ObjectiveTo summarize the surgical learning curve and evaluate the effectiveness, safety and feasibility of the robotic-assisted thoracoscopic surgery (RATS) by comparing with the conventional vedio-assisted thoracoscopic surgery (VATS).MethodsThe clinical data of 40 patients receiving robotic assisted thoracoscopic anatomic lung resection from March to June 2016 in our department were reviewed. There were 29 males and 11 females with the age of 54-78 (60.2±12.7) years in the RATS group, and 27 males and 10 females with the age of 52-76 (58.7±11.5) years in the VATS group. Lung space-occupying lesions were comfirmed by preoperative diagnosis. The operative time, blood loss, chest tube retention time, postoperative hospital stay and perioperative morbidity and mortality were analyzed. The safety and feasibility were evaluated, and the learning curve was summed up.ResultsOperative time, postoperative ventilation time, intraoperative blood loss, chest tube retention time, postoperative pain, average hospital stay, postoperative complication rate between two groups were not statistically significant. In the RATS group preoperative preparation time was longer than that of the VATS group (24.5 min vs. 15.6 min, P=0.003), and the rate of conversion to thoracotomy of the RATS group was lower than that of the VATS group (0 vs. 10.8%). There was no perioperative death in two groups.ConclusionRobotic-assisted thoracic surgery is safe and effective in the early learning process, and the learning curve can be entered into the standard stage from the learning stage after initial 10 operations.
ObjectiveTo study the learning curve of minimal invasive coronary artery bypass grafting (MICS CABG) and the influence on the perioperative clinical effects by analyzing operation time.MethodsFrom March 2012 to November 2020, 212 patients underwent MICS CABG by the same surgeon. Among them, 59 patients (52 males and average age of 62.89±8.27 years) with single vessel bypass grafting were as a single-vessel group and 153 patients (138 males, average age of 59.80±9.22 years) with multi-vessel bypass grafting were as a multi-vessel group. Two sets of operation time-operation sequence scatter plots were made and learning curve was analyzed by cumulative summation (CUSUM) and regression method of operation time. The surgical data of each group before and after the inflection point of the learning curve were compared with the main clinical outcome events within 30 days after surgery.ResultsThere was no death, perioperative myocardial infarction and stroke in 212 MICS CABG patients and no transfer to cardiopulmonary bypass or redo thoracotomy. The learning curve conformed to the cubic fitting formula. In the single-vessel group, CUSUM (x operation number)=–1.93+93.45×x–2.33×x2+0.01×x3, P=0.000, R2=0.986, the tipping point was 27 patients. In the multi-vessel group, CUSUM (x)=y=2.87+1.15×x–1.29× x2+3.463×x3, P=0.000, R2=0.993, and the tipping point was 59 patients. The two sets of case data were compared before and after the learning curve and there was no statistical difference in main clinical outcomes within 30 days (mortality, acute myocardial infarction, stroke, perioperative blood transfusion rate), ventilator tube, and intensive care unit retention.ConclusionThe learning curve of MICS CABG conforms to the cubic formula, and the process transitions from single to multiple vessels bypass. To enter the mature stage of the learning phase, a certain number of patients need to be done. Reasonable surgical procedures and quality control measures can ensure the safety during the learning phase.
ObjectiveTo summarize the characteristics of the learning curve and the occurrence of postoperative adverse events during the development of unilateral biportal endoscopy (UBE) technique by comparing the clinical data of early and late patients treated with UBE technique. Methods All patients who underwent single-level UBE technique between April 1, 2020 and December 31, 2021 were selected as the research subjects. According to the surgical options, all patients were allocated into 3 groups: unilateral decompression and discectomy (UDD) group, unilateral laminotomy for bilateral decompression (ULBD) group, and lumbar intervertebral fusion (LIF) group. The first 60 cases from each group were extracted and ranked orderly. The endoscopic operation time, the times of fluoroscopy during non-internal fixation implantation, the postoperative hospital stay, the drainage volume, the decrease of hemoglobin, the decrease of hematocrit, and the adverse events were collected. In each group, the patients were allocated into early and late cases according to the operation sequence. The first 30 cases of each group were classified as early cases, and the last 30 cases as late cases. Statistical analysis was performed on the above observation indicators between the early and late cases, and a scatter plot of relevant data changes was drawn to observe the change trend. Results Compared with the early cases, the endoscopic operation time and the times of fluoroscopy during non-internal fixation implantation of late cases in each group were significantly lower (P<0.05); the postoperative hospital stay of late cases in LIF group was significantly shorter (P<0.05); the decreased values of hemoglobin and hematokrit of late cases in ULBD group and LIF group were significantly lower (P<0.05); the postoperative drainage volume of late cases in ULBD group significantly decreased (P<0.05). The endoscopic operation time and the times of fluoroscopy during non-internal fixation implantation of 3 groups showed a significant downward trend. The adverse events occurred in 3 early cases and 1 late case of the UDD group, in 6 and 3 cases of the UBLD group, and 8 and 3 cases of the LIF group, respectively. The difference was not significant between the early and late cases (P>0.05). Conclusion In the early practice of UBE technique, there is a high incidence of complication, and the surgical trauma is relatively large, which is related to the lack of understanding of the UBE technique characteristics and insufficient surgical experience. With the proficiency of surgical techniques and accumulation of experience, the operation time and the incidence of postoperative adverse events were significantly reduced.
Objective To investigate the learning curve for da Vinci robot-assisted mediastinal tumor resection (DRMTR). Methods A total of 50 consecutive patients received DRMTR between March 2011 and September 2012 in our hospital. Clinical data of the 50 patients were collected and analyzed. There were 23 males, 27 females aged 46.9(17–80) years. The learning curve was evaluated by using the cumulative sum (CUSUM) analysis. Results The mean operation time was 124.6 min. The CUSUM learning curve was best modeled as a third-order polynomial curve with the equation: CUSUM=0.046×case-number3–4.681×case-number2+127.508×case-number–237.940, which had a highR2 value of 0.868. The fitting curve reached the top after the 19th case, which suggested that the surgeons master the technique after they finished 19 cases. As a cut-off point, the 19th case divided the learning curve into two phases, in which there was statistical diffference in operation time (P<0.01), intraoperative blood loss (P<0.01), the postoperative duration of chest tube drainage (P<0.01 ) and the rate of postoperative complications (P<0.05 ). Conclusion The DRMTR identified by CUSUM analysis represents two characteristic stages of DRMTR: the learning stage and the mastery stage. It is suggested from our data that the surgeons need finish about 19 cases to master DRMTR.
Objective To summarize the surgical learning curve and preliminary operative experience of dual-robotic navigated minimally invasive treatment on pelvic fractures by TiRobot and Artis Zeego. Methods Between July 2019 and February 2021, 90 patients with pelvic fractures were treated with dual-robotic navigated minimally invasive surgery by TiRobot and Artis Zeego. There were 64 males and 26 females, with an average age of 46.5 years (range, 13-78 years). Body mass index was 14.67-32.66 kg/m2 (mean, 23.61 kg/m2). Causes of injuries included traffic accident in 43 cases, falling from height in 37 cases, low-energy injuries such as flat falls in 10 cases. The interval between injury and surgery was 1-36 days (mean, 7.3 days). According to the location of the implanted screws, the patients were divided into sacroiliac screw group (n=33), acetabular screw group (acetabulum anterior/posterior column, n=24), composite screws group (sacroiliac and acetabulum anterior/posterior column, n=33). According to the screw implantation time and accuracy, the surgical learning curve was plotted, and the differences in the relevant indicators between learning stage and skilled stage were compared. Results All 90 patients successfully completed the operation, the intraoperative bleeding volume was 5-200 mL (median, 20 mL). There was no vascular or nerve injury. All incisions healed by first intention. The screw implantation time ranged from 7.5 to 33.0 minutes (mean, 18.92 minutes), and the screw implantation accuracy ranged from 1.1 to 1.8 mm (mean, 1.56 mm). According to the learning curve, the practice stage of 3 groups was reached after 7, 10, and 11 cases, respectively. With the accumulation of surgical experience, the screw implantation time had a significant downward trend. Compared with the learning stage, the screw implantation time on skilled stage in 3 groups significantly shortened (P<0.05), but the difference in the screw implantation accuracy was not significant (P>0.05). Conclusion TiRobot and Artis Zeego assisted pelvic fracture surgery is safe and efficient, which helps the surgeon to quickly master the pelvic channel screw surgery, and the operation time is significantly shortened on the premise of ensuring the implantation accuracy.
Objective To explore the clinical efficacy and learning curve of robot-assisted thymectomy via subxiphoid approach. MethodsThe clinical data of patients with robot-assisted thymectomy surgery via subxiphoid approach performed by the same surgical team in the Department of Thoracic Surgery of Shanghai Pulmonary Hospital from February 2021 to August 2022 were retrospectively analyzed. The cumulative sum (CUSUM) analysis and best fit curve were used to analyze the learning curve of this surgery. The general information and perioperative indicators of patients at different learning stages were compared to explore the impact of different learning stages on clinical efficacy of patients. ResultsA total of 67 patients were enrolled, including 31 males and 36 females, aged 57.10 (54.60, 59.60) years. The operation time was 117.00 (87.00, 150.00) min. The best fitting equation of CUSUM learning curve was y=0.021 2x3–3.192 5x2 +120.17x–84.444 (x was the number of surgical cases), which had a high R2 value of 0.977 8, and the fitting curve reached the top at the 25th case. Based on this, the learning curve was divided into a learning period and a proficiency period. The operation time and intraoperative blood loss in the proficiency stage were significantly shorter or less than those in the learning stage (P＜0.001), and there was no statistical difference in thoracic drainage time and volume between the two stages (P＞0.05). ConclusionThe learning process of robot-assisted thymectomy via subxiphoid approach is safe, and this technique can be skillfully mastered after 25 cases.
Objective To investigate the learning curve of laparoscopic assisted rectal cancer radical resection of a surgeon and share the experience of laparoscopic surgery. Methods The date of 119 consecutive patients who were suffered operation by same team during January 2010 to December 2015 were retrospectively analyzed. The learning curve and its stages were obtained by using weighted moving average method, cumulative sum analysis(CUSUM), risk-adjusted CUSUM (RA-CUSUM)and Matlab software. The effects of each stage, such as operative time, intraoperative bold loss, harvested lymph node numbers, distal margin to the edge of tumor, complications after operation, hospital stay days, and the first time take soft food were compared, and the experience of laparoscopic assisted surgery for rectal cancer was summarized. Results Our learning curve was divided into three periods, the cutting point was around 36th and 80th cases, respectively. There was no significant difference between the 3 stages in general data, however when comparing the operative time, loss of blood, harvested lymph node numbers, the distal margin to the edge of tumor, hospital stay and total complications, the last period were best and the first stage were worst. Conclusions The learning curve can be divided into three stages, the exploration, mastery and proficient period. Our term, fixed and with rich experience in laparotomy, completed our first exploration period at about 36th patients and the second stage is around 80th cases. And the short term effect of each period’s had gradually improved with master of laparoscopic technique.
ObjectiveTo evaluate the learning curve of CT-guided medical glue localization for pulmonary nodule before video-assisted thoracic surgery (VATS). MethodsThe clinical data of the patients with pulmonary nodules who underwent CT-guided medical glue localization before VATS in our hospital from July 2018 to March 2021 were retrospectively analyzed. The patients were divided into 3 groups: a group A (from July 2018 to August 2019), a group B (from September 2019 to June 2020) and a group C (from July 2020 to March 2021). The localization time, morbidity, complete resection rate and other indexes were compared among the three groups. ResultsA total of 77 patients were enrolled, including 24 males and 53 females aged 57.4±10.1 years. There were 25 patients in the group A, 21 patients in the group B, and 31 patients in the group C. 77 pulmonary nodules were localized. There was no significant difference among the groups in the basic data (P＞0.05). The localization time in the group C was 10.6±2.0 min, which was statistically shorter than that in the group A (15.4±4.4 min) and group B (12.9±4.3 min) (P＜0.01). The incidence of complications in the group C was lower than that in the group A and group B (25.8% vs. 52.0% vs. 47.6%, P=0.04). The success rate of localization of the three groups was not statistically different (P=0.12). ConclusionThere is a learning curve in CT-guided medical glue localization for single pulmonary nodule before VATS. After the first 46 cases, the operation time can be shortened, and the incidence of complications can be decreased.
ObjectiveTo explore the learning curve of endoscopic thyroidectomy using the gasless unilateral axillary approach for papillary thyroid microcarcinoma.MethodsWe retrospectively analyzed the clinical data of 51 patients diagnosed with papillary thyroid microcarcinoma who underwent an endoscopic thyroidectomy using a gasless unilateral axillary approach by the same surgeon from November 2019 to September 2020 in the Department of Thyroid and Parathyroid Surgery, West China Hospital, Sichuan University. The cumulative sum (CUSUM) analysis was used to determine the learning curve of the technology, and the CUSUM learning curve was modeled by the best fit. The operative time, intraoperative blood loss, number of lymph nodes dissected, incidence of complications and postoperative hospital stay in different phases of the learning curve were compared.ResultsThe CUSUM fitting curve reached the top at the 18th case. As a cut-off point, the learning curve was divided into two stages: the learning improvement period and the proficiency period. The operative time of patients in the proficiency stage was significantly shorter than that in the learning improvement stage (P<0.05), and there were no statistically significant differences in other data of patients in the two stages (P>0.05).ConclusionThe CUSUM analysis method is used to accurately analyze the learning curve of endoscopic thyroidectomy using the gasless unilateral axillary approach for papillary thyroid microcarcinoma, indicating that the cumulative number of operations required to master this technique is 18 cases.
ObjectiveTo compare the differences in the learning curve and surgeon's perception for pulmonary lobectomy performed by a single surgeon using the da Vinci surgical robot versus a domestically-made robotic system. Methods A retrospective analysis was conducted on the clinical data of the first 70 consecutive patients who underwent lobectomy with the da Vinci robot and the first 70 with a domestic robot. All procedures were performed by a single thoracic surgeon at Gansu Provincial Hospital who initiated the use of both systems concurrently between 2021 and 2024. Data were analyzed using SPSS 26.0, and learning curves for both groups were plotted and analyzed using the cumulative sum (CUSUM) method. Results The da Vinci group included 41 males and 29 females with a mean age of (66.0±6.83) years and the domestic robot group included 42 males and 28 females;with a mean age of (65.09±6.14) years. For the da Vinci group, the mean operative time was (196.14±29.63) min. The CUSUM learning curve was best fitted by a cubic equation (R2=0.986; CUSUM=0.012X3−1.799X2+69.149X−59.239, where X was the surgical volume), which peaked at the 26th case, delineating the learning and mastery phases. Statistically significant differences were observed between these phases in operation time, setup time, console time, intraoperative blood loss, postoperative day 1 drainage, and number of lymph nodes dissected (all P<0.01). For the domestic robot group, the mean operative time was (187.57±24.62) min. Its CUSUM learning curve also followed a cubic fit (R2=0.910; CUSUM=0.008X3−1.152X2+40.465X+91.940), peaking at the 18th case. Significant improvements between the learning and mastery phases were also found for the same surgical metrics (all P<0.05). The surgeon's perception score was significantly higher for the da Vinci system compared to the domestic system (4.21±0.88 vs. 3.29±1.02, P<0.05). ConclusionCUSUM analysis effectively distinguishes the learning and mastery phases for both systems. The learning curve for da Vinci robotic lobectomy is overcome after 26 cases, whereas the domestic robot required 18 cases. In the mastery phase, operative time, setup time, intraoperative blood loss, and postoperative day 1 drainage are significantly lower, while the number of lymph nodes dissected is significantly higher compared to the learning phase for both systems. There are no significant differences in short-term efficacy or safety between the two groups. However, the da Vinci system provids a superior surgeon experience.