Learning curve of robot-assisted choledochal cyst excision in pediatrics: report of 60 cases

A young adult male presented with biliary colic and intermittent jaundice for 1 year. Abdomen findings were unremarkable. Routine investigations revealed a raised total bilirubin. On abdominal ultrasonography, common bile duct (CBD) dilatation with multiple stones was noted. On further imaging with magnetic resonance cholangiopancreatography, type I choledochal cyst (CDC) was suspected. A laparoscopic approach was planned. Intraoperatively, dilatation of cystic duct was noted which constitute type VI CDC. Partial malrotation of the gut and accessory right hepatic artery were also noted as incidental finding. Laparoscopic cholecystectomy with CBD exploration and removal of stones, biliary stent placement, cystic duct cyst excision and primary repair of CBD was done. Postoperatively, the patient improved symptomatically with a fall in bilirubin to normal range. We are describing the laparoscopic management of a rare case of type IV CDC which was diagnosed intraoperatively.

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Learning curve for robot-assisted Ivor Lewis esophagectomy

Diseases of the Esophagus ◽

10.1093/dote/doab026 ◽

2021 ◽

Author(s):

Yu Han ◽

Yajie Zhang ◽

Wentian Zhang ◽

Jie Xiang ◽

Kai Chen ◽

...

Keyword(s):

Learning Curve ◽

Complication Rate ◽

Major Complication ◽

Robot Assisted ◽

Ivor Lewis ◽

Initial Learning ◽

Cusum Analysis ◽

Technical Proficiency ◽

Major Complication Rate ◽

Two Phases

Summary This study aimed to demonstrate the learning curve of robot-assisted minimally invasive esophagectomy (RAMIE). A retrospective analysis of the first 124 consecutive patients who underwent RAMIE with intrathoracic anastomosis (Ivor Lewis) by a single surgeon between May 2015 and August 2020 was performed. An risk-adjusted cumulative sum (RA-CUSUM) analysis was applied to generate a learning curve of RAMIE considering the major complication rate, which reflected the technical proficiency. The overall 30-day morbidity rate was 38.7%, while the major complication rate was 25.8%. The learning curve was divided into two phases based on the RA-CUSUM analysis: phase I, the initial learning phase (cases 1–51) and phase II, the proficiency phase (cases 52–124). As we compared the proficiency phase with the initial learning phase, significantly decreased trends were observed in relation to the major complication rate (37.3% vs. 18.7%, P = 0.017), total operation time (330.9 ± 55.6 vs. 267.3 ± 39.1 minutes, P < 0.001), and length of hospitalization (10 [IQR, 9–14] days vs. 9 [IQR, 8–11] days, P = 0.034). In conclusion, the learning curve of RAMIE consisted of two phases, and at least 51 cases were required to gain technical proficiency.

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Laparoscopic treatment of congenital choledochal cyst and hepaticojejunostomy with extracorporeal Roux-en-Y anastomosis: technical aspects and early experience with three cases

La Pediatria Medica e Chirurgica ◽

10.4081/pmc.2016.125 ◽

2016 ◽

Vol 38 (2) ◽

Cited By ~ 2

Author(s):

Mario Lima ◽

Tommaso Gargano ◽

Giovanni Ruggeri ◽

Francesca Destro ◽

Michela Maffi

Keyword(s):

Choledochal Cyst ◽

Laparoscopic Approach ◽

Rare Condition ◽

Early Experience ◽

Cyst Excision ◽

Intrahepatic Bile Ducts ◽

First Case ◽

Laparoscopic Excision ◽

Extracorporeal Anastomosis ◽

Laparoscopic Removal

Choledochal cyst (CDC) is a congenital dilatation of the extra and/or intrahepatic bile ducts and it is a rare condition in western countries. Classical treatment consists of cyst excision and hepaticojejunostomy. The first case of a laparoscopic CDC excision was described in 1995 and since that time an increasing number of institutions have adopted this technique, with good success. We describe our early experience of 3 cases of CDC treated with laparoscopic approach. We used a 10 mm umbilical port for the camera, and four 3-5 mm operative ports. We performed the laparoscopic removal of the cyst and gallbladder, videoassisted preparation of the Roux-en-Y loop and laparoscopic hepaticjejunostomy. No post-operative complications occurred. Laparoscopic excision of CDCs has been supposed to give better observation, a better cosmetic result, potentially less postoperative pain, and a shorter recovery. The main argument for performing an extracorporeal anastomosis is that it decreases the operative time. We recommend caution to prevent injury to the pancreatic duct and biliary structures during dissection and anastomosis. Lifelong surveillance is mandatory, even after resection of the choledochal cyst.

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The impact of a structured intensive modular training in the learning curve of robot assisted radical prostatectomy

Archivio Italiano di Urologia e Andrologia ◽

10.4081/aiua.2018.1.1 ◽

2018 ◽

Vol 90 (1) ◽

pp. 1 ◽

Cited By ~ 6

Author(s):

Riccardo Schiavina ◽

Marco Borghesi ◽

Hussam Dababneh ◽

Martina Sofia Rossi ◽

Cristian Vincenzo Pultrone ◽

...

Keyword(s):

Learning Curve ◽

Functional Outcomes ◽

Statistical Significance ◽

Urinary Continence ◽

Operating Table ◽

Open Approach ◽

Robot Assisted ◽

Modular Training ◽

Continence Rate ◽

The Impact

Aim: The success of Robot Assisted Laparoscopic Prostatectomy (RALP) is mainly due to his relatively short learning curve. Twenty cases are needed to reach a “4 hours-proficiency”. However, to achieve optimal functional outcomes such as urinary continence and potency recovery may require more experience. We aim to report the perioperative and early functional outcomes of patients undergoing RALP, after a structured modular training program. Methods: A surgeon with no previous laparoscopic or robotic experience attained a 3 month modular training including: a) e-learning; b) assistance and training to the operating table; c) dry console training; d) step by step in vivo modular training performing 40 surgical steps in increasing difficulty, under the supervision of an experienced mentor. Demographics, intraoperative and postoperative functional outcomes were recorded after his first 120 procedures, considering four groups of 30 cases. Results: All procedures were completed successfully without conversion to open approach. Overall 19 (15%) post operative complications were observed and 84% were graded as minor (Clavien I-II). Overall operative time and console time gradually decreased during the learning curve, with statistical significance in favour of Group 4. The overall continence rate at 1 and 3 months was 74% and 87% respectively with a significant improvement in continence rate throughout the four groups (p = 0.04). Considering those patients submitted to nerve-sparing procedure we found a significant increase in potency recovery over the four groups (p = 0.04) with the higher potency recovery rate up to 80% in the last 30 cases. Conclusions: Optimal perioperative and functional outcomes have been attained since early phase of the learning curve after an intensive structured modular training and less than 100 consecutive procedures seem needed in order to achieve optimal urinary continence and erectile function recovery.

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