title: Defining the learning curve in laparoscopic paraesophageal hernia repair: a CUSUM analysis.
abstract: BACKGROUND
  There are numerous reports in the literature documenting high recurrence rates after laparoscopic paraesophageal hernia repair. The purpose of this study was to determine the learning curve for this procedure using the Cumulative Summation (CUSUM) technique.
  
  
  METHODS
  Forty-six consecutive patients with paraesophageal hernia were evaluated prospectively after laparoscopic paraesophageal hernia repair. Upper GI series was performed 3 months postoperatively to look for recurrence. Patients were stratified based on the surgeon's early (first 20 cases) and late experience (>20 cases). The CUSUM method was then used to further analyze the learning curve.
  
  
  RESULTS
  Nine patients (21%) had anatomic recurrence. There was a trend toward a higher recurrence rate during the first 20 cases, although this did not achieve statistical significance (33% vs. 13%, p = 0.10). However, using a CUSUM analysis to plot the learning curve, we found that the recurrence rate diminishes after 18 cases and reaches an acceptable rate after 26 cases.
  
  
  CONCLUSIONS
  Surgeon experience is an important predictor of recurrence after laparoscopic paraesophageal hernia repair. CUSUM analysis revealed there is a significant learning curve to become proficient at this procedure, with approximately 20 cases required before a consistent decrease in hernia recurrence rate is observed.
authors.affiliation: Division of General Surgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada.
authors.forename: Allan
authors.initials: A
authors.lastname: Okrainec
authors.forename: Lorenzo E
authors.initials: LE
authors.lastname: Ferri
authors.forename: Liane S
authors.initials: LS
authors.lastname: Feldman
authors.forename: Gerald M
authors.initials: GM
authors.lastname: Fried
mesh_terms: D000368:Aged; D002983:Clinical Competence; D005260:Female; D018662:Fundoplication / Q000193:education* / Q000379:methods; D006551:Hernia, Hiatal / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000193:education*; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D009048:Motor Skills; D011214:Practice, Psychological; D012008:Recurrence