institute, Sichuan University, Chengdu, China.
| | - Zongke Zhou
- Department of Orthopedics, West China Hospital, Orthopedic Research Institute, Sichuan University, Chengdu, China.
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11
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Chaoui AM, Chaoui I, Olivier F, Geers J, Abasbassi M. Outcomes of robotic versus laparoscopic ventral mesh rectopexy for rectal prolapse. Acta Chir Belg 2024; 124:91-98. [PMID: 36905354 DOI: 10.1080/00015458.2023.2191073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/07/2023] [Indexed: 02/06/2024]
Abstract
INTRODUCTION Minimally invasive ventral mesh rectopexy is considered the standard of care in the surgical management of rectal prolapse syndromes in fit patients. We aimed to investigate the outcomes after robotic ventral mesh rectopexy (RVR) and compare them with our laparoscopic series (LVR). Additionally, we report the learning curve of RVR. As the financial aspect for the use of a robotic platform remains an important obstacle to allow generalized adoption, cost-effectiveness was also evaluated. PATIENTS AND METHODS A prospectively maintained data set including 149 consecutive patients who underwent a minimally invasive ventral rectopexy between December 2015 and April 2021 was reviewed. The results after a median follow-up of 32 months were analyzed. Additionally, a thorough assessment of the economic aspect was performed. RESULTS On a total of 149 consecutive patients 72 underwent a LVR and 77 underwent a RVR. Median operative time was comparable for both groups (98 min (RVR) vs. 89 min (LVR); p = 0.16). Learning curve showed that an experienced colorectal surgeon required approximately 22 cases in stabilizing the operative time for RVR. Overall functional results were similar in both groups. There were no conversions or mortality. There was, however, a significant difference (p < 0.01) in hospital stay in favor of the robotic group (1 day vs. 2 days). The overall cost of RVR was higher than LVR. CONCLUSIONS This retrospective study shows that RVR is a safe and feasible alternative for LVR. With specific adjustments in surgical technique and robotic materials, we developed a cost-effective way of performing RVR.
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Affiliation(s)
- Ahmed M Chaoui
- Department of Abdominal Surgery, AZ Damiaan, Ostend, Belgium
| | - Ismaël Chaoui
- Department of Abdominal Surgery, AZ Damiaan, Ostend, Belgium
| | | | - Joachim Geers
- Department of Abdominal Surgery, AZ Damiaan, Ostend, Belgium
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12
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Choi MS, Yun SH, Lee SC, Shin JK, Park YA, Huh J, Cho YB, Kim HC, Lee WY. Learning curve for single-port robot-assisted colectomy. Ann Coloproctol 2024; 40:44-51. [PMID: 36535706 PMCID: PMC10915530 DOI: 10.3393/ac.2022.00745.0106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/05/2022] [Accepted: 11/06/2022] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Since the introduction of robotic surgery, robots for colorectal cancer have replaced laparoscopic surgery, and a single-port robot (SPR) platform has been launched and is being used to treat patients. We analyzed the learning curve and initial complications of using an SPR platform in colorectal cancer surgery. METHODS We reviewed 39 patients who underwent SPR colectomy from April to October 2019. All surgeries were performed by the same surgeon using an SPR device. A learning curve was generated using the cumulative sum methodology to assess changes in total operation time, docking time, and surgeon console time. We grouped the patients into 3 groups according to the time period: the first 11 were phase 1, the next 11 were phase 2, and the last 17 were phase 3. RESULTS The mean age of the patients was 61.28±13.03 years, and they had a mean body mass index of 23.79±2.86 kg/m2. Among the patients, 23 (59.0%) were male, and 16 (41.0%) were female. The average operation time was 186.59±51.30 minutes, the average surgeon console time was 95.49±35.33 minutes, and the average docking time (time from skin incision to robot docking) was 14.87±10.38 minutes. The surgeon console time differed significantly among the different phases (P<0.001). Complications occurred in 8 patients: 2 ileus, 2 postoperation hemoglobin changes, 3 urinary retentions, and 1 complicated fluid collection. CONCLUSION In our experience, the learning curve for SPR colectomy was achieved after the 18th case.
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Affiliation(s)
- Moon Suk Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Hyeon Yun
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Chul Lee
- Department of Surgery, Dankook University Hospital, Cheonan, Korea
| | - Jung Kyong Shin
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon Ah Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jungwook Huh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Beom Cho
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Cheol Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Yong Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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13
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Zhang G, Wang B, Liu H, Jia G, Tao B, Zhang H, Wang C. How many cases are required to achieving early proficiency in purely off-clamp robot-assisted partial nephrectomy? Front Surg 2024; 10:1309522. [PMID: 38234451 PMCID: PMC10792019 DOI: 10.3389/fsurg.2023.1309522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 11/16/2023] [Indexed: 01/19/2024] Open
Abstract
Background and purpose Off-clamp robot-assisted partial nephrectomy (Offc-RAPN) is a technically challenging procedure that can effectively avoid renal ischemia owing to the absence of hilar vessel preparation and clamping. However, data on the learning curve (LC) for this technique are limited. The purpose of this study was to assess the LC of Offc-RAPN and compare the perioperative outcomes between different learning phases. Methods This retrospective study included 50 consecutive patients who underwent purely Offc-RAPN between January 2022 and April 2023. Multidimensional cumulative sum (CUSUM) analysis method was used to assess LC. Spearman's correlation and LOWESS analysis were performed to analyze the continuous variables of perioperative outcomes. Baseline characteristics and perioperative outcomes were compared using χ2-test, t-test and U-test. Results CUSUM analysis identified two LC phases: phase I (the first 24 cases) and phase II (the subsequent 26 cases). Phase II showed significant reductions in mean operative time (133.5 vs. 115.31 min; p = 0.04), mean console time (103.21 vs. 81.27 min; p = 0.01), and mean postoperative length of stay (5.33 vs. 4.30 days; p = 0.04) compared to phase I. However, no significant differences were observed in other perioperative outcomes or baseline characteristics between the two LC phases. Conclusions Offc-RAPN performed by a surgeon with experience in laparoscopic and robotic surgeries achieved early proficiency in 24 cases. Moreover, Offc-RAPN alone is safe and feasible even in the initial phase of the LC for an experienced surgeon.
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Affiliation(s)
| | | | | | | | | | | | - Chunyang Wang
- Department of Urology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
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14
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Feng F, Chen X, Liu Z, Han Y, Chen H, Li Q, Lao L, Shen H. Learning curve of junior surgeons in robot-assisted pedicle screw placement: a comparative cohort study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:314-323. [PMID: 37964170 DOI: 10.1007/s00586-023-08019-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/07/2023] [Accepted: 10/21/2023] [Indexed: 11/16/2023]
Abstract
OBJECTIVE Robot-assisted technology has been gradually applied to pedicle screw placement in spinal surgery. This study was designed to detailedly evaluate the learning curve of junior surgeons in robot-assisted spine surgery. METHODS From December 2020 to February 2022, 199 patients requiring surgical treatment with posterior pedicle screw fixation were prospectively recruited into the study. The patients were randomized to the robot-assisted group (the RA group) or the conventional freehand group (the CF group). Under the senior specialist's supervision, pedicle screws were placed by two junior fellows without prior experience. Cumulative summation (CUSUM) analysis was performed on the learning curve of pedicle screw placement for performing quantitative assessment based on the time of screw insertion. RESULTS In total, 769 and 788 pedicle screws were placed in the RA and CF groups. Compared with the CF group, the learning duration in the RA group was shorter in the upper thoracic region (57 vs. 70 screws), but longer in the lower thoracic (62 vs. 58 screws) and the lumbosacral region (56 vs. 48 screws). The slope of learning curve was lower in the RA group than in the CF group. The screw accuracy in the RA group was superior to that in the CF group, especially in upper thoracic region (89.4% vs. 76.7%, P < 0.001). This disparity of accuracy became wider in deformity cases. In the upper thoracic region, the mean placement time was 5.34 ± 1.96 min in the RA group and 5.52 ± 2.43 min in the CF groups, while in the lower thoracic and lumbosacral regions, the CF group's mean placement times were statistically shorter. Three screw-related neural complications occurred in the CF group. CONCLUSION Robot-assisted technique has its advantages in the upper thoracic region and deformity cases, which is easier and safer to insert pedicle screws. The robot-assisted technique allowed a short learning curve for junior surgeons and exhibited consistently excellent results even in the early application period.
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Affiliation(s)
- Fan Feng
- Department of Spine Surgery, Department of Orthopaedics, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pujian Road, Shanghai, 200120, China
| | - Xiuyuan Chen
- Department of Spine Surgery, Department of Orthopaedics, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pujian Road, Shanghai, 200120, China
| | - Zude Liu
- Department of Spine Surgery, Department of Orthopaedics, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pujian Road, Shanghai, 200120, China
| | - Yingchao Han
- Department of Spine Surgery, Department of Orthopaedics, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pujian Road, Shanghai, 200120, China
| | - Hao Chen
- Department of Spine Surgery, Department of Orthopaedics, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pujian Road, Shanghai, 200120, China
| | - Quan Li
- Department of Spine Surgery, Department of Orthopaedics, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pujian Road, Shanghai, 200120, China
| | - Lifeng Lao
- Department of Spine Surgery, Department of Orthopaedics, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pujian Road, Shanghai, 200120, China.
| | - Hongxing Shen
- Department of Spine Surgery, Department of Orthopaedics, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pujian Road, Shanghai, 200120, China.
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15
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Sim GY, Caparó M, Varrassi G, Lu CR, Ding ME, Singh R, Slinchenkova K, Shaparin N, Koushik SS, Viswanath O, Gitkind AI. Comparing the Effectiveness of Hands-on vs. Observational Training of Residents in Interlaminar Epidural Steroid Injections (ILESI) Using a High-Fidelity Spine Simulator. Cureus 2023; 15:e49829. [PMID: 38164314 PMCID: PMC10758203 DOI: 10.7759/cureus.49829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/02/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction The Accreditation Council for Graduate Medical Education (ACGME) requires that residents in the Physical Medicine and Rehabilitation (PM&R) residency observe or perform certain interventional procedures, one of which is an interlaminar epidural steroid injection (ILESI). While the traditional learning model relying heavily on observation is commonplace, it leaves the practice phase of learning to happen on real patients. High-fidelity simulation may be a worthwhile alternative as a training approach to increase physician comfort with the procedure and improve patient safety. Methods Current PM&R residents from two programs between their second and fourth year, inclusively, who lacked prior training experience in ILESI attended one hour of either: (1) an experimental arm of supervised hands-on training on a simulation device or (2) a control arm observing the procedures performed by an attending on the same device. Assignments were made based on resident schedule availability. Pre-training knowledge, training, and post-training knowledge were assessed at the Multidisciplinary Pain Clinic at Montefiore Medical Center. Participants were assessed on their procedural competence using an adapted version of a previously published grading checklist before the session. Participants also evaluated their confidence in performing the procedure prior to and after training. Data was analyzed using the Wilcoxon signed-rank test and the Wilcoxon rank-sum test. SAS Version 9.4 was used for analysis. Results Fifteen residents initially participated, but three residents dropped out at the 15-week follow-up. There was a significant increase in test scores in both arms immediately after the intervention (p=0.008 in control, p=0.016 in the experiment), with greater improvement shown in the hands-on training group (p=0.063). At the 15-week follow-up, there was no significant change in test scores in the control arm (p=0.969) while there was a decrease in the experiment arm (p<0.001). Conclusion Hands-on learning with high-fidelity simulation demonstrated more improvement for short-term motor-skill acquisition, while observational learning with repetition showed more benefits for long-term retention. Optimal procedural training should employ both educational modalities for best short- and long-term results.
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Affiliation(s)
- Geum Y Sim
- Physical Medicine and Rehabilitation, Albert Einstein College of Medicine, The Bronx, USA
| | - Moorice Caparó
- Physical Medicine and Rehabilitation, Albert Einstein College of Medicine, The Bronx, USA
| | | | - Christopher R Lu
- Physical Medicine and Rehabilitation, Albert Einstein College of Medicine, The Bronx, USA
| | - Michael E Ding
- Physical Medicine and Rehabilitation, Albert Einstein College of Medicine, The Bronx, USA
| | - Rohini Singh
- Physical Medicine and Rehabilitation, Albert Einstein College of Medicine, The Bronx, USA
| | | | - Naum Shaparin
- Anesthesiology, Albert Einstein College of Medicine, The Bronx, USA
| | - Sarang S Koushik
- Anesthesiology, Creighton University School of Medicine, Phoenix, USA
- Anesthesiology, Valleywise Health Medical Center, Phoenix, USA
| | - Omar Viswanath
- Anesthesiology, Creighton University School of Medicine, Phoenix, USA
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Andrew I Gitkind
- Physical Medicine and Rehabilitation, Albert Einstein College of Medicine, The Bronx, USA
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16
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Saqib SU, Bajwa AA. The role of Da Vinci Xi robotic simulation curriculum in enhancing skills in robotic colorectal surgery. Ann Med Surg (Lond) 2023; 85:6001-6007. [PMID: 38098541 PMCID: PMC10718376 DOI: 10.1097/ms9.0000000000001342] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/11/2023] [Indexed: 12/17/2023] Open
Abstract
Robotic surgery in comparison to open and laparoscopic surgery allows better ergonomics, three-dimensional vision, and seven-degree freedom of movement. This ensures fast recovery, fewer postoperative complications, and safe oncological resections. Robotic surgery has revolutionized the field of colorectal surgery, providing surgeons with enhanced precision, dexterity, and visualization. To ensure safe and successful outcomes, surgeons must acquire competency and proficiency in robotic surgical techniques. Robotic simulation exercises have emerged as a valuable tool for training and skill development in robotic colorectal surgery. This research paper explores the importance and relationship between robotic simulation exercises and the acquisition of skills and competency required for carrying out safe colorectal surgery using a robotic platform. The authors discuss the benefits of virtual simulation-based training using the Da Vinci Xi skill simulator, and the evidence supporting its effectiveness in colorectal surgery. In this article, emphasis has been made on some important Da Vinci Xi skill simulator exercises for enhancing skills in robotic colorectal surgery.
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Affiliation(s)
- Sabah Uddin Saqib
- Senior clinical fellow Colorectal surgery, University hospital Coventry and warwickshire trust
| | - Adeel Ahmad Bajwa
- Consultant colorectal surgery, University Hospital Coventry and Warwickshire Trust, Coventry, UK
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17
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Korneffel K, Nuzzo W, Belden CM, McPhail L, O'Connor S. Learning curves of robotic extended totally extraperitoneal (eTEP) hernia repair among two surgeons at a high-volume community hospital: a cumulative sum analysis. Surg Endosc 2023; 37:9351-9357. [PMID: 37640953 DOI: 10.1007/s00464-023-10349-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 07/30/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Robotic extended totally extraperitoneal hernia (eTEP) repair is a novel technique for minimally invasive ventral hernia repair with retromuscular placement of mesh. This study aimed to evaluate the learning curve for robotic eTEP hernia repair using risk-adjusted cumulative sum (RA-CUSUM) analysis for two general surgeons-one with dedicated fellowship training in robotic eTEP technique (surgeon 2) and another without robotic eTEP-specific training (surgeon 1). METHODS We conducted a retrospective analysis of 98 patients undergoing robotic eTEP hernia repair from July 2020 to February 2022 for two surgeons. RA-CUSUM method was applied to the overall operative time (OT) in minutes, adjusting for transversus abdominis release (TAR). RESULTS Figures 3 (surgeon 1) and 4 (surgeon 2) illustrate the three phases in the RA-CUSUM graphs of OT. For surgeon 1, the cases for each phase were determined: phase 1 (1 to 12), phase 2 (13 to 24), and phase 3 (25 to 51). For surgeon 2, the three phases were similarly determined as 1 to 8, 9 to 32, and 33 to 47, respectively. A significant (p = 0.017) difference existed for the OTs between phases 1 (262 ± 69) and 3 (192 ± 63.0) for surgeon 1. OT compared to the risk-adjusted value stabilized after case 12 and decreased after case 24 for surgeon 1; it began to decrease after case 8 for surgeon 2. CONCLUSIONS The initial learning curve for surgeon 1 reached its plateau after 12 cases, shorter than comparable studies. This was likely due to the surgeon's intentional focus on learning this technique through courses, proctoring, and active mentorship. The flat learning curve seen in surgeon 2's series illustrates the value of experience gained during fellowship training. Our data support that, given the right resources and support, a short learning curve for eTEP is attainable for community surgeons without prior training in the technique.
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Affiliation(s)
- Katie Korneffel
- General Surgery Residency, Mountain Area Health Education Center (MAHEC), Asheville, NC, USA.
| | - Wendy Nuzzo
- Department of Research, MAHEC, Asheville, USA
| | | | - Lindsee McPhail
- Department of Surgery, Mission Hospital, HCA Healthcare, Asheville, USA
| | - Sean O'Connor
- Department of Surgery, Mission Hospital, HCA Healthcare, Asheville, USA
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18
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Rosen SA, Rupji M, Liu Y, Paul Olson TJ. Robotic Proctectomy: Beyond the Initial Learning Curve. Am Surg 2023; 89:5332-5339. [PMID: 36560892 DOI: 10.1177/00031348221146931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Multiple authors have described an initial learning curve (LC) for robotic proctectomy (RP), but there is scant literature regarding continued technical progression beyond this stage. Total operating time is the most commonly used metric to measure proficiency. Our goal was to examine RP experience after the initial LC looking for evidence of further technical progression. METHODS We reviewed our robotic surgery database for a single surgeon during operations 100 through 550 to identify 83 RPs for tumor. These were divided into quartiles by series order, indicating surgeon experience level over time. Demographics and outcomes were compared among the groups. We defined percent console time (PCT) as a new metric. PCT was defined as console time divided by total operative time (TOT). RESULTS From March 2014 through March 2019, 450 robotic colorectal operations were performed, including 83 RPs for polyp or cancer. No significant differences were found among the quartiles in regard to demographics, tumor features, hospital stay, conversions, or readmissions. As experience was gained, there were significant increases in intracorporeal anastomosis (ICA), TOT, and PCT. Complications decreased with experience. Number of lymph nodes in the specimen increased. On multivariate analysis, later experience group, body mass index ≥30, and ICA were associated with increased PCT. DISCUSSION ICA became a routine part of RP after the initial LC, with increases in TOT and PCT. Number of lymph nodes increased and number and severity of complications decreased with experience. Increased PCT may indicate increased expertise during RP.
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Affiliation(s)
- Seth A Rosen
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - Manali Rupji
- Department of Biostatistics, Emory University, Atlanta, GA, USA
| | - Yuan Liu
- Department of Biostatistics, Emory University, Atlanta, GA, USA
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19
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Calleja R, Medina-Fernández FJ, Vallejo-Lesmes A, Durán M, Torres-Tordera EM, Díaz-López CA, Briceño J. Transition from laparoscopic to robotic approach in rectal cancer: a single-center short-term analysis based on the learning curve. Updates Surg 2023; 75:2179-2189. [PMID: 37874533 DOI: 10.1007/s13304-023-01655-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/23/2023] [Indexed: 10/25/2023]
Abstract
As a novel procedure becomes more and more used, knowledge about its learning curve and its impact on outcomes is useful for future implementations. Our aim is (i) to identify the phases of the robotic rectal surgery learning process and assess the safety and oncological outcomes during that period, (ii) to compare the robotic rectal surgery learning phases outcomes with laparoscopic rectal resections performed before the implementation of the robotic surgery program. We performed a retrospective study, based on a prospectively maintained database, with methodological quality assessment by STROBE checklist. All the procedures were performed by the same two surgeons. A total of 157 robotic rectal resections from June 2018 to January 2022 and 97 laparoscopic rectal resections from January 2018 to July 2019 were included. The learning phase was completed at case 26 for surgeon A, 36 for surgeon B, and 60 for the center (both A & B). There were no differences in histopathological results or postoperative complications between phases, achieving the same ratio of mesorectal quality, circumferential and distal resection margins as the laparoscopic approach. A transitory increase of major complications and anastomotic leakage could occur once overcoming the learning phase, secondary to the progressive complexity of cases. Robotic rectal cancer surgery learning curve phases in experienced laparoscopic surgeons was completed after 25-35 cases. Implementation of a robotic rectal surgery program is safe in oncologic terms, morbidity, mortality and length of stay.
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Affiliation(s)
- Rafael Calleja
- General and Digestive Surgery Department, Reina Sofia University Hospital, Avenida Menéndez Pidal s/n 14004, Cordoba, Spain.
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain.
| | - Francisco Javier Medina-Fernández
- General and Digestive Surgery Department, Reina Sofia University Hospital, Avenida Menéndez Pidal s/n 14004, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain
| | - Ana Vallejo-Lesmes
- General and Digestive Surgery Department, Reina Sofia University Hospital, Avenida Menéndez Pidal s/n 14004, Cordoba, Spain
| | - Manuel Durán
- General and Digestive Surgery Department, Reina Sofia University Hospital, Avenida Menéndez Pidal s/n 14004, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain
| | - Eva M Torres-Tordera
- General and Digestive Surgery Department, Reina Sofia University Hospital, Avenida Menéndez Pidal s/n 14004, Cordoba, Spain
| | - César A Díaz-López
- General and Digestive Surgery Department, Reina Sofia University Hospital, Avenida Menéndez Pidal s/n 14004, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain
| | - Javier Briceño
- General and Digestive Surgery Department, Reina Sofia University Hospital, Avenida Menéndez Pidal s/n 14004, Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain
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Jiang K, Hersh AM, Bhimreddy M, Weber-Levine C, Davidar AD, Menta AK, Routkevitch D, Alomari S, Judy BF, Lubelski D, Weingart J, Theodore N. Learning Curves for Robot-Assisted Pedicle Screw Placement: Analysis of Operative Time for 234 Cases. Oper Neurosurg (Hagerstown) 2023; 25:482-488. [PMID: 37578266 DOI: 10.1227/ons.0000000000000862] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/07/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Robot-assisted pedicle screw placement is associated with greater accuracy, reduced radiation, less blood loss, shorter hospital stays, and fewer complications than freehand screw placement. However, it can be associated with longer operative times and an extended training period. We report the initial experience of a surgeon using a robot system at an academic medical center. METHODS We retrospectively reviewed all patients undergoing robot-assisted pedicle screw placement at a single tertiary care institution by 1 surgeon from 10/2017 to 05/2022. Linear regression, analysis of variance, and cumulative sum analysis were used to evaluate operative time learning curves. Operative time subanalyses for surgery indication, number of levels, and experience level were performed. RESULTS In total, 234 cases were analyzed. A significant 0.19-minute decrease in operative time per case was observed (r = 0.14, P = .03). After 234 operations, this translates to a reduction in 44.5 minutes from the first to last case. A linear relationship was observed between case number and operative time in patients with spondylolisthesis (-0.63 minutes/case, r = 0.41, P < .001), 2-level involvement (-0.35 minutes/case, r = 0.19, P = .05), and 4-or-more-level involvement (-1.29 minutes/case, r = 0.24, P = .05). This resulted in reductions in operative time ranging from 39 minutes to 1.5 hours. Continued reductions in operative time were observed across the learning, experienced, and expert phases, which had mean operative times of 214, 197, and 146 minutes, respectively ( P < .001). General proficiency in robot-assisted surgery was observed after the 20th case. However, 67 cases were required to reach mastery, defined as the inflection point of the cumulative sum curve. CONCLUSION This study documents the long-term learning curve of a fellowship-trained spine neurosurgeon. Operative time significantly decreased with more experience. Although gaining comfort with robotic systems may be challenging or require additional training, it can benefit surgeons and patients alike with continued reductions in operative time.
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Affiliation(s)
- Kelly Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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21
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Guo Y, Hinoki A, Deie K, Tainaka T, Sumida W, Makita S, Okamoto M, Takimoto A, Yasui A, Takada S, Nakagawa Y, Kato D, Maeda T, Amano H, Kawashima H, Uchida H, Shirota C. Anastomotic time was associated with postoperative complications: a cumulative sum analysis of thoracoscopic repair of tracheoesophageal fistula in a single surgeon's experience. Surg Today 2023; 53:1363-1371. [PMID: 37087700 DOI: 10.1007/s00595-023-02687-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 04/02/2023] [Indexed: 04/24/2023]
Abstract
PURPOSE This study aimed to evaluate the learning curve of thoracoscopic repair of tracheoesophageal fistula (TEF) by a single surgeon using a cumulative sum (CUSUM) analysis. METHODS Prospective clinical data of consecutive Gross type-C TEF repairs performed by a pediatric surgeon from 2010 to 2020 were recorded. CUSUM charts for anastomosis and operating times were generated. The learning curves were compared with the effect of accumulation based on case experience. RESULTS For 33 consecutive cases, the mean operative and anastomosis times were 139 ± 39 min and 3137 ± 1110 s, respectively. Significant transitions beyond the learning phase for total operating and anastomosis times were observed at cases 13 and 17. Both the total operating time and anastomosis time were significantly faster in the proficiency improvement phase than in the initial learning phase. Postoperative complications significantly decreased after the initial anastomosis learning phase but not after the initial total operating learning phase. CONCLUSIONS Thoracoscopic repair of TEF is considered safe and feasible after 13 cases, where the surgeon can improve their proficiency with the total operation procedure, and 17 cases, which will enable the surgeon to achieve proficiency in anastomosis. Postoperative complications significantly decreased after gaining familiarity with the anastomosis procedure through the learning phase.
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Affiliation(s)
- Yaohui Guo
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akinari Hinoki
- Department of Rare/Intractable Cancer Analysis Research, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kyoichi Deie
- Department of Saitama Prefectural Children's Medical Center, Saitama, Japan
| | - Takahisa Tainaka
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Wataru Sumida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Satoshi Makita
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masamune Okamoto
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Aitarou Takimoto
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akihiro Yasui
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shunya Takada
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoichi Nakagawa
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daiki Kato
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takuya Maeda
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hizuru Amano
- Department of Rare/Intractable Cancer Analysis Research, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Kawashima
- Department of Saitama Prefectural Children's Medical Center, Saitama, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Chiyoe Shirota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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22
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Coleman K, Fellner AN, Guend H. Learning curve for robotic rectal cancer resection at a community-based teaching institution. J Robot Surg 2023; 17:3005-3012. [PMID: 37922066 PMCID: PMC10678792 DOI: 10.1007/s11701-023-01671-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/04/2023] [Indexed: 11/05/2023]
Abstract
The surgical management of rectal cancer is shifting toward more widespread use of robotics across a spectrum of medical centers. There is evidence that the oncologic outcomes are equivalent to laparoscopic resections, and the post-operative outcomes may be improved. This study aims to evaluate the learning curve of robotic rectal cancer resections at a community-based teaching institution and evaluate clinical and oncologic outcomes. A retrospective review of consecutive robotic rectal cancer resections by a single surgeon was performed for a five-year period. The cumulative sum (CUSUM) for total operative time was calculated and plotted to establish a learning curve. The oncologic and post-operative outcomes for each phase were analyzed and compared. The CUSUM learning curve yielded two phases, the learning phase (cases 1-79) and the proficiency phase (cases 80-130). The median operative time was significantly lower in the proficiency phase. The type of neoadjuvant therapy used between the two groups was statistically different, with chemoradiation being the primary regimen in the learning phase and total neoadjuvant therapy being more common in the proficiency phase. Otherwise, oncologic and overall post-operative outcomes were not significantly different between the groups. Robotic rectal resections can be done in a community-based hospital system by trained surgeons with outcomes that are favorable and similar to larger institutions.
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Affiliation(s)
- Kristen Coleman
- Department of Surgery, TriHealth, 375 Dixmyth Ave, Cincinnati, OH, 45220, USA.
| | | | - Hamza Guend
- TriHealth Surgical Institute, Cincinnati, OH, USA
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23
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Lee S, Mun S. Surgical outcomes of laparoscopic sleeve gastrectomy by a single surgeon: Before and after learning curve in a non-tertiary low-volume bariatric center. Asian J Surg 2023; 46:4755-4759. [PMID: 37169683 DOI: 10.1016/j.asjsur.2023.04.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/20/2023] [Accepted: 04/18/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND In Korea, the need for bariatric surgery (BS) is increasing because of the increasing incidence of morbid obesity. There is no special training program for BS, and most BS are conducted in non-tertiary hospitals in capital area. We evaluated the surgical outcomes of laparoscopic sleeve gastrectomy (LSG) before and after the learning curve (LC) to prove that the barrier of entry for LSG is not very high. METHODS We retrospectively analyzed the data of patients who underwent LSG in a secondary hospital without the supervision of an experienced surgeon between April 2019 and August 2022. We compared the surgical outcomes and changes in body measurements before the LC (BL) and after the LC (AL) after 1 year of follow-up. RESULTS The duration of operation for BL and AL were 118.4 and 61.9 min (p = 0.000), respectively. No mortality was observed. There were four and eight cases of morbidity; the weight loss after 1 year was 90.6 and 89.7 kg (p = 0.804); changes in body mass index (BMI) were 10.3 and 10.2 kg/m2 (p = 0.928); excess weight loss after 1 year was 93.0 and 89.3% (p = 0.762); and excess BMI loss after 1 year was 92.7 and 89.5% (p = 0.807) in the BL and AL groups, respectively. %Total weight loss was 26.8 and 23.7 in the BL and AL group. There was no statistical significance of all parameters of body measurements between two groups. CONCLUSION LSG can be safely and effectively performed by novice bariatric surgeons in non-tertiary hospitals if patients are cautiously selected. Surgical outcomes of BL and AL is not different, except for the operation time.
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Affiliation(s)
- Sungbae Lee
- Department of Surgery, Hankook Hospital, Mokpo, South Korea
| | - Seongpyo Mun
- Department of Surgery, School of Medicine, Chosun University, Gwangju, South Korea.
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24
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Al-Nader M, Radtke JP, Püllen L, Darr C, Kesch C, Hess J, Krafft U, Hadaschik BA, Harke N, Mahmoud O. Cumulative sum analysis (CUSUM) for evaluating learning curve (LC) of robotic-assisted laparoscopic partial nephrectomy (RALPN). J Robot Surg 2023; 17:2089-2098. [PMID: 37213028 DOI: 10.1007/s11701-023-01620-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/13/2023] [Indexed: 05/23/2023]
Abstract
Robotic-assisted laparoscopic partial nephrectomy (RALPN) is becoming a standard treatment for localized renal tumors worldwide. Data on the learning curve (LC) of RALPN are still insufficient. In the present study, we have attempted to gain further insight in this area by evaluating the LC using cumulative summation analysis (CUSUM). A series of 127 robotic partial nephrectomies were performed by two surgeons at our center between January 2018 and December 2020. CUSUM analysis was used to evaluate LC for operative time (OT). The different phases of surgical experience were compared in terms of perioperative parameters and pathologic outcomes. In addition, multivariate linear regression analysis was used to confirm the results of the CUSUM analysis by adjusting the phases of surgical experience for the other confounding factors that may affect OT. The median age of patients was 62 years, mean BMI was 28, and mean tumor size was 32 mm. Tumor complexity was classified as low, intermediate, and high risk according to the PADUA score in 44%, 38%, and 18%, respectively. The mean OT was 205 min, and trifecta was achieved in 72.4%. According to the CUSUM diagram, the LC of OT was divided into three phases: initial learning phase (18 cases), plateau phase (20 cases), and mastery phase (subsequent cases). The mean OT was 242, 208, and 190 min in the first, second, and third phases, respectively (P < 0.001). Surgeon experience phases were significantly associated with OT in multivariate analysis considering other preoperative and operative parameters. Surgical outcome was comparable between the three phases in terms of complications and achievement of trifecta; hospital stay was shorter in the mastery phase than in the first 2 phases (4 days vs 5 days, P = 0.02). The LC for RALPN is divided into 3 performance phases with CUSUM. Mastery of surgical technique was achieved after performing 38 cases. The initial learning phase of RALPN has no negative impact on surgical and oncologic outcomes .
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Affiliation(s)
- Mulham Al-Nader
- Department of Urology, University Hospital Essen, Essen, Germany
| | - Jan Philipp Radtke
- Department of Urology, University Hospital Essen, Essen, Germany
- Department of Urology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Lukas Püllen
- Department of Urology, University Hospital Essen, Essen, Germany
| | - Christopher Darr
- Department of Urology, University Hospital Essen, Essen, Germany
| | - Claudia Kesch
- Department of Urology, University Hospital Essen, Essen, Germany
| | - Jochen Hess
- Department of Urology, University Hospital Essen, Essen, Germany
| | - Ulrich Krafft
- Department of Urology, University Hospital Essen, Essen, Germany
| | | | - Nina Harke
- Department of Urology, University Hospital Essen, Essen, Germany
- Department of Urology, Hannover Medical School, Hannover, Germany
| | - Osama Mahmoud
- Department of Urology, University Hospital Essen, Essen, Germany.
- Department of Urology, Qena Faculty of Medicine, South Valley University, Qena, Egypt.
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25
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Kolehmainen CSJ, Ukkonen MT, Tomminen T, Helavirta IM, Laukkarinen JM, Hyöty M, Kotaluoto S. Short learning curve in transition from laparoscopic to robotic-assisted rectal cancer surgery: a prospective study from a Finnish Tertiary Referral Centre. J Robot Surg 2023; 17:2361-2367. [PMID: 37421570 PMCID: PMC10492689 DOI: 10.1007/s11701-023-01626-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/16/2023] [Indexed: 07/10/2023]
Abstract
The narrow pelvis causes special challenges in surgery, and robotic-assisted surgery has been proven beneficial in these circumstances. While robotic surgery has some specific advantages in rectal cancer surgery, there is still limited evidence of the learning curve of the technique involved. The aim here was to study the transition from laparoscopic to robotic-assisted surgery among experienced laparoscopic surgeons. The data for this study were collected from a prospectively compiled register that includes patients operated on by the Da Vinci Xi robot in Tampere University Hospital. Each consecutive rectal cancer patient was included. The information on the surgical and oncological outcomes was analysed. The learning curve was assessed using cumulative sum (CUSUM) analysis. CUSUM already demonstrated an overall positively sloped curve at the beginning of the study, with neither the conversion rate nor morbidity reaching unacceptable thresholds. Conversions (4%) and postoperative complications (Clavien-Dindo III-IV 15%, no intraoperative complications) were rare. One patient died within one month and the death was not procedure-associated. While surgical and oncological outcomes were similar among all surgeons, the console times showed a decreasing trend and were shorter among those with more experience in laparoscopic rectal cancer surgery. Robotic-assisted rectal cancer surgery can be safely adapted by experienced laparoscopic colorectal surgeons.
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Affiliation(s)
- Charlotta S J Kolehmainen
- Faculty of Medicine and Health Technology, Tampere University, Kauppi Campus, Arvo Building, Arvo Ylpön katu 34, 33520, Tampere, Finland.
| | - Mika T Ukkonen
- Faculty of Medicine and Health Technology, Tampere University, Kauppi Campus, Arvo Building, Arvo Ylpön katu 34, 33520, Tampere, Finland
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Timo Tomminen
- Faculty of Medicine and Health Technology, Tampere University, Kauppi Campus, Arvo Building, Arvo Ylpön katu 34, 33520, Tampere, Finland
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Ilona M Helavirta
- Faculty of Medicine and Health Technology, Tampere University, Kauppi Campus, Arvo Building, Arvo Ylpön katu 34, 33520, Tampere, Finland
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Johanna M Laukkarinen
- Faculty of Medicine and Health Technology, Tampere University, Kauppi Campus, Arvo Building, Arvo Ylpön katu 34, 33520, Tampere, Finland
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Marja Hyöty
- Faculty of Medicine and Health Technology, Tampere University, Kauppi Campus, Arvo Building, Arvo Ylpön katu 34, 33520, Tampere, Finland
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Sannamari Kotaluoto
- Faculty of Medicine and Health Technology, Tampere University, Kauppi Campus, Arvo Building, Arvo Ylpön katu 34, 33520, Tampere, Finland
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
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26
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Zaepfel S, Marcovei R, Fernandez-de-Sevilla E, Sourrouille I, Honore C, Gelli M, Faron M, Benhaim L. Robotic-assisted surgery for mid and low rectal cancer: a long but safe learning curve. J Robot Surg 2023; 17:2099-2108. [PMID: 37219783 DOI: 10.1007/s11701-023-01624-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/15/2023] [Indexed: 05/24/2023]
Abstract
The number of robotic-assisted procedures for rectal cancer is rising. The risk of this procedure when performed by surgeon with limited robotic experience is unknown and the precise duration of the learning curve debated. We, therefore, aimed to analyze the learning curve and its related safety in a single center before the development of mentoring programs. We prospectively recorded all robotic procedures performed for colorectal cancer between 2015 and 2020 by a single surgeon. Operative times for partial and total proctectomy were analyzed. The learning curve was defined by comparison with the standard duration of the laparoscopic procedure performed in expert centers (published in GRECCAR 5 and GRECCAR 6 trials) and calculated using a cumulative summation for learning curve test (LC-CUSUM). Among the 174 patients operated for colorectal cancer, we analyzed the outcomes of the 89 patients operated by partial and total robotic proctectomy. To reach repeatedly the same surgical duration as laparoscopic procedure for partial or complete proctectomy, the LC-CUSUM identified a learning curve of 57 patients. A severe morbidity in this population, defined by Clavien-Dindo classification ≥ 3, was observed in 15 cases (16.8%) with an anastomotic leak rate of 13.5%. The rate of completeness of mesorectal excision was 90% and the mean number of harvested lymph nodes was 15 (± 9). Using operative time as end-point, the learning curve of rectal cancer robotic surgery identified a cut-off of 57 patients. The technic remained safe with acceptable morbidity and oncological outcomes.
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Affiliation(s)
- Sophie Zaepfel
- Department of Surgical Oncology, Gustave Roussy Cancer Center, 39 rue Camille Desmoulins, 94800, Villejuif, France
| | - Raluca Marcovei
- Department of Surgical Oncology, Gustave Roussy Cancer Center, 39 rue Camille Desmoulins, 94800, Villejuif, France
| | - Elena Fernandez-de-Sevilla
- Department of Surgical Oncology, Gustave Roussy Cancer Center, 39 rue Camille Desmoulins, 94800, Villejuif, France
| | - Isabelle Sourrouille
- Department of Surgical Oncology, Gustave Roussy Cancer Center, 39 rue Camille Desmoulins, 94800, Villejuif, France
| | - Charles Honore
- Department of Surgical Oncology, Gustave Roussy Cancer Center, 39 rue Camille Desmoulins, 94800, Villejuif, France
| | - Maximiliano Gelli
- Department of Surgical Oncology, Gustave Roussy Cancer Center, 39 rue Camille Desmoulins, 94800, Villejuif, France
| | - Matthieu Faron
- Department of Surgical Oncology, Gustave Roussy Cancer Center, 39 rue Camille Desmoulins, 94800, Villejuif, France
- Oncostat U1018, Inserm, Université Paris-Saclay, Équipe Labellisée Ligue Contre le Cancer, Villejuif, France
| | - Leonor Benhaim
- Department of Surgical Oncology, Gustave Roussy Cancer Center, 39 rue Camille Desmoulins, 94800, Villejuif, France.
- Centre de Recherche Des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Equipe Labellisée Ligue Nationale Contre le Cancer, CNRS SNC 5096, 15 rue de l'école de Médecine, 75006, Paris, France.
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27
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Pathak A, Wanjari M. Minimally Invasive Colorectal Surgery Techniques. Cureus 2023; 15:e47203. [PMID: 38021760 PMCID: PMC10652800 DOI: 10.7759/cureus.47203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Colorectal surgery has witnessed a transformative shift with the advent of minimally invasive techniques, offering patients reduced postoperative discomfort, shorter hospital stays, and accelerated recovery compared to conventional open surgery. This comprehensive review aims to assess the current state of minimally invasive approaches in colorectal surgery, encompassing various techniques such as single-incision laparoscopic surgery, robot-assisted surgery, and conventional laparoscopic surgery. The article meticulously explores the benefits and drawbacks of each technique, delves into the established criteria for their application, delineates cautious circumstances, and analyzes the outcomes of minimally invasive colorectal surgery. Additionally, the integration of virtual reality and augmented reality for surgical planning and training is discussed, shedding light on the future trajectory of this field. Surgeons and researchers striving to enhance patient care and surgical outcomes in colorectal surgery will find this review article an invaluable resource, presenting crucial components of minimally invasive colorectal surgery and paving the way for continued advancements in the field.
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Affiliation(s)
- Akash Pathak
- Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Mayur Wanjari
- Research and Development, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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28
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Ahuja V, Paredes LG, Leeds IL, Perkal MF, King JT. Clinical outcomes of elective robotic vs laparoscopic surgery for colon cancer utilizing a large national database. Surg Endosc 2023; 37:7199-7205. [PMID: 37365394 DOI: 10.1007/s00464-023-10215-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/11/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Prior studies have shown comparable outcomes between laparoscopic and robotic approaches across a range of surgeries; however, these have been limited in size. This study investigates differences in outcomes following robotic (RC) vs laparoscopic (LC) colectomy across several years utilizing a large national database. METHODS We analyzed data from ACS NSQIP for patients who underwent elective minimally invasive colectomies for colon cancer from 2012 to 2020. Inverse probability weighting with regression adjustment (IPWRA) incorporating demographics, operative factors, and comorbidities was used. Outcomes included mortality, complications, return to the operating room (OR), post-operative length of stay (LOS), operative time, readmission, and anastomotic leak. Secondary analysis was performed to further assess anastomotic leak rate following right and left colectomies. RESULTS We identified 83,841 patients who underwent elective minimally invasive colectomies: 14,122 (16.8%) RC and 69,719 (83.2%) LC. Patients who underwent RC were younger, more likely to be male, non-Hispanic White, with higher body mass index (BMI) and fewer comorbidities (for all, P < 0.05). After adjustment, there were no differences between RC and LC for 30-day mortality (0.8% vs 0.9% respectively, P = 0.457) or overall complications (16.9% vs 17.2%, P = 0.432). RC was associated with higher return to OR (5.1% vs 3.6%, P < 0.001), lower LOS (4.9 vs 5.1 days, P < 0.001), longer operative time (247 vs 184 min, P < 0.001), and higher rates of readmission (8.8% vs 7.2%, P < 0.001). Anastomotic leak rates were comparable for right-sided RC vs LC (2.1% vs 2.2%, P = 0.713), higher for left-sided LC (2.7%, P < 0.001), and highest for left-sided RC (3.4%, P < 0.001). CONCLUSIONS Robotic approach for elective colon cancer resection has similar outcomes to its laparoscopic counterpart. There were no differences in mortality or overall complications, however anastomotic leaks were highest after left RC. Further investigation is imperative to better understand the potential impact of technological advancement such as robotic surgery on patient outcomes.
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Affiliation(s)
- Vanita Ahuja
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA
| | - Lucero G Paredes
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA.
- National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT, 06510-8088, USA.
- Department of Surgery, Maine Medical Center, Portland, ME, USA.
| | - Ira L Leeds
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA
| | - Melissa F Perkal
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA
| | - Joseph T King
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
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29
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Arquillière J, Dubois A, Rullier E, Rouanet P, Denost Q, Celerier B, Pezet D, Passot G, Aboukassem A, Colombo PE, Mourregot A, Carrere S, Vaudoyer D, Gourgou S, Gauthier L, Cotte E. Learning curve for robotic-assisted total mesorectal excision: a multicentre, prospective study. Colorectal Dis 2023; 25:1863-1877. [PMID: 37525421 DOI: 10.1111/codi.16695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/19/2023] [Accepted: 06/26/2023] [Indexed: 08/02/2023]
Abstract
AIM Robotic-assisted surgery (RAS) is becoming increasingly important in colorectal surgery. Recognition of the short, safe learning curve (LC) could potentially improve implementation. We evaluated the extent and safety of the LC in robotic resection for rectal cancer. METHOD Consecutive rectal cancer resections (January 2018 to February 2021) were prospectively included from three French centres, involving nine surgeons. LC analyses only included surgeons who had performed more than 25 robotic rectal cancer surgeries. The primary endpoint was operating time LC and the secondary endpoint conversion rate LC. Interphase comparisons included demographic and intraoperative data, operating time, conversion rate, pathological specimen features and postoperative morbidity. RESULTS In 174 patients (69% men; mean age 62.6 years) the mean operating time was 334.5 ± 92.1 min. Operative procedures included low anterior resection (n = 143) and intersphincteric resection (n = 31). For operating time, there were two or three (centre-dependent) LC phases. After 12-21 cases (learning phase), there was a significant decrease in total operating time (all centres) and an increase in the number of harvested lymph nodes (two centres). For conversion rate, there were two or four LC phases. After 9-14 cases (learning phase), the conversion rate decreased significantly in two centres; in one centre, there was a nonsignificant decrease despite the treatment of significantly more obese patients and patients with previous abdominal surgery. There were no significant differences in interphase comparisons. CONCLUSION The LC for RAS in rectal cancer was achieved after 12-21 cases for the operating time and 9-14 cases for the conversion rate. RAS for rectal cancer was safe during this time, with no interphase differences in postoperative complications and circumferential resection margin.
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Affiliation(s)
- J Arquillière
- Department of Digestive and Oncological Surgery, Lyon University Hospital, Lyon-Sud Hospital, Pierre-Bénite, France
| | - A Dubois
- Department of Colorectal Surgery, CHU Estaing, Clermont-Ferrand, France
| | - E Rullier
- Department of Digestive Surgery, Colorectal Unit, Bordeaux University Hospital, Haut-Lévèque Hospital, Pessac, France
| | - P Rouanet
- Department of Colorectal Surgery, Institut Du Cancer De Montpellier, Montpellier, France
| | - Q Denost
- Bordeaux Colorectal Institute, Clinique Tivoli, Bordeaux, France
| | - B Celerier
- Department of Digestive Surgery, Colorectal Unit, Bordeaux University Hospital, Haut-Lévèque Hospital, Pessac, France
| | - D Pezet
- Department of Colorectal Surgery, CHU Estaing, Clermont-Ferrand, France
| | - G Passot
- Department of Digestive and Oncological Surgery, Lyon University Hospital, Lyon-Sud Hospital, Pierre-Bénite, France
- Lyon Center for Innovation in Cancer, CICLY EA 3738, Lyon 1 University, Lyon, France
| | - A Aboukassem
- Department of Colorectal Surgery, CHU Estaing, Clermont-Ferrand, France
| | - P E Colombo
- Department of Colorectal Surgery, Institut Du Cancer De Montpellier, Montpellier, France
| | - A Mourregot
- Department of Colorectal Surgery, Institut Du Cancer De Montpellier, Montpellier, France
| | - S Carrere
- Department of Colorectal Surgery, Institut Du Cancer De Montpellier, Montpellier, France
| | - D Vaudoyer
- Department of Digestive and Oncological Surgery, Lyon University Hospital, Lyon-Sud Hospital, Pierre-Bénite, France
- Lyon Center for Innovation in Cancer, CICLY EA 3738, Lyon 1 University, Lyon, France
| | - S Gourgou
- Biometrics Unit, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - L Gauthier
- Biometrics Unit, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - E Cotte
- Department of Digestive and Oncological Surgery, Lyon University Hospital, Lyon-Sud Hospital, Pierre-Bénite, France
- Lyon Center for Innovation in Cancer, CICLY EA 3738, Lyon 1 University, Lyon, France
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de Rezende BB, Assumpção LR, Haddad R, Terra RM, Marques RG. Characteristics of the learning curve in robotic thoracic surgery in an emerging country. J Robot Surg 2023; 17:1809-1816. [PMID: 37083992 DOI: 10.1007/s11701-023-01590-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/26/2023] [Indexed: 04/22/2023]
Abstract
It is not established which factors impact the learning curve (LC) in robotic thoracic surgery (RTS), especially in emerging countries. The aim of this study is to analyze LC in RTS in Brazil and identify factors that can accelerate LC. We selected the first cases of two Brazilian surgeons who started their LC. We used CUSUM and the Lowess technique to measure LC for each surgeon and Poisson regression to assess factors associated with shorter console time (CT). 58 patients were operated by each surgeon and included in the analysis. Surgeries performed were different: Surgeon I (SI) performed 54 lobectomies (93.11%), whereas Surgeon II (SII) had a varied mix of cases. SI was proctored in his first 10 cases (17.24%), while SII in his first 41 cases (70.68%). The mean interval between surgeries was 8 days for SI and 16 days for SII. There were differences in the LC phases of the two surgeons, mainly regarding complications and conversions. There was shorter CT by 30% in the presence of a proctor, and by 20% with the Da Vinci Xi. Mix of cases did not seem to contribute to faster LC. Higher frequency between surgeries seems to be associated with a faster curve. Presence of proctor and use of bolder technologies reduced console time. We wonder if in phase 3 it is necessary to keep a proctor on complex cases to avoid serious complications. More studies are necessary to understand which factors impact the LC.
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Affiliation(s)
- Bruna Brandão de Rezende
- Universidade do Estado do Rio de Janeiro, Pós Graduação em Fisiopatologia e Ciências Cirúrgicas, Rio de Janeiro, RJ, Brazil.
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Lia Roque Assumpção
- Universidade do Estado do Rio de Janeiro, Pós Graduação em Fisiopatologia e Ciências Cirúrgicas, Rio de Janeiro, RJ, Brazil
| | - Rui Haddad
- Departamento de Cirurgia, Pontifícia Universidade Católica - PUC-RIO, Rio de Janeiro, RJ, Brazil
| | - Ricardo Mingarini Terra
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
- Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ruy Garcia Marques
- Universidade do Estado do Rio de Janeiro, Pós Graduação em Fisiopatologia e Ciências Cirúrgicas, Rio de Janeiro, RJ, Brazil
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Matsuura N, Igai H, Ohsawa F, Numajiri K, Kamiyoshihara M. Learning curve for uniportal thoracoscopic pulmonary segmentectomy: how many procedures are required to acquire expertise? Transl Lung Cancer Res 2023; 12:1466-1476. [PMID: 37577322 PMCID: PMC10413023 DOI: 10.21037/tlcr-23-104] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 07/04/2023] [Indexed: 08/15/2023]
Abstract
Background Minimally invasive surgeries are increasingly being performed. However, few studies have evaluated the learning curve for uniportal thoracoscopic segmentectomies. Therefore, we investigated the learning curve for uniportal thoracoscopic segmentectomy in our department. Methods We retrospectively reviewed the clinical data of consecutive patients who underwent uniportal thoracoscopic segmentectomy at our institution between February 2019 and January 2022. Two senior surgeons [Hitoshi Igai (H.I.) and Natsumi Matsuura (N.M.)] performed all of the surgeries. H.I. introduced uniportal thoracoscopic segmentectomy in our department and supervised N.M. performing this operation. Resident surgeons participated in the operations as assistants. The learning curve for uniportal thoracoscopic segmentectomy was evaluated on the basis of operative time and cumulative sum (CUSUMOT). Results The entire team, including resident surgeons, completed the learning curve by performing 60 surgeries. The learning curve consisted of three phases: initial learning (60 surgeries), accumulation of competence (16 surgeries), and acquisition of expertise (17 surgeries), respectively. The operative time, blood loss, postoperative drainage, and postoperative hospitalization time significantly improved across the phases. N.M. completed the initial learning curve faster than H.I. (16 and 29 surgeries, respectively). Conclusions Under supervision by an experienced surgeon, a team successfully completed the learning curve for uniportal thoracoscopic segmentectomy and achieved good perioperative outcomes, which indicates the importance of appropriate supervision for acquiring expertise for this surgery.
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Affiliation(s)
- Natsumi Matsuura
- Department of General Thoracic Surgery, Japanese Red Cross Maebashi Hospital, Maebashi, Gunma, Japan
| | - Hitoshi Igai
- Department of General Thoracic Surgery, Japanese Red Cross Maebashi Hospital, Maebashi, Gunma, Japan
| | - Fumi Ohsawa
- Department of General Thoracic Surgery, Japanese Red Cross Maebashi Hospital, Maebashi, Gunma, Japan
| | - Kazuki Numajiri
- Department of General Thoracic Surgery, Japanese Red Cross Maebashi Hospital, Maebashi, Gunma, Japan
| | - Mitsuhiro Kamiyoshihara
- Department of General Thoracic Surgery, Japanese Red Cross Maebashi Hospital, Maebashi, Gunma, Japan
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Duan X, Zhao Y, Zhang J, Kong N, Cao R, Guan H, Li Y, Wang K, Yang P, Tian R. Learning curve and short-term clinical outcomes of a new seven-axis robot-assisted total knee arthroplasty system: a propensity score-matched retrospective cohort study. J Orthop Surg Res 2023; 18:425. [PMID: 37308901 DOI: 10.1186/s13018-023-03899-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/01/2023] [Indexed: 06/14/2023] Open
Abstract
OBJECTIVE The purpose of the present study was to determine the learning curve for a novel seven-axis robot-assisted (RA) total knee arthroplasty (TKA) system and to explore whether it could provide superior short-term clinical and radiological outcomes compared with conventional surgery. METHODS In the present retrospective study, 90 patients who underwent RA-TKA were included in robot-assisted system (RAS) group and 90 patients who underwent conventional TKA were included in the conventional group. The duration of surgery and robot-related complications were recorded to evaluate the learning curve through cumulative sum and risk-adjusted cumulative sum methods. The demographic data, preoperative clinical data, preoperative imaging data, duration of surgery, alignment of the prosthesis, lower limb force line alignment, Knee Society score, 10-cm visual analog scale pain score and range of motion were compared between the RAS and conventional groups. In addition, the proficiency group was compared with the conventional group using propensity score matching. RESULTS RA-TKA was associated with a learning curve of 20 cases for the duration of surgery. There was no significant difference in indicators representing the accuracy of the prosthetic installation between the learning and proficiency phases in RA-TKA group patients. A total of 49 patients in the proficiency group were matched with 49 patients from the conventional group. The number of postoperative hip-knee-ankle (HKA) angle, component femoral coronal angle (CFCA), component tibial coronal angle (CTCA), and sagittal tibial component angle (STCA) outliers in the proficiency phase was lower than that in the conventional group, while deviations of the HKA angle, CFCA, CTCA, and STCA in the proficiency phase were significantly lower than those in the conventional group (P < 0.05). CONCLUSION In summary, from the learning curve data, 20 cases are required for a surgeon using a novel seven-axis RA-TKA system to enter the proficiency phase. In the proficiency group, compared with the conventional group using propensity score matching, the RAS was found to be superior to the conventional group in prosthesis and lower limb alignment.
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Affiliation(s)
- Xudong Duan
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - Yiwei Zhao
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - Jiewen Zhang
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - Ning Kong
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - Ruomu Cao
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - Huanshuai Guan
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - Yiyang Li
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - Kunzheng Wang
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - Pei Yang
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China.
| | - Run Tian
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China.
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Tian R, Duan X, Kong N, Wang K, Yang P. Precise acetabular positioning, discrepancy in leg length, and hip offset using a new seven-axis robot-assisted total hip arthroplasty system requires no learning curve: a retrospective study. J Orthop Surg Res 2023; 18:236. [PMID: 36964615 PMCID: PMC10037797 DOI: 10.1186/s13018-023-03735-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 03/20/2023] [Indexed: 03/26/2023] Open
Abstract
Objective The purpose of the present study was to determine the learning curve for a novel seven-axis robot-assisted total hip arthroplasty (RA-THA) system, and to explore whether it was able to provide greater accuracy in acetabular cup positioning, superior leg length discrepancy (LLD), and hip offset than conventional methods. Methods A total of 160 patients in which unilateral THA was performed in the second affiliated Hospital of Xi'an Jiaotong University from July 2021 to September 2022 were studied. The first 80 patients underwent robot-assisted THA, while conventional THA was performed on the subsequent 80 by the same team of experienced surgeons. The learning curve for the RA-THA system was evaluated using cumulative sum (CUSUM) analysis. The demographic data, preoperative clinical data, duration of surgery, postoperative Harris hip score (HHS) and postoperative radiographic data from patients that had conventional THA were compared. Results The 80 patients who underwent primary unilateral RA-THA comprised 42 males and 38 females and were followed up for 12 weeks. Using analysis by CUSUM, the learning curve of the RA-THA system could be divided into learning and proficiency phases, the former of which consisted of the first 17 cases. There was no significant difference between the learning and proficiency phases in terms of LLD, hip offset, or accuracy of acetabular prosthesis position in the RA-THA groups. The proportion of acetabular prostheses located in the Lewinnek safe zone was 90.5% in the proficiency group and 77.5% in the conventional group, respectively, a difference that was statistically significant (P < 0.05). The absolute error between target angle and postoperative measured angle of anteversion was statistically significant in the proficiency group and the conventional group((P < 0.05). Postoperative acetabular anteversion and LLD were 19.96 ± 5.68° and 6.00 (5.00) mm in the proficiency group, respectively, and 17.84 ± 6.81° and 8.09 (4.33) mm using conventional surgery, respectively (anteversion: P = 0.049; LLD: P < 0.001). Conclusions The surgical team required a learning curve of 17 cases using the RA-THA system to become proficient. There was no learning curve for other parameters, namely LLD, hip offset, or accuracy of acetabular prosthesis positioning. During the proficiency phase, the RA system was superior to conventional THA for control of leg length and accuracy of acetabular cup placement.
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Affiliation(s)
- Run Tian
- grid.452672.00000 0004 1757 5804Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710004 China
| | - Xudong Duan
- grid.452672.00000 0004 1757 5804Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710004 China
| | - Ning Kong
- grid.452672.00000 0004 1757 5804Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710004 China
| | - Kunzheng Wang
- grid.452672.00000 0004 1757 5804Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710004 China
| | - Pei Yang
- grid.452672.00000 0004 1757 5804Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710004 China
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He T, Sun X, Liu C, Yuan M, Yang G, Cheng K, Dai S, Xu C. Learning curve for total thoracoscopic segmentectomy in treating pediatric patients with congenital lung malformation. Surg Endosc 2023:10.1007/s00464-023-09987-8. [PMID: 36941411 DOI: 10.1007/s00464-023-09987-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 02/25/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Total thoracoscopic segmentectomy (TTS) is a technically challenging procedure in children but results in more parenchyma preservation, better pain control, better cosmetic results, and a shorter hospital stay. However, definitive data describing the learning curve of TTS has yet to be obtained. Here, we review the safety and efficiency of our initial experiences with pediatric TTS and evaluate our learning curve. METHODS This was a retrospective study of all pediatric patients undergoing TTS between December 2016 and January 2020. Pediatric patients who underwent TTS were included, while those undergoing lobectomy or wedge resection were excluded. RESULTS One hundred and twelve patients were retrospectively analyzed to evaluate the learning curve and were divided chronologically into three phases, the ascending phase (A), plateau phase (B) and descending phase (C), through cumulative summation (CUSUM) of the operative time (OT). Phases A, B, and C comprised 28, 51, and 33 cases, respectively. OT decreased significantly from phases A to B (p < 0.001) and from phase B to C (p = 0.076). No significant differences were observed in the demographic factors among the three phases. The conversion rate was zero, and the complication rate was 0.9%. Differences in technical parameters, such as length of stay and chest tube duration, were statistically insignificant between phases A and B or B and C. There were no mortalities. CONCLUSION CUSUMOT indicates that the learning curve of at least 79 cases is required for TTS in our institute. We emphasize that the learning curve should be cautiously interpreted because many factors in different institutions may influence the exact parabola and actual learning curve.
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Affiliation(s)
- Taozhen He
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Xiaoyan Sun
- Health Management Centre, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Chenyu Liu
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Miao Yuan
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Gang Yang
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Kaisheng Cheng
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Shiyi Dai
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Chang Xu
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China.
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Gap Balancing Throughout the Arc of Motion with Navigated TKA and a Novel Force-Controlled Distractor: A Review of the First 273 Cases. J Arthroplasty 2023; 38:S246-S252. [PMID: 36931358 DOI: 10.1016/j.arth.2023.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/01/2023] [Accepted: 03/05/2023] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND This study evaluated the ability to achieve the targeted soft-tissue balance in terms of medio-lateral (ML) laxity and gap values when using a computer-assisted orthopedic surgery (CAOS) system featuring an intraarticular, force-controlled distractor and assessed learning curves associated with the adoption of this technology. METHODS The first 273 cases using this technology were reported without any exclusions comparing 1) final ML laxity and 2) final average gap to their pre-defined targets. For both parameters, the signed and unsigned differentials were reported. The linear mixed model was used to evaluate laxity curve differences between surgeons. A cumulative sum control chart (CUSUM) was applied to assess surgeon learning curves regarding surgical time. RESULTS Both the average signed ML laxity and gap differentials were neutral throughout the full arc of motion. Both the average unsigned ML laxity and gap differentials were linear. Signature of ML laxity and gap differential curves tended to be surgeon-specific. The CUSUM analyses of surgical times demonstrated either a short learning curve or the absence of a discernable learning pattern for surgeons. CONCLUSION Data from all users involved with the pilot release of the balancing device were considered to capture variability in familiarity with the technique and learning curve cases were included. A high ability to achieve targeted gap balance throughout the arc of motion using the proposed method was observed.
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Levy BE, MacDonald M, Bontrager N, Castle JT, Draus JM, Worhunsky DJ. Evaluation of the learning curve for laparoscopic pyloromyotomy. Surg Endosc 2023:10.1007/s00464-023-09962-3. [PMID: 36922426 DOI: 10.1007/s00464-023-09962-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 02/12/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Laparoscopic pyloromyotomy is the preferred surgical management of hypertrophic pyloric stenosis at most centers. We aimed to analyze the learning curve for laparoscopic pyloromyotomy using the experience of five fellowship-trained pediatric surgeons. METHODS A retrospective review of consecutive patients undergoing laparoscopic pyloromyotomy was performed. All cases were performed with general surgery residents. Cumulative sum (CUSUM) analysis for operating time was performed for up to the first 150 consecutive cases for individual surgeons. Outcomes were compared to identify different phases of the learning curve for operative competency. RESULTS A total of 414 patients were included in the analysis as not all surgeons had reached 150 cases at time of analysis. The mean operating time was 29.2 min for all cases across the 5 surgeons. CUSUM analysis for mean operating time revealed three phases of learning: Learning Phase (cases 1-16), Plateau Phase (cases 17-87), and a Proficiency Phase (cases 88-150). The mean operating time during the three phases was 34.1, 29.0, and 28.3 min, respectively (P = 0.005). There were no differences in complications, reoperations, length of stay, or readmissions across the three phases. CONCLUSION Three distinct phases of learning for laparoscopic pyloromyotomy were identified with no differences in outcomes across the phases. The operating time differed only for the Learning Phase, suggesting that some degree of proficiency occurs after 16 cases.
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Affiliation(s)
- Brittany E Levy
- Division of Pediatric Surgery, Department of Surgery, University of Kentucky and Kentucky Children's Hospital, 800 Rose Street, MS463A, Lexington, KY, 40536, USA
| | - Mia MacDonald
- Department of General Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Nicholas Bontrager
- Division of Pediatric Surgery, Department of Surgery, University of Kentucky and Kentucky Children's Hospital, 800 Rose Street, MS463A, Lexington, KY, 40536, USA
| | - Jennifer T Castle
- Division of Pediatric Surgery, Department of Surgery, University of Kentucky and Kentucky Children's Hospital, 800 Rose Street, MS463A, Lexington, KY, 40536, USA
| | - John M Draus
- Department of Surgery, Nemours Children's Health, Jacksonville, FL, USA
| | - David J Worhunsky
- Division of Pediatric Surgery, Department of Surgery, University of Kentucky and Kentucky Children's Hospital, 800 Rose Street, MS463A, Lexington, KY, 40536, USA.
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Shu D, Cai Z, Yin X, Zheng M, Li J, Yang X, Zhang S, Aikemu B, Qin W, Xu X, Lian Y, Zhou J, Jing C, Feng B. Structured training curricula for robotic colorectal surgery in China: does laparoscopic experience affect training effects? J Gastrointest Oncol 2023; 14:198-205. [PMID: 36915428 PMCID: PMC10007934 DOI: 10.21037/jgo-22-1193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/14/2023] [Indexed: 03/02/2023] Open
Abstract
Background Robotic surgery has been widely adopted for colorectal cancer (CRC). Many surgeons in China have completed structured training programs and have performed robotic colorectal surgeries. This multicenter study aimed to evaluate the training effects of structured training curricula in China for surgeons with different laparoscopic experiences during their initial implementation of robotic colorectal surgery. Methods Ten surgeons from five high-volume centers participated in this retrospective study. The baseline characteristics, perioperative data, and pathological outcomes were compared between the first 15 robotic surgeries performed by five surgeons with extensive laparoscopic experience (group A) and the first 15 robotic surgeries performed by five surgeons with limited laparoscopic experience (group B) at each center. Results Compared with group B, group A showed shorter operation time (200.9 vs. 254.2 min, P<0.001), less blood loss (100.0 vs. 150.0 mL, P=0.025), and a lower incidence of intraoperative complications (2.7% vs. 21.4%, P=0.015). The reoperation rate (1.3% vs. 5.3%, P=0.036) and postoperative complication rate (6.7% vs. 22.7%, P=0.025) were significantly lower in group A than in group B. There were no statistically significant differences in baseline characteristics (e.g., age, sex, and tumor location) and pathological information (e.g., tumor stage, lymph node count, and tumor size) between the two groups. Radical resection (R0) was performed in all cases. Conclusions In China, structured training curricula can help surgeons with extensive laparoscopic experience make a smooth transition from laparoscopic to robotic surgery. However, the higher intraoperative and postoperative complication rates indicate that structured training curricula still require further refinement for surgeons with limited laparoscopic experience.
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Affiliation(s)
- Duohuo Shu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhenghao Cai
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiang Yin
- Department of Minimally Invasive Tumor Surgery, Daqing Oilfield General Hospital, Daqing, China
| | - Minhua Zheng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianwen Li
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao Yang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sen Zhang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Batuer Aikemu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Qin
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ximo Xu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yugui Lian
- Department of Colorectal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jianping Zhou
- Department of Gastrointestinal Surgery & Hernia and Abdominal Wall Surgery, The First Hospital, China Medical University, Shenyang, China
| | - Changqing Jing
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Bo Feng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Burghgraef TA, Sikkenk DJ, Crolla RMPH, Fahim M, Melenhorst J, Moumni ME, Schelling GVD, Smits AB, Stassen LPS, Verheijen PM, Consten ECJ. Assessing the learning curve of robot-assisted total mesorectal excision: a multicenter study considering procedural safety, pathological safety, and efficiency. Int J Colorectal Dis 2023; 38:9. [PMID: 36630001 PMCID: PMC9834356 DOI: 10.1007/s00384-022-04303-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 01/12/2023]
Abstract
PURPOSE Evidence regarding the learning curve of robot-assisted total mesorectal excision is scarce and of low quality. Case-mix is mostly not taken into account, and learning curves are based on operative time, while preferably clinical outcomes and literature-based limits should be used. Therefore, this study aims to assess the learning curve of robot-assisted total mesorectal excision. METHODS A retrospective study was performed in four Dutch centers. The primary aim was to assess the safety of the individual and institutional learning curves using a RA-CUSUM analysis based on intraoperative complications, major postoperative complications, and compound pathological outcome (positive circumferential margin or incomplete TME specimen). The learning curve for efficiency was assessed using a LC-CUSUM analysis for operative time. Outcomes of patients before and after the learning curve were compared. RESULTS In this study, seven participating surgeons performed robot-assisted total mesorectal excisions in 531 patients. Learning curves for intraoperative complications, postoperative complications, and compound pathological outcome did not exceed predefined literature-based limits. The LC-CUSUM for operative time showed lengths of the learning curve ranging from 12 to 35 cases. Intraoperative, postoperative, and pathological outcomes did not differ between patients operated during and after the learning curve. CONCLUSION The learning curve of robot-assisted total mesorectal excision based on intraoperative complications, postoperative complications, and compound pathological outcome did not exceed predefined limits and is therefore suggested to be safe. Using operative time as a surrogate for efficiency, the learning curve is estimated to be between 12 and 35 procedures.
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Affiliation(s)
- T A Burghgraef
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands.
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands.
| | - D J Sikkenk
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
| | - R M P H Crolla
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - M Fahim
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - J Melenhorst
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - M El Moumni
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - A B Smits
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - L P S Stassen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - P M Verheijen
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
| | - E C J Consten
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
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Han SH, Ji JY, Cha W, Jeong WJ. Cumulative sum analysis of the learning curve for robotic retroauricular thyroidectomy. Gland Surg 2023; 12:30-38. [PMID: 36761485 PMCID: PMC9906102 DOI: 10.21037/gs-22-365] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 11/18/2022] [Indexed: 12/29/2022]
Abstract
Background Remote-access robotic thyroid surgery enables avoiding a visible scar on the neck and allows precise manipulation through a magnified surgical view. The retroauricular approach has many advantages. This study aimed to evaluate the learning curve for robotic retroauricular thyroidectomy using cumulative sum analysis. Methods The medical records of 36 patients who underwent robotic retroauricular thyroidectomy between 2018 and 2021 were retrospectively reviewed. The clinical features and surgical outcomes were analyzed; the learning curve was evaluated using the cumulative sum analysis. Results The learning curve using cumulative sum analysis was divided into two phases based on 15 cases: phase I (first 15 cases) and phase II (remaining 21 cases). The total operation time was significantly shorter in phase II than that in phase I (161.9±23.4 vs. 199±41.0 min, P=0.002). The flap dissection and docking time (77.1±14.3 vs. 90.0±21.5 min, P=0.037) and console time (36.5±16.2 vs. 50.3±17.8 min, P=0.020) were significantly shorter in phase II than that in phase I. There was no significant difference between the two phases in the total amount of drainage, duration of hospital stay, and complications after the surgery. Conclusions The learning curve for robotic retroauricular thyroidectomy demonstrates that the operation time decreased rapidly after 15 cases. Proficiency in docking and manipulating the instruments accelerate the learning curve.
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Affiliation(s)
- Seung Hoon Han
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Jeong-Yeon Ji
- Department of Otorhinolaryngology-Head & Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Wonjae Cha
- Department of Otorhinolaryngology-Head & Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Woo-Jin Jeong
- Department of Otorhinolaryngology-Head & Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea;,Sensory Organ Research Institute, Seoul National University Medical Research Center, Seoul, Korea
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Seniority of the assistant surgeon and perioperative outcomes in robotic-assisted proctectomy for rectal cancer. J Robot Surg 2022; 17:1097-1104. [PMID: 36586036 DOI: 10.1007/s11701-022-01515-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 12/25/2022] [Indexed: 01/01/2023]
Abstract
The background of this study is to evaluate the impact of the assistant surgeon's in robotic-assisted proctectomy (RAP) on perioperative outcomes. A retrospective analysis of all patients who underwent RAP for rectal adenocarcinoma between 2011 and 2020 was conducted. Patient cohort was divided into three groups based on the assistant surgeon's training level: post-graduate years (PGY) 1-3 surgical residents (Group 1), PGY 4-5 surgical residents (Group 2), and board-certified general surgeons (Group 3). Overall, 175 patients were included in the study: 29 patients (17%) in Group 1, 84 (48%) in Group 2, and 62 (35%) in Group 3. The median tumor distance from the anal verge was 8 cm in all groups (p = 0.73). The median operative time was similar across all groups: 290, 291, and 281 min in Groups 1, 2, and 3, respectively (p = 0.69). In a multivariable analysis, the lack of association between assistant training level and procedure time maintained when adjusting for the year of operation (p = 0.84). Patients operated with junior residents as assistant surgeons (Group 1) had a more postoperative complications (p = 0.01) and a slightly longer hospital length of stay [7 days, interquartile range (IQR) 3], compared to those operated by assistant surgeons that were senior residents or attendings (6 IQR 2.5, and 6 IQR 2 in Groups 2 and 3, respectively; p = 0.02). Conversion rates (p = 0.12), intraoperative complications (p = 0.39), major postoperative complications (Clavien-Dindo ≥ 3; p = 0.32), 30-day readmission (p = 0.45), and mortality (p = 0.99) were similar between the groups. Robotic-assisted proctectomy performed with the assistance of a junior resident was found to be correlated with worse postoperative outcomes compared to more experienced assistants. No difference was seen in intraoperative outcomes.
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A method for identifying the learning curve for the surgical stabilization of rib fractures. J Trauma Acute Care Surg 2022; 93:743-749. [PMID: 36121229 DOI: 10.1097/ta.0000000000003788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Surgical stabilization of rib fractures (SSRF) is an accepted efficacious treatment modality for patients with severe chest wall injuries. Despite increased adoption of SSRF, surgical learning curves are unknown. We hypothesized intraoperative duration could define individual SSRF learning curves. METHODS Consecutive SSRF operations between January 2017 and December 2021 at a single institution were reviewed. Operative time, as measured from incision until skin closure, was evaluated by cumulative sum methodology using a range of acceptable "missteps" to determine the learning curves. Misstep was defined by extrapolation of accumulated operative time data. RESULTS Eighty-three patients underwent SSRF by three surgeons during this retrospective review. Average operative times ranged from 135 minutes for two plates to 247 minutes for seven plates. Using polynomial regression of average operative times, 75 minutes for general procedural requirements plus 35 minutes per plate were derived as the anticipated operative times per procedure. Cumulative sum analyses using 5%, 10%, 15%, and 20% incident rates for not meeting expected operative times, or "missteps" were used. An institutional learning curve between 15 and 55 SSRF operations was identified assuming a 90% performance rate. An individual learning curve of 15 to 20 operations assuming a 90% performance rate was observed. After this period, operative times stabilized or decreased for surgeons A, B, and C. CONCLUSION The institutional and individual surgeon learning curves for SSRF appears to steadily improve after 15 to 20 operations using operative time as a surrogate for performance. The implementation of SSRF programs by trauma/acute care surgeons is feasible with an attainable learning curve. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Stern N, Li Y, Wang PZ, Dave S. A cumulative sum (CUSUM) analysis studying operative times and complications for a surgeon transitioning from laparoscopic to robot-assisted pediatric pyeloplasty: Defining proficiency and competency. J Pediatr Urol 2022; 18:822-829. [PMID: 36064506 DOI: 10.1016/j.jpurol.2022.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/16/2022] [Accepted: 07/24/2022] [Indexed: 01/12/2023]
Abstract
INTRODUCTION The transition from laparoscopic to robot-assisted procedures leads to potential increase in operative times and health care costs. Cumulative sum (CUSUM) analysis can objectively study the learning curve to detect significant changes in operative timing and monitor complication rates. OBJECTIVE The objective of this study is to investigate the total and step-specific times for pediatric robot-assisted pyeloplasty (RAP) to investigate the learning curve of a single surgeon transitioning from laparoscopic to RAP. STUDY DESIGN This prospective cohort study included 50 consecutive RAP procedures performed since the inception of our robotic program from June 2013 to January 2019. The CUSUM of RAP total operative time (OT) was calculated to determine the breakpoints between learning phases using piecewise linear regression. Cumulative-observed-minus-expected failure chart with 80% and 95% reassurance boundary lines was constructed using 5% acceptable and 10% unacceptable complication rates. Step-specific operative times were prospectively recorded by an independent observer for port placement, dissection and hitch stitch placement, pelvis dismemberment and spatulation, suturing and port removal. RESULTS Piecewise linear regression for OT identified breakpoints at case 13 and 29 suggesting transition at these points between Learning to Proficiency, and Proficiency to Competency. The overall mean OT was 142.2 ± 46.0 min. There was a significant difference in the mean OT between Learning (203.9 ± 35.3 min, the initial 13 cases), Proficiency (159.2 ± 18.6 min, the middle 16 cases), and Competency (126.6 ± 19.7 min, the last 21 cases) phases (p < 0.001). The complication rate for RAP stabilized around the acceptable level of 5% up to case 41 before finalizing at 8% overall. The step-specific analysis suggested that suturing entered the Competency phase at case 27, with a 50% decrease in suturing time from Learning to Proficiency and Competency. DISCUSSION Our study suggests that by case 30 a surgeon transitioning to RAP can achieve a significant decrease in OT. Complication rates remained within acceptable limits throughout, indicating that RAP can be safely adopted, even in low volume RAP centres. Suturing competency seems to be a significant advantage of the robotic platform as suggested by early significant decrease in suturing times noted between the Learning and Proficiency phases. CONCLUSION Future studies can confirm these findings and establish reference operative times to aid surgeons and trainees transitioning from laparoscopic pyeloplasty to RAP. Moreover, total OT decreases significantly and relatively soon after transition to RAP.
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Affiliation(s)
- Noah Stern
- Schulich School of Medicine and Dentistry: Western University Schulich School of Medicine & Dentistry, London ON, N6A 5C1, Canada.
| | - Yilong Li
- Schulich School of Medicine and Dentistry: Western University Schulich School of Medicine & Dentistry, London ON, N6A 5C1, Canada.
| | - Peter Zhantao Wang
- Schulich School of Medicine and Dentistry: Western University Schulich School of Medicine & Dentistry, Department of Surgery and Pediatrics, Division of Urology, London ON, N6A 5W9, Canada.
| | - Sumit Dave
- Schulich School of Medicine and Dentistry: Western University Schulich School of Medicine & Dentistry, Department of Surgery and Pediatrics, Division of Urology, London ON, N6A 5W9, Canada.
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Lin CY, Liu YC, Chen MC, Chiang FF. Learning curve and surgical outcome of robotic assisted colorectal surgery with ERAS program. Sci Rep 2022; 12:20566. [PMID: 36446802 PMCID: PMC9709162 DOI: 10.1038/s41598-022-24665-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/18/2022] [Indexed: 11/30/2022] Open
Abstract
This study analyzed learning curve and the surgical outcome of robotic assisted colorectal surgery with ERAS program. The study results serve as a reference for future robotic colorectal surgeon who applied ERAS in clinical practice. This was a retrospective case-control study to analyze the learning curve of 141 robotic assisted colorectal surgery (RAS) by Da Vinci Xi (Xi) system and compare the surgical outcomes with 147 conventional laparoscopic (LSC) surgery in the same team. Evaluation for maturation was performed by operation time and the CUSUM plot. Patients were recruited from 1st February 2019 to 9th January 2022; follow-up was conducted at 30 days, and the final follow-up was conducted on 9th February 2022. It both took 31 cases for colon and rectal robotic surgeries to reach the maturation phase. Teamwork maturation was achieved after 60 cases. In the maturation stage, RAS required a longer operation time (mean: colon: 249.5 ± 46.5 vs. 190.3 ± 57.3 p < 0.001; rectum 314.9 ± 59.6 vs. 223.6 ± 63.5 p < 0.001). After propensity score matching, robotic surgery with ERAS program resulted in significant shorter length of hospital stay (mean: colon: 5.5 ± 4.5 vs. 10.0 ± 11.9, p < 0.001; rectum: 5.4 ± 3.5 vs. 10.1 ± 7.0, p < 0.001), lower minor complication rate (colon: 6.0% vs 20.0%, p = 0.074 ; rectum: 11.1% vs 33.3%, p = 0.102), and no significant different major complication rate (colon: 2.0% vs 6.0%, p = 0.617; rectum: 7.4% cs 7.4%, p = 1.0) to conventional LSC. Learning curve for robotic assisted colorectal surgery takes 31 cases. Robotic surgery with ERAS program brings significant faster recovery and fewer complication rate compared to laparoscopy in colorectal surgery.
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Affiliation(s)
- Chun-Yu Lin
- Department of Colorectal Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, National Defense Medical University, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Yi-Chun Liu
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Ming-Cheng Chen
- Department of Colorectal Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Feng-Fan Chiang
- Department of Colorectal Surgery, Taichung Veterans General Hospital, Taichung, Taiwan.
- College of Humanities and Social Sciences, Providence University, Taichung, Taiwan.
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Vanella S, Bottazzi EC, Farese G, Murano R, Noviello A, Palma T, Godas M, Crafa F. Minimally invasive colorectal surgery learning curve. World J Gastrointest Endosc 2022; 14:731-736. [PMID: 36438877 PMCID: PMC9693684 DOI: 10.4253/wjge.v14.i11.731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/01/2022] [Accepted: 10/31/2022] [Indexed: 11/14/2022] Open
Abstract
The learning curve in minimally invasive colorectal surgery is a constant subject of discussion in the literature. Discordant data likely reflects the varying degrees of each surgeon’s experience in colorectal, laparoscopic or robotic surgery. Several factors are necessary for a successful minimally invasive colorectal surgery training program, including: Compliance with oncological outcomes; dissection along the embryological planes; constant presence of an expert tutor; periodic discussion of the morbidity and mortality rate; and creation of a dedicated, expert team.
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Affiliation(s)
- Serafino Vanella
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Enrico Coppola Bottazzi
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Giancarlo Farese
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Rosa Murano
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Adele Noviello
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Tommaso Palma
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Maria Godas
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Francesco Crafa
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
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Ozeki Y, Hirasawa K, Sawada A, Ikeda R, Nishio M, Fukuchi T, Kobayashi R, Sato C, Maeda S. Learning curve analysis for duodenal endoscopic submucosal dissection: A single-operator experience. J Gastroenterol Hepatol 2022; 37:2131-2137. [PMID: 36066185 DOI: 10.1111/jgh.15995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/31/2022] [Accepted: 09/04/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIMS Superficial duodenal epithelial tumors are emerging targets for endoscopic submucosal dissection (ESD). However, it is unknown how competence is achieved in duodenal ESD. This study aimed to elucidate the learning curve for duodenal ESD. METHODS This retrospective observational study included 100 consecutive patients who underwent duodenal ESD by a single endoscopist between March 2014 and September 2021. The primary outcome was to define the learning curve for duodenal ESD by an endoscopist with sufficient non-duodenal ESD experience. Cumulative sum (CUSUM) curve analysis was used to assess the learning curve in terms of procedural speed. Comparative analyses of phases identified using the CUSUM method were performed. RESULTS In total, 98 patients were included in the analysis. Evaluation of the cumulative sum curve revealed four distinct phases in the graph: phase I, cases 1-25 (learning phase); phase II, cases 26-47 (proficiency phase); phase III, cases 48-72 (mastery phase); and phase IV, cases 73-98 (after introduction of general anesthesia). The median procedural speed was significantly faster in phase II than in phase I (11.1 mm2 /min vs 7.0 mm2 /min, P = .002). Clinically significant intraoperative perforation tended to decrease through phase II to phase IV (22.7%, 12.0%, and 3.8% in phases II, III, and IV, respectively). Delayed perforation occurred only in phases I and II. CONCLUSIONS Duodenal ESD requires 25 cases to gain proficiency and 50 to achieve mastery even for an endoscopist with extensive non-duodenal ESD experience.
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Affiliation(s)
- Yuichiro Ozeki
- Division of Endoscopy, Yokohama City University Medical Center, Yokohama, Japan
| | - Kingo Hirasawa
- Division of Endoscopy, Yokohama City University Medical Center, Yokohama, Japan
| | - Atsushi Sawada
- Division of Endoscopy, Yokohama City University Medical Center, Yokohama, Japan
| | - Ryosuke Ikeda
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Masafumi Nishio
- Division of Endoscopy, Yokohama City University Medical Center, Yokohama, Japan
| | - Takehide Fukuchi
- Division of Endoscopy, Yokohama City University Medical Center, Yokohama, Japan
| | - Ryosuke Kobayashi
- Division of Endoscopy, Yokohama City University Medical Center, Yokohama, Japan
| | - Chiko Sato
- Division of Endoscopy, Yokohama City University Medical Center, Yokohama, Japan
| | - Shin Maeda
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Norasi H, Tetteh E, Law KE, Ponnala S, Hallbeck MS, Tollefson M. Intraoperative workload during robotic radical prostatectomy: Comparison between multi-port da Vinci Xi and single port da Vinci SP robots. APPLIED ERGONOMICS 2022; 104:103826. [PMID: 35724472 DOI: 10.1016/j.apergo.2022.103826] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/05/2022] [Accepted: 06/03/2022] [Indexed: 06/15/2023]
Abstract
The goal of this study was to quantify and compare prospective self-reported intraoperative workload and teamwork during robot-assisted radical prostatectomy (RARP) for multi-port da Vinci Xi (MP) and single-port da Vinci SP (SP) robots. The self-reported workload (surgeon and surgical team) and teamwork (surgeon) measures were collected and compared between MP and SP RARPs, as well as the learning curve. Results from 25 MP and SP RARPs showed that overall, the NASA-TLX workload subscales were lower, and the teamwork modified NOTECHS subscales were higher for the MP RARPs compared to the SP RARPs. The underlying reason for the significant differences between these two RARP surgical procedures could be other factors (e.g., robot design factors) in addition to the surgeon and surgical team's experience. The results also suggested learning effects through the 25 SP RARPs; however, twenty-five procedures may not be enough to achieve proficiency with the SP system.
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Affiliation(s)
- Hamid Norasi
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN, USA; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA.
| | - Emmanuel Tetteh
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN, USA; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Katherine E Law
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN, USA; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Sid Ponnala
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN, USA
| | - M Susan Hallbeck
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN, USA; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA; Department of Surgery, Mayo Clinic, Rochester, MN, USA.
| | - Matthew Tollefson
- Department of Surgery, Mayo Clinic, Rochester, MN, USA; Department of Urology, Mayo Clinic, Rochester, MN, USA
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Using a modified Delphi process to explore international surgeon-reported benefits of robotic-assisted surgery to perform abdominal rectopexy. Tech Coloproctol 2022; 26:953-962. [DOI: 10.1007/s10151-022-02679-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/31/2022] [Indexed: 11/25/2022]
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Han KN, Lee JH, Hong JI, Kim HK. Comparison of Two-Port and Three-Port Approaches in Robotic Lobectomy for Non-Small Cell Lung Cancer. World J Surg 2022; 46:2517-2525. [PMID: 35879445 DOI: 10.1007/s00268-022-06660-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Robot-assisted lobectomy has been used to treat non-small cell lung cancer and usually uses 3 or 4 ports and 3 or 4 robotic arms. We recently developed a two-port approach for robotic lobectomy using three robotic arms and performed a propensity score-matched analysis to compare the feasibility of the two-port and three-port techniques. METHODS Data on robotic lobectomy for non-small cell lung cancer were retrospectively reviewed. Patients were matched using propensity score based on age, sex, smoking, diabetes, hypertension, forced expiratory volume per 1 s, neoadjuvant chemotherapy, clinical stage, lobe involved, tumor size, and cell types. Overall, 53 and 89 patients who underwent the two-port and three-port approaches, respectively, were matched (1:1 ratio; caliper distance, 0.2). We analyzed the perioperative outcomes and postoperative pain to evaluate the feasibility and safety. RESULTS The matched group included 37 patients each who underwent two-port and three-port robotic lobectomy. The operation time was shorter in the two-port group (P = .01). The number of lymph nodes resected (P = .70), conversion to multiport or thoracotomy (P > .99), morbidity and mortality (P = .31), drain indwelling time (P = .32), and hospital stay (P = .11) were not significantly different between the groups. The postoperative pain was less at 0-3 postoperative days (P < .01) in the two-port group. The total medical cost was not markedly increased after transitioning to the two-port technique. CONCLUSIONS Two-port approach in robotic lobectomy is a safe and feasible alternative approach for treating non-small cell lung cancer.
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Affiliation(s)
- Kook Nam Han
- Department of Thoracic and Cardiovascular Surgery, Guro Hospital, Korea University College of Medicine, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Jun Hee Lee
- Department of Thoracic and Cardiovascular Surgery, Guro Hospital, Korea University College of Medicine, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Jeong In Hong
- Department of Thoracic and Cardiovascular Surgery, Guro Hospital, Korea University College of Medicine, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Hyun Koo Kim
- Department of Thoracic and Cardiovascular Surgery, Guro Hospital, Korea University College of Medicine, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea.
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Oncological outcomes of open, laparoscopic and robotic colectomy in patients with transverse colon cancer. Tech Coloproctol 2022; 26:821-830. [PMID: 35804251 DOI: 10.1007/s10151-022-02650-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 05/25/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Literature concerning surgical management of transverse colon cancer is scarce, since many key trials excluded transverse colon cancer. The aim of this study was to evaluate clinical and oncological outcomes comparing open, laparoscopic and robotic transverse colon cancer resection. METHODS Consecutive patients who underwent elective surgery for transverse colon cancer between December 2005 and July 2021 were included. Data were kept in a prospective database approved by the institutional ethics committee. Primary outcome was overall and disease-free survival. Secondary outcomes included complications, operative time, length of stay and lymph node harvest. Statistical analysis was corrected for age and tumour localisation. RESULTS Two hundred and forty-six (38 robotic, 71 open and 137 laparoscopic resections) were recruited in this study. There were five conversions during laparoscopic procedures. Operative time was significantly shorter in robotic vs laparoscopic procedures (195 vs 238 min, p = 0.005) and length of stay was shorter in robotic vs laparoscopic and open group (7 vs 9 vs 15 days, p < 0.001). There was no difference in overall complications. R0 resections were similar. Lymph node harvest was highest in the robotic group vs. laparoscopic or open (32 vs. 29 vs. 21, p < 0.001). Overall survival was 97%, 85% and 60% (p < 0.001) and disease-free survival was 91%, 78% and 56% (p < 0.001) for the robotic, laparoscopic and open groups, respectively. CONCLUSIONS Minimally invasive surgery for transverse colon cancer is safe and offers good clinical and oncological outcomes. Robotic resection is associated with significantly shorter operating times, higher lymph node harvest, lower conversion rate and does not increase morbidity. Differences in disease-free and overall survival should be further explored in randomised controlled trials.
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Gil PJ, Ruiz-Manzanera JJ, Ruiz de Angulo D, Munitiz V, Ferreras D, López V, Conesa A, Ortiz Á, Martínez de Haro LF, Ramírez P. Learning Curve for Laparoscopic Sleeve Gastrectomy: a Cumulative Summation (CUSUM) Analysis. Obes Surg 2022; 32:2598-2604. [PMID: 35687255 DOI: 10.1007/s11695-022-06145-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/03/2022] [Accepted: 06/03/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Bariatric surgery is currently considered the most effective and durable treatment option for morbid obesity. Laparoscopic sleeve gastrectomy (LSG) has become a popular technique and may currently be the most frequently practiced surgical operation to treat obesity. However, no objective analyses of its learning curve have been reported. OBJECTIVE to analyze the learning curve for LSG. MATERIALS AND METHODS We included all LSGs performed in our hospital (University Hospital, Spain; Public Practice) from April 2013 to February 2016. The learning curve for LSG was evaluated using cumulative sum (CUSUM) analysis. All variables among the learning curve phases were compared. RESULTS According to the CUSUM analysis, the learning curve was divided into three unique phases: early learning (the initial 26 patients), acquisition of skills (the middle 30 patients), and mastery of technique (the final 56 patients). The operative time and gastric stenosis significantly decreased with progression of the learning curve without differences in the 30-day postoperative complication rate, postoperative stay, or weight loss. CONCLUSION According to this study, the learning curve for LSG can be divided into 3 distinct phases, and about 25 patients are needed to demonstrate an improvement in surgical skill.
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Affiliation(s)
- Pedro J Gil
- General Surgery Service, "Virgen de La Arrixaca" Clinical University Hospital, 30120, El Palmar, Murcia, Spain
| | - Juan José Ruiz-Manzanera
- General Surgery Service, "Virgen de La Arrixaca" Clinical University Hospital, 30120, El Palmar, Murcia, Spain.
| | - David Ruiz de Angulo
- Bariatric Surgery Unit and Upper Gastrointestinal Surgical, General Surgery Service, "Virgen de La Arrixaca" Clinical University Hospital, 30120, El Palmar, Murcia, Spain
| | - Vicente Munitiz
- General Surgery Service, Upper Gastrointestinal Surgical Unit, "Virgen de La Arrixaca" Clinical University Hospital, 30120, El Palmar, Murcia, Spain
| | - David Ferreras
- General Surgery Service, "Virgen de La Arrixaca" Clinical University Hospital, 30120, El Palmar, Murcia, Spain
| | - Víctor López
- General Surgery Service, "Virgen de La Arrixaca" Clinical University Hospital, 30120, El Palmar, Murcia, Spain
| | - Ana Conesa
- General Surgery Service, Upper Gastrointestinal Surgical Unit, "Virgen de La Arrixaca" Clinical University Hospital, 30120, El Palmar, Murcia, Spain
| | - Ángeles Ortiz
- General Surgery Service, Upper Gastrointestinal Surgical Unit, "Virgen de La Arrixaca" Clinical University Hospital, 30120, El Palmar, Murcia, Spain
| | - Luisa F Martínez de Haro
- General Surgery Service, Upper Gastrointestinal Surgical Unit, "Virgen de La Arrixaca" Clinical University Hospital, 30120, El Palmar, Murcia, Spain
| | - Pablo Ramírez
- General Surgery Service, "Virgen de La Arrixaca" Clinical University Hospital, 30120, El Palmar, Murcia, Spain.,Instituto Murciano De Investigación Biosanitaria (IMIB), 30120, El Palmar, Murcia, Spain
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