Technical proficiency in hand-assisted laparoscopic colon and rectal surgery: Determining how many cases are required to achieve mastery

Objective: To determine how many cases are required to achieve technical proficiency for hand-assisted laparoscopic surgery (HALS). Design: Retrospective study. Setting: Tertiary care hospital. Patients: Using a prospective database, all HALS colorectal resections from 2003 to 2009 by 2 surgeons (A and B) were reviewed. Over 6 years, surgeons A and B performed 397 and 322 cases. Interventions: Change-Point Analysis (CUSUM) was used to define the number of cases required to effect improvement in operative time. Cases before and after the change point were considered as being in the "learning period" and "skilled period."Main Outcome Measures: Operative time; short-term outcomes. Results: The change point occurred after 108 and 105 cases for surgeons A and B, respectively. The learning period and skilled period were similar with respect to age, sex, body mass index, prior abdominal surgery, medical comorbidities, and American Society of Anesthesiologists class. Mean overall operative time decreased from 263 to 185 minutes (P≲λτ ∀.001). The decrease in mean operative duration for specific resections were as follows: right colectomy, 35 minutes (P=.003); left colectomy, 63 minutes (P=.006); sigmoid colectomy, 63 minutes (P≲λτ∀. 001); anterior resection, 70 minutes (P≲λτ∀.001); coloanal anastomosis, 52 minutes (P=.003); subtotal colectomy, 75 minutes (P≲λτ∀.001); and total proctocolectomy with ileal reservoir, 80 minutes (P≲λτ∀.001). Intraoperative complications and conversion rate were similar, but overall morbidity, infectious complications, readmissions, and length of stay were all significantly (P≲λτ∀.05) lower during the skilled period. Conclusions: For HALS colorectal resection, technical proficiency occurred after approximately 105 cases, and increased surgeon experience resulted in improved short-term outcomes. These data suggest that the learning curve for HALS colorectal resection will extend beyond fellowship training for many colorectal surgeons.