title: The learning curve for the laparoscopic approach to conservative mesorectal excision for rectal cancer: lessons drawn from a single institution's experience.
abstract: OBJECTIVE
  We aimed to determine the most sensitive markers of the learning process for laparoscopic conservative mesorectal excision (LCME) for rectal cancer to (1) generate a relevant training program for junior surgeons and (2) define appropriate settings for prospective trials.
  
  
  BACKGROUND
  The learning process for the laparoscopic approach to treating rectal cancer has not yet been clearly described.
  
  
  METHODS
  Over a 42-month period, 127 patients received LCME at our institution. The procedure was performed or supervised by a single referent surgeon. The operative time, conversion to open procedure postoperative morbidity, microscopic margins, and local recurrence were thought to be the most relevant parameters related to the learning process. To give a comprehensive view of success, a single hybrid variable was generated. Curves were drawn using the moving average method for continuous variables and the CUSUM analysis was used for binary variables.
  
  
  RESULTS
  A slow but continuous decrease in operative time was observed over all the study period. The overall and surgical morbidities were the most sensitive markers. The conversion rate and R0-resection rate remained stable at 14.9% and 91%, respectively. The overall local recurrence rate was 4.7% at a median follow-up time of 40 months and was not affected by the learning process. The success rate reached a steady state after 50 patients.
  
  
  CONCLUSIONS
  Despite surgeons' early command of the conversion rate, the learning process for LCME affects morbidity for the first 50 patients operated on, but does not adversely affect the oncological results. Much emphasis should therefore be placed on technical training.
authors.affiliation: Department of Surgical Oncology, Paoli Calmettes Institute, Regional Comprehensive Cancer Center, Marseille, France.
authors.forename: Thierry
authors.initials: T
authors.lastname: Bege
authors.forename: Bernard
authors.initials: B
authors.lastname: Lelong
authors.forename: Benjamin
authors.initials: B
authors.lastname: Esterni
authors.forename: Olivier
authors.initials: O
authors.lastname: Turrini
authors.forename: Jerôme
authors.initials: J
authors.lastname: Guiramand
authors.forename: Daniel
authors.initials: D
authors.lastname: Francon
authors.forename: Djamel
authors.initials: D
authors.lastname: Mokart
authors.forename: Gilles
authors.initials: G
authors.lastname: Houvenaeghel
authors.forename: Marc
authors.initials: M
authors.lastname: Giovannini
authors.forename: Jean Robert
authors.initials: JR
authors.lastname: Delpero
mesh_terms: D013505:Digestive System Surgical Procedures / Q000193:education / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000193:education / Q000706:statistics & numerical data; D011446:Prospective Studies; D012004:Rectal Neoplasms / Q000601:surgery*