Korneffel Katie, Nuzzo Wendy, Belden C Micha, McPhail Lindsee, O'Connor Sean
General Surgery Residency, Mountain Area Health Education Center (MAHEC), Asheville, NC, USA.
Department of Research, MAHEC, Asheville, USA.
Surg Endosc. 2023 Dec;37(12):9351-9357. doi: 10.1007/s00464-023-10349-7. Epub 2023 Aug 28.
Robotic extended totally extraperitoneal hernia (eTEP) repair is a novel technique for minimally invasive ventral hernia repair with retromuscular placement of mesh. This study aimed to evaluate the learning curve for robotic eTEP hernia repair using risk-adjusted cumulative sum (RA-CUSUM) analysis for two general surgeons-one with dedicated fellowship training in robotic eTEP technique (surgeon 2) and another without robotic eTEP-specific training (surgeon 1).
We conducted a retrospective analysis of 98 patients undergoing robotic eTEP hernia repair from July 2020 to February 2022 for two surgeons. RA-CUSUM method was applied to the overall operative time (OT) in minutes, adjusting for transversus abdominis release (TAR).
Figures 3 (surgeon 1) and 4 (surgeon 2) illustrate the three phases in the RA-CUSUM graphs of OT. For surgeon 1, the cases for each phase were determined: phase 1 (1 to 12), phase 2 (13 to 24), and phase 3 (25 to 51). For surgeon 2, the three phases were similarly determined as 1 to 8, 9 to 32, and 33 to 47, respectively. A significant (p = 0.017) difference existed for the OTs between phases 1 (262 ± 69) and 3 (192 ± 63.0) for surgeon 1. OT compared to the risk-adjusted value stabilized after case 12 and decreased after case 24 for surgeon 1; it began to decrease after case 8 for surgeon 2.
The initial learning curve for surgeon 1 reached its plateau after 12 cases, shorter than comparable studies. This was likely due to the surgeon's intentional focus on learning this technique through courses, proctoring, and active mentorship. The flat learning curve seen in surgeon 2's series illustrates the value of experience gained during fellowship training. Our data support that, given the right resources and support, a short learning curve for eTEP is attainable for community surgeons without prior training in the technique.
机器人辅助完全腹膜外疝（eTEP）修补术是一种用于微创腹疝修补的新技术，采用肌后补片放置。本研究旨在使用风险调整累积和（RA-CUSUM）分析评估两位普通外科医生进行机器人辅助eTEP疝修补术的学习曲线，其中一位接受了机器人辅助eTEP技术的专项进修培训（外科医生2），另一位未接受机器人辅助eTEP的专项培训（外科医生1）。
我们对2020年7月至2022年2月期间两位外科医生进行的98例机器人辅助eTEP疝修补术患者进行了回顾性分析。RA-CUSUM方法应用于以分钟为单位的总手术时间（OT），并对腹横肌松解（TAR）进行调整。
图3（外科医生1）和图4（外科医生2）展示了OT的RA-CUSUM图中的三个阶段。对于外科医生1，确定了每个阶段的病例数：第1阶段（1至12例）、第2阶段（13至24例）和第3阶段（25至51例）。对于外科医生2，三个阶段分别类似地确定为1至8例、9至32例和33至47例。外科医生1的第1阶段（262±69分钟）和第3阶段（192±63.0分钟）的OT存在显著差异（p = 0.017）。对于外科医生1，与风险调整值相比，OT在第12例后趋于稳定，在第24例后下降；对于外科医生2，在第8例后开始下降。
外科医生1的初始学习曲线在12例后达到平稳期，比同类研究的时间短。这可能是由于该外科医生通过课程、指导和积极的导师指导，有意专注于学习这项技术。外科医生2的系列研究中呈现的平缓学习曲线说明了在进修培训期间积累经验的价值。我们的数据支持，在有合适的资源和支持的情况下，未接受过该技术先前培训的社区外科医生也可实现eTEP的短学习曲线。
