Real-time assessment of learning curve for robot-assisted laparoscopic prostatectomy

Introduction The learning curves analysed to date for robot-assisted laparoscopic prostatectomy are based on arbitrary cut-offs of the total cases. Methods We analysed a large dataset of robot-assisted laparoscopic prostatectomies from a single centre between 2008 and 2019 for assessment of the learning curve for perioperative outcomes with respect to time and individual cases. Results A total of 1,406 patients were evaluated, with mean operative time 198.08 minutes and mean console time 161.05 minutes. A plot of operative time and console time showed an initial decline followed by a near-constant phase. The inflection points were detected at 1,398 days (308th case) for operative time and 1,470 days (324th case) for console time, with a declining trend of 8.83 minutes and 7.07 minutes, respectively, per quarter-year (p<0.001). Mean estimated blood loss showed a 70.04% reduction between the start (214.76ml) and end (64.35ml) (p<0.001). The complication rate did not vary with respect to time (p=0.188) or the number of procedures (p=0.354). There was insufficient evidence to claim that the number of operations (p=0.326), D’Amico classification (p=0.114 for intermediate versus low; p=0.158 for high versus low) or time (p=0.114) was associated with the odds of positive surgical margins. Conclusions It takes about 300 cases and nearly 4 years to standardise operative and console times, with a requirement of around 80 cases per annum for a single surgical team in the initial years to optimise the outcomes of robot-assisted laparoscopic prostatectomy.

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P99 A STRUCTURED TRAINING PATHWAY TO IMPLEMENT ROBOT-ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY (RAMIE): LEARNING CURVE RESULTS FROM A HIGH VOLUME CENTER

Diseases of the Esophagus ◽

10.1093/dote/doz092.99 ◽

2019 ◽

Vol 32 (Supplement_2) ◽

Author(s):

Kingma BF ◽

Hadzijusufovic E ◽

van der Sluis PC ◽

Lang H ◽

Ruurda JP ◽

...

Keyword(s):

Blood Loss ◽

Minimally Invasive ◽

Learning Curve ◽

Minimally Invasive Esophagectomy ◽

Operating Time ◽

Learning Curves ◽

Perioperative Outcomes ◽

Intraoperative Blood Loss ◽

Robot Assisted ◽

Invasive Esophagectomy

Abstract Aim The aim of this study was to describe the results of a structured training pathway that was developed to implement robot-assisted minimally invasive esophagectomy (RAMIE) in new centers. Background & Methods To safely and effectively implement RAMIE in new centers, the learning process needs to be optimized. In this context, a structured training pathway was created (Table 1). The results of this training pathway were investigated by evaluating consecutive patients who underwent RAMIE by a single surgeon who followed the structured training pathway. These patients were included from the trainee center’s prospective database. Cumulative sum (CUSUM) learning curves were plotted for thoracic operating time and intraoperative blood loss. Perioperative outcomes were compared between patients who underwent surgery before and after a learning curve plateau occurred. Results Between 2017-2018, the trainee team adhered to the structured training pathway and a total of 70 patients were included. The learning curves showed plateaus after 22 cases. In cases 23-70, the operating time was shorter for both the thoracic phase (median 215 vs. 249 minutes, P=0.001) and overall procedure (median 394 vs. 440 minutes, P=0.005), intraoperative blood loss was less (median 210 vs. 400 milliliters, P=0.029), and lymph node yield was higher (median 32 vs. 23 nodes, P=0.001) when compared to the first 22 cases. No significant differences were found for conversion rates, postoperative complications, length of hospital stay, radicality, or mortality. Conclusions The structured RAMIE training pathway results in a short learning curve and is an effective way to introduce RAMIE without compromising the oncological outcomes and complication rates. The pathway is therefore advised to surgeons who are willing to adopt this technique.

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Robotic Pneumonectomy for Lung Cancer: Perioperative Outcomes and Factors Leading to Conversion to Thoracotomy

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1177/1556984520978227 ◽

2021 ◽

pp. 155698452097822

Author(s):

Byron D. Patton ◽

Daniel Zarif ◽

Donna M. Bahroloomi ◽

Iam C. Sarmiento ◽

Paul C. Lee ◽

...

Keyword(s):

Lung Cancer ◽

Statistical Significance ◽

Patient Characteristics ◽

Perioperative Outcomes ◽

Safe Procedure ◽

Open Approach ◽

Robotic Approach ◽

Robotic Group ◽

Robot Assisted ◽

Estimated Blood Loss

Objective In the tide of robot-assisted minimally invasive surgery, few cases of robot-assisted pneumonectomy exist in the literature. This study evaluates the perioperative outcomes and risk factors for conversion to thoracotomy with an initial robotic approach to pneumonectomy for lung cancer. Methods This study is a single-center retrospective review of all pneumonectomies for lung cancer with an initial robotic approach between 2015 and 2019. Patients were divided into 2 groups: surgeries completed robotically and surgeries converted to thoracotomy. Patient demographics, preoperative clinical data, surgical pathology, and perioperative outcomes were compared for meaningful differences between the groups. Results Thirteen total patients underwent robotic pneumonectomy with 8 of them completed robotically and 5 converted to thoracotomy. There were no significant differences in patient characteristics between the groups. The Robotic group had a shorter operative time ( P < 0.01) and less estimated blood loss ( P = 0.02). There were more lymph nodes harvested in the Robotic group ( P = 0.08) but without statistical significance. There were 2 major complications in the Robotic group and none in the Conversion group. Neither tumor size nor stage were predictive of conversion to thoracotomy. Conversions decreased over time with a majority occurring in the first 2 years. There were no conversions for bleeding and no mortalities. Conclusions Robotic pneumonectomy for lung cancer is a safe procedure and a reasonable alternative to thoracotomy. With meticulous technique, major bleeding can be avoided and most procedures can be completed robotically. Larger studies are needed to elucidate any advantages of a robotic versus open approach.

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Retrospective comparison of three minimally invasive approaches for adrenal tumors: perioperative outcomes of transperitoneal laparoscopic, retroperitoneal laparoscopic and robot-assisted laparoscopic adrenalectomy

BMC Urology ◽

10.1186/s12894-020-00637-y ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Changwei Ji ◽

Qun Lu ◽

Wei Chen ◽

Feifei Zhang ◽

Hao Ji ◽

...

Keyword(s):

Length Of Stay ◽

Blood Loss ◽

Minimally Invasive ◽

Laparoscopic Adrenalectomy ◽

Perioperative Outcomes ◽

Adrenal Tumors ◽

Transfusion Rate ◽

Robot Assisted ◽

Estimated Blood Loss ◽

Minimally Invasive Adrenalectomy

Abstract Background To compare the perioperative outcomes of transperitoneal laparoscopic (TLA), retroperitoneal laparoscopic (RLA), and robot-assisted transperitoneal laparoscopic (RATLA) adrenalectomy for adrenal tumors in our center. Methods Between April 2012 and February 2018, 241 minimally invasive adrenalectomies were performed. Cases were categorized based on the minimally invasive adrenalectomy technique. Demographic characteristics, perioperative information and pathological data were retrospectively collected and analyzed. Results This study included 37 TLA, 117 RLA, and 87 RATLA procedures. Any two groups had comparable age, ASA score, Charlson Comorbidity Index, and preoperative hemoglobin. The tumor size for RLA patients was 2.7 ± 1.1 cm, which was significantly smaller compared to patients who underwent TLA/RATLA (p = 0.000/0.000). Operative time was similar in any two groups, while estimated blood loss was lower for RATLA group (75.6 ± 95.6 ml) compared with the TLA group (131.1 ± 204.5 ml) (p = 0.041). Conversion to an open procedure occurred in only one (2.7%) patient in the TLA group for significant adhesion and hemorrhage. There were no significant differences between groups in terms of transfusion rate and complication rate. Length of stay was shorter for the RATLA group versus the TLA/RLA group (p = 0.000/0.029). In all groups, adrenocortical adenoma and pheochromocytoma were the most frequent histotypes. Conclusions Minimally invasive adrenalectomy is associated with expected excellent outcomes. In our study, the RATLA approach appears to provide the benefits of decreased estimated blood loss and length of stay. Robotic adrenalectomy appears to be a safe and effective alternative to conventional laparoscopic adrenalectomy.

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P36. Operative time and learning curve between conventional fluoroscopy, fluoroscopy-based instrument navigation, and robot-assisted instrumentation in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF)

The Spine Journal ◽

10.1016/j.spinee.2020.05.434 ◽

2020 ◽

Vol 20 (9) ◽

pp. S163-S164

Author(s):

Timothy Wang ◽

Farah Hamouda ◽

Eric W. Sankey ◽

C. Rory Goodwin ◽

Isaac O. Karikari ◽

...

Keyword(s):

Minimally Invasive ◽

Learning Curve ◽

Interbody Fusion ◽

Operative Time ◽

Transforaminal Lumbar Interbody Fusion ◽

Lumbar Interbody Fusion ◽

Robot Assisted

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Global Benchmark Values for Laparoscopic Roux-en-Y-Gastric Bypass: a Potential New Indicator of the Surgical Learning Curve

Obesity Surgery ◽

10.1007/s11695-020-05030-0 ◽

2020 ◽

Author(s):

Guillaume Giudicelli ◽

Michele Diana ◽

Mickael Chevallay ◽

Benjamin Blaser ◽

Chloé Darbellay ◽

...

Keyword(s):

Bariatric Surgery ◽

Gastric Bypass ◽

Learning Curve ◽

Operative Time ◽

High Volume ◽

Perioperative Outcomes ◽

Morbidity Rate ◽

Bariatric Surgeon ◽

Senior Surgeon ◽

Surgical Learning

Abstract Background Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a technically demanding procedure. The learning curve of LRYGB is challenging and potentially associated with increased morbidity. This study evaluates whether a general laparoscopic surgeon can be safely trained in performing LRYGB in a peripheral setting, by comparing perioperative outcomes to global benchmarks and to those of a senior surgeon. Methods All consecutive patients undergoing primary LRYGB between January 2014 and December 2017 were operated on by a senior (A) or a trainee (B) bariatric surgeon and were prospectively included. The main outcome of interest was all-cause morbidity at 90 days. Perioperative outcomes were compared with global benchmarks pooled from 19 international high-volume centers and between surgeons A and B for their first and last 30 procedures. Results The 213 included patients had a mean all-cause morbidity rate at 90 days of 8% (17/213). 95.3% (203/213) of the patients were uneventfully discharged after surgery. Perioperative outcomes of surgeon B were all within the global benchmark cutoffs. Mean operative time for the first 30 procedures was significantly shorter for surgeon A compared with surgeon B, with 108.6 min (± 21.7) and 135.1 min (± 28.1) respectively and decreased significantly for the last 30 procedures to 95 min (± 33.7) and 88.8 min (± 26.9) for surgeons A and B respectively. Conclusion Training of a new bariatric surgeon did not increase morbidity and operative time improved for both surgeons. Perioperative outcomes within global benchmarks suggest that it may be safe to teach bariatric surgery in peripheral setting.

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Minimally Invasive Pediatric Surgery: The Learning Curve

European Journal of Pediatric Surgery ◽

10.1055/s-0040-1703011 ◽

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.

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