Cumulative sum learning curve analysis of tubularized incised plate repair for hypospadias: a study of a single surgeon with a single surgical procedure.

Purpose: To ascertain the quantity of instances by which a single surgeon achieves competency and proficiency in using tubularized incised plate (TIP) technique for the repair of distal and mid-shaft hypospadias using the cumulative sum (CUSUM) analysis. Methods: We retrospectively evaluated patients with distal and mid-shaft hypospadias who were treated by a single surgeon between 2015 and 2021, using a single primary TIP technique with a de-epithelialized Byars flap. Data including type of hypospadias, age at surgery, curvature, operation time (OT), length of the reconstructed urethra, and postoperative outcomes were collected and assessed. CUSUM was used to assess the trends in OT and complication rate (CR) in order to generate the learning curve. The evolution of OT and CR can be divided into three phases: learning, competence, and proficiency. Results: CUSUM identified three phases in the learning curves of all TIP repairs. The median OT decreased from 135 min [interquartile range (IQR) = 125-155] to 92 min (IQR = 80-100) (P < 0.001), CR decreased from 28 (28%) to 8 (5.3%) (P < 0.001), and reoperations decreased from 15 (15.2%) to 4 (2.6%) (P < 0.001). According to the CUSUM learning curve, technical competency plateaued after the 99th case, and both OT and CR entered a significantly declining proficiency phase after the 231st case. Further, when the neourethral length exceeded the total average, total complications, urethrocutaneous fistula, and reoperations increased (P = 0.013, P = 0.006, and P = 0.028, respectively). Conclusions: Our study suggests that surgeons performing TIP repair may reach technical competency and achieve proficiency after operating on 99,231 cases, respectively. Moreover, the longer the neourethral length, the higher is the CR.

Evaluating the learning curve of endoscopic surgery for spontaneous intracerebral hemorrhage: A single-center experience in a county hospital.

BACKGROUND: Endoscopic surgery has shown promise in treating Spontaneous Intracerebral Hemorrhage (sICH), but its adoption in county-level hospitals has been hindered by the high level of surgical expertise required. METHODS: In this retrospective study at a county hospital, we utilized a Cumulative Sum (CUSUM) control chart to visualize the learning curve for two neurosurgeons. We compared patient outcomes in the learning and proficient phases, and compared them with expected outcomes based on ICH score and ICH functional outcome score, respectively. RESULTS: The learning curve peaked at the 12th case for NS1 and the 8th case for NS2, signifying the transition to the proficient stage. This stage saw reductions in operation time, blood loss, rates of evacuation < 90 %, rebleeding rates, intensive care unit stay, hospital stay, and overall costs for both neurosurgeons. In the learning stage, 6 deaths occurred within 30 days, less than the 10.66 predicted by the ICH score. In the proficient stage, 3 deaths occurred, less than the 15.88 predicted. In intermediate and high-risk patients by the ICH functional outcome score, the proficient stage had fewer patients with an mRS ≥ 3 at three months than the learning stage (23.8 % vs. 69.2 %, P = 0.024; 40 % vs. 80 %, P = 0.360). Micromanipulating bipolar precision hemostasis and aspiration devices in the endoport's channels sped up the transition from learning to proficient. CONCLUSION: The data shows a learning curve, with better surgical outcomes as surgeons gain proficiency. This suggests cost benefits of surgical proficiency and the need for ongoing surgical education and training in county hospitals.

Cumulative sum analysis of the learning curve for retrograde intrarenal stone surgery in newbie surgeons.

INTRODUCTION: This study investigated the learning curve of retrograde intrarenal surgery (RIRS) in patients with medium-sized stones using cumulative sum analysis (CUSUM) to evaluate the competence and proficiency of three new surgeons during their first RIRS procedures. MATERIALS AND METHODS: We conducted a retrospective review of 227 patients from 2019 to 2022 at a single institution. The patients were divided into four groups based on the operating surgeon: tutor surgeon (85 patients), newbie surgeon A (21 patients), newbie surgeon B (85 patients), and newbie surgeon C (36 patients). Patients had one or multiple stones with the largest stone diameter fell within the range of 10-30 mm. Fragmentation efficacy was calculated as "removed stone volume (mm3) divided by operative time (minutes)." CUSUM analysis monitored changes in fragmentation efficacy and validated surgical outcomes. RESULTS: No statistically significant differences were observed in the total stone volume, maximum stone size, or total operation time between the three newbie surgeons and the tutor surgeon. The mean fragmentation efficacy value was comparable among the newbie surgeons, but significantly different from that of the tutor surgeon. The minimum acceptable fragmentation efficacy level was set at 25.12 mL/min, based on the tutor's average value. The CUSUM curves for the three surgeons initially remained relatively flat until Cases 12-15, after which they increased and eventually plateaued. Stone-free rates and postoperative complications did not differ significantly among the surgeons. CONCLUSION: Learning curve analysis for the three newbie surgeons indicated that approximately 12-15 cases were required to reach a plateau.

Evaluation of the learning curve for Thulium laser enucleation of the prostate in a contemporary cohort.

PURPOSE: To assess the learning curve of Thulium laser enucleation of the prostate (ThuLEP) of a single surgeon. METHODS: Hundred patients suffering from benign prostatic hyperplasia were treated by the same surgeon. In all cases, a well-trained urologist was present in the operating room. Patients urinary function was assessed preoperatively using the International Prostate Symptoms Score (IPSS), maximum flow rate and Post-Void Residual volume. Preoperative prostate volume was recorded. Enucleation and morcellation efficiency and complication rate were evaluated. Patients were divided into 5 cohorts of 20 consecutive cases to assess changes in outcomes through time. RESULTS: Mean age of patients was 73.1 years (SD 17.5) and mean prostate volume was 89.7 ml (SD 55.1). Overall, mean enucleation and morcellation efficiency were 1.7 (SD 2.9) and 5.1 (SD 2.7) g/min. A statistically significant increase in enucleation efficiency was observed when comparing cohort 1 vs 2 (0.9 vs 1.3 g/min, p = 0.03) and cohort 2 vs 3 (1.3 vs 1.7 g/min, p = 0.02). A statistically significant increase in morcellation efficiency was observed when comparing cohort 1 vs 2 (2.8 vs 3.7 g/min, p = 0.02) and cohort 2 vs 3 (3.7 vs 4.9 g/min, p = 0.03). In both cases, no significant differences were observed when comparing the following cohorts. Complication rate showed no significant differences throughout the caseload. CONCLUSIONS: In our single-surgeon experience, we observed a learning curve of nearly 60 cases for the ThuLEP procedure in presence of a well-trained surgeon. Complication rate was low from the beginning of surgical experience.

Clinical outcomes and learning curve of Tip-in endoscopic mucosal resection for 15-25 mm colorectal neoplasms among non-experts.

BACKGROUND AND AIM: Tip-in endoscopic mucosal resection (EMR) has a high en bloc resection rate for large colorectal neoplasms. However, non-experts' performance in Tip-in EMR has not been investigated. We investigated whether Tip-in EMR can be achieved effectively and safely even by non-experts. METHODS: This retrospective study included consecutive patients who underwent Tip-in EMR for 15-25 mm colorectal nonpedunculated neoplasms at a Japanese tertiary cancer center between January 2014 and December 2020. Baseline characteristics, treatment outcomes, learning curve of non-experts, and risk factors of failing self-achieved en bloc resection were analyzed. RESULTS: A total of 597 lesions were analyzed (438 by experts and 159 by non-experts). The self-achieved en bloc resection (69.8% vs 88.6%, P < 0.001) and self-achieved R0 resection (58.3% vs 76.5%, P < 0.001) rates were significantly lower in non-experts with <10 cases of experience than in experts, but not in non-experts with >10 cases. Adverse event (P = 0.165) and local recurrence (P = 0.892) rates were not significantly different between experts and non-experts. Risk factors of failing self-achieved en bloc resection were non-polypoid morphology (OR 3.4, 95% CI 1.6-7.3, P = 0.001), lesions with an underlying semilunar fold (OR 3.6, 95% CI 1.6-7.3, P < 0.001), positive non-lifting sign (OR 3.1, 95% CI 1.2-8.0, P = 0.023), and non-experts with an experience of ≤10 cases (OR 3.6, 95% CI 2.1-6.3, P < 0.001). CONCLUSION: The clinical outcomes of Tip-in EMR for 15-25 mm lesions performed by non-experts were favorable.

Analysis of donor morbidity in 177 donor hepatectomies for living donor liver transplant: Experience from a high-volume centre in western India.

BACKGROUND: Living donor liver transplant (LDLT) is based on the principle of double equipoise. Organ shortage in Asian countries has led to development of high-volume LDLT programs with good outcomes. Safety of live liver donor is the Achilles heel of LDLT program and every effort should be made to achieve low morbidity and near zero mortality rates. METHODS: We retrospectively analyzed our prospectively maintained donor morbidity data (outcomes) of 177 donors in a new transplant program setup in western India by an experienced surgeon. The primary end point was to analyze the morbidity rates and the factors associated with it. RESULTS: None of the donors in our cohort of 177 donors developed grade IV or V complication (Clavien-Dindo classification). One-fourth (1/4th) of the donors developed complications ranging from grade I to grade III(b). The rate of complications according to modified Clavien-Dindo classification is as follows: (1) grade I in 5.6% (n = 10), (2) grade II in 14.6% (n = 26), (3) grade III(a) in 3.9% (n = 7), (4) grade III(b) in 2.2% (n = 4). Three donors (1.6%) developed post-hepatectomy intra-abdominal bleeding and required re-exploration (grade IIIb). All of them recovered well post-surgery and are doing well in follow-up. The mean follow-up of the entire cohort was 2871 ± 521 days (range 1926-3736 days). CONCLUSION: Donor safety (outcome) is determined by meticulous donor surgery and good-quality remnant.

Arthroscopic Anterior Cruciate Ligament Reconstruction Learning Curve: Analysis of Operating Time and Clinical Outcomes.

Background: Technical proficiency for arthroscopic anterior cruciate ligament reconstruction (ACLR) is complex and requires learning and practice. Achieving an appropriate level of competency with this surgery is important for patient safety and satisfactory surgical outcomes. There is limited literature about the learning curve in ACLR in Africa. Objectives: This study aimed to demonstrate the learning curve associated with ACLR. Materials and Methods: This retrospective study on arthroscopic ACLR was conducted between January 2020 and June 2023 with a minimum of 12 months follow-up. The primary outcome measure was operation time, whereas the secondary outcome measures were functional outcome and postoperative complications. Results: One hundred fifty-nine ACLR met the inclusion criteria and were analysed. The mean age of the patients was 31.47 ± 9.50 years. There were 148 (93.1%) males and 11 (6.9%) females. The median operation time was 50 min (45-190 min). There was progressively decreasing operation time with increasing number of cases done until after the first 19 cases. The mean operating time for the first 19 cases was 143.89 ± 32.84 min, whereas the mean operating time for the later 140 cases was 53.81 ± 9.72 min (P = 0.000). Conclusions: The operation time for arthroscopic ACLR progressively decreased until after the first 19 cases. There was, however, no significant difference in the clinical outcome between the cases done during the learning curve and those done at proficiency.

Comparison of Time Taken in Conventional versus Active Robotic-Assisted Total Knee Arthroplasty.

Background: Computer- and robotic-assisted total knee replacement procedures have been shown to improve the accuracy of the implant size. It also allows dynamic confirmation of the implant and limb alignment during total knee arthroplasty (TKA). The major inhibition of the arthroplasty surgeon in adapting to the robotic-assisted TKA (RA-TKA) is the extra time spent during the registration process and milling of the bone with the robot. The aim of the study was to ascertain the extra time spent during these 2 steps as compared to the conventional TKA (C-TKA). Methods: It is a prospective study involving 30 patients each in the conventional TKA and RA-TKA operated by the same surgical team. The patients were given a choice between the C-TKA and RA-TKA and consecutive 30 cases in each group were studied by an independent observer. In the C-TKA group, the time for the application of appropriate zigs and execution of the bone cuts and soft-tissue release was recorded whereas in the RA-TKA group, the time taken for fixation of the tibial and femoral arrays and bone registration and bone milling with robot and required soft-tissue release was measured. Results: The preoperative patient characteristics were the same in both groups. The time taken in the C-TKA and RA-TKA groups was 24.77 ± 1.92 minutes and 25.03 ± 3.27 minutes, respectively, which is statistically insignificant (p = 0.709). Conclusions: The study findings show that RA-TKA does not take additional time than C-TKA.

Mid-term results of cemented hip arthroplasties through the direct anterior approach in the lateral decubitus position: a retrospective cohort study.

BACKGROUND: Reports show a high complication rate when starting with the Direct Anterior Approach (DAA) in a supine position for hip arthroplasty. The DAA with the patient in lateral decubitus position may avoid this problem because it supposedly provides better visibility, especially on the femoral side. However, this approach did show a rather high complication rate during the adoption of the approach at 1 year follow up in our previous report. We were interested what the overall 7 year survival estimate would be and whether improvement could be seen with growing experience. METHODS: A cohort of patients undergoing total hip arthroplasty right from the start of applying the DAA in lateral decubitus position was analysed. RESULTS: In total 175 hip prostheses (162 patients) were evaluated. The 7-year survival estimate was 95.1%, 95 CI: 91.8-98.4%. In 6 of 8 revisions there was aseptic loosening of the stem. By dividing the cohort into 3 consecutive groups in time we did not see a significantly improving revision rate. CONCLUSIONS: In our experience, the adoption of the direct anterior approach in lateral decubitus position caused a relatively low 7-year survival estimate without an apparent decrease with growing experience, however given the low number of cases further research is needed to investigate the long-term risk of adopting a new approach.

Efficacy of computer-assisted robotic based clinical training program for spinal oncology education on pedicle screw placement.

Pedicle screw placement (PSP) is the fundamental surgical technique that requires high accuracy for novice orthopedists studying spinal oncology education. Therefore, we set forth to establish a computer-assisted robotic navigation training program for novice spinal oncology education. Novice orthopedists were involved in this study to evaluate the feasibility and safety of the computer-assisted robotic navigation (CARN) training program. In this research, trainees were randomly taught by the CARN training program and the traditional training program. We prospectively collected the clinical data of patients with spinal tumors from 1st May 2021 to 1st March 2022. The ability of PSP was evaluated by cumulative sum (CUSUM) analysis, learning curve, and accuracy of pedicle screws. The patients included in both groups had similar baseline characteristics. In the CUSUM analysis of the learning curve for accurate PSP, the turning point in the CARN group was lower than that in the traditional group (70th vs. 92nd pedicle screw). The LC-CUSUM test indicated competency for PSP at the 121st pedicle screw in the CARN group and the 138th pedicle screw in the traditional group. The accuracy of PSP was also significantly higher in the CARN group than in the traditional group (88.17% and 79.55%, P = 0.03 < 0.05). Furthermore, no major complications occurred in either group. We first described CARN in spinal oncology education and indicated the CARN training program as a novel, efficient and safe training program for surgeons.

The learning curve of a bronchus-first method in bi-port video-assisted thoracoscopic surgery for left upper lobe lung cancer.

Video-assisted thoracic surgery (VATS) has been widely used in lung cancer treatment. However, VATS left upper lobectomy (LUL) is complex due to the intricate branching pattern of the left pulmonary artery (PA). Nevertheless, VATS right upper lobectomy can be simplified through a bronchus-first and simultaneous vessel stapling technique. In this study, the learning curve was obtained while ensuring favorable oncological outcomes using bronchus-first method for VATS LUL. First, retrospective data of 148 consecutive patients who underwent VATS LUL (bronchus-first method) for non-small cell lung cancer (NSCLC) from March 2018 to October 2020 were analyzed. The learning curve was then assessed via cumulative sum (CUSUM) analysis. Moreover, data at different stages of the learning curve, including operation time, blood loss, postoperative hospital stay, lymph node harvested, thoracotomy conversion, postoperative complications, endoscopic stapler consumptions, and 3 year overall survival, were recorded. The learning curve was best modeled as the equation: y = - 7.78 + 2.05x-2.23 × 10-2x2 + 6.43 × 10-5x3, with a good-to-fit test R2 = 0.97. The surgeon entered the proficient stage (59th case-148th case) after consecutive operations of 58 cases (learning stage, 1st case-58th case). Notably, more lymph nodes were harvested in the proficient stage than in the learning stage (17.69 ± 1.47 vs. 15.53 ± 1.43, P < 0.01). Compared with the learning stage, the proficient stage was associated with shorter operation time (114.28 ± 8.56 min vs. 126.81 ± 7.30 min, P < 0.01), fewer blood loss (44.22 ± 7.75 mL vs. 57.41 ± 22.98 mL, P < 0.01), shorter postoperative hospital stay (6.02 ± 0.99 d vs. 7.22 ± 1.34 d, P < 0.01), and fewer endoscopic stapler consumptions (5.89 ± 0.64 vs. 6.53 ± 0.50, P < 0.01). However, thoracotomy conversion (4/90 vs. 5/58, P = 0.32), postoperative complications (10/90 vs. 11/58, P = 0.23) and 3 year overall survival (62.2% vs. 50.8%, log-rank test, P = 0.11) showed no significant difference between the two stages. The surgeon with former single-direction VATS lobectomy experience can master bronchus-first VATS LUL after attending to 58 cases.

Minimally invasive pancreatoduodenectomy by junior surgeon: Initial experience of the next generation.

BACKGROUND: Several guidelines exist for minimally invasive pancreatoduodenectomy (MIPD) regarding its prerequisites and learning curve. However, these guidelines are based on the experience of the pioneers of MIPD; minimal data exist on the experience of the next generation of surgeons. The aim of this study was to compare the two surgeon types (veteran and junior) for MIPD in terms of immediate postoperative outcomes. METHODS: The postoperative outcomes of 22 patients who underwent robot-assisted pancreatoduodenectomy (RAPD) by a junior surgeon from July 2021 to December 2022 were retrospectively reviewed. The outcomes were compared with the initial postoperative outcomes and the contemporary postoperative outcomes of RAPD by a veteran surgeon. RESULTS: In comparing the initial outcomes between the two surgeon types, the veteran surgeons showed a shorter operation time (junior surgeon vs. veteran surgeon: 606 ± 89 vs. 467 ± 77 min, p < 0.001). However, there was no significant difference in terms of postoperative outcomes, such as blood loss (300 [200-600] ml. vs. 200 [100-500] ml, p = 0.208), major complications (≥CDC IIIa: 4 (18.2%) vs. 4 (18.2%), p = 1.000), postoperative pancreatic fistula (POPF; ≥ISGPF Grade B: 2 (9.1%) vs. 3 (13.6%), p > 0.999), and length of hospital stay (18.0 ± 8.9 days vs. 18.3 ± 7.9 days, p = 0.915), between the two surgeon types. In addition, in a comparison of the contemporary outcomes, there was no significant difference in terms of postoperative outcome (complications: 4 (18.2%) vs 11 (11.1%), p = 0.580; POPF: 2 (9.1%) vs. 3 (3.0%), p = 0.484; length of hospital stay: 18.0 ± 8.9 vs. 15.0 ± 6.5 days, p = 0.065). CONCLUSION: The initial outcomes of MIPD by a well-trained junior surgeon were found to be comparable to those of MIPD by a veteran surgeon.

Robotic-Assisted Spine Surgery: Role in Training the Next Generation of Spine Surgeons.

OBJECTIVE: This study aimed to assess the degree of interest in robot-assisted spine surgery (RASS) among residents and to investigate the learning curve for beginners performing robotic surgery. METHODS: We conducted a survey to assess awareness and interest in RASS among young neurosurgery residents. Subsequently, we offered a hands-on training program using a dummy to educate one resident. After completing the program, the trained resident performed spinal fusion surgery with robotic assistance under the supervision of a mentor. The clinical outcomes and learning curve associated with robotic surgery were then analyzed. RESULTS: Neurosurgical residents had limited opportunities to participate in spinal surgery during their training. Despite this, there was a significant interest in the emerging field of robotic surgery. A trained resident performed RASS under the supervision of a senior surgeon. A total of 166 screw insertions were attempted in 28 patients, with 2 screws failing due to skiving. According to the Gertzbein-Robbins classification, 85.54% of the screws were rated as grade A, 11.58% as grade B, 0.6% as grade C, and 1.2% as grade D. The clinical acceptance rate was approximately 96.99%, which is comparable to the results reported by senior experts and time per screw statistically significantly decreased as experience was gained. CONCLUSION: RASS can be performed with high accuracy within a relatively short timeframe, if residents receive adequate training.

Pancreatic anastomosis training models: Current status and future directions.

Postoperative pancreatic fistula (POPF) is a major cause of morbidity and mortality after pancreatoduodenectomy (PD), and previous research has focused on patient-related risk factors and comparisons between anastomotic techniques. However, it is recognized that surgeon experience is an important factor in POPF outcomes, and that there is a significant learning curve for the pancreatic anastomosis. The aim of this study was to review the current literature on training models for the pancreatic anastomosis, and to explore areas for future research. It is concluded that research is needed to understand the mechanical properties of the human pancreas in an effort to develop a synthetic model that closely mimics its mechanical properties. Virtual reality (VR) is an attractive alternative to synthetic models for surgical training, and further work is needed to develop a VR pancreatic anastomosis training module that provides both high fidelity and haptic feedback.

Advancements in Aesthetic Breast Augmentation: Evaluating the Safety, Efficacy, and Naturalistic Outcomes of Ergonomix2 Implants.

BACKGROUND: This pioneering study evaluates the safety, efficacy, and Aesthetic outcomes of Ergonomix2 Motiva Ergonomic Implants in breast augmentation. It aims to assess their capability to offer more natural touch and dynamics, delineate the learning curve for surgical techniques, and examine their safety profile compared to Ergonomix1 implants. MATERIALS AND METHODS: A prospective cohort study was conducted, comparing 31 patients who received Ergonomix2 implants with a control group of 51 patients with Ergonomix1 implants. Eligible patients were those seeking Aesthetic breast augmentation without prior surgeries or chronic illnesses. Detailed documentation of surgical techniques, implant characteristics, and patient demographics was performed. The study assessed surgical learning curve, implant positioning accuracy, and short-term and early complications. Aesthetic outcomes were evaluated using the BreastQ questionnaire and quantitative elastography. RESULTS: Patients with Ergonomix2 implants showed significant improvements in Aesthetic outcomes, including breast contour symmetry and natural feel. The learning curve demonstrated a decrease in surgical time and higher implant positioning accuracy. The safety profile was favorable, with a low complication rate and high patient satisfaction levels. Ergonomix2 implants exhibited enhanced softness and pliability, closely mimicking natural breast tissue, as confirmed by elastographic analyzes. CONCLUSIONS: Ergonomix2 implants represent a significant advancement in Aesthetic breast surgery, offering natural-feeling and dynamically adaptable outcomes. Despite the promising results, the need for specialized surgical techniques and further research on long-term safety and efficacy is emphasized. This study contributes foundational knowledge to the field of ergonomic breast implants and their application in modern plastic surgery. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Proficiency Development and Learning Curve in Robot-Assisted Spine Surgery Using the ExcelsiusGPS® System: Experience From a Single Institution.

STUDY DESIGN: Retrospective Cohort Study Objectives: Robot-assisted spine surgery (RASS) is a rapidly evolving technique with potential benefits for improving surgical outcomes. A number of studies on RASS learning curve have focused on early iterations of the Mazor robot. Limited research exists on the learning curve associated with using the Globus Medical ExcelsiusGPS® system. In this retrospective study, we aimed to evaluate the learning curve of RASS using the ExcelsiusGPS® system at a single institution. METHODS: A total of 95 patients (541 screws) who underwent RASS between 2021 and 2022 were included. Variables including operative time, robot registration time, screw placement time, fluoroscopy utilization, and complications were analyzed. Statistical analysis was performed using descriptive statistics and two-sample t-tests. RESULTS: The average operative time significantly decreased after the first 14 cases, indicating a learning curve. However, no significant improvement was observed in robot registration time. Notably, screw placement time significantly improved after approximately 13 cases. When controlling for the number of levels fused, the trends remained consistent. CONCLUSIONS: Our study confirmed the presence of a learning curve in RASS using the ExcelsiusGPS® system and demonstrated rapid proficiency development. Our findings highlight the relatively quick learning curve of 1 RASS system.

Perspective: How can risks to patients be limited during spine surgeons' learning curves?

Background: Learning curves (LC) are typically defined by the number of different spinal procedures surgeons must perform before becoming "proficient," as demonstrated by reductions in operative times, estimated blood loss (EBL), length of hospital stay (LOS), adverse events (AE), fewer conversions to open procedures, along with improved outcomes. Reviewing 12 studies revealed LC varied widely from 10-44 cases for open vs. minimally invasive (MI) lumbar diskectomy, laminectomy, transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), and oblique/extreme lateral interbody fusions (OLIF/XLIF). We asked whether the risks of harm occurring during these LC could be limited if surgeons routinely utilized in-person/intraoperative mentoring (i.e., via industry, academia, or well-trained colleagues). Methods: We evaluated LC for multiple lumbar operations in 12 studies. Results: These studies revealed no LC for open vs. MI lumbar diskectomy. LC required 29 cases for MI laminectomy, 10-44 cases for MI TLIF, 24-30 cases for MI OLIF, and 30 cases for XLIF. Additionally, the LC for MI ALIF was 30 cases; one study showed that 32% of major vascular injuries occurred in the first 25 vs. 0% for the next 25 cases. Shouldn't the risks of harm to patients occurring during these LC be limited if surgeons routinely utilized in-person/intraoperative mentoring? Conclusions: Twelve studies showed that the LC for at different MI lumbar spine operations varied markedly (i.e., 10-44 cases). Wouldn't and shouldn't spine surgeons avail themselves of routine in-person/intraoperative mentoring to limit patients' risks of injury during their respective LC for these varied spine procedures ?

Learning Curve of a Laparoscopic Pancreaticoduodenectomy Program at a Second Institution.

BACKGROUND: Historically, pancreaticoduodenectomy (PD) has been performed via a laparotomy, but increasingly, laparoscopic and robotic platforms are being employed for PD. Laparoscopic PD has a steep surgeon specific learning curve and programmatic elements that must be optimized. These factors may limit a surgeon who is proficient at laparoscopic PD to develop a program at another institution. We hypothesize that the learning curve for a surgeon transferring a program to a second institution is shorter than the initial laparoscopic PD learning curve for the same surgeon. METHODS: A retrospective review of patients who underwent laparoscopic PD for any indication at the first institution (FI) from 2012 to 2017 and the second institution (SI) from 2018 to 2021 was conducted. Standard statistical analysis was performed. The learning curve was identified using one-sided CUSUM analysis of operative times. RESULT: We identified 110 participants, 90 from the FI and 20 from the SI. More patients at the FI were diagnosed with periampullary adenocarcinoma on final pathology compared to the SI (65.6% vs 40.0%, P = .0132). FI operative times stabilized after the 25th laparoscopic PD and SI operative times stabilized after the 5th operation. No statistically significant difference was identified in postoperative complications. CONCLUSIONS: The learning curve and average operative time of an SI laparoscopic PD program was shorter than the initial learning curve for a single surgeon with comparable outcomes. This suggests that complex minimally invasive surgical programs can be safely transferred to another high-volume institution without significant loss of progress.

Learning Curve Analysis After 500 Robotic Hepatectomies.

BACKGROUND: The robotic platform is growing in popularity for hepatobiliary resections. While the learning curve for basic competency has been reported, this is the first study to analyze the learning curve to achieve long-term mastery on a decade of experience with over 500 robotic hepatectomies. METHODS: After Institutional Review Board (IRB) approval, 500 consecutive robotic hepatectomies from 2013-2023 were analyzed. Cumulative Sum Chart (CUSUM) analysis using operative duration was utilized to determine the learning curves. RESULTS: 500 patients were included in this study: 46% men 54% women, aged 63(61 ± 14.6) years, with BMI 28(29 ± 8.0) kg/m2, MELD 7(8 ± 3.0), ALBI -3(-3 ± 0.6) and Child-Pugh score 5(5 ± 0.7). Operative duration was 235(260.1 ± 131.9) minutes, EBL was 100(165 ± 208.1) mL, tumor size was 4(5 ± 3.5) cm, and 94% achieved R0 margins. Length of hospital stay was 3(4 ± 3.7) days with 4% of patient had major complications. 30-day readmission was 17% with 30-day mortality of 2%, and 90-day mortality of 3%. On CUSUM analysis, the learning curve for minor resection (n=215) was 75 cases, major resection (n=154) was 100 cases, and technically challenging minor resection (n=131) was 57 cases. As we gained experience, we had shorter operative duration, lower blood loss, higher R0 resections, and lower major postoperative complications. CONCLUSIONS: The minimum number of robotic hepatectomies to overcome the learning curves for mastery of minor, major, and technically challenging minor resections was significant. This can help guide surgeons in their early experience to optimize patient safety and outcomes.

Robot-assisted laparoscopic retroperitoneal donor nephrectomy: a safe and efficient improvement.

PURPOSE: Reducing operative injuries is important in living donor nephrectomy. The robot-assisted transperitoneal approach has some advantages than traditional laparoscopic techniques. However, longer operation time and risks of abdominal complications indicate the need for improved techniques. The aim of this study is to present the robot-assisted laparoscopic retroperitoneal donor nephrectomy and evaluate its safety and feasibility. METHODS: This was a retrospective study. From June 2016 to December 2020, 218 living donors underwent robot-assisted laparoscopic retroperitoneal donor nephrectomy. Perioperative data such as operation time, warm ischemia time, length of stay and complications were collected and analyzed. To evaluate the feasibility of this surgical technique, the cumulative summation method was used to construct a learning curve. RESULTS: There were 60 male and 158 female donors aged 36-72 years, with an average age of 53.1 ± 6.8 years. Three patients (1.4%) were converted to open surgery. The mean operation time was 115.4 ± 41.9 min, the warm ischemia time was 206.6 ± 146.7 s, and the length of stay was 4.1 ± 1.4 days. Complications were reported in 22 patients (10.1%), three of whom (1.4%) had Clavien‒Dindo IIIa complications. No ileus occurred. No donors were readmitted. Four patients had delayed graft function. The cumulative summation curve showed that the number needed to reach proficiency was 33. The operation time and warm ischemia time after technical proficiency were 100.4 ± 21.6 min and 142.5 ± 50.7 s, respectively. CONCLUSION: Robot-assisted laparoscopic retroperitoneal donor nephrectomy is a safe and efficient technique that offers advantages of shorter operation time and no abdominal organ interference.