title: The learning curve of totally laparoscopic aortobifemoral bypass for occlusive disease. How many cases and how safe?
abstract: OBJECTIVE
  Totally laparoscopic aortic surgery is appealing. However, the adoption of this technique in the broad vascular world is hampered by the steep learning curve and the fear of exposing patients to excessive morbidity and mortality. We assessed how many patients should be treated to overcome this learning curve.
  
  
  METHODS
  The first 50 patients treated with totally laparoscopic aortobifemoral bypass for severe aorto-iliac occlusive disease were followed prospectively. Operative variables such as operative time, aortic clamping time, amount of blood loss, conversion to laparotomy etc were recorded (as well as 30-day mortality and morbidity). To discover a turning point we used the technique of sliding averages. These data were compared with the mortality and morbidity as predicted by POSSUM and P-POSSUM.
  
  
  RESULTS
  A clear turning point, with improved operative variables, was seen after 20-30 patients. Mortality and morbidity were not higher than predicted by POSSUM and P-POSSUM.
  
  
  CONCLUSIONS
  These data confirm the intuition of most people involved in laparoscopic aortic surgery that the learning curve could be set at 25-30 cases. However, patients are not exposed to excessive morbidity and mortality during this learning curve.
authors.affiliation: Department of Vascular Surgery, University Hospital Gasthuisberg, Leuven, Belgium. inge.fourneau@uzleuven.be
authors.forename: I
authors.initials: I
authors.lastname: Fourneau
authors.forename: P
authors.initials: P
authors.lastname: Lerut
authors.forename: T
authors.initials: T
authors.lastname: Sabbe
authors.forename: S
authors.initials: S
authors.lastname: Houthoofd
authors.forename: K
authors.initials: K
authors.lastname: Daenens
authors.forename: A
authors.initials: A
authors.lastname: Nevelsteen
mesh_terms: D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical / Q000193:education; D001011:Aorta / Q000601:surgery*; D001157:Arterial Occlusive Diseases / Q000401:mortality / Q000601:surgery*; D016063:Blood Loss, Surgical; D002983:Clinical Competence; D005260:Female; D005263:Femoral Artery / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000193:education*; D016526:Workload