title: Learning Curves in Pediatric Minimally Invasive Surgery: A Systematic Review of the Literature and a Framework for Reporting.
abstract: OBJECTIVE
  There exists a learning curve (LC) with the adoption of any minimally invasive surgical (MIS) technique with implications for training, implementation, and evaluation. A standardized approach to describing and analyzing LCs in pediatric MIS is lacking. We sought to determine how pediatric MIS LCs are quantified and present a framework for reporting.
  
  
  METHODS
  Systematic search of MEDLINE and EMBASE 1985-October 2015 for articles describing MIS in the pediatric population and presenting formal analysis of the LC. Articles screened by two independent reviewers.
  
  
  RESULTS
  Twenty-nine articles (n = 17 general abdominal/thoracic, n = 12 urological) from an 18-year period (1997-2015) were included representing 3345 procedures (n = 3116 laparoscopic, n = 10 thoracoscopic, n = 219 robotic). Seven (24%) were prospective, three multicenter. Twenty-two (76%) presented data pertaining to >1 operating surgeon. Operative time was the most commonly employed surrogate of proficiency (n = 26 [90%] studies). Twenty (69%) described >1 LC outcome measure. Sixteen additional measures were described, including conversion (n = 12 studies); blood loss (n = 4 studies); complications (n = 10 studies); and postoperative outcomes (n = 14 studies). Three studies assessed impact of LC on trainees and one considered economic impact. LCs were presented in tabular form (n = 14 studies) and graphically (n = 19). Eleven (38%) studies undertook statistical appraisal utilizing comparative statistics (n = 8 studies) and regression analysis (n = 4 studies).
  
  
  CONCLUSIONS
  Multiple outcome measures of proficiency are employed in reporting pediatric MIS experience and analysis of LCs is inconsistent. A standardized multioutcome approach to reporting should be encouraged. In addition, attempts should be made to quantify the impact on trainee involvement. We present an idealized framework for reporting.
authors.affiliation: Department of Pediatric Surgery Chelsea and Westminster Hospital NHS Foundation Trust , London, United Kingdom .
authors.forename: Alexander L
authors.initials: AL
authors.lastname: Macdonald
authors.affiliation: Department of Pediatric Surgery Chelsea and Westminster Hospital NHS Foundation Trust , London, United Kingdom .
authors.forename: Munther
authors.initials: M
authors.lastname: Haddad
authors.affiliation: Department of Pediatric Surgery Chelsea and Westminster Hospital NHS Foundation Trust , London, United Kingdom .
authors.forename: Simon A
authors.initials: SA
authors.lastname: Clarke
mesh_terms: D002983:Clinical Competence; D006801:Humans; D059032:Learning Curve; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000193:education* / Q000379:methods; D061646:Operative Time; D017063:Outcome Assessment, Health Care; D010372:Pediatrics