Learning curve and initial outcomes of a novel percutaneously endoscopic-assisted total hip arthroplasty through mini bikini direct anterior approach: an observational cohort study.

OBJECTIVE: Although the direct anterior approach can reduce muscle damage and ensure accurate prosthesis placement, the steep learning curve and increased risk of complications associated with DAA necessitate careful consideration. Therefore, we describe a technique for a novel percutaneously endoscopic-assisted total hip arthroplasty through mini bikini direct anterior approach (mDAA) and report the learning curve and initial outcomes. METHODS: The first 125 THA performed by a single surgeon between September 2020 and February 2022 using the anterior approach were included, comprising the initial 41 cases of bikini DAA (bDAA) and the subsequent 84 cases of mDAA. Outcome measures included perioperative outcomes and postoperative complications. The cumulative sum analysis (CUSUM) was used to determine the learning curve of anterior approach THA for each patient's ORT. Multivariable analysis was performed to determine risk correlation. RESULTS: A total of 125 anterior approach THA completed between 2020 and 2022 were identified. Among these, 41 were performed via bDAA and 84 via mDAA. No statistically significant differences were observed between the groups in terms of age, gender distribution, BMI or follow-up time. A significant reduction in ORT was noted, from 140 min for bDAA to 130 min for mDAA. Furthermore, there was a consistent decrease in LOI, LOS, and wound-healing problems. There was no statistically significant difference between groups with respect to Harris Hip Scores and other postoperative complications. The curve inflection points of the learning curve for the bDAA and mDAA group were located in the 22nd and 68th cases, respectively. The reduction of hemoglobin indicated a predicted increase in ORT. CONCLUSIONS: In this study, ORT, LOI, LOS, and wound-healing problems decreased overall in mDAA group. After mastering the bDAA technique, approximately 27 mDAA cases are needed to acquire proficiency in this technique. Hence, mDAA is a valuable alternative for those seeking smaller incisions, resolving wound healing problems, and aiming for enhanced recovery after surgery.

The long-term learning curve of holmium laser enucleation of the prostate (HoLEP) in the en-bloc technique: a single surgeon series of 500 consecutive cases.

PURPOSE: To evaluate perioperative parameters, clinical outcomes, and the learning curve of holmium laser enucleation of the prostate (HoLEP) of a single surgeon in 500 consecutive cases. METHODS: Demographic parameters, outcomes, and adverse events were evaluated. The learning curve for HoLEP in en-bloc technique of the first 500 consecutive patients was analyzed in clusters of 100 (clusters 1-5) using the Wilcoxen rank test, Chi² test and Kruskal Wallis test. RESULTS: Enucleation weight was similar in the clusters 1,2,3, and 5 (62 g, 63 g, 61 g, 61 g), in cluster 4 it was slightly higher at 73 g. There was a significant reduction in operating time from 67 min (cluster 1) to 57 min (cluster 2), 46 min (cluster 3), 53 min (cluster 4), and 43 min (cluster 5), p < 0.001. Enucleation efficiency (g/min) showed a steady increase (1.72, 2.24, 2.79, 2.92 vs. 2.99, p < 0.001). Laser energy efficiency also improved (2.17 vs. 2.12 vs. 1.71 vs. 1.65 vs. 1.55; p < 0.001). There was no measurable learning curve regarding the length of hospital stay (mean 2.5 days), catheterization time (1.9 days), hemoglobin drop (approx. 1 g/dl) or complications (p > 0.1). CONCLUSIONS: HoLEP using the en-bloc technique is a safe and highly effective method. Over time, a slight but steady learning curve and improvement in operation time, enucleation efficiency and laser energy efficiency were shown even for an experienced surgeon - after 500 cases, still no plateau was reached. There was no measurable learning curve regarding blood loss, complications, length of hospital stay, and catheterization time.

Learning curve of laparoscopic appendectomy in a low-resource setting: a cumulative sum analysis of operative length.

BACKGROUND: Cumulative sum (CUSUM) analysis is a valuable tool for quantifying the learning curve of surgical teams by detecting significant changes in operative length. However, there is limited research evaluating the learning curve of laparoscopic techniques in low-resource settings. The objective of this study is to evaluate the learning curve for laparoscopic appendectomy within a single surgical team in Senegal. METHODS: This was a single-center prospective study conducted from May 1, 2018, to August 31, 2023 of patients who underwent laparoscopic appendectomy at a tertiary care institution in West Africa. The AAST classification was used to describe the severity of appendicitis. Parameters studied included age, sex, operative length, conversion rate, and postoperative outcomes. To quantify the learning curve, CUSUM analysis of operative length was performed. RESULTS: A total of 81 patients were included. The mean age was 26.7 years (range 11-70 years) with a sex ratio of 1.9. Pre-operative severity according to AAST was Grade I in 75.4% (n = 61), Grade III in 7.4% (n = 6), Grade IV in 6.1% (n = 5), and Grade V in 11.1% (n = 9). Conversion occurred in 5 cases (6.1%). The average operative length was 76.8 min (range 30-180 min) and the average length of hospitalization was 2.7 days (range 1-13 days). Morbidity was observed in 3.7% (n = 3) and there were no deaths. The CUSUM analysis showed that a steady operative length was achieved after 28 procedures, with decreasing operative lengths thereafter. CONCLUSION: Surgeons in our setting overcame the learning curve for laparoscopic appendectomy after performing 28 procedures. Moreover, laparoscopic appendectomy is safe and feasible throughout the learning curve. CUSUM analysis should be applied to other laparoscopic procedures and individualized by surgical teams to improve surgical performance and patient outcomes in low-resource settings.

Implementing a robotic hepatopancreatobiliary program for new faculty: safety, feasibility and lessons learned.

Robotic surgery is increasingly utilized in hepatopancreatobiliary (HPB) surgery, but the learning curve is a substantial obstacle hindering implementation. Comprehensive robotic training can help to surmount this obstacle; however, despite the expansion of robotic training into residency and fellowship programs, limited data are available about how this translates into successful incorporation in faculty practice. All operations performed during the first three years of practice of a surgical oncologist at a tertiary care academic institution were retrospectively reviewed. The surgeon underwent comprehensive robotic training during residency and fellowship. 137 HPB operations were performed during the initial three years of practice. Over 80% were performed robotically each year across a spectrum of HPB procedures with a 6% conversion rate. Median operative time, a metric for operative proficiency and evaluation for a learning curve, was similar throughout the study period for each major operation and below several reported optimized operative time benchmarks. The major complications, defined as a Clavien-Dindo of 3 or more, were similar across the experience and comparable to published series. Comprehensive robotic training in residency and fellowship as well as a dedicated, well-trained operative team allows for early attainment of optimized outcomes in a new HPB robotic practice.

Impact of proficiency in the transcatheter aortic valve implantation procedure on clinical outcomes: a single center retrospective study.

BACKGROUND: We used transcatheter aortic valve implantation (TAVI) procedure time to investigate the association between surgical team maturity and outcome. METHODS: Among patients who underwent TAVI between October 2015 and November 2019, those who had Sapien™ implanted with the transfemoral artery approach were included in the analysis. We used TAVI procedure time and surgery number to draw a learning curve. Then, we divided the patients into two groups before and after the number of cases where the sigmoid curve reaches a plateau. We compared the two groups regarding the surveyed factors and investigated the correlation between the TAVI procedure time and survey factors. RESULTS: Ninety-nine of 149 patients were analysed. The sigmoid curve had an inflection point in 23.2 cases and reached a plateau in 43.0 cases. Patients in the Late group had a shorter operating time, less contrast media, less radiation exposure, and less myocardial escape enzymes than the Early group. Surgical procedure time showed the strongest correlation with the surgical case number. CONCLUSION: The number of cases required for surgeon proficiency for isolated Sapien™ valve implantation was 43. This number may serve as a guideline for switching the anesthesia management of TAVI from general to local anesthesia.

The Accuracy of the Learning-Curve Cumulative Sum Method in Assessing Brachial Plexus Block Competency.

BACKGROUND: The learning-curve cumulative sum method (LC-CUSUM) and its risk-adjusted form (RA-LC-CUSUM) have been proposed as performance-monitoring methods to assess competency during the learning phase of procedural skills. However, scarce data exist about the method's accuracy. This study aimed to compare the accuracy of LC-CUSUM forms using historical data consisting of sequences of successes and failures in brachial plexus blocks (BPBs) performed by anesthesia residents. METHODS: Using historical data from 1713 BPB performed by 32 anesthesia residents, individual learning curves were constructed using the LC-CUSUM and RA-LC-CUSUM methods. A multilevel logistic regression model predicted the procedure-specific risk of failure incorporated in the RA-LC-CUSUM calculations. Competency was defined as a maximum 15% cumulative failure rate and was used as the reference for determining the accuracy of both methods. RESULTS: According to the LC-CUSUM method, 22 residents (84.61%) attained competency after a median of 18.5 blocks (interquartile range [IQR], 14-23), while the RA-LC-CUSUM assigned competency to 20 residents (76.92%) after a median of 17.5 blocks (IQR, 14-25, P = .001). The median failure rate at reaching competency was 6.5% (4%-9.75%) under the LC-CUSUM and 6.5% (4%-9%) for the RA-LC-CUSUM method ( P = .37). The sensitivity of the LC-CUSUM (85%; 95% confidence interval [CI], 71%-98%) was similar to the RA-LC-CUSUM method (77%; 95% CI, 61%-93%; P = .15). Identical specificity values were found for both methods (67%; 95% CI, 29%-100%, P = 1). CONCLUSIONS: The LC-CUSUM and RA-LC-CUSUM methods were associated with substantial false-positive and false-negative rates. Also, small lower limits for the 95% CIs around the accuracy measures were observed, indicating that the methods may be inaccurate for high-stakes decisions about resident competency at BPBs.

Retrospective analysis of the learning curve in perineal robot-assisted prostate biopsy.

INTRODUCTION: Magnetic resonance imaging-transrectal ultrasound (MRI-TRUS)-fusion biopsy (FBx) of the prostate allows targeted sampling of suspicious lesions within the prostate, identified by multiparametric MRI. Due to its reliable results and feasibility, perineal MRI/TRUS FBx is now the gold standard for prostate cancer (PC) diagnosis. There are various systems for performing FBx on the market, for example, software-based, semirobotic, or robot-assisted platform solutions. Their semiautomated workflow promises high process quality independent of the surgeon's experience. The aim of this study was to analyze how the surgeon's experience influences the cancer detection rate (CDR) via targeted biopsy (TB) and the procedure's duration in robot-assisted FBx. PATIENTS AND METHODS: A total of 1716 men who underwent robot-assisted FBx involving a combination of targeted and systematic sampling between October 2015 and April 2022 were analyzed. We extracted data from the patients' electronic medical records retrospectively. Primary endpoints were the CDR by TB and the procedure's duration. For our analysis, surgeons were divided into three levels of experience: ≤20 procedures (little), 21-100 procedures (intermediate), and >100 procedures (high). Statistical analysis was performed via regression analyses and group comparisons. RESULTS: Median age, prostate-specific antigen level, and prostate volume of the cohort were 67 (±7.7) years, 8.13 (±9.4) ng/mL, and 53 (±34.2) mL, respectively. Median duration of the procedure was 26 (±10.9) min. The duration decreased significantly with the surgeon's increasing experience from 35.1 (little experience) to 28.4 (intermediate experience) to 24.0 min (high experience) (p < 0.001). Using TB only, significant PC (sPC) was diagnosed in 872/1758 (49.6%) of the men. The CDR revealed no significant correlation with the surgeon's experience in either group comparison (p = 0.907) or in regression analysis (p = 0.65). CONCLUSION: While the duration of this procedure decreases with increasing experience, the detection rate of sPC in TB is not significantly associated with the experience of the surgeon performing robot-assisted FBx. This robot-assisted biopsy system's diagnostic accuracy therefore appears to be independent of experience.

Training radiology residents to evaluate deep myometrial invasion in endometrial cancer patients on MRI: A learning curve study.

PURPOSE: To evaluate the impact of a four-month training program on radiology residents' diagnostic accuracy in assessing deep myometrial invasion (DMI) in endometrial cancer (EC) using MRI. METHOD: Three radiology residents with limited EC MRI experience participated in the training program, which included conventional didactic sessions, case-centric workshops, and interactive classes. Utilizing a training dataset of 120 EC MRI scans, trainees independently assessed subsets of cases over five reading sessions. Each subset consisted of 30 scans, the first and the last with the same cases, for a total of 150 reads. Diagnostic accuracy metrics, assessment time (rounded to the nearest minute), and confidence levels (using a 5-point Likert scale) were recorded. The learning curve was obtained plotting the diagnostic accuracy of the three trainees and the average over the subsets. Anatomopathological results served as the reference standard for DMI presence. RESULTS: The three trainees exhibited heterogeneous starting point, with a learning curve and a trend to more homogeneous performance with training. The diagnostic accuracy of the average trainee raised from 64 % (56 %-76 %) to 88 % (80 %-94 %) across the five subsets (p < 0.001). Reductions in assessment time (5.92 to 4.63 min, p < 0.018) and enhanced confidence levels (3.58 to 3.97, p = 0.12) were observed. Improvements in sensitivity, specificity, positive predictive value, and negative predictive value were noted, particularly for specificity which raised from 56 % (41 %-68 %) in the first to 86 % (74 %-94 %) in the fifth subset (p = 0.16). Although not reaching statistical significance, these advancements aligned the trainees with literature performance benchmarks. CONCLUSIONS: The structured training program significantly enhanced radiology residents' diagnostic accuracy in assessing DMI for EC on MRI, emphasizing the effectiveness of active case-based training in refining oncologic imaging skills within radiology residency curricula.

Outcomes from Early Experience with Laparoscopic Inguinal Hernia Repair Versus Open Technique: Navigating the learning curve.

Objectives: This study aimed to evaluate the outcomes of laparoscopic inguinal hernia repair (LIHR) regarding postoperative pain, recurrence rates, duration of hospital stay and other postoperative outcomes within the context of a tertiary care teaching hospital in South India, and the initial experience of laparoscopic repairs. The current consensus in the literature often suggests LIHR as superior to open inguinal hernia repair (OIHR). Methods: This single-centre, retrospective, observational study was conducted at the Jawaharlal Institute of Postgraduate Education and Research, Puducherry, India, from January 2011 to September 2020. All patients who underwent elective OIHR and LIHR were included. Data on the patients demographics, comorbidities, hernia type, mesh characteristics, surgery duration, hospital stay and immediate postoperative complications were collected and analysed. Results: A total of 2,690 OIHR and 158 LIHR cases were identified. The demographic profiles, hospital stay and complication rates were similar in both groups. However, surgical site infection was present exclusively in the OIHR group (3.55% versus 0.0%; P <0.05). The timeline for returning to normal activities was statistically shorter for the LIHR group (6 versus 8 days; P <0.05). The most frequent immediate complication in the LIHR group was subcutaneous emphysema (6.54% versus 0.0%; P <0.05). Recurrence (9.23% versus 3.61%; P = 0.09) and chronic pain (41.53% versus 13.55%; P <0.05) were higher in the LIHR group. Conclusion: Lower recurrence and chronic pain rates were observed with OIHR in the initial experience with LIHR in the hospital. However, LIHR had significant advantages concerning faster patient recovery and lower rates of surgical site infections. While the results contribute an interesting deviation from the standard narrative, they should be interpreted within the context of a learning curve associated with the early experience of the research team with LIHR.

Proficiency in performing radiofrequency ablation procedure for non-functioning benign thyroid nodules: a qualitative rather than quantitative matter.

Objective: Radiofrequency ablation (RFA) is an emerging non-surgical treatment for benign thyroid nodules (BTN). Despite its proven safety profile, data on the learning curve (LC) required to achieve proficiency are still lacking. Materials and methods: The first 179 RFA procedures performed by a single operator in patients with non-functioning BTN were retrospectively analyzed. Six-month nodule volume reduction rate (VRR) ≥ 50% was regarded as reflection of proficiency. Multiple linear regression analysis has been performed to determine the relationship between the VRR and clinical variables. Cumulative sum (CUSUM) charts were plotted to assess LCs for all consecutive procedures and in relation to basal nodule size. In details, Group 1 (G1): 57 patients with small nodules (<10 ml); Group 2 (G2): 87 patients with intermediate nodules (10 - 25 ml); Group 3 (G3): 35 patients with large size (> 25 ml). Results: LC of all 179 procedures showed 3 phases: initial learning (1-39 procedures); consolidation (40-145 procedures); and experienced period (146-179 procedures). For G1 and G2 proficiency is achieved starting from the 10th procedure within the group (or 37th considering consecutively all procedures) and from the 59th procedure within the group (or 116th considering consecutively all procedures), respectively. LC of G3 did not detect operator proficiency. Conclusion: Specific LCs exist concerning the basal size of the nodule treated with RFA. In nodules with baseline volume > 25 ml suboptimal VRR has to be expected. Previously achieved experience on small-intermediate nodules does not seem to provide advantages in terms of higher VRR in the treatment of large nodules. Other potential and non-modifiable factors likely play a key role in the final volume reduction independently from the increased skill of the operator.

Introduction of a new surgical robot platform "hinotori™" in an institution with established da Vinci surgery™ for digestive organ operations.

BACKGROUND: New platforms for robotic surgery have recently become available for clinical use; however, information on the introduction of new surgical robotic platforms compared with the da Vinci™ surgical system is lacking. In this study, we retrospectively determined the safe introduction of the new "hinotori™" surgical robot in an institution with established da Vinci surgery using four representative digestive organ operations. METHODS: Sixty-one patients underwent robotic esophageal, gastric, rectal, and pancreatic operations using the hinotori system in our department in 2023. Among these, 22 patients with McKeown esophagectomy, 12 with distal gastrectomy, 11 with high- and low-anterior resection of the rectum, and eight with distal pancreatectomy procedures performed by hinotori were compared with historical controls treated using da Vinci surgery. RESULTS: The console (cockpit) operation time for distal gastrectomy and rectal surgery was shorter in the hinotori group compared with the da Vinci procedure, and there were no significant differences in the console times for the other two operations. Other surgical results were almost similar between the two robot surgical groups. Notably, the console times for hinotori surgeries showed no significant learning curves, determined by the cumulative sum method, for any of the operations, with similar values to the late phase of da Vinci surgery. CONCLUSIONS: This study suggests that no additional learning curve might be required to achieve proficient surgical outcomes using the new hinotori surgical robotic platform, compared with the established da Vinci surgery.

Experimental guide wire placement for total shoulder arthroplasty in glenoid models: higher precision for patient-specific aiming guides compared to standard technique without learning curve.

BACKGROUND: Patient-specific aiming devices (PSAD) may improve precision and accuracy of glenoid component positioning in total shoulder arthroplasty, especially in degenerative glenoids. The aim of this study was to compare precision and accuracy of guide wire positioning into different glenoid models using a PSAD versus a standard guide. METHODS: Three experienced shoulder surgeons inserted 2.5 mm K-wires into polyurethane cast glenoid models of type Walch A, B and C (in total 180 models). Every surgeon placed guide wires into 10 glenoids of each type with a standard guide by DePuy Synthes in group (I) and with a PSAD in group (II). Deviation from planned version, inclination and entry point was measured, as well as investigation of a possible learning curve. RESULTS: Maximal deviation in version in B- and C-glenoids in (I) was 20.3° versus 4.8° in (II) (p < 0.001) and in inclination was 20.0° in (I) versus 3.7° in (II) (p < 0.001). For B-glenoid, more than 50% of the guide wires in (I) had a version deviation between 11.9° and 20.3° compared to ≤ 2.2° in (II) (p < 0.001). 50% of B- and C-glenoids in (I) showed a median inclination deviation of 4.6° (0.0°-20.0°; p < 0.001) versus 1.8° (0.0°-4.0°; p < 0.001) in (II). Deviation from the entry point was always less than 5.0 mm when using PSAD compared to a maximum of 7.7 mm with the standard guide and was most pronounced in type C (p < 0.001). CONCLUSION: PSAD enhance precision and accuracy of guide wire placement particularly for deformed B and C type glenoids compared to a standard guide in vitro. There was no learning curve for PSAD. However, findings of this study cannot be directly translated to the clinical reality and require further corroboration.

The learning curve of laparoscopic single-site salpingectomy with conventional laparoscopic instruments: A retrospective cohort study.

Tubal pregnancy is a common cause of maternal mortality in early pregnancy. Transumbilical laparoendoscopic single-site surgery (TU-LESS) has gained popularity due to its safety and aesthetic advantages. However, the lack of affordable disposable entry platforms hinders its widespread adoption. This study aimed to investigate the learning curve of tubal pregnancy removal using single-incision multiport (SIMP) laparoscopy and provide guidance for novice gynecologists. A retrospective analysis was conducted on cases of ectopic pregnancy (EP) diagnosed at Dongguan Songshan Lake Central Hospital from June 2020 to June 2022. The analysis included 50 cases, with 25 undergoing single-port laparoscopy and 25 undergoing conventional laparoscopy (CL). Various indicators, including body mass index (BMI), previous pregnancies, mass size, hemoglobin levels, surgical duration, and complications, were collected. Learning curve analysis using the cumulative sum (CUSUM) technique was performed to assess procedural proficiency. There were no significant differences in patient characteristics or complications between the 2 groups. However, the single-port laparoscopy group exhibited a statistically significant longer average surgical time (41.60 ±â€…13.38 minutes) compared to the conventional laparotomy group (32.96 ±â€…7.32 minutes). The CUSUM analysis demonstrated a decline in surgical time after the completion of approximately 11 cases, indicating an improvement in SIMP laparoscopy surgical proficiency. SIMP laparoscopy for tubal pregnancy removal achieved similar safety outcomes as CL. Notably, the CUSUM analysis revealed that proficiency in single-port laparoscopy could be achieved after approximately 11 cases, leading to stable surgical times. These findings serve as valuable guidance for novice gynecologists interested in adopting single-incision laparoscopy.

Influence of proficiency in conventional laparoscopic surgery in colorectal cancer on the introduction of robotic surgery.

PURPOSE: Although there have been many reports on learning curves for robotic surgery, it is unclear how surgeons' conventional laparoscopic surgical skills influence their ability in performing robotic surgery for colorectal cancer (CRC). The aim of this study was to determine the surgical outcomes of robotic surgery for CRC during the induction phase by skilled laparoscopic surgeons. METHODS: Surgical outcomes of consecutive CRC cases between January 2021 and March 2023 following the skilled phase of laparoscopic surgery and introductory phase of robotic surgery performed by three skilled laparoscopic surgeons were compared. RESULTS: Overall, 77 consecutive patients diagnosed with sigmoid colon or rectosigmoid cancer were analysed, including 50 in the laparoscopy group (LAP) and 27 in the robotic group (Ro). Patient characteristics, including age, sex, body mass index, and tumour progression, did not differ between the groups. The median operation time was 204 min in the robotic group and 170 min in the laparoscopic group (p < 0.001). Blood loss was significantly lower in the robotic group (p = 0.0059). The incidence of grade 2 or higher complications did not differ between the two groups (LAP, 10.0% vs. Ro, 7.4%, p = 1). In the robotic group, the time required for lymph node dissection had a greater impact on operative duration. CONCLUSION: Skills acquired from performing conventional laparoscopic surgery may contribute to the safe and reliable performance of robotic surgery for CRC. TRIAL REGISTRATION: UMIN000050923.

Shaping the curve from the microscopic transsphenoidal to the endoscopic endonasal approach for the sellar region.

OBJECTIVE: This study aimed to investigate the limitations, barriers, and complications in the early transition from the microscopic transsphenoidal approach (MTA) to the endonasal endoscopic approach (EEA) to the skull base in our institution. METHODS: Technical challenges, as well as clinical features and complications, were compared between MTA, EEA, and mixed cases during the early surgical curve. RESULTS: The period from the early learning curve was 1 year until the EEA protocol was used routinely. A total of 34 patients registered a resection using a transsphenoidal approach. Eighteen patients underwent EEA, 11 underwent MTA, and five underwent a mixed endonasal and microscopic approach. Non-significant differences were found in endocrine outcomes between the three groups. Patients with unchanged or improved visual function were higher in the EEA group (p = 0.147). Non-significant differences were found in terms of the extent of resection (EOR) between groups (p = 0.369). Only 1 (2.9%) patient in the whole series developed a post-operative CSF leaking that resolved with medical management, belonging to the EEA group (5.5%). CONCLUSIONS: The early phase of the learning curve did not affect our series significantly in terms of the EOR, endocrine status, and visual outcomes.

OBJETIVO: Investigar las limitaciones, las barreras y las complicaciones en la transición del abordaje transesfenoidal microscópico (ATM) al abordaje endonasal endoscópico (AEE) para la base del cráneo en nuestra institución. MÉTODO: Se compararon las características clínicas y las complicaciones entre ATM, AEE y casos mixtos durante la curva quirúrgica temprana. RESULTADOS: El periodo desde la curva de aprendizaje inicial fue de 1 año hasta que se utilizó el protocolo AEE de forma sistemática. Un total de 34 pacientes tuvieron una resección por vía transesfenoidal. A 18 pacientes se les realizó AEE, a 11 ATM y a 5 abordaje mixto endonasal y microscópico. Se encontraron diferencias no significativas en los resultados endocrinos entre los tres grupos. Los pacientes con función visual sin cambios o mejorada fueron más en el grupo AEE (p = 0.147). No se encontraron diferencias significativas respecto a la extensión de la resección (p = 0.369). Solo 1 (2.9%) paciente desarrolló una fístula de líquido cefalorraquídeo que se resolvió con manejo médico, perteneciente al grupo AEE (5.5%). CONCLUSIONES: La fase inicial de la curva de aprendizaje no afectó significativamente a nuestra serie en términos de extensión de la resección, estado endocrino y resultados visuales.

Effects of Real Time Feedback on Novice's Laparoscopic Learning Curve.

OBJECTIVE: Analyze the learning curve of medical students when they are trained with a laparoscopic box trainer and are presented with different modes of real-time feedback on their performance in the laparoscopic suturing procedure. DESIGN: A prospective randomized controlled trial (RTC) was performed. Three groups were proposed: control, visual, and haptic. The block randomization technique was used to assign the participants to one of the three groups. Each group trained the intracorporeal square flat knot task in a standardized FLS box simulator. A total of 11 sessions were programmed for this study: a pre-training session, eight training sessions, a post-training session, and a follow-up session. Measurement of the generated reaction force during the task were taken weekly for the first 10 sessions (pre-training, training, and post-training); then, the follow-up measurement was taken a month after. SETTING: This study was carried out in a single center at the Unidad de Simulación de Posgrado (USIP) of the postgraduate medicine program of the Universidad Nacional Autónoma de México (UNAM) between May and August 2023. PARTICIPANTS: The eligible participants were medical students without experience in minimally invasive surgery. All social service intern medics doing their social service in the USIP were invited to participate. A total of 20 participants entered the study from which 18 of them finished all the programmed sessions. RESULTS: A total of ten metrics were extracted from the reaction force signal measured at each session. All metrics are directly proportional to the reaction force and low magnitudes imply high tissue-handling proficiency. All groups improved their tissue handling skills, being the visual group the one who achieved better performance, followed by the haptic group and lastly the control group. CONCLUSION: The use of real time feedback, especially visual feedback can help novices to shorten the learning process of tissue handling and achieve a better proficiency in advanced tasks in shorter training periods.

Antecubital vein combined with femoral vein pathway could shorten the learning curve of simultaneous bilateral adrenal vein sampling.

During our previous bilateral adrenal vein sampling (AVS) procedure, the authors observed that accessing the left adrenal vein through the antecubital vein was more feasible than the conventional femoral vein. Meanwhile, the femoral vein pathway facilitated access to the right adrenal vein than the antecubital vein pathway. Therefore, the authors hypothesized that simultaneous bilateral AVS via the antecubital combined with the femoral vein pathway could improve the success rate. A total of 94 cases of AVS via the antecubital combined with the femoral vein pathway were performed, while the remaining 20 cases employed the antecubital vein pathway at our center between August 2020 and April 2023. Furthermore, a meta-analysis was conducted in this study using 15 selected articles to determine the success rate of AVS in each center and pathway. The success rate of ACTH-stimulated simultaneous bilateral AVS via the antecubital vein combined with the femoral vein pathway was 92.85% (P = .503) on the right and 95.00% (P < .001) on the left. In the antecubital vein pathway, the success rates were only 25.00% (P < .001) on the right side and 80.00% (P = .289) on the left side. The results of meta-analysis demonstrated a success rate of 78.16% on the right and 94.98% on the left for ACTH-stimulated AVS via the femoral vein pathway. Based on our center's experience, simultaneous bilateral adrenal vein sampling via the combined pathway could improve the success rate of AVS in the short term and shorten the learning curve.

"Window to Window": A Variant Technique of Laparoscopic Sleeve Gastrectomy.

PURPOSE: Laparoscopic sleeve gastrectomy (LSG) may present many technical modifications depending on the surgeon. However, no significant variation was noted in the chronological order of the surgical steps in the current technique. We present the "Window to Window," a variant LSG technique. MATERIAL AND METHODS: The technique, introduced in our institution in 2007, requires three trocars. Surgical steps, presented chronologically in a descriptive video, start by creating the "paracardial window" then the "antral window." Subsequently, the gastric transection is performed in two phases after progressive retro-gastric liberation. Lastly, the mobilization of greater curvature is carried out followed by specimen extraction and fascial closure. RESULTS: The procedure was performed for approximately 3200 patients and was comparable in terms of medium-term percent of excess weight loss compared with the standard technique. CONCLUSION: This variant technique of LSG presents many technical advantages for surgeons in terms of safety and exposure compared with the standard technique, while presenting a longer learning curve.