Does laparoscopic surgery offer adequate clearance in rectal cancer?--A discussion

Multidimensional analysis of the learning curve for robotic total mesorectal excision for rectal cancer: lessons from a single surgeon's experience

BACKGROUND

Little data are available about the learning curve for robotic rectal resection.

OBJECTIVE

The purpose of this work was to provide a multidimensional analysis of the learning process in patients undergoing robotic total mesorectal excision for rectal cancer.

DESIGN

This was a retrospective review of a prospectively collected database designed to evaluate the results of robotic rectal resection.

SETTINGS

The study was conducted at a tertiary-care hospital.

PATIENTS

From December 2007 to August 2012, 167 patients who underwent robotic total mesorectal excision for rectal cancer were included.

MAIN OUTCOME MEASURES

A single hybrid variable including operative time, conversion, perioperative morbidity, and circumferential margin was generated to measure the success of the procedure. A moving average method for operative time and a risk-adjusted cumulative sum analysis were used to derive the learning curve.

RESULTS

Overall conversion was noted in 2 cases (1.2%). The cumulative sum plot of a single hybrid variable representing the success of each operation demonstrated that the composite event was more frequent at the beginning of the series and began to decrease after 32 cases. The moving average for robotic console time decreased steadily and showed 2 plateaus; the first plateau was noted after 33 cases, and the second plateau was noted after 72 cases. The learning process was divided into 3 phases based on 2 cutoff points. The robotic console time decreased significantly with each phase (p < 0.001). Complicated rectal cancer was more frequent in the later phases; however, the incidence of postoperative complications remained constant throughout the series (p = 0.82).

LIMITATIONS

This study is limited by a single surgeon's experience.

CONCLUSIONS

The learning process for robotic total mesorectal excision has a greater effect on the first 32 cases. These results help form a basis for performance monitoring of robotic total mesorectal excision.

Robot-assisted total mesorectal excision: is there a learning curve?

BACKGROUND

Laparoscopic total mesorectal excision (TME) is associated with a steep learning curve, but the learning curve for robotic TME is unknown. This study aimed to evaluate the learning curve for robotic TME.

METHODS

Between November 2004 and April 2009, 80 patients underwent robotic TME performed by a single surgeon. The operative experience was divided into two groups: group 1 (the first 40 cases) and group 2 (the subsequent 40 cases). Patient demographics, operative characteristics, and morbidities were compared.

RESULTS

The two patient populations selected did not differ statistically in age, body mass index (BMI), preoperative risk assessment, stage, preoperative chemoradiotherapy, or tumor location. The mean operative times in group 1 (310 min) and group 2 (297 min) were similar (p = 0.55), and the mean robotic TME time did not differ between the two groups (60 vs. 64 min; p = 0.65). In addition, the operative times did not improve during the course of the study. There were no differences in EBL, margin status, or number of lymph nodes harvested. Furthermore, there were no differences in conversion rate, time to resumption of diet, length of hospital stay, or postoperative complications.

CONCLUSION

Robot-assisted TME may attenuate the learning curve for laparoscopic rectal cancer resection. Further studies are necessary to establish the role of robotic surgery in minimally invasive rectal operations.

Are minimally invasive procedures harder to acquire than conventional surgical procedures?

BACKGROUND

It is frequently suggested that minimally invasive surgery (MIS) is harder to acquire than conventional surgery. To test this hypothesis, residents' learning curves of both surgical skills are compared.

METHODS

Residents had to be assessed using a general global rating scale of the OSATS (Objective Structured Assessment of Technical Skills) for every procedure they performed as primary surgeon during a 3-month clinical rotation in gynecological surgery.

RESULTS

Nine postgraduate-year-4 residents collected a total of 319 OSATS during the 2 years and 3 months investigation period. These assessments concerned 129 MIS (laparoscopic and hysteroscopic) and 190 conventional (open abdominal and vaginal) procedures. Learning curves (in this study defined as OSATS score plotted against procedure-specific caseload) for MIS and conventional surgery were compared using a linear mixed model. The MIS curve revealed to be steeper than the conventional curve (1.77 vs. 0.75 OSATS points per assessed procedure; 95% CI 1.19-2.35 vs. 0.15-1.35, p < 0.01).

CONCLUSIONS

Basic MIS procedures do not seem harder to acquire during residency than conventional surgical procedures. This may have resulted from the incorporation of structured MIS training programs in residency. Hopefully, this will lead to a more successful implementation of the advanced MIS procedures.