title: Defining the Tipping Point in Surgical Performance for Laparoscopic Donor Nephrectomy Among Transplant Surgery Fellows: A Risk-Adjusted Cumulative Summation Learning Curve Analysis.
abstract: The United Network for Organ Sharing recommends that fellowship-trained surgeons participate in 15 laparoscopic donor nephrectomy (LDN) procedures to be considered proficient. The American Society of Transplant Surgeons (ASTS) mandates 12 LDNs during an abdominal transplant surgery fellowship. We performed a retrospective intraoperative case analysis to create a risk-adjusted cumulative summation (RACUSUM) model to assess the learning curve of novice transplant surgery fellows (TSFs). Between January 2000 and December 2014, 30 novice TSFs participated in the organ procurement rotation of our ASTS-approved abdominal transplant surgery fellowship. Measures of surgical performance included intraoperative time, estimated blood loss, and incidence of intraoperative complications. The performance of senior TSFs was used to benchmark novice TSF performance. Scores were tabulated in a learning curve model, adjusting for case complexity and prior TSF case volume. Rates of adverse surgical events were significantly higher for novice TSFs than for senior TSFs. In univariable analysis, multiple renal arteries, high BMI, prior abdominal surgery, male donor, and nephrolithiasis were correlated with higher incidence of adverse surgical events. Based on the RACUSUM model, high intraoperative time is mitigated after 28 procedures, incidence of intraoperative complications tends to diminish after 24 procedures, and improvement in estimated blood loss did not remain consistent. TSFs exhibit a tipping point in LDN performance by 24-28 cases and proficiency by 35-38 cases.
authors.affiliation: Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN.
authors.forename: O K
authors.initials: OK
authors.lastname: Serrano
authors.affiliation: Biostatistics and Bioinformatics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN.
authors.forename: A S
authors.initials: AS
authors.lastname: Bangdiwala
authors.affiliation: Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN.
authors.forename: D M
authors.initials: DM
authors.lastname: Vock
authors.affiliation: Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN.
authors.forename: D
authors.initials: D
authors.lastname: Berglund
authors.affiliation: Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN.
authors.forename: T B
authors.identifier: http://orcid.org/0000-0002-5941-0659
authors.initials: TB
authors.lastname: Dunn
authors.affiliation: Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN.
authors.forename: E B
authors.initials: EB
authors.lastname: Finger
authors.affiliation: Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN.
authors.forename: T L
authors.initials: TL
authors.lastname: Pruett
authors.affiliation: Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN.
authors.forename: A J
authors.initials: AJ
authors.lastname: Matas
authors.affiliation: Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN.
authors.forename: R
authors.initials: R
authors.lastname: Kandaswamy
mesh_terms: D005257:Fellowships and Scholarships; D005260:Female; D005500:Follow-Up Studies; D013502:General Surgery / Q000193:education*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000601:surgery*; D016030:Kidney Transplantation / Q000379:methods*; D010535:Laparoscopy / Q000379:methods*; D059032:Learning Curve; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods*; D011379:Prognosis; D012189:Retrospective Studies; D020858:Tissue and Organ Harvesting / Q000379:methods*
keywords: clinical research/practice; donors and donation: living; education; kidney transplantation/nephrology; kidney transplantation: living donor; organ procurement; organ procurement and allocation