- Email: [email protected]
The Learning Curve of a Robotic-assisted Total Laparoscopic Hysterectomy: A Retrospective Evaluation and Cumulative Summation Analysis
S26
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S26 TM
sutures of 0-vicryl and the 0-Vloc (VLOC) group had cuff closure using 0VlocTM. Baseline patient descriptive information included age, uterine weight (UW), and body mass index (BMI). Patient risk factors identified from the medical history were: smoking status, history of stroke, hypertension (HTN), diabetes mellitus (DM), immune suppression (IS), and malignancy. Surgical outcomes of procedure time, length of stay (LOS), and cuff dehiscence (CD) rates were also collected. The characteristics and outcomes of each group were compared using Kruskal-Wallis U, Student t test, chisquare, or Fisher exact tests, as applicable, using SPSS 22.0. Results: There were no significant differences in baseline patient descriptive information between the VIC (n = 259) and VLOC (n = 112) groups for age p = 0.339 [43.1 years (8.08); 42.2 years (7.19)], BMI p = 0.488 [31.9 (8.78); 31.4 (8.21)], and UW p = 0.507 [244.4 grams (245.27); 224.0 grams (332.12)], respectively. Also, there were no significant differences in patient risk factors between the VIC and VLOC groups for smoking status p = 0.264 [Never, n = 151 (58.3%); n = 66 (58.9%); Current, n = 55 (21.2%); n = 30 (26.8%); Former, n = 53 (20.5%); n = 16 (14.3%)], stroke p = 0.587 [n = 2 (0.8%); n = 2 (1.8%)], HTN p = 0.132 [n = 75 (29.0%); n = 24 (21.4%), DM p = 0.170 [n = 22 (8.5%); n = 5 (4.5%)], IS p = 0.603 [n = 15 (5.8%); n = 5 (4.5%)], and malignancy p = 0.641 [n = 3 (1.2%); n = 2 (1.8%)], respectively. The VLOC group LOS of 1.03 days (0.46) was significantly longer (p = 0.001) than the VIC group of 0.86 days (0.71). The VIC group procedure time of 113.0 minutes (34.05) was significantly(p \ 0.001) longer than the VLOC group of 99.1 minutes (31.60). A trend toward a significant difference (p = 0.069) in rates of cuff dehiscence was noted between VIC and VLOC groups, [(n = 2 (0.8%); n = 4 (3.6%)], respectively. There was no significant difference (p = 0.533) in the time to cuff dehiscence between VIC of 36.5 days (33.23) and VLOC of 55.3 days (29.87). Conclusion: The rates of cuff dehiscence were not statistically different between groups using two different suture materials. Although using V-locTM suture results in a shorter operating time, gynecologic surgeons performing a RTLH should weigh the clinical significance of longer length of stay, and a potential higher rate of cuff dehiscence before deciding if it is superior to 0-vicryl for vaginal cuff closure. Further studies are warranted to explore the connection of superior suture types along with vaginal cuff complications over time. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Elise M. Schrop: Nothing to disclose Christine Nkemeh: Nothing to disclose Suzanne Lababidi: Nothing to disclose Thomas Mendise: Nothing to disclose Edward Ferris: Nothing to disclose Michele L. McCarroll: Nothing to disclose G. Dante Roulette: Nothing to disclose
Non-Oral Poster 25 The Learning Curve of a Robotic-assisted Total Laparoscopic Hysterectomy: A Retrospective Evaluation and Cumulative Summation Analysis Schrop EM,1 Nkemeh C,3 Lababidi S,3 Mendise T,1,2 Ferris E,1,2 McCarroll ML,1,2 Roulette G.1,2 1Obstetrics and Gynecology, Summa Health System, Akron, Ohio; 2Obstetrics and Gynecology, Northeast Ohio Medical University, Rootstown, Ohio; 3College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio
Objectives: The study aimed to assess the learning curve of three gynecologic surgeons by comparing surgical outcomes on robotic-assisted total laparoscopic hysterectomy (RTLH). Materials and Methods: A retrospective chart review from the participating three surgeons was conducted of patients who underwent a RTLH between November 2006 and June 2012. All surgeries were performed by one of the three surgeons at the robotic console who were trained and credentialed to perform roboticallyassisted hysterectomies. Baseline patient descriptive information included age, race, body mass index (BMI), and uterine weight (UW). Surgical outcomes of procedure time, estimated blod loss (EBL), and length of stay (LOS) were also collected. Cumulative summation analysis (CUSUM) plots were used to evaluate the learning curve. The characteristics and outcomes of each group were compared using Kruskal-Wallis U, Student t test, single factor ANOVA, heterogeneity via Tukey HSD or Mann-Whitney U (with Bonferroni adjustment), chi-square, or Fisher exact tests (as applicable) using SPSS 22.0. Results: Significant differences in patient descriptive information were noted between surgeons one and two, who often operate as a team, (n = 100) compared to surgeon three (n = 100) for age p \ 0.001 [43.0 years (8.15) and 54.8 years (12.13)]; BMI p = 0.012 [29.5 (7.69) and 33.0 (9.36)]; and UW p \ 0.001 [230.9 grams (206.29) and 134.2 grams (114.86)], respectively. No significant differences (p = 0.214) were noted in race categories of patients served by the three surgeons. Procedure times were significantly different (p \ 0.001) between surgeons one and two at 111.6 minutes (48.68) compared to surgeon three at 124.3 minutes (33.18). No significant differences were noted in EBL (p = 0.314) and LOS (p = 0.178) among the three surgeons. The initial times for the first robotic-assisted procedures for each surgeon ranged from 215 minutes (surgeon one) to 177 minutes (surgeon two) compared to 72 minutes (surgeon two) to 45 minutes (surgeon three) toward the end of the analysis. CUSUM plots demonstrated complications that were within acceptable limits for all surgeons; whereas, clinical improvements were noted differently for each surgeon around specified volumes: surgeon one n = 32 (as lead surgeon); surgeon two n = 21 (as lead surgeon); and surgeon three n = 70. Conclusion: CUSUM analysis may provide a robust assessment of surgeon proficiency and skill. Robotic skills programs should focus on CUSUM analysis and the elements involved to help determine proficient skill in robotically-assisted hysterectomies. Each of the three surgeons analyzed had different surgical experience when the roboticassisted approach was introduced; yet, all had a clinical improvement as evidence by their CUSUM analysis. Each surgeon improved their time to completion of the procedure and reduced their complications rates over time from the initial group of patients. Further research is warranted to assess whether robotic simulation versus (or along with) live robotic-assisted cases would impact the learning curve via CUSUM analysis. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Elise M. Schrop: Nothing to disclose Christine Nkemeh: Nothing to disclose Suzanne Lababidi: Nothing to disclose Thomas Mendise: Nothing to disclose Edward Ferris: Nothing to disclose Michele L. McCarroll: Nothing to disclose G. Dante Roulette: Nothing to disclose
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S26 TM
sutures of 0-vicryl and the 0-Vloc (VLOC) group had cuff closure using 0VlocTM. Baseline patient descriptive information included age, uterine weight (UW), and body mass index (BMI). Patient risk factors identified from the medical history were: smoking status, history of stroke, hypertension (HTN), diabetes mellitus (DM), immune suppression (IS), and malignancy. Surgical outcomes of procedure time, length of stay (LOS), and cuff dehiscence (CD) rates were also collected. The characteristics and outcomes of each group were compared using Kruskal-Wallis U, Student t test, chisquare, or Fisher exact tests, as applicable, using SPSS 22.0. Results: There were no significant differences in baseline patient descriptive information between the VIC (n = 259) and VLOC (n = 112) groups for age p = 0.339 [43.1 years (8.08); 42.2 years (7.19)], BMI p = 0.488 [31.9 (8.78); 31.4 (8.21)], and UW p = 0.507 [244.4 grams (245.27); 224.0 grams (332.12)], respectively. Also, there were no significant differences in patient risk factors between the VIC and VLOC groups for smoking status p = 0.264 [Never, n = 151 (58.3%); n = 66 (58.9%); Current, n = 55 (21.2%); n = 30 (26.8%); Former, n = 53 (20.5%); n = 16 (14.3%)], stroke p = 0.587 [n = 2 (0.8%); n = 2 (1.8%)], HTN p = 0.132 [n = 75 (29.0%); n = 24 (21.4%), DM p = 0.170 [n = 22 (8.5%); n = 5 (4.5%)], IS p = 0.603 [n = 15 (5.8%); n = 5 (4.5%)], and malignancy p = 0.641 [n = 3 (1.2%); n = 2 (1.8%)], respectively. The VLOC group LOS of 1.03 days (0.46) was significantly longer (p = 0.001) than the VIC group of 0.86 days (0.71). The VIC group procedure time of 113.0 minutes (34.05) was significantly(p \ 0.001) longer than the VLOC group of 99.1 minutes (31.60). A trend toward a significant difference (p = 0.069) in rates of cuff dehiscence was noted between VIC and VLOC groups, [(n = 2 (0.8%); n = 4 (3.6%)], respectively. There was no significant difference (p = 0.533) in the time to cuff dehiscence between VIC of 36.5 days (33.23) and VLOC of 55.3 days (29.87). Conclusion: The rates of cuff dehiscence were not statistically different between groups using two different suture materials. Although using V-locTM suture results in a shorter operating time, gynecologic surgeons performing a RTLH should weigh the clinical significance of longer length of stay, and a potential higher rate of cuff dehiscence before deciding if it is superior to 0-vicryl for vaginal cuff closure. Further studies are warranted to explore the connection of superior suture types along with vaginal cuff complications over time. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Elise M. Schrop: Nothing to disclose Christine Nkemeh: Nothing to disclose Suzanne Lababidi: Nothing to disclose Thomas Mendise: Nothing to disclose Edward Ferris: Nothing to disclose Michele L. McCarroll: Nothing to disclose G. Dante Roulette: Nothing to disclose
Non-Oral Poster 25 The Learning Curve of a Robotic-assisted Total Laparoscopic Hysterectomy: A Retrospective Evaluation and Cumulative Summation Analysis Schrop EM,1 Nkemeh C,3 Lababidi S,3 Mendise T,1,2 Ferris E,1,2 McCarroll ML,1,2 Roulette G.1,2 1Obstetrics and Gynecology, Summa Health System, Akron, Ohio; 2Obstetrics and Gynecology, Northeast Ohio Medical University, Rootstown, Ohio; 3College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio
Objectives: The study aimed to assess the learning curve of three gynecologic surgeons by comparing surgical outcomes on robotic-assisted total laparoscopic hysterectomy (RTLH). Materials and Methods: A retrospective chart review from the participating three surgeons was conducted of patients who underwent a RTLH between November 2006 and June 2012. All surgeries were performed by one of the three surgeons at the robotic console who were trained and credentialed to perform roboticallyassisted hysterectomies. Baseline patient descriptive information included age, race, body mass index (BMI), and uterine weight (UW). Surgical outcomes of procedure time, estimated blod loss (EBL), and length of stay (LOS) were also collected. Cumulative summation analysis (CUSUM) plots were used to evaluate the learning curve. The characteristics and outcomes of each group were compared using Kruskal-Wallis U, Student t test, single factor ANOVA, heterogeneity via Tukey HSD or Mann-Whitney U (with Bonferroni adjustment), chi-square, or Fisher exact tests (as applicable) using SPSS 22.0. Results: Significant differences in patient descriptive information were noted between surgeons one and two, who often operate as a team, (n = 100) compared to surgeon three (n = 100) for age p \ 0.001 [43.0 years (8.15) and 54.8 years (12.13)]; BMI p = 0.012 [29.5 (7.69) and 33.0 (9.36)]; and UW p \ 0.001 [230.9 grams (206.29) and 134.2 grams (114.86)], respectively. No significant differences (p = 0.214) were noted in race categories of patients served by the three surgeons. Procedure times were significantly different (p \ 0.001) between surgeons one and two at 111.6 minutes (48.68) compared to surgeon three at 124.3 minutes (33.18). No significant differences were noted in EBL (p = 0.314) and LOS (p = 0.178) among the three surgeons. The initial times for the first robotic-assisted procedures for each surgeon ranged from 215 minutes (surgeon one) to 177 minutes (surgeon two) compared to 72 minutes (surgeon two) to 45 minutes (surgeon three) toward the end of the analysis. CUSUM plots demonstrated complications that were within acceptable limits for all surgeons; whereas, clinical improvements were noted differently for each surgeon around specified volumes: surgeon one n = 32 (as lead surgeon); surgeon two n = 21 (as lead surgeon); and surgeon three n = 70. Conclusion: CUSUM analysis may provide a robust assessment of surgeon proficiency and skill. Robotic skills programs should focus on CUSUM analysis and the elements involved to help determine proficient skill in robotically-assisted hysterectomies. Each of the three surgeons analyzed had different surgical experience when the roboticassisted approach was introduced; yet, all had a clinical improvement as evidence by their CUSUM analysis. Each surgeon improved their time to completion of the procedure and reduced their complications rates over time from the initial group of patients. Further research is warranted to assess whether robotic simulation versus (or along with) live robotic-assisted cases would impact the learning curve via CUSUM analysis. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Elise M. Schrop: Nothing to disclose Christine Nkemeh: Nothing to disclose Suzanne Lababidi: Nothing to disclose Thomas Mendise: Nothing to disclose Edward Ferris: Nothing to disclose Michele L. McCarroll: Nothing to disclose G. Dante Roulette: Nothing to disclose