Table 1 Studies reporting on learning curve during urgent/emergent minimally invasive surgery
From: Training curriculum in minimally invasive emergency digestive surgery: 2022 WSES position paper
References | Study design | Time period | Surgical emergency | Nb. of pts/procedures | Type of intervention | Surgeons involved | Surgeon experience | Groups calculation and methods | Outcomes (on which LC was evaluated) | Main results | Estimated learning curve |
|---|---|---|---|---|---|---|---|---|---|---|---|
Jaffer et al (2008) [29] | Retrospective observational study - prospectively collected database | May 2005 - November 2006 | Appendicitis | 40 | Laparoscopic appendectomy | 1 | NR | 4 groups (10 pts each) - according to moving average method and CUSUM | OT CR | OT was significantly shorter after 20 cases (p < 0.0001). CR decreased after 20 cases | 20 cases are sufficient to gain competences in term of operative time and conversion rate |
Kim et al (2010) [27] | Retrospective observational study with subgroup analysis | March 2008 - December 2008 | Appendicitis | 103 (50 laparoscopic, 53 open) | Laparoscopic and open appendectomy | 1 | Single 2nd year resident who had performed > 30 open appendectomies (Supervised) | Subgroup analysis for laparoscopic cases: 5 groups (10 pts each) - according to moving average method | OT LOS CR | OT was significantly shorter after 30 cases LOS and CR were comparable | The LC is reached after 30 operations |
Lin et al (2010) [21] | Retrospective observational study | January 2002 - December 2007 | Appendicitis | 240 | Laparoscopic appendectomy | 6 | Residents (FLS certified; trained in basic laparoscopy in wet and simulation laboratories for 2–4 years while assisting in simple laparoscopic surgeries (Supervised) | 2 groups (120 pts LC; 120 pts after LC) | OT POC LOS CR | OT was significantly shorter after the LC. (p = 0.005). POC rate was significantly reduced after the LC. (p = 0.04) LOS and CR were not different between the two groups | The LC is reached after 20 cases only for OT |
Liao et al (2013) [22] | Retrospective observational study with subgroup analysis | July 2009 - June 2010 | Appendicitis | 30 | Laparoscopic single port appendectomy | 1 | At least 30 conventional three-port laparoscopic appendectomy | 3 groups (10 pts each) - consecutively assigned | OT POC LOS CR TTOI | OT were longest in the first group (P = 0.017). No difference in CR, TTOI, LOS, POC | Significant improvement in OT after the first 10 cases. An experience of 30 cases achieved an OT equivalent to conventional three-port laparoscopic appendectomy First 10 cases had a much steeper downward slope of OT. (–1.5 min/case) |
Abdelrahman et al (2016) [31] | Retrospective observational study | August 2007 - August 2014 | Appendicitis | / | Laparoscopic and open appendectomy | 69 | Higher surgical trainees from 3rd to 8th year | According to procedural-based assessment | Procedural-based assessment | Three consultant-validated PBAs at level 4 (competent to perform independently and deal with complications) are reached after 107 cases | The proficiency is reached after 107 cases (median) The number is 35% higher than the number imposed to certify the trainee |
Kim et al (2016) [23] | Retrospective observational study | March 2013 - February 2015 | Appendicitis | 120 | Laparoscopic single port appendectomy | 1 | More than 500 open appendectomy; more than 500 laparoscopic appendectomy | 4 groups (30 pts each) - consecutively assigned | OT POC LOS CR TTOI | OT were longest in group A and shortest in group D (P = 0.012) The mean OT was shortened after 30 operations, it was further shortened after 90 operations No difference in POC, LOS, TTOI, CR | Surgical skills can be achieved after 30 operations and more experienced surgical skills after 90 operations |
Mán et al (2016) [24] | Retrospective observational study | January 2006 - December 2009 | Appendicitis | 600 | Laparoscopic appendectomy | 10 | 5 residents (2—3 years of surgical experience) Completed a two-week basic laparoscopic skills course and assisted in other laparoscopic procedures (Supervised) 5 consultants (8—9 years of surgical experience) Regularly performed other surgical procedures independently (Supervised) | 4 groups (100 pts residents LC; 100 pts consultant LC; 219 residents after LC; 181 consultants after LC) - consecutively assigned | OT POC LOS CR | OT was significantly shorter in both groups (residents and consultants) after the completion of the LC (P < 0.05) The OT was significantly different between the two groups, before and after the completion of the LC (P < 0.05) | The LC is reached after 20 cases both for residents and consultants |
Brown et al (2017) [32] | Retrospective observational study | August 2007 - August 2016 | Appendicitis | / | Laparoscopic appendectomy | 84 | Higher surgical trainees from 3rd to 8th year | According to procedural-based assessment | Procedural-based assessment | Three consultant-validated PBAs at level 4 (competent to perform independently and deal with complications) are reached after 95 cases Significant variance was observed in the gradients of all LC related to both the caseload between the first level 3 and the first level 4 PBA (P = 0.001), and between the first and third level 4 PBAs (P < 0.001). Significant variance was also observed in the gradients of all learning curves related to time between the first and third level 4 PBA (P = 0⋅025), but not related to the period between the first level 3 and first level 4 PBA (P = 0.732) | The proficiency is reached after 95 cases (median) |
Kim et al (2020) [30] | Retrospective observational study | October 2015 - November 2016 | Appendicitis | 150 | Laparoscopic appendectomy | 3 | Resident A (1st year 96 surgeries comprising 19 appendectomies and performed 4 laparoscopic appendectomies.) Resident B (2nd year, participated in 272 general surgeries comprising 42 appendectomies and performed 3 laparoscopic appendectomies) Resident C (3rd year, participated in 510 general surgeries comprising 98 appendectomies and performed 4 laparoscopic appendectomies) | (50 pts each resident) - according to moving average method and CUSUM | OT Surgical failure | CUSUM for OT exhibited peaks at the 24th, 18th, and 31st cases for residents A, B, and C, respectively In terms of surgical failure, residents A, B, and C reached steady states after their 35th, 11th, and 16th cases, respectively No significant difference in surgical failure but resident A showed a relatively equal distribution of surgical failure throughout the study period, whereas residents B and C experienced surgical failure earlier on | According to the OR, the LC varies depending on surgical experience ranging from 11 to 35 cases based on a multidimensional analysis |
Lee et al (2021) [25] | Retrospective observational study | May 2008 - November 2014 | Appendicitis | 1948 | Laparoscopic single port appendectomy | 41 | 8 surgeons 33 residents (training protocol: at list 10 cases as assistant then first three procedures supervised) | 2 groups (483 pts LC; 1465 pts after LC) | OT POC LOS CR HRR Mortality | After a PSM: OT was significantly longer in group 1 than in group 2 (p < 0.001) POC, LOS, CR, HRR and mortality were comparable The rate of incisional hernia tended to be larger in group 1 than in group 2 | The LC is reached after 40 cases |
Ussia et al (2021) [26] | Retrospective observational study | January 2013 - December 2018 | Appendicitis | 1173 | Laparoscopic appendectomy | 73 | 9 attendings 64 residents (asked to spectate several cases before assisting) | Comparison after PSM: (409 pts attendings 409 pts residents) | OT POC LOS Mortality | After a PSM: LOS was significantly longer in attendings group (p < 0.007) OT, POC and mortality rate were comparable After stratification: OT was significantly reduced only in edematous and suppurative cases as the number of years of training increased CUSUM for OT showed a reduction in OT for attendings at around 300 cases (more than 30 pts/surgeon) | Not specified |
Angeramo et al. [28] | Retrospective observational study | June 2000 - December 2019 | Postoperative complications in colorectal surgery | 132 | Various laparoscopic procedures (Lavage and loop ileostomy; resection, redo anastomosis; lavage and drainage; anastomosis takedown; wall repair; bowel repair; adhesiolysis; internal hernia reduction) | 3 | National board-certified colorectal surgeons | 3 groups (50, 52 and 30 pts each) - according to CUSUM analysis (for OT) | OT POC LOS CR Mortality | CR was higher in the first group (P = 0.02) OT was higher in the first group (P = 0.003) Overall postoperative morbidity was lower in the last group (P = 0.01) Major morbidity, mortality and LOS were comparable across the LC | 50 re-laparoscopies might be needed to achieve an appropriate LC reducing OT and CR |
Kubat et al. [20] | Retrospective observational study with subgroup analysis | May 2012 - August 2013 | Acute cholecystitis, biliary pancreatitis, choledocholithiasis, severe chronic cholecystitis, symptomatic cholelithiasis, gallbladder polyposis | 150 (76 elective surgery, 74 urgent surgery) | Robotic single port cholecystectomy | 1 | Experienced minimally invasive surgeon (both in multiport robotic cholecystectomy and in single-incision laparoscopic cholecystectomy) | 3 groups (48, 47 and 55 pts each) - according to CUSUM analysis (for OT) Subgroup analysis for urgent cases: 3 groups (35, 34 and 15 pts each) | OT POC LOS CR HRR Mortality | OT was significantly shorter in elective interventions compared with urgent interventions (P < 0.05) LOS was longer in urgent cases (P = 0.003) | The LC is reached after 48 operations, inclusive of urgent and elective cases In the subgroup analysis, the first phase of the CUSUM chart was 25% longer in urgent cases compared to elective cases |