title: Totally laparoscopic distal gastrectomy after learning curve completion: comparison with laparoscopy-assisted distal gastrectomy.
abstract: OBJECTIVE
  THE AIMS ARE TO: (i) display the multidimensional learning curve of totally laparoscopic distal gastrectomy, and (ii) verify the feasibility of totally laparoscopic distal gastrectomy after learning curve completion by comparing it with laparoscopy-assisted distal gastrectomy.
  
  
  METHODS
  From January 2005 to June 2012, 247 patients who underwent laparoscopy-assisted distal gastrectomy (n=136) and totally laparoscopic distal gastrectomy (n=111) for early gastric cancer were enrolled. Their clinicopathological characteristics and early surgical outcomes were analyzed. Analysis of the totally laparoscopic distal gastrectomy learning curve was conducted using the moving average method and the cumulative sum method on 180 patients who underwent totally laparoscopic distal gastrectomy.
  
  
  RESULTS
  Our study indicated that experience with 40 and 20 totally laparoscopic distal gastrectomy cases, is required in order to achieve optimum proficiency by two surgeons. There were no remarkable differences in the clinicopathological characteristics between laparoscopy-assisted distal gastrectomy and totally laparoscopic distal gastrectomy groups. The two groups were comparable in terms of open conversion, combined resection, morbidities, reoperation rate, hospital stay and time to first flatus (P>0.05). However, totally laparoscopic distal gastrectomy had a significantly shorter mean operation time than laparoscopy-assisted distal gastrectomy (P<0.01). We also found that intra-abdominal abscess and overall complication rates were significantly higher before the learning curve than after the learning curve (P<0.05).
  
  
  CONCLUSIONS
  Experience with 20~40 cases of totally laparoscopic distal gastrectomy is required to complete the learning curve. The use of totally laparoscopic distal gastrectomy after learning curve completion is a feasible and timesaving method compared to laparoscopy-assisted distal gastrectomy.
authors.affiliation: Department Surgery, Postgraduate School of Medicine, Gyeongsang National University, Jinju, Korea. ; Department Surgery, Postgraduate School of Medicine, Gyeongsang National University, Jinju, Korea.
authors.forename: Han-Gil
authors.initials: HG
authors.lastname: Kim
authors.forename: Ji-Ho
authors.initials: JH
authors.lastname: Park
authors.forename: Sang-Ho
authors.initials: SH
authors.lastname: Jeong
authors.forename: Young-Joon
authors.initials: YJ
authors.lastname: Lee
authors.forename: Woo-Song
authors.initials: WS
authors.lastname: Ha
authors.forename: Sang-Kyung
authors.initials: SK
authors.lastname: Choi
authors.forename: Soon-Chan
authors.initials: SC
authors.lastname: Hong
authors.forename: Eun-Jung
authors.initials: EJ
authors.lastname: Jung
authors.forename: Young-Tae
authors.initials: YT
authors.lastname: Ju
authors.forename: Chi-Young
authors.initials: CY
authors.lastname: Jeong
authors.forename: Taejin
authors.initials: T
authors.lastname: Park
keywords: Anastomosis; Laparoscopy; Learning curve; Morbidity; Stomach neoplasms