title: Learning curves and surgical outcomes for proctored adoption of laparoscopic ventral mesh rectopexy: cumulative sum curve analysis.
abstract: Laparoscopic ventral mesh rectopexy (VMR) is an effective and well-recognised treatment for symptoms of obstructive defecation in the context of rectal prolapse and recto-rectal intussusception. However, due to the technical complexity of VMR, a significant learning curve has been previously described. This paper examines the effect of proctored adoption of VMR on learning curves, operative times, and outcomes.
  
  
  
  A retrospective database analysis of two district general hospitals was conducted, with inclusion of all cases performed by two surgeons since first adoption of the procedure in 2007-2015. Operative time, length of stay, and in-hospital complications were evaluated, with learning curves assessed using cumulative sum curves.
  
  
  
  Three hundred and eleven patients underwent VMR during the study period and were included for analysis. Patients were near-equally distributed between surgeons (surgeon A: n = 151, surgeon B, n = 160) with no significant differences between gender, age, or ASA grade. In-hospital morbidity was 3.2 %, with 0 % mortality. Cumulative sum curve analysis suggested a change point of between 25 and 30 cases based on operative times and length of stay and was similar between both surgeons. No significant change point was seen for morbidity or mortality.
  
  
  
  VMR is an effective and safe treatment for rectal prolapse. Surgeons in this study were proctored during the adoption process by another surgeon experienced in VMR; this may contribute to increased safety and abbreviated learning curve. In the context of proctored adoption, this study estimates a learning curve of 25-30 cases, without detrimental impact on patient outcomes.
authors: Department of Surgery, Dorset County Hospital NHS Foundation Trust, Dorchester, UK. p.pucher@imperial.ac.uk.|Division of Surgery and Cancer, St Mary's Hospital, Imperial College London, 10th Floor, QEQM Building, London, W2 1NY, UK. p.pucher@imperial.ac.uk.
authors: Philip H
authors: PH
authors: Pucher
authors: Department of Surgery, Poole Hospital NHS Foundation Trust, Poole, UK.
authors: Damian
authors: D
authors: Mayo
authors: Department of Colorectal Surgery, Frenchay Hospital, Bristol, UK.
authors: Anthony R
authors: AR
authors: Dixon
authors: Department of Surgery, Poole Hospital NHS Foundation Trust, Poole, UK.
authors: Andrew
authors: A
authors: Clarke
authors: Department of Surgery, Dorset County Hospital NHS Foundation Trust, Dorchester, UK.
authors: Michael J
authors: MJ
authors: Lamparelli
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003107:Colorectal Surgery / Q000193:education*; D003248:Constipation / Q000209:etiology / Q000601:surgery*; D013505:Digestive System Surgical Procedures / Q000193:education* / Q000379:methods; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000193:education* / Q000379:methods; D059032:Learning Curve; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D019651:Plastic Surgery Procedures / Q000193:education* / Q000379:methods; D012005:Rectal Prolapse / Q000150:complications / Q000601:surgery*; D012189:Retrospective Studies; D066231:Surgeons; D013526:Surgical Mesh; D016896:Treatment Outcome
keywords: CUSUM; Cumulative sum; Learning curve; Mentoring; Mesh rectopexy