Learning curve of trans‐areola single‐site endoscopic thyroidectomy in a high‐volume center: A CUSUM‐based assessment

Abstract

BackgroundLimited attempts have been made in trans‐areola single‐site endoscopic thyroidectomy (TASSET) due to technical challenges and the lengthy time for proficiency. This study aimed to define the learning curve of TASSET and to describe improvements in operative performance over time.MethodsBased on 222 consecutive TASSET procedures, the learning curve was established according to the operation time by using cumulative sum analysis (CUSUM). The end‐point of learning curve was defined as the number of cases necessitated to reach the initial surgical proficiency stage. The demographic information, surgical and oncological outcomes, surgical stress, and postoperative complications were also analyzed.ResultsThere were 70 cases of simple lobectomy for benign nodules and 152 cases of lobectomy with central neck dissection (CND) for malignancy. The mean operative time was 106.54 ± 38.07 min (range: 46–274 min). The learning curve identified two phases: the skill acquisition phase (Case 1–Case 41) and the proficiency phase (Case 42–Case 222). There were no significant differences in demographic information, drainage amount and duration, oncological outcomes, and postoperative complications between the two phases (p > 0.05). Both operation time and postoperative hospitalization decreased significantly in Phase 2 (154.63 ± 52.21 vs. 95.64 ± 22.96 min, p < 0.001; 4.12 ± 0.93 vs. 3.65 ± 0.63 days, p < 0.001). Additionally, the mean variations of surgical stress factors (C‐reactive protein and erythrocyte sedimentation rate) decreased significantly as the phase progress. The case number required for proficiency phase in benign and malignant tumor were 18 and 33, respectively, and lymph node resection posed a significant impact on the endpoint of the learning curve (p < 0.001). Meanwhile, the size of nodule showed no significant impact (p = 0.622). For right‐handed surgeons, 16 cases and 25 cases were required for technical competence in left‐sided and right‐sided lesions, respectively, and no significant difference reached (p = 0.266).ConclusionsTASSET has demonstrated safe and technically feasible with comparable oncological outcomes. Experience of 41 cases was required for surgical competence and proficiency. The initial learning stage could be more quickly adopted by high‐volume thyroid surgeons with standardized procedures.

Parathyroidectomy for solitary parathyroid adenoma via trans‐areola single site endoscopic approach: Results of a case‐match study

“…CUSUM analysis was employed to better define the learning curve of TASSEP, and the turning point was identified as case 17 (Figure 5B ). 47 After the end‐point of the learning curve, the operation time of TASSEP significantly improved from 90.41 ± 12.34 min (case 1–17) to 73.74 ± 4.34 min (case 17–40). EBL was evaluated using dry medical gauze strips (0.5 × 5 cm), and did not differ significantly between TASSEP and COP (20.42 ± 10.21 mL vs. 18.86 ± 12.59 mL, p = 0.649).…”

“…In current study, 17 cases were required to qualify for the initial surgical proficiency stage in TASSEP. Whereas the end point of the learning curve in trans‐areola single site endoscopic thyroidectomy (TASSET) was case 41, which indicated that the surgeons could adopt TASSEP more quickly than TASSET, making it a promising alternative to open surgery for both surgeons and patients 47 . Therefore, in line with the standardized TASSEP procedure, technique challenges could be overcome readily with reliable operational precision and safety.…”