title: The learning curve of robot-assisted laparoscopic fundoplication in children: a prospective evaluation and CUSUM analysis.
abstract: BACKGROUND
  Fundoplication is a leading application of robotic surgery in children, yet the learning curve for this procedure (RF) remains ill-defined. This study aims to identify various learning curve transition points, using cumulative summation (CUSUM) analysis.
  
  
  METHODS
  A prospective database was examined to identify RF cases undertaken during 2006-2014. Time-based surgical process outcomes were evaluated, as well as clinical outcomes.
  
  
  RESULTS
  A total of 57 RF cases were included. Statistically significant transitions beyond the learning phase were observed at cases 42, 34 and 37 for docking, console and total operating room times, respectively. A steep early learning phase for docking time was overcome after 12 cases. There were three Clavien-Dindo grade ≥ 3 complications, with two patients requiring redo fundoplication.
  
  
  CONCLUSIONS
  We identified numerous well-defined learning curve trends to affirm that experience confers significant temporal improvements. Our findings highlight the value of the CUSUM method for learning curve evaluation.
authors.affiliation: Department of Paediatric Surgery, Leeds General Infirmary, UK.|The Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, UK.
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Cundy
authors.affiliation: Department of Paediatric Surgery, Leeds General Infirmary, UK.
authors.forename: Simon P
authors.initials: SP
authors.lastname: Rowland
authors.affiliation: Department of Paediatric Surgery, Leeds General Infirmary, UK.
authors.forename: Nicholas E
authors.initials: NE
authors.lastname: Gattas
authors.affiliation: Department of Paediatric Surgery, Leeds General Infirmary, UK.
authors.forename: Alan D
authors.initials: AD
authors.lastname: White
authors.affiliation: Department of Paediatric Surgery, Leeds General Infirmary, UK.
authors.forename: Azad S
authors.initials: AS
authors.lastname: Najmaldin
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D016208:Databases, Factual; D005260:Female; D018662:Fundoplication / Q000009:adverse effects / Q000379:methods* / Q000706:statistics & numerical data; D005764:Gastroesophageal Reflux / Q000601:surgery*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D059032:Learning Curve; D008297:Male; D011183:Postoperative Complications / Q000209:etiology; D011446:Prospective Studies; D065287:Robotic Surgical Procedures / Q000009:adverse effects / Q000379:methods* / Q000706:statistics & numerical data; D016896:Treatment Outcome
keywords: CUSUM; children; fundoplication; learning curve; paediatric; robotic