Overcoming the Learning Curve in a Complex Laparoscopic Procedure (Laparoscopic Donor Nephrectomy)

Virinder K Bansal, Professor¹, Devanshu Bansal¹, Krishna Asuri¹, Minz M², Sarabjeet Singh², Omprakash Prajapati¹, Rajeshwari Subramaniam¹, Mahesh C Misra¹. ¹All India Institute of medical Sciences, ²PGIMER, chandigarh

Background: LDN is a complex laparoscopic operation which requires advanced laparoscopic skills and dexterity because of the delicate nature of various structures and the organ which needs to be preserved so that the graft can perform optimally in the recipient. The vascular structures and ureter need to be handled carefully because of increased complications if proper harvesting is not done. Such complex procedure entails a significant learning curve with it. This study was done to estimate our learning curve associated with this complex surgical procedure.

Materials and methods: This prospective study was undertaken between January 2013 and January 2015. 100 patients were included. A Preceptership – Proctorship model was used to learn this procedure. Senior expert surgeon from other center was called to mentor the laparoscopic surgeons at our institute. Data recorded included demographic profile, pre-operative and intra-operative variables, post-operative complications, hospital stay, pain, quality of life and graft outcome. Learning curve was calculated using the moving average method and calculating the average of operative time of every five consecutive cases. The learning phase was considered overcome when the moving average of operative times reached a plateau and when the mean operative time of every five consecutive cases reached a low point and subsequently did not vary by more than 30 minutes. Statistical analysis was done using STATA and p value < 0.05 was considered significant.

Results: The mean operative time of the procedure was 108.1 ± 26.5 min (range 60-180 min) Learning curve of LDN as measured by the moving average method was achieved at around 20 cases and between 26 and 30 cases according to the mean operative time of every five consecutive cases. Only few minor intraoperative visceralinjuries were encountered and all could be managed laparoscopically. Two cases required conversion to open, both being within the learning curves.

Conclusion: In conclusion, LDN is a complex surgery and has a learning curve associated with it. The best method to overcome this learning curve even for experienced laparoscopic surgeon is to adopt the perceptorship-proctorship model of training which as we have shown gives the best results.