Minimally Invasive Pediatric Surgery: The Learning Curve

2020 ◽  
Vol 30 (02) ◽  
pp. 172-180
Author(s):  
Marie Uecker ◽  
Joachim F. Kuebler ◽  
Benno M. Ure ◽  
Nagoud Schukfeh
Keyword(s):  
Postoperative Complications ◽  
Minimally Invasive ◽  
Learning Curve ◽  
Clinical Outcomes ◽  
Surgical Procedures ◽  
Operative Time ◽  
Learning Curves ◽  
Current Evidence ◽  
Stenosis Rate ◽  
Mucosal Perforation

AbstractThe use of minimally invasive surgery (MIS) in pediatric patients has increased over the past decades. The process of mastering a new procedure is termed the learning curve, during which the ability to operate increases but poorer outcomes are produced. We aim to analyze the current evidence on learning curves in pediatric MIS and evaluate its impact on patient's clinical outcomes. A systematic literature search was performed for studies listed on PubMed that reported on the learning curve for MIS surgical procedures. Studies were included if they stated the number of procedures required to reach a consistency in outcomes or if they compared outcomes between early and late period of MIS experience regarding the endpoints operative time, conversions, and intra-/postoperative complications. A total of 22 articles reporting on 11 surgical procedures were included in the study. Most authors reported a significant decrease in operative time as well as peri- and postoperative complications with increasing experience of the surgeon. Complications ranged from minor to major, the latter being especially severe for patients receiving pyloromyotomy (5–7% higher risk of mucosal perforation), esophageal atresia repair (15% higher leakage rate and 19–77% higher stenosis rate), or Kasai portoenterostomy (26–35% more liver transplants in the first year after surgery) during the learning curve period. Pediatric MIS comes with a considerable learning curve that may have a significant impact on the patient's clinical outcomes. Efforts should be made to minimize the effect of the learning curve on the patients.

scholarly journals P-OGC26 Learning curves in minimally invasive esophagectomy- a systematic review and evaluation of benchmarking parameters

2021 ◽  
Vol 108 (Supplement_9) ◽  
Author(s):  
Pooja Prasad ◽  
Lauren Wallace ◽  
Maziar Navidi ◽  
Alexander Phillips
Keyword(s):  
Minimally Invasive ◽  
Learning Curve ◽  
Patient Outcomes ◽  
Minimally Invasive Esophagectomy ◽  
Operating Time ◽  
Learning Curves ◽  
Curve Progression ◽  
Current Evidence ◽  
Invasive Esophagectomy ◽  
Multiple Parameters

Abstract Background Minimally invasive techniques are increasingly used in the treatment of esophageal cancer. The learning curve for minimally invasive oesophagectomy (MIO) is variable and can impact on patient outcomes. The aim of this study was to review the current evidence on learning curves in MIO and identify which parameters are used for benchmarking. Methods A search of the major reference databases (PubMed, Medline, Cochrane) was performed with no time limits up to February 2020. Results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if an assessment of the learning curve was reported on, regardless of which (if any) statistical method was used.  Results Twenty-nine studies comprising 3741 patients were included. Twenty-two studies reported on a combination of thoracoscopic, hybrid and total MIO, 6 studies reported robotic assisted MIO (RAMIE) alone and 1 study evaluated both RAMIE and thoracoscopic esophagectomies. Operating time was the most frequently used parameter to determine learning curve progression (23/39 studies), with number of resected lymph nodes, morbidity and blood loss also frequently used. Learning curves were found to plateau at 7-60 cases for thoracoscopic esophagectomy, 12-175 cases for total and thoracoscopic/hybrid esophagectomy and 9-85 cases for RAMIE.  Conclusions Multiple parameters are employed to gauge MIO learning curve progression. However, there are no validated or approved sets of outcomes. Further work is required to determine the optimum parameters that should be utilised to ensure best patient outcomes and required length of proctoring. 

Laparoscopic Pyloromyotomy: A Study of the Learning Curve

2017 ◽  
Vol 28 (03) ◽  
pp. 238-242 ◽  
Author(s):  
François Bastard ◽  
Pierre Meignan ◽  
Karim Braïk ◽  
Anne Le Touze ◽  
Thierry Villemagne ◽  
...  
Keyword(s):  
Postoperative Complications ◽  
Learning Curve ◽  
Operative Time ◽  
Hospital Length ◽  
Learning Curves ◽  
Hospital Length Of Stay ◽  
Minimally Invasive Surgical ◽  
Significant Difference ◽  
Laparoscopic Pyloromyotomy

Introduction Laparoscopic pyloromyotomy (LPM) is a minimally invasive surgical technique used in pyloric stenosis treatment. This technique is safe, effective, and does not show more complications than laparotomy. Nevertheless, this technique requires an acquisition period to be optimally applied. This study analyses the learning curve of LPM. Materials and Methods Seven surgeons were retrospectively evaluated on their 40 first LPM. Patient data were recorded, including peroperative data (operation length and complications) and postoperative recoveries (renutrition, vomiting, and complications). The learning curves were evaluated and each variable was compared with the different moments of the learning curve. Results The mean operative time is 25 ± 11 minutes. It significantly decreases with the learning curve (p < 0.01). Ten procedures were necessary to acquire the operative technics. However, postoperative complications with a necessary redo procedure appear after the 10th patient. There is no significant difference concerning long-term postoperative complications according to the learning curve and to surgeons. The best results are recorded after the 20th patients. Hospital length of stay also decreases significantly after the 10th procedure. The recorded postoperative vomiting is independent to the operative time as the ad libitum feedings recovery. Conclusion The learning curve of LPM is cut into three stages. Only 10 cases are needed to acquire the gesture. Complications appear after this acquirement period.

scholarly journals Learning Curve for Laparoscopic Repair of Pediatric Inguinal Hernia Using Percutaneous Internal Ring Suturing

Children ◽  
2021 ◽  
Vol 8 (4) ◽  
pp. 294
Author(s):  
Zenon Pogorelić ◽  
Dario Huskić ◽  
Tin Čohadžić ◽  
Miro Jukić ◽  
Tomislav Šušnjar
Keyword(s):  
Inguinal Hernia ◽  
Laparoscopic Surgery ◽  
Postoperative Complications ◽  
Hernia Repair ◽  
Learning Curve ◽  
Operative Time ◽  
Learning Curves ◽  
The Other ◽  
Internal Ring ◽  
Significant Difference

Background: Percutaneous internal ring suturing (PIRS) is a simple and popular technique for the treatment of inguinal hernia in children. The aim of this study was to analyze the learning curves during implementation of PIRS in our department. Methods: A total of 318 pediatric patients underwent hernia repair using the PIRS technique by three pediatric surgeons with different levels of experience in laparoscopic surgery. These patients were enrolled in a prospective cohort study during the period October 2015–January 2021. Surgical times, intraoperative and postoperative complications, in addition to outcomes of treatment were compared among the pediatric surgeons. Results: Regarding operative time a significant difference among the surgeons was found. Operative time significantly decreased after 25–30 procedures per surgeon. The surgeon with advanced experience in laparoscopic surgery had significantly less operative times for both unilateral (12 (interquartile range, IQR 10.5, 16.5) min vs. 21 (IQR 16.5, 28) min and 25 (IQR 21.5, 30) min; p = 0.002) and bilateral (19 (IQR 14, 21) min vs. 28 (IQR 25, 33) min and 31 (IQR 24, 36) min; p = 0.0001) hernia repair, compared to the other two surgeons. Perioperative complications, conversion, and ipsilateral recurrence rates were higher at the beginning, reaching the benchmarks when each surgeon performed at least 30 PIRS procedures. The most experienced surgeon had the lowest number of complications (1.4%) and needed a fewer number of cases to reach the plateau. The other two surgeons with less experience in laparoscopic surgery had higher rates of complications (4.4% and 5.4%) and needed a higher number of cases to reach the plateau (p = 0.190). Conclusions: A PIRS learning curve for perioperative and postoperative complications, recurrences, and conversion rates reached the plateau after each surgeon had performed at least 30 cases. After that number of cases PIRS is a safe and effective approach for pediatric hernia repair. A surgeon with an advanced level of experience in pediatric laparoscopic surgery adopted the technique more easily and had a significantly faster learning curve.

scholarly journals Learning curve and complications of minimally invasive transforaminal lumbar interbody fusion

2013 ◽  
Vol 35 (2) ◽  
pp. E7 ◽  
Author(s):  
Pedro S. Silva ◽  
Paulo Pereira ◽  
Pedro Monteiro ◽  
Pedro A. Silva ◽  
Rui Vaz
Keyword(s):  
Minimally Invasive ◽  
Learning Curve ◽  
Interbody Fusion ◽  
Operative Time ◽  
Pedicle Screws ◽  
Transforaminal Lumbar Interbody Fusion ◽  
Complication Rates ◽  
Lumbar Interbody Fusion ◽  
Adjacent Level ◽  
Negative Exponential

Object Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) has the potential advantage of minimizing soft-tissue damage and reducing recovery time compared to open procedures. A steep learning curve has been described for the technique. The aim of the present study was to define the learning curve that describes the progress of a single surgeon performing the MI-TLIF. Methods One hundred fifty consecutive patients with degenerative lumbar disease who underwent 1- or 2-level MI-TLIF were included in the study. Operative time, corrected operative time per level, and complications were analyzed. The learning curve was assessed using a negative exponential curve-fit regression analysis. Results One hundred ten patients underwent 1-level and 18 patients underwent 2-level MI-TLIF; the remaining 22 underwent a single-level procedure plus an ancillary procedure (decompression at adjacent level, vertebral augmentation through fenestrated pedicle screws, interspinous device at adjacent level). Negative exponential curves appropriately described the relationship between operative time and experience for 1-level surgery and after correction of operative time per level (R2 = 0.65 and 0.57). The median operative time was 140 minutes (interquartile range 120–173 minutes), and a 50% learning milestone was achieved at Case 12; a 90% learning milestone was achieved at Case 39. No patient required transfusion in the perioperative period. The overall complication rate was 12.67% and the most frequent complication was a dural tear (5.32%). Before the 50% and 90% learning milestones, the complication rates were 33% and 20.51%, respectively. Conclusions The MI-TLIF is a reliable and effective option for lumbar arthrodesis. According to the present study, 90% of the learning curve can be achieved at around the 40th case.

Getting it right first time: implementation of laparoscopic pyloromyotomy without a learning curve

2021 ◽  
Vol 103 (2) ◽  
pp. 130-133
Author(s):  
GS Arul ◽  
W Moni-Nwinia ◽  
G Soccorso ◽  
M Pachl ◽  
M Singh ◽  
...  
Keyword(s):  
Learning Curve ◽  
New Technologies ◽  
Wound Dehiscence ◽  
Learning Curves ◽  
Routine Practice ◽  
Female Ratio ◽  
Day Range ◽  
Implementation Period ◽  
Mucosal Perforation ◽  
Laparoscopic Pyloromyotomy

Introduction Laparoscopic pyloromyotomy is now an accepted procedure for the treatment of pyloric stenosis. However, it is clear that during the implementation period there are significantly higher incidences of mucosal perforation and incomplete pyloromyotomy. We describe how we introduced a new laparoscopic procedure without the complications associated with the learning curve. Materials and methods Five consultants tasked one surgeon to pilot and establish laparoscopic pyloromyotomy before mentoring the others until they were performing the procedure independently; all agreed to use exactly the same instruments and operative technique. This involved a 5mm 30-degree infra-umbilical telescope with two 3mm instruments. Data were collected prospectively. Results Between 1 January 2013 and 31 December 2017, 140 laparoscopic pyloromyotomies were performed (median age 27 days, range 13–133 days, male to female ratio 121:19). Fifty-five per cent of procedures were performed by trainees. Complications were one mucosal perforation and one inadequate pyloromyotomy. There were no injuries to other organs, problems with wound dehiscence or other significant complications. The median time of discharge was one day (range one to six days). Conclusion Our rate of perforation and incomplete pyloromyotomy was 1.4%, which is equivalent to the best published series of either open or laparoscopic pyloromyotomy. We believe that this resulted from the coordinated implementation of the procedure using a single technique to reduce clinical variability, increase mentoring and improve training. This approach appears self-evident but is rarely described in the literature of learning curves. In this age of increased accountability, new technologies should be incorporated into routine practice without an increase in morbidity to patients.

scholarly journals Learning curve in minimally invasive mitral valve surgery: a single-center experience

2019 ◽  
Vol 14 (1) ◽  
Author(s):  
Anh Tuan Vo ◽  
Dinh Hoang Nguyen ◽  
Sy Van Hoang ◽  
Khoi Minh Le ◽  
Thu Trang Nguyen ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Minimally Invasive ◽  
Learning Curve ◽  
Mitral Valve Surgery ◽  
Learning Curves ◽  
Valve Surgery ◽  
Technical Failure ◽  
Cumulative Number ◽  
Excellent Outcome ◽  
Single Center Experience

Abstract Background Minimally invasive mitral valve surgery is becoming a gold standard and provides many advantages for patients. A learning curve is required for a surgeon to become proficient, and the exact number to overcome this curve is controversial. Our study aimed to define this number for mitral valve surgery in general, for replacement and repair separately. Methods A total of 204 mitral valve surgeries were performed via the right minithoracotomy approach from October 2014 to January 2019 by a single surgeon who isexperienced in conventional mitral valve surgery. Learning curves were analysed based on the trend of important variables (cross-clamp time, CPB time, ventilation time, ICU time, composite technical failure) over time, and the number of operations required was calculated by CUSUM method. Results MIMVS provided an excellent outcome in the carefully selected patients, with low mortality of 0.5% and low rate of complications. The decreasing trend of the important variables were observed over the years and as the cumulative number of procedures increased. The number of operations required to overcome the learning curve was 75 to 100 cases. When considered separately, the quantity for mitral valve replacement was 60 cases, whereas valve repair necessitated at least 90 cases to have an acceptable technical complication rate. Conclusion MIMVS is an excellent choice for mitral valve surgery. However, this approach required a long learning curve for a surgeon who is experienced in conventional mitral valve surgery. Trial registration The research was registered and approved by the ethical board of the University of Medicine and Pharmacy at Ho Chi Minh City, number 141/DHYD-HDDD, on April 11th 2018.

scholarly journals The Learning Curve of Minimally-Invasive Lumbar Microdiscectomy

2008 ◽  
Vol 35 (1) ◽  
pp. 75-78 ◽  
Author(s):  
Gregory S. McLoughlin ◽  
Daryl R. Fourney
Keyword(s):  
Minimally Invasive ◽  
Learning Curve ◽  
Operative Time ◽  
Controlled Trial ◽  
Lumbar Disc ◽  
Tubular Retractor ◽  
Lumbar Microdiscectomy ◽  
Randomized Controlled ◽  
Length Of Hospitalization ◽  
New Surgical Technique

Object:The safe integration into practice of a new surgical technique requires an appreciation of the learning curve. The object of this study was to assess the learning curve for minimally invasive microdiscectomy (MIM) utilizing a tubular retractor system.Methods:A prospective evaluation of a single surgeon's first 52 consecutive MIM cases for radiculopathy secondary to single-level posterolateral lumbar disc herniation was performed. The learning curve was assessed using operative time, conversion to open rate, complications, and length of hospitalization.Results:The duration of operative time decreased over the course of the study (range, 49-151 min). By case 15, operative time was typically 60 min or less. There was only one conversion to an open procedure (Case 2). Complications occurred in three cases. All but nine patients were discharged home on the day of surgery.Conclusion:The learning curve for MIM was demonstrated. Further assessment of this curve for a large group of surgeons is necessary before a randomized controlled trial comparing standard microdiscectomy to MIM can be conducted.

scholarly journals Less invasive spinal deformity surgery: the impact of the learning curve at tertiary spine care centers

2019 ◽  
Vol 31 (6) ◽  
pp. 865-872 ◽  
Author(s):  
Michael Y. Wang ◽  
Stacie Tran ◽  
G. Damian Brusko ◽  
Robert Eastlack ◽  
Paul Park ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Learning Curve ◽  
Clinical Outcomes ◽  
Spinal Deformity ◽  
Adult Spinal Deformity ◽  
Perioperative Outcomes ◽  
Less Invasive ◽  
The Past ◽  
Spinal Deformity Surgery ◽  
Spine Care

OBJECTIVEThe past decade has seen major advances in techniques for treating more complex spinal disorders using minimally invasive surgery (MIS). While appealing from the standpoint of patient perioperative outcomes, a major impediment to adoption has been the significant learning curve in utilizing MIS techniques.METHODSData were retrospectively analyzed from a multicenter series of adult spinal deformity surgeries treated at eight tertiary spine care centers in the period from 2008 to 2015. All patients had undergone a less invasive or hybrid approach for a deformity correction satisfying the following inclusion criteria at baseline: coronal Cobb angle ≥ 20°, sagittal vertical axis (SVA) > 5 cm, or pelvic tilt > 20°. Analyzed data included baseline demographic details, severity of deformity, surgical metrics, clinical outcomes (numeric rating scale [NRS] score and Oswestry Disability Index [ODI]), radiographic outcomes, and complications. A minimum follow-up of 2 years was required for study inclusion.RESULTSAcross the 8-year study period, among 222 patients, there was a trend toward treating increasingly morbid patients, with the mean age increasing from 50.7 to 62.4 years (p = 0.013) and the BMI increasing from 25.5 to 31.4 kg/m2 (p = 0.12). There was no statistical difference in the severity of coronal and sagittal deformity treated over the study period. With regard to radiographic changes following surgery, there was an increasing emphasis on sagittal correction and, conversely, less coronal correction. There was no statistically significant difference in clinical outcomes over the 8-year period, and meaningful improvements were seen in all years (ODI range of improvement: 15.0–26.9). Neither were there statistically significant differences in major complications; however, minor complications were seen less often as the surgeons gained experience (p = 0.064). Operative time was decreased on average by 47% over the 8-year period.Trends in surgical practice were seen as well. Total fusion construct length was unchanged until the last year when there was a marked decrease in conjunction with a decrease in interbody levels treated (p = 0.004) while obtaining a higher degree of sagittal correction, suggesting more selective but powerful interbody reduction methods as reflected by an increase in the lateral and anterior column resection techniques being utilized.CONCLUSIONSThe use of minimally invasive methods for adult spinal deformity surgery has evolved over the past decade. Experienced surgeons are treating older and more morbid patients with similar outcomes. A reliance on selective, more powerful interbody approaches is increasing as well.

418 SYSTEMATIC REVIEW OF LEARNING CURVES IN MINIMALLY INVASIVE PARAESOPHAGEAL HERNIA REPAIR: IS THERE ENOUGH EVIDENCE FOR MENTORSHIP IN SURGICAL RESIDENCY?

2020 ◽  
Vol 33 (Supplement_1) ◽  
Author(s):  
P Prasad ◽  
M Navidi ◽  
N Hayes ◽  
S Wahed ◽  
A Immanuel ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Learning Curve ◽  
Paraesophageal Hernia ◽  
Learning Curves ◽  
Cochrane Library ◽  
Surgical Residents ◽  
Trainee Group ◽  
Newcastle Ottawa Scale ◽  
Meta Analyses ◽  
The Cochrane Library

Abstract   Laparoscopic repair remains the approach of choice for the surgical management of symptomatic paraesophageal hernia (PEH), although robotic techniques are becoming increasingly popular. The learning curve for minimally invasive PEH repair can be variable and little is known of its potential impact upon surgical residents’ training. The aim of this review is to appraise current literature on learning curves in PEH repair and its impact on training and mentorship of surgical residents. Methods Literature searches were performed in three databases: MEDLINE (1980-2020), EMBASE and the Cochrane Library. Search results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data quality was assessed in accordance with the Newcastle-Ottawa Scale for cohort studies. Results A total of 6 studies were identified; 4 laparoscopic and 2 robotic assisted with 2678 patients assessed in total. One study used a cumulative sum (CUSUM) analysis to define learning with the remainder of studies using between 3 and 11 parameters. 2 studies evaluated trainees’ performance in performing laparoscopic PEH repair when mentored by surgeons who had achieved competence on the learning curve. Both studies reported equivalent clinical outcomes for laparoscopic PEH repair performed by trainees versus consultants, although one study suggested 5-year outcomes were inferior in the trainee group despite mentorship. Conclusion Despite being commonly performed, little is known about the learning curves for minimally invasive PEH repair. Furthermore, whether prior laparoscopic experience confers any advantage to performing robotic PEH repair is not known at present. Further data to help evaluate the learning curve for those performing PEH is required in order to enhance training and permit quicker attainment of competency.

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