Critical Appraisal of Learning Curve for Single Incision Laparoscopic Right Colectomy

Javier Nieto, MD, Madhu Ragupathi, MD, Chirag Patel, MD, Ali Aminian, MD, Eric M Haas, MD, FACS, FASCRS

Colorectal Surgical Associates, Ltd, LLP / Minimally Invasive Colon and Rectal Surgery, Department of Surgery, The University of Texas Medical School / Michael E. DeBakey Department of Surgery, Baylor College of Medicine / Houston, TX

INTRODUCTION: Single incision laparoscopic colectomy (SILC) has emerged as a viable minimally invasive (MI) approach with benefits and limitations yet to be fully elucidated. Although shown to be safe and feasible, determination of the learning curve has not been fully addressed. Our aim was to identify a learning curve for SILC right hemicolectomy (RH) and to determine the incidence of operative failure and complication rates during this phase.

METHODS AND PROCEDURES: Over a two-year period, data from 54 consecutive SILC RH cases performed by the same surgeon were tabulated in an IRB approved database. A learning curve was generated utilizing cumulative sum (CUSUM) methodology of the operative time (OT) across the case sequence. A separate learning curve was generated utilizing risk-adjusted CUSUM (RA-CUSUM) analysis taking into account patient risk factors and operative failure. Risk factors were defined as age ≥75 years, ASA ≥3, BMI ≥30 kg/m2, ≥3 prior abdominal surgeries, or presence of a bulky tumor (>6 cm on CT scan). Operative failure was defined as OT ≥1.5 standard deviation (SD) above the mean, conversion, length of stay (LOS) ≥1 SD above the mean, reoperation, readmission, or complications. In malignant cases, failure also included positive surgical margins or fewer than 12 resected lymph nodes.

RESULTS: Patients had a mean age of 63.6±11.5 years, BMI of 27.3±3.9 kg/m2, and median ASA of 2. The mean OT and LOS were 123.5±28.9 min and 3.4±2.4 days, respectively. There were a total of 10 complications, no conversions and no oncologic failures. CUSUM analysis of OT identified the achievement of the learning phase after 30 cases. When taking into account both analyses, the rate of operative failure was not statistically different between the initial 30 and the final 24 cases.

CONCLUSIONS: We present a multi-dimensional learning curve analysis for SILC RH taking into account OT, risk factors and failure rates. In our experience, the learning curve is achieved between 30 to 36 cases. Most importantly, results indicate that offering this MI approach does not result in increased complications or harmful results even in the early phases of the learning curve.

Session: Podium Presentation

Program Number: S045

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