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Ndong A, Diallo AC, Rouhi AD, Diao ML, Leon S, Dia DA, Alberstadt AN, Tendeng JN, Williams NN, Cissé M, Dumon KR, Konaté I. Learning curve of laparoscopic appendectomy in a low-resource setting: a cumulative sum analysis of operative length. Surg Endosc 2024; 38:4042-4047. [PMID: 38864885 DOI: 10.1007/s00464-024-10954-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/23/2024] [Indexed: 06/13/2024]
Abstract
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.
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Affiliation(s)
- Abdourahmane Ndong
- Department of Surgery, Saint-Louis Regional Hospital, Gaston Berger University, Road of Ngallelle, 234, Saint-Louis, Senegal.
| | - Adja C Diallo
- Department of Surgery, Saint-Louis Regional Hospital, Gaston Berger University, Road of Ngallelle, 234, Saint-Louis, Senegal
| | - Armaun D Rouhi
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mohamed L Diao
- Department of Surgery, Saint-Louis Regional Hospital, Gaston Berger University, Road of Ngallelle, 234, Saint-Louis, Senegal
| | - Sebastian Leon
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Diago A Dia
- Department of Surgery, Saint-Louis Regional Hospital, Gaston Berger University, Road of Ngallelle, 234, Saint-Louis, Senegal
| | - Angelika N Alberstadt
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jacques N Tendeng
- Department of Surgery, Saint-Louis Regional Hospital, Gaston Berger University, Road of Ngallelle, 234, Saint-Louis, Senegal
| | - Noel N Williams
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mamadou Cissé
- Department of Surgery, Saint-Louis Regional Hospital, Gaston Berger University, Road of Ngallelle, 234, Saint-Louis, Senegal
| | - Kristoffel R Dumon
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ibrahima Konaté
- Department of Surgery, Saint-Louis Regional Hospital, Gaston Berger University, Road of Ngallelle, 234, Saint-Louis, Senegal
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Stern N, Li Y, Wang PZ, Dave S. A cumulative sum (CUSUM) analysis studying operative times and complications for a surgeon transitioning from laparoscopic to robot-assisted pediatric pyeloplasty: Defining proficiency and competency. J Pediatr Urol 2022; 18:822-829. [PMID: 36064506 DOI: 10.1016/j.jpurol.2022.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/16/2022] [Accepted: 07/24/2022] [Indexed: 01/12/2023]
Abstract
INTRODUCTION The transition from laparoscopic to robot-assisted procedures leads to potential increase in operative times and health care costs. Cumulative sum (CUSUM) analysis can objectively study the learning curve to detect significant changes in operative timing and monitor complication rates. OBJECTIVE The objective of this study is to investigate the total and step-specific times for pediatric robot-assisted pyeloplasty (RAP) to investigate the learning curve of a single surgeon transitioning from laparoscopic to RAP. STUDY DESIGN This prospective cohort study included 50 consecutive RAP procedures performed since the inception of our robotic program from June 2013 to January 2019. The CUSUM of RAP total operative time (OT) was calculated to determine the breakpoints between learning phases using piecewise linear regression. Cumulative-observed-minus-expected failure chart with 80% and 95% reassurance boundary lines was constructed using 5% acceptable and 10% unacceptable complication rates. Step-specific operative times were prospectively recorded by an independent observer for port placement, dissection and hitch stitch placement, pelvis dismemberment and spatulation, suturing and port removal. RESULTS Piecewise linear regression for OT identified breakpoints at case 13 and 29 suggesting transition at these points between Learning to Proficiency, and Proficiency to Competency. The overall mean OT was 142.2 ± 46.0 min. There was a significant difference in the mean OT between Learning (203.9 ± 35.3 min, the initial 13 cases), Proficiency (159.2 ± 18.6 min, the middle 16 cases), and Competency (126.6 ± 19.7 min, the last 21 cases) phases (p < 0.001). The complication rate for RAP stabilized around the acceptable level of 5% up to case 41 before finalizing at 8% overall. The step-specific analysis suggested that suturing entered the Competency phase at case 27, with a 50% decrease in suturing time from Learning to Proficiency and Competency. DISCUSSION Our study suggests that by case 30 a surgeon transitioning to RAP can achieve a significant decrease in OT. Complication rates remained within acceptable limits throughout, indicating that RAP can be safely adopted, even in low volume RAP centres. Suturing competency seems to be a significant advantage of the robotic platform as suggested by early significant decrease in suturing times noted between the Learning and Proficiency phases. CONCLUSION Future studies can confirm these findings and establish reference operative times to aid surgeons and trainees transitioning from laparoscopic pyeloplasty to RAP. Moreover, total OT decreases significantly and relatively soon after transition to RAP.
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Affiliation(s)
- Noah Stern
- Schulich School of Medicine and Dentistry: Western University Schulich School of Medicine & Dentistry, London ON, N6A 5C1, Canada.
| | - Yilong Li
- Schulich School of Medicine and Dentistry: Western University Schulich School of Medicine & Dentistry, London ON, N6A 5C1, Canada.
| | - Peter Zhantao Wang
- Schulich School of Medicine and Dentistry: Western University Schulich School of Medicine & Dentistry, Department of Surgery and Pediatrics, Division of Urology, London ON, N6A 5W9, Canada.
| | - Sumit Dave
- Schulich School of Medicine and Dentistry: Western University Schulich School of Medicine & Dentistry, Department of Surgery and Pediatrics, Division of Urology, London ON, N6A 5W9, Canada.
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KOÇ MA. Sağ kolon tümörlerinde laparoskopik komplet mezokolik eksizyon ve santral vasküler ligasyon öğrenme eğrisi için kümülatif toplam analizi. CUKUROVA MEDICAL JOURNAL 2022. [DOI: 10.17826/cumj.1162953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Amaç: Her prosedürün, ne kadar zor olursa olsun, bir öğrenme eğrisi vardır. Ancak, hiç kimse basit işlemler için öğrenme eğrisinden bahsetmez. Bu kavram alışkanlıklara meydan okuyan zorlu bir cerrahi yöntem söz konusu olduğunda karşımıza çıkar. Bu çalışmanın amacı, sağ taraflı kolon kanseri için zorlayıcı bir yöntem olan laparoskopik komplet mezokolik eksizyon ve santral vasküler ligasyon tekniğinin kümülatif toplam analizi ile öğrenme eğrisinin belirlenmesidir.
Gereç ve Yöntem: Bu retrospektif çalışmada Ocak 2015-Haziran 2022 tarihleri arasında Ankara Üniversitesi Tıp Fakültesi Genel Cerrahi Anabilim Dalı'na başvuran 18 yaşından büyük sağ kolon kanserli hastalar dahil edilmiştir. Ameliyat süresi ve lenf nodu miktarına göre kümülatif toplam (CUSUM) analizi kullanılarak öğrenme eğrisi belirlenmiştir.
Bulgular: 53 hasta çalışmaya dahil edildi. Operasyon süresine göre yapılan CUSUM analizi, cerrahın 21 vakadan sonra öğrenme aşamasını geçtiğini ve yeterlik kazandığını göstermiştir. Lenf nodlarına göre yapılan CUSUM analizi ise cerrahın 25. vakada yeterlik kazandığını ortaya koymuştur. CUSUM analizlerine göre yeterlik öncesi ve sorası fazlardaki hastaların karşılaştırılmasında demografik, onkolojik ve operasyonel veriler açısından fark bulunamamıştır.
Sonuç: Cerrahlar sağ kolon kanseri için laparoskopik komplet mezokolik eksizyon prosedürünü yaklaşık 21 ile 25 vaka sonrasında rahatlıkla yapabilirler.
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Park JW, Lee HH, Lee HS, Kim YS. Reproducibility and Step-By-Step Learning Curve of Retroperitoneal Video-Assisted Mini-Laparotomy Surgery for Living Donor Nephrectomy: A Single-Center Experience. EXP CLIN TRANSPLANT 2022; 20:657-662. [DOI: 10.6002/ect.2022.0086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Learning Curve Analysis of Single-Site Robot-Assisted Hysterectomy. J Clin Med 2022; 11:jcm11051378. [PMID: 35268470 PMCID: PMC8911377 DOI: 10.3390/jcm11051378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/19/2022] [Accepted: 02/28/2022] [Indexed: 02/01/2023] Open
Abstract
We aim to analyze the surgical outcomes and learning curve of single-site robot-assisted hysterectomy. This was a retrospective cohort study from a single academic medical center. A total of 123 patients who underwent single-site robotic surgery for gynecologic disease were enrolled. Gynecologic surgeries were performed by a single surgeon using single-site robot-assisted hysterectomy. The median age of enrolled patients was 49 years (range: 30–74 years). The median operation time was 131 min (range: 59–502 min) and the median docking time was 3 min (range: 1–10 min). In addition, the median console time was 76 min (range: 29–465 min). The cumulative sum (CUSUM) graph for total operation time indicated an initial decrease at case 41, generating 3 distinct performance phases: learning (n = 41 initial cases), competence (n = 54 middle cases), and mastery (n = 28 final cases). There was one case conversion to open surgery due to the difficulty in securing the field of view because of a 16-cm bulky mass protruding from the left pelvic wall. No patients required a transfusion and two complications including vaginal cuff dehiscence were identified. The single-site robot-assisted hysterectomy is a safe and feasible procedure. The learning curve consisted of 41 cases to significantly decrease the total operation time.
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Transanal total mesorectal excision for stage II or III rectal cancer: pattern of local recurrence in a tertiary referral center. Surg Endosc 2021; 35:7191-7199. [PMID: 33398553 DOI: 10.1007/s00464-020-08200-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 11/19/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND For mid and low rectal cancer, transanal total mesorectal excision (TaTME) has been established as an alternative approach to laparoscopic surgery. However, there are concerns about an unexpected pattern of local recurrence. This study aimed to analyze the pattern of local recurrence for patients treated with TaTME in a tertiary referral center. METHODS A retrospective single-center analysis was performed. Since 2011, all patients with rectal cancer undergoing TaTME with curative intent were prospectively included in a standardized database. Patients with tumors within 12 cm, clinical stage II or III were included. The primary endpoint of the study was the overall local recurrence rate, together with a critical analysis of the patterns of local failures. RESULTS Two hundred and five patients were included in this analysis. At the time of surgery, patients had a mean age of 67.1 years (SD 12.3), and 66.8% were male. Neoadjuvant therapy was administered in 73.7%. Mesorectal specimen quality was complete or near-complete in 98.5%, while circumferential resection margin was ≤ 1 mm (including T4 tumors) in 11.8%. After a median follow-up of 34.3 months (95% CI 30.1-38.5), 3.4% (n = 7) presented with local recurrent disease. Six out of the seven patients were also diagnosed with hematogenous metastases. Of the seven patients, three presented with at least one of the following risk factors: T4 tumor, N2 disease, incomplete mesorectal specimen, or positive CRM. Local failure was noted posteriorly (n = 3), laterally (n = 2), anteriorly (n = 1), and in the axial compartment (n = 1). Median time to relapse was 31.5 months (10.3-40.9). The median follow-up after local recurrence was 7.9 (95% CI 6.7-9.1) months, with an overall survival of 85.7%. CONCLUSIONS TaTME provided satisfactory local recurrence outcomes, and the most common patterns of failure were in the central pelvis.
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Kim KH, Yang HJ, Heo NH, Kim SH, Kim DS, Lee CH, Jeon YS. Comparison Study of Learning Curve Using Cumulative Sum Analysis Between Holmium Laser Enucleation of the Prostate and Transurethral Resection of the Prostate: Is Holmium Laser Enucleation of the Prostate a Difficult Procedure for Beginner Urologists? J Endourol 2020; 35:159-164. [PMID: 32731753 DOI: 10.1089/end.2020.0492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objectives: Although there is no comparison study about the learning curves for holmium laser enucleation and other surgical modalities to treat benign prostatic hyperplasia (BPH), beginner urologists are hesitant to perform holmium laser enucleation because of its steep learning curve. Therefore, we investigated the degree of surgical difficulty of holmium laser enucleation by comparing its learning curve with that of transurethral resection. Patients and Methods: Two beginner urologists performed surgery for BPH: H.J.Y. performed holmium laser enucleation and K.H.K. performed transurethral resection. Of 141 patients, 72 were enrolled in the holmium laser enucleation group and 69 in the transurethral prostate resection group. After retrospectively reviewing medical records, we performed a cumulative sum analysis of resection speed (RS) and resected ratio (RR) to compare the learning curves of holmium laser enucleation and transurethral resection. Results: Both surgeons achieved RS competency with a speed <0.13 g/min. The surgeon who performed holmium laser enucleation achieved RR competency with a ratio <0.40, whereas the surgeon who performed transurethral resection achieved competency with a ratio <0.35. To achieve RS competency of 0.13 g/mL, the holmium laser enucleation and transurethral resection groups required 12 and 23 cases, respectively. To achieve RR competency of 0.35, the holmium laser enucleation and transurethral resection groups required 12 and 5 cases, respectively. Conclusions: Holmium laser enucleation is not a difficult procedure compared with transurethral resection in beginner urologists. Therefore, it is unnecessary to avoid holmium laser enucleation because the concerns that it may be difficult are unfounded.
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Affiliation(s)
- Ki Hong Kim
- Department of Urology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Hee Jo Yang
- Department of Urology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Nam Hun Heo
- Department of Biostatistics, Soonchunhyang University Clinical Trial Center, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Si Hyun Kim
- Department of Urology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Doo Sang Kim
- Department of Urology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Chang Ho Lee
- Department of Urology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Youn Soo Jeon
- Department of Urology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
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Kang WS, Jo YG, Park YC. Quality Improvement of Damage Control Laparotomy: Impact of the Establishment of a Single Korean Regional Trauma Center. World J Surg 2020; 43:2814-2821. [PMID: 31297581 DOI: 10.1007/s00268-019-05083-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Damage control laparotomy (DCL) is a lifesaving technique to minimize the lethal triad of coagulopathy, hypothermia, and acidosis. The government has nominated and supported our center as one of the regional trauma centers of South Korea since 2014. This study aimed to investigate the improving outcomes of patients undergoing DCL before and after the establishment of the trauma center. METHOD The period from January 2011 to December 2017 was divided into pre-trauma center (pre-TC) (2011-2013) and trauma center (TC) (2014-2017) periods. Multivariable logistic regression was performed to identify the risk factors and risk-adjusted cumulative sum (RA-CUSUM), and graphs were used to monitor the change in mortality. RESULT Of the 485 patients who underwent trauma laparotomy, DCL was performed for 119 patients (24.5%). The operation time (99 vs. 80 min, p = 0.022), time from admission to operation (125 vs. 112 min, p = 0.010), time from admission to first treatment (119 vs. 99 min, p = 0.004), and time from admission to first transfusion (70 vs. 52 min, p = 0.009) were significantly shortened in the TC period. The ratio of plasma to packed red blood cells in massive transfusions (≥PRBCs 10 units within the first 24 h) was significantly increased in the TC period (0.56 vs. 0.72, p = 0.004). RA-CUSUM curves revealed that the risk-adjusted 30-day mortality improved and then plateaued in the TC period. CONCLUSION After the implementation of a trauma center, more prompt intervention and damage control resuscitation could be achieved. Moreover, risk-adjusted mortality of DCL was improved.
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Affiliation(s)
- Wu Seong Kang
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital and Medical School, 42, Jebong-ro, Dong-gu, Gwangju, Korea.,Department of Trauma Surgery, Wonkwang University Hospital, Iksan, Korea
| | - Young Goun Jo
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital and Medical School, 42, Jebong-ro, Dong-gu, Gwangju, Korea.
| | - Yun Chul Park
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital and Medical School, 42, Jebong-ro, Dong-gu, Gwangju, Korea
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