Elsevier

Gynecologic Oncology

Volume 114, Issue 2, August 2009, Pages 162-167
Gynecologic Oncology

A detailed analysis of the learning curve: Robotic hysterectomy and pelvic-aortic lymphadenectomy for endometrial cancer

https://doi.org/10.1016/j.ygyno.2009.04.017Get rights and content

Abstract

Objective

To define the learning curve for robotic hysterectomy and pelvic-aortic lymphadenectomy for endometrial carcinoma.

Methods

Patient demographics and segmental operative times on all patients at one institution who underwent robotic comprehensive surgical staging (hysterectomy, pelvic and aortic lymphadenectomy) for endometrial cancer were prospectively collected. Patients were arranged in order based on surgery date and outcomes were compared between quartiles (cases 1–20, 21–40, 41–60, and 61–79). Proficiency was defined as the point at which the slope of the curve becomes less steep for operative times. Efficiency was defined as the point at which the slope is zero. ANOVA or Fisher's exact test was used to compare the procedure times. Locally weighted regression generated smoothed lines that represent operative time over the sequence of the operations.

Results

79 patients were comprehensively staged robotically. While age, the percentage of patients with ≥ 2 co-morbidities, number of patients with previous laparotomy, EBL, LOS and lymph node counts do not differ between groups, the first 20 patients had a lower BMI compared to the next 20 (27 vs. 34 kg/m2, P = 0.009). Operative times decreased from the first 20 cases to next 20, but was not significantly changed over the next three quartiles. Each component of the procedure has a separate learning curve.

Conclusions

Proficiency for robotic hysterectomy with pelvic–aortic lymphadenectomy for endometrial cancer is achieved after 20 cases; however, the number of procedures to gain efficiency varies for each portion of the case and continues to improve over time.

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.

References (28)

  • L.G. Seamon et al.

    Minimally invasive comprehensive surgical staging for endometrial cancer: robotics or laparoscopy?

    Gynecol. Oncol.

    (2009)
  • A. Jemal et al.

    Cancer statistics

    CA Cancer J. Clin.

    (2008)
  • A.S. Kuek et al.

    Laparoscopic technology for the treatment of endometrial cancer

    Int. J. Gynaecol. Obstet.

    (2006)
  • G.H. Eltabbakh et al.

    Laparoscopy as the primary modality for the treatment of women with endometrial carcinoma

    Cancer

    (2001)
  • Cited by (0)

    Presented at Fortieth Annual Meeting of the Society of Gynecologic Oncologists, San Antonio, Texas, February 5–8 2009.

    View full text