title: Multifactorial analysis of the learning curve for totally robotic Roux-en-Y gastric bypass for morbid obesity.
abstract: BACKGROUND
  Laparoscopic Roux-en-Y gastric bypass is one of the most commonly performed bariatric operation worldwide for the surgical management of obesity. Totally robotic Roux-en-Y gastric bypass (TR-RYGBP) has been considered to be a better approach by some groups especially early in a surgeon's experience. However, the learning curve associated with TR-RYGBP has been poorly evaluated yet. The aim of this study was to evaluate the learning curve of patients who underwent TR-RYGBP.
  
  
  METHODS
  This is a prospective study of 154 first consecutive patients undergoing TR-RYGBP to analyze the influence of surgeon experience, bedside first assistant, and patient factors on operative time and postoperative complications. To give a comprehensive view of success related to the learning process, a single hybrid variable was generated. Multivariate analysis predicted the risk factors for complications and operative time. A risk-adjusted cumulative sum analysis estimated the learning curve.
  
  
  RESULTS
  The learning curve for TR-RYGBP was 84 cases. Case rank and first assistant level were independent predictors of total operative time. Overall 30-day postoperative morbidity rate was 33.1 % and decreased over time. Surgeon experience (OR 2.6; CI 95 [1.290 to 5.479]; p = 0.0081) and first assistant level (OR 2.42; CI 95 [1.197 to 4.895]; p = 0.0139) remained independent predictors of composite event (operative time and complications).
  
  
  CONCLUSIONS
  This study identifed criteria that should be assessed in future studies about TR-RYGBP. Both surgeon experience and bedside first assistant level affected operative duration, but surgeon experience was the most significant factor in reducing complication rates.
authors.affiliation: Department of Digestive, Hepato-Biliary and Endocrine Surgery, Hopital Brabois Adultes, pôle UND, Université de Lorraine-CHU Nancy, Vandoeuvre les Nancy, 54511, France.
authors.forename: Myriam
authors.initials: M
authors.lastname: Renaud
authors.forename: Nicolas
authors.initials: N
authors.lastname: Reibel
authors.forename: Rasa
authors.initials: R
authors.lastname: Zarnegar
authors.forename: Adeline
authors.initials: A
authors.lastname: Germain
authors.forename: Didier
authors.initials: D
authors.lastname: Quilliot
authors.forename: Ahmet
authors.initials: A
authors.lastname: Ayav
authors.forename: Laurent
authors.initials: L
authors.lastname: Bresler
authors.forename: Laurent
authors.initials: L
authors.lastname: Brunaud
mesh_terms: D000328:Adult; D002983:Clinical Competence / Q000706:statistics & numerical data*; D005260:Female; D015390:Gastric Bypass / Q000009:adverse effects / Q000379:methods / Q000639:trends; D006801:Humans; D010535:Laparoscopy; D059032:Learning Curve; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D009767:Obesity, Morbid / Q000453:epidemiology / Q000601:surgery*; D061646:Operative Time; D011446:Prospective Studies; D018570:Risk Assessment; D012371:Robotics; D016896:Treatment Outcome; D015431:Weight Loss