A detailed analysis of the learning curve: Robotic hysterectomy and pelvic-aortic lymphadenectomy for endometrial cancer☆
Introduction
With approximately 40,100 new endometrial cancer cases per year [1] and surgery as the foundation of treatment, the surgical approach (minimally invasive versus laparotomy) impacts patient morbidity [2], [3], [4], [5]. The potential benefits of minimally invasive surgery include less blood loss, shorter hospital stays, and improved cosmesis with equivalent oncologic outcomes [2], [3], [4], [5]. Despite these benefits, the widespread application of laparoscopic lymphadenectomy for endometrial cancer is limited by two main factors—the obese patient and the physician learning curve [6].
While the learning curve for the laparoscopic staging of endometrial cancer is described [7], [8], [9], [10], [11], little is known about this experience using the robotics platform. In our initial description of the feasibility of robotic hysterectomy and aortic–pelvic lymphadenectomy for endometrial cancer, we determined 20 procedures were needed to get through the steepest portion of the learning curve [12]. Here, we expand both this concept and our analysis to include the learning curve after this initial phase.
Section snippets
Materials and methods
Institutional Review Board approval was obtained from The Ohio State University. From the inception of the robotics program at The Ohio State University in January 2006 until April 2008, we prospectively collected data from two surgeons (J.M.F. and D.E.C.) on all patients undergoing robotic hysterectomy pelvic–aortic lymphadenectomy for clinical stage I or occult stage II endometrial cancer. Regardless of pre-operative grade and surgical approach, our management of endometrial cancer includes
Results
Between January 2006 and April 2008, 105 patients underwent exploration with the intent of comprehensive robotic staging. Ninety-two (87.6%) were completed robotically and were available for analysis. The remaining 13 patients (12.4%) were converted to laparotomy; no conversions were seen beyond the 65th procedure as has been previously published [12]. Of the 92 cases completed robotically, 79 were comprehensively staged with hysterectomy, pelvic–aortic lymphadenectomy and formed the basis for
Discussion
Although many surgeons acquire advanced laparoscopic skills prior to incorporating robotics into their surgical armamentarium, the learning curve is distinctly different from laparoscopy. Investigators have demonstrated that surgical drills and suturing are performed with enhanced precision and dexterity when comparing robotic technologies to conventional laparoscopy in a training lab [17], [18]. Similarly, Yohannes et al. compared the da Vinci® surgical system (Intuitive Surgical®, Sunnydale,
Conflicts of interest statement
The authors declare that there are no conflicts of interest.
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Presented at Fortieth Annual Meeting of the Society of Gynecologic Oncologists, San Antonio, Texas, February 5–8 2009.