Defining the learning curve for laparoscopic splenectomy for immune thrombocytopenia purpura.

BACKGROUND: The current study was undertaken to define the learning curve for laparoscopic splenectomy (LS) in patients with immune thrombocytopenic purpura (ITP). METHODS: The data of 50 patients who underwent LS for ITP between March 1996 and February 2003 were reviewed. Patients were divided into sequential groups of 10. Operative time, estimated blood loss, conversion to open procedure, length of stay (LOS), time to oral intake, complications, and mortality rates were analyzed. RESULTS: The mean OR time in the 3rd, 4th, and 5th groups of 10 were significantly shorter than the 1st and 2nd groups of 10. There were no significant differences in estimated blood loss, LOS, or time to oral intake between the groups. Three conversions to open splenectomy occurred; one each in the 2nd, 3rd, and 4th groups of 10. Complications were evenly distributed between groups. There were no deaths. CONCLUSION: The learning curve for LS in patients with ITP is a minimum of 20 cases.

Laparoscopic colon resection early in the learning curve: what is the appropriate setting?

INTRODUCTION: Laparoscopic colon resection (LCR) is a safe and effective treatment of benign and malignant colonic lesions. There is little question that a steep learning curve exists for surgeons to become skilled and proficient at LCR. Because of this steep learning curve, debate exists regarding the appropriate hospital setting for LCR. We hypothesize that outcomes of LCR performed early in the learning curve at a regional medical center (New Hanover Regional Medical Center; NHRMC) and a university medical center (Baylor College of Medicine; BCM) would not be significantly different. METHODS: The first 50 consecutive LCRs performed at each institution between August 2001 and December 2003 were reviewed. Age, mean body mass index (BMI), gender, history of previous abdominal surgery (PAS), operative approach [laparoscopic (LAP) versus hand/laparoscopic assisted (HAL)], conversions (Conv), operative time (OR time), pathology (benign vs. malignant), lymph nodes (LN) harvested in malignant cases, length of stay (LOS), morbidity and mortality were obtained. Continuous data were expressed as mean +/- SD. Data were analyzed by chi, Fisher exact test, or t test. RESULTS: NHRMC patients were on average older females with a higher incidence of PAS. A LAP approach was more frequently performed at BCM (86%), whereas HAL was used more frequently at NHRMC (24%). Conversions to open were similar at both institutions (12%). Benign disease accounted for the majority of operations at both institutions. In cases of malignancy, more LN were harvested at BCM. OR time and LOS were shorter at NHRMC. Complication rates were similar between institutions. There were no anastomotic leaks or deaths. CONCLUSIONS: LCR can be performed safely and with acceptable outcomes early in the learning curve at regional medical centers and university medical centers. Outcomes depend more on surgeons possessing advanced laparoscopic skills and adhering to accepted oncologic surgical principles in cases of malignancy, than on the size or location of the healthcare institution.