title: Critical appraisal of learning curve for single incision laparoscopic right colectomy.
abstract: BACKGROUND
  Single-incision laparoscopic colectomy (SILC) has emerged as a viable minimally invasive surgical approach with benefits and limitations yet to be fully elucidated. Although shown to be safe and feasible, characterization of the learning curve has not been addressed. Our aim was to identify a learning curve for SILC right hemicolectomy and to determine the incidence of operative failure and complication rates during this phase.
  
  
  METHODS
  Over a 2-year period, data from 54 consecutive SILC cases performed by the same surgeon were tabulated in an institutional review board-approved database. A learning curve was generated utilizing cumulative sum (CUSUM) methodology to assess changes in total operative time (OT) across the case sequence. A separate learning curve was generated utilizing risk-adjusted CUSUM analysis, taking into account patient risk factors (i.e., age, American Society of Anesthesiologists score, body mass index, prior abdominal surgeries, and tumor size for malignant cases) and operative failure (i.e., prolonged OT, conversion to open surgery, intraoperative and 30-day postoperative complications, prolonged length of stay, reoperation, readmission, and mortality).
  
  
  RESULTS
  Patients had a mean age of 63.6 ± 11.5 years, mean body mass index of 27.3 ± 3.9 kg/m(2), and median American Society of Anesthesiologists score of 2. Mean OT and length of stay were 123.5 ± 28.9 min and 3.9 ± 2.4 days, respectively. There were no conversions or oncologic failures. Six patients developed 30-day postoperative complications. CUSUM analysis of OT identified achievement of the learning phase after 30 cases. When taking into account both analyses, the rate of operative failure was not statistically different between the initial 30 and the final 24 cases.
  
  
  CONCLUSIONS
  In our experience, the learning curve is achieved between 30 to 36 cases. Offering this minimally invasive surgical approach does not result in increased complications or harmful results even in the early phases of the learning curve.
authors.affiliation: Colorectal Surgical Associates, LLP, Ltd, 7900 Fannin Street, Suite 2700, Houston, TX, 77054, USA, ehaasmd@houstoncolon.com.
authors.forename: Eric M
authors.initials: EM
authors.lastname: Haas
authors.forename: Javier
authors.initials: J
authors.lastname: Nieto
authors.forename: Madhu
authors.initials: M
authors.lastname: Ragupathi
authors.forename: Ali
authors.initials: A
authors.lastname: Aminian
authors.forename: Chirag B
authors.initials: CB
authors.lastname: Patel
mesh_terms: D003082:Colectomy / Q000193:education* / Q000379:methods; D003108:Colonic Diseases / Q000601:surgery*; D061887:Conversion to Open Surgery / Q000193:education; D004502:Education, Medical, Continuing / Q000379:methods*; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000193:education*; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D015203:Reproducibility of Results; D012189:Retrospective Studies; D013781:Texas / Q000453:epidemiology