Learning curve analysis of the first 100 robotic-assisted laparoscopic hysterectomies performed by a single surgeon

Robotic technology is the most advanced development of minimally invasive surgery, but there are still some unresolved issues concerning its use in a clinical setting. The study describes the clinical experience of the Department of General Surgery, Misericordia Hospital, Grosseto, Italy, in robot-assisted surgery using the da Vinci Surgical System. Between October 2000 and November 2002, 193 patients underwent a minimally invasive robotic procedure (74 men and 119 women; mean age, 55.9 years [range, 16-91 years]). A total of 207 robotic surgical operations, including abdominal, thoracic and vascular procedures, were performed; 179 were single procedures, and 14 were double (2 operations on the same patient). There were 4 conversions to open surgery and 3 to conventional laparoscopy (conversion rate, 3.6%; 7 of 193 patients). The perioperative morbidity rate was 9.3% (18 of 193 patients), and 6 patients (3.1%) required a reoperation. The postoperative mortality rate was 1.5% (3 of 193 patients). Our preliminary experience at a large community hospital suggests that robotic surgery is feasible in a clinical setting. Its daily use is safe and easily managed, and it expands the applications of minimally invasive surgery. However, the best indications still have to be defined, and the cost-benefit ratio must be evaluated. This report could serve as a basis for a future prospective, randomized trial.

The purpose of this study was to estimate the learning curve when using the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) in benign gynecologic cases by a team of 2 gynecologic laparoscopists. Retrospective case series (Canadian Task Force classification II-1). A private practice obstetrics/gynecology clinic. Patients requiring major benign gynecologic surgery who were candidates for a laparoscopic approach. All patients who would have otherwise been offered a transabdominal or conventional laparoscopic procedure were offered the option of having their procedure performed laparoscopically with robotic assistance. Data that were collected included robot set-up times by the operative room staff, operative times for use of robot, total operative times, and perioperative outcome. We analyzed the learning curve defined as the number of cases required to stabilize operative time to perform the various procedures. One hundred thirteen patients were treated over a 22-month period with the da Vinci Surgical System. Most procedures were hysterectomies, whereas other gynecologic procedures included supracervical hysterectomy, laparoscopic vaginal assisted hysterectomy, myomectomy, sacrocolpopexy, and oophorectomy. Total operative times for hysterectomies studied sequentially stabilized at approximately 95 minutes after 50 cases. The decrease in robotic time did not depend on uterine size. The mean length of hospital stay was 24 hours, and return to normal activities averaged 2.8 weeks. Robotic assisted surgery is an enabling technology that allows gynecologic surgeons the ability to offer laparoscopic procedures to most of their patients. In the hands of surgeons with advanced laparoscopic skills, the learning curve to stabilize operative times for the various surgical procedures in women requiring benign gynecolologic interventions is 50 cases.

To examine factors associated with undergoing laparoscopic hysterectomy compared with abdominal hysterectomy or vaginal hysterectomy. This is a cross-sectional analysis of the 2005 Nationwide Inpatient Sample. All women aged 18 years or older who underwent hysterectomy for a benign condition were included. Multivariable analyses were used to examine demographic, clinical, and health-system factors associated with each hysterectomy route. Among 518,828 hysterectomies, 14% were laparoscopic, 64% abdominal, and 22% vaginal. Women older than 35 years had lower rates of laparoscopic than abdominal (odds ratio [OR] 0.85, 95% confidence interval [CI] 0.77-0.94 for age 45-49 years) or vaginal hysterectomy (OR 0.61, 95% CI 0.540.69 for age 45-49 years). The odds of laparoscopic compared with abdominal hysterectomy were higher in the West than in the Northeast (OR 1.77, 95% CI 1.2-2.62). African-American, Latina, and Asian women had 40-50% lower odds of laparoscopic compared with abdominal hysterectomy (P<.001). Women with low income, Medicare, Medicaid, or no health insurance were less likely to undergo laparoscopic than either vaginal or abdominal hysterectomy (P<.001). Women with leiomyomas (P<.001) and pelvic infections (P<.001) were less likely to undergo laparoscopic than abdominal hysterectomy. Women with leiomyomas (P<.001), endometriosis (P<.001), or pelvic infections (P<.001) were more likely to have laparoscopic than vaginal hysterectomy. Laparoscopic hysterectomy had the highest mean hospital charges ($18,821, P<.001) and shortest length of stay (1.65 days, P<.001). In addition to age and clinical diagnosis, nonclinical factors such as race/ethnicity, insurance status, income, and region appear to affect use of laparoscopic hysterectomy compared with abdominal hysterectomy and vaginal hysterectomy. III.