Abstract
Background
Robotic assisted oesophagectomy (RAO) is increasingly being utilised in the management of oesophageal cancer. RAO implementation into practice has an inevitable learning curve. As oesophagectomy usually involves at least 2 stages, a staggered approach to training and introduction of RAO can be done. A major advantage of this is that the surgeon can concentrate on overcoming the learning curve in one phase of the procedure at a time, whilst the remaining phase can be completed by an established technique.
This study looks at the learning curve of a robotic assisted abdominal phase for two-stage oesophagectomy compared to an open abdominal phase to achieve parity.
Methods
This study uses a prospectively maintained database to retrospectively analyse the abdominal phase of the first 17 RAO compared to the previous 20 open abdominal phase procedures. The cases are sequential, done by a single surgeon at a large UK oesophagogastric referral centre. Operating time, nodal count, and R0 rate were reviewed to determine the number of cases on the learning curve to reach parity with the open procedure.
Results
The open abdominal phase group had a similar age (65.6 vs 65.7), pre-op anaerobic threshold (13.9 vs 14.6 p = 0.3) but a higher BMI (mean 30.6 vs 24.6 p < 0.05) then the RAO group. All cases were T3 adenocarcinoma except for 2 cases in the robotic group (one HGD and one T2 adenocarcinoma). No RAO cases were converted to open. The mean time for the abdominal phase in the open group was 175.4 minutes with an average nodal count of 32.9. After 8 robotic assisted cases the mean operating time decreased from 267 minutes to 197 minutes, which was when a non-significant difference to the open group (p = 0.094) became apparent. The mean nodal count in the first 8 robotic assisted cases was 29.5 and increased to 38.4 in the subsequent cases. All patients had a R0 resection.
Conclusions
The multi-phase nature of oesophagectomy allows for modular implementation of a robotic programme. We have found that the learning curve for robotic assisted abdominal is around 8 cases. This allows for parity to open abdominal phase to be achieved regarding operative time, nodal count and R0 resection.
On the nodal count statistics for separable systems in any dimension
