The learning curve of robot-assisted laparoscopic fundoplication in children: a prospective evaluation and CUSUM analysis.

BACKGROUND: Fundoplication is a leading application of robotic surgery in children, yet the learning curve for this procedure (RF) remains ill-defined. This study aims to identify various learning curve transition points, using cumulative summation (CUSUM) analysis. METHODS: A prospective database was examined to identify RF cases undertaken during 2006-2014. Time-based surgical process outcomes were evaluated, as well as clinical outcomes. RESULTS: A total of 57 RF cases were included. Statistically significant transitions beyond the learning phase were observed at cases 42, 34 and 37 for docking, console and total operating room times, respectively. A steep early learning phase for docking time was overcome after 12 cases. There were three Clavien-Dindo grade ≥ 3 complications, with two patients requiring redo fundoplication. CONCLUSIONS: We identified numerous well-defined learning curve trends to affirm that experience confers significant temporal improvements. Our findings highlight the value of the CUSUM method for learning curve evaluation.

Learning curve evaluation using cumulative summation analysis-a clinical example of pediatric robot-assisted laparoscopic pyeloplasty.

BACKGROUND: The cumulative summation (CUSUM) method for learning curve analysis remains under-utilized in the surgical literature in general, and is described in only a small number of publications within the field of pediatric surgery. This study introduces the CUSUM analysis technique and applies it to evaluate the learning curve for pediatric robot-assisted laparoscopic pyeloplasty (RP). METHODS: Clinical data were prospectively recorded for consecutive pediatric RP cases performed by a single-surgeon. CUSUM charts and tests were generated for set-up time, docking time, console time, operating time, total operating room time, and postoperative complications. Conversions and avoidable operating room delay were separately evaluated with respect to case experience. Comparisons between case experience and time-based outcomes were assessed using the Student's t-test and ANOVA for bi-phasic and multi-phasic learning curves respectively. Comparison between case experience and complication frequency was assessed using the Kruskal-Wallis test. RESULTS: A total of 90 RP cases were evaluated. The learning curve transitioned beyond the learning phase at cases 10, 15, 42, 57, and 58 for set-up time, docking time, console time, operating time, and total operating room time respectively. All comparisons of mean operating times between the learning phase and subsequent phases were statistically significant (P=<0.001-0.01). No significant difference was observed between case experience and frequency of post-operative complications (P=0.125), although the CUSUM chart demonstrated a directional change in slope for the last 12 cases in which there were high proportions of re-do cases and patients <6 months of age. CONCLUSIONS: The CUSUM method has a valuable role for learning curve evaluation and outcome quality monitoring. In applying this statistical technique to the largest reported single surgeon series of pediatric RP, we demonstrate numerous distinctly shaped learning curves and well-defined learning phase transition points.

Experience related factors compensate for haptic loss in robot-assisted laparoscopic surgery.

BACKGROUND AND PURPOSE: Surgeons anecdotally report awareness of nontactile sensory cues that compensate for absent haptic feedback in robot-assisted surgery. This study investigates this poorly understood adaptive process by evaluating frequency of in vivo suture damage. PATIENTS AND METHODS: Consecutive cases of children undergoing robot-assisted dismembered pyeloplasty were examined. Suture damage was defined as incomplete (i.e., fraying) or complete (i.e., broken) loss of thread integrity and prospectively recorded with clinical data. Suture technique, size, and robotic instruments used for suturing were subjected to post hoc analysis. Statistical analysis was undertaken using appropriate nonparametric tests. RESULTS: Overall frequency of suture damage was 2.6% among 1135 sutures used in 52 patients. The mean number of sutures used for cases in this series was 22 (standard deviation±6). There was a significant inverse trend between surgeon experience and suture damage frequency (P=0.014), implying that greater surgeon experience was associated with less suture damage. The impact of experience on suture damage was most apparent when comparing the earliest quartile subgroup (Q1) with the later three quartile subgroups (Q2-Q4) (P<0.001). Plateau of suture damage frequency was seen after approximately 28 cases. Continuous sutures had significantly higher damage frequency compared with interrupted sutures (P=0.022). Significantly higher frequency of suture damage was seen with cases in which forceps instruments were used for suturing compared with paired needle drivers (1.4% vs 7.1%, P<0.001). All events of inadvertent tissue injury involved damage to exposed edges of the renal pelvis (n=5). CONCLUSIONS: Suture damage is likely to be encountered during the learning curve of robot-assisted surgery but decreases with surgeon experience. Preferential use of larger suture size, interrupted sutures, and paired needle driver instruments may help to minimize suture damage. Experience-related perceptual skills that compensate for haptic loss are likely to be acquirable in a preclinical simulation environment.

The first decade of robotic surgery in children.

BACKGROUND: Robotic surgery offers technological solutions to current challenges of minimal access surgery, particularly for delicate and dexterous procedures within spatially constrained operative workspaces in children. The first robotic surgical procedure in a child was reported in April 2001. This review aims to examine the literature for global case volumes, trends, and quality of evidence for the first decade of robotic surgery in children. METHODS: A systematic literature search was performed for all reported cases of robotic surgery in children during the period of April 2001 to March 2012. RESULTS: Following identification of 220 relevant articles, 137 articles were included, reporting 2393 procedures in 1840 patients. The most prevalent gastrointestinal, genitourinary, and thoracic procedures were fundoplication, pyeloplasty, and lobectomy, respectively. There was a progressive trend of increasing number of publications and case volumes over time. The net overall reported conversion rate was 2.5%. The rate of reported robot malfunctions or failures was 0.5%. CONCLUSIONS: Robotic surgery is an expanding and diffusing innovation in pediatric surgery. Future evolution and evaluation should occur simultaneously, such that wider clinical uptake may be led by higher quality and level of evidence literature.