How to reduce the laparoscopic colorectal learning curve.
BACKGROUND
The laparoscopic approach for colorectal pathologies is becoming more widely used, and surgeons have had to learn how to perform this new technique. The purpose of this work is to study the indicators of the learning curve for laparoscopic colectomy in a community hospital and to find when the group begins to improve.


METHODS
From January 1 2005 to December 31 2012, 313 consecutive laparoscopic colorectal surgeries were performed (105 rectal and 208 colonic) by at least 60% of the same surgical team (6 members) in each operation. We evaluate the learning curve by moving averages and cumulative sums (CUSUM) for different variables related to the surgery outcomes.


RESULTS
Moving average curves for postoperative stay, fasting, and second step analgesia show a stabilizing trend toward improvement as we get more experience. However, intensive care unit stay, number of lymph nodes achieved, and operating time did not show a clear decreasing tendency. CUSUM curves of conversion, specimens<12 lymph nodes, and complications all show a clear turning point marked on all the charts around the procedure 60, accumulating a positive trend toward improvement. The CUSUM curve of the "learning variable" shows this improvement point at procedure 70.


CONCLUSIONS
The laparoscopic colectomy learning curve accelerates with a collective team involvement in each procedure. The CUSUM and moving average curves are useful for initial and ongoing monitoring of new surgical procedures. The markers of the learning curve evidenced in our study are the conversion rate, postoperative surgical morbidity, and the number of patients with a lymph node count<12. WHAT IS NEW IN THIS PAPER?: The significance of this study is the evaluation of the learning curve, in laparoscopic colorectal surgery, of a surgical team in a community hospital, using moving average and CUSUM curves. This study demonstrated that the number of patients needed to achieve skilful practice decreased when there is collective team involvement in each procedure.
Department of Digestive Surgery, Hospital Medina del Campo, Valladolid, Spain.
Miguel
M
Toledano Trincado
Department of Digestive Surgery, Hospital Medina del Campo, Valladolid, Spain.
Javier
J
Sánchez Gonzalez
Department of Digestive Surgery, Hospital Medina del Campo, Valladolid, Spain.
Francisco
F
Blanco Antona
Department of Digestive Surgery, Hospital Medina del Campo, Valladolid, Spain.
Maria Luz
ML
Martín Esteban
Department of Digestive Surgery, Hospital Medina del Campo, Valladolid, Spain.
Laura
L
Colao García
Department of Pathology, Hospital Medina del Campo, Valladolid, Spain.
Jorge
J
Cuevas Gonzalez
Department of Statistics and Operational Research, University of Valladolid, Spain.
Agustin
A
Mayo Iscar
Department of Colorectal Surgery, Hospital Rio Hortega, Valladolid, Spain.
Jose Ignacio
JI
Blanco Alvarez
Department of Digestive Surgery, Hospital Medina del Campo, Valladolid, Spain.
Juan Carlos
JC
Martín del Olmo
D000368:Aged; D003082:Colectomy / Q000193:education* / Q000379:methods; D003108:Colonic Diseases / Q000601:surgery; D004501:Education, Medical / Q000592:standards*; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000193:education* / Q000379:methods; D059032:Learning Curve; D008297:Male; D061646:Operative Time; D012002:Rectal Diseases / Q000601:surgery
Colorectal surgery; Laparoscopic; Learning curve