TY  - JOUR
T1  - Technical proficiency in hand-assisted laparoscopic colon and rectal surgery: Determining how many cases are required to achieve mastery
AU  - Pendlimari R, Holubar SD, Dozois EJ, Larson DW, Pemberton JH, Cima RR
Y1  - 2012/04/01
N1  - 10.1001/archsurg.2011.879
JO  - Archives of Surgery
SP  - 317
EP  - 322
VL  - 147
IS  - 4
N2  - Objective 
                  To determine how many cases are required to achieve technical proficiency for hand-assisted laparoscopic surgery (HALS).Design 
                  Retrospective study.Setting 
                  Tertiary care hospital.Patients 
                  Using a prospective database, all HALS colorectal resections from 2003 to 2009 by 2 surgeons (A and B) were reviewed. Over 6 years, surgeons A and B performed 397 and 322 cases.Interventions 
                  Change-Point Analysis (CUSUM) was used to define the number of cases required to effect improvement in operative time. Cases before and after the change point were considered as being in the “learning period” and “skilled period.”Main Outcome Measures 
                  Operative time; short-term outcomes.Results 
                  The change point occurred after 108 and 105 cases for surgeons A and B, respectively. The learning period and skilled period were similar with respect to age, sex, body mass index, prior abdominal surgery, medical comorbidities, and American Society of Anesthesiologists class. Mean overall operative time decreased from 263 to 185 minutes (P < .001). The decrease in mean operative duration for specific resections were as follows: right colectomy, 35 minutes (P = .003); left colectomy, 63 minutes (P = .006); sigmoid colectomy, 63 minutes (P < .001); anterior resection, 70 minutes (P < .001); coloanal anastomosis, 52 minutes (P = .003); subtotal colectomy, 75 minutes (P < .001); and total proctocolectomy with ileal reservoir, 80 minutes (P < .001). Intraoperative complications and conversion rate were similar, but overall morbidity, infectious complications, readmissions, and length of stay were all significantly (P < .05) lower during the skilled period.Conclusions 
                  For HALS colorectal resection, technical proficiency occurred after approximately 105 cases, and increased surgeon experience resulted in improved short-term outcomes. These data suggest that the learning curve for HALS colorectal resection will extend beyond fellowship training for many colorectal surgeons.
SN  - 0004-0010
M3  - doi: 10.1001/archsurg.2011.879
UR  - http://dx.doi.org/10.1001/archsurg.2011.879
ER  -