Characterizing the Learning Curve for Laparoscopic Radical Hysterectomy
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OBJECTIVE: Total laparoscopic radical hysterectomy (TLRH) requires advanced skill in laparoscopy. We evaluated various objective measurements of surgical skill representing the learning curve throughout the first 2 years of implementation of TLRH at our institution. We also describe our technique of "buddy operating," where 2 surgeons combine referrals and operate together, thereby increasing the rate of skill acquisition. METHODS: Charts were retrospectively reviewed for 45 patients undergoing TLRH and pelvic lymphadenectomy at the Hamilton Health Sciences from August 14, 2007, to August 14, 2009. A discriminant function analysis was used to describe the learning curve. χ² and t tests were used for discrete variables. RESULTS: The most predictive learning curve model divided the sample in two, with an accurate group assignment 72.1% of the time. After the first 23 procedures, operative time was significantly shorter (201.7 vs 176.6 min, P=0.02), estimated blood loss was significantly lower (355.7 vs 196.3 mL, P=0.01), the number of lymph nodes removed was significantly higher (11.5 vs 15.3, P=0.02), and hospital length of stay was significantly shorter (1.57 vs 0.14 days, P=0.002). There were nonsignificant trends toward decreasing intraoperative complications and postoperative morbidity. CONCLUSIONS: Total laparoscopic radical hysterectomy with pelvic lymphadenectomy is an important procedure in gynecologic oncology. After a fellowship training program including laparoscopy, we demonstrate the learning curve improves after only 23 cases. This is shorter than previously reported and may be due to "buddy operating," a novel technique for reducing the learning curve in infrequently performed complex procedures.
