The learning curve of laparoscopic, robot-assisted and transanal total mesorectal excisions: a systematic review

Abstract

Background The standard treatment of rectal carcinoma is surgical resection according to the total mesorectal excision principle, either by open, laparoscopic, robot-assisted or transanal technique. No clear consensus exists regarding the length of the learning curve for the minimal invasive techniques. This systematic review aims to provide an overview of the current literature regarding the learning curve of minimal invasive TME. Methods A systematic literature search was performed. PubMed, Embase and Cochrane Library were searched for studies with the primary or secondary aim to assess the learning curve of either laparoscopic, robot-assisted or transanal TME for rectal cancer. The primary outcome was length of the learning curve per minimal invasive technique. Descriptive statistics were used to present results and the MINORS tool was used to assess risk of bias. Results 45 studies, with 7562 patients, were included in this systematic review. Length of the learning curve based on intraoperative complications, postoperative complications, pathological outcomes, or a composite endpoint using a risk-adjusted CUSUM analysis was 50 procedures for the laparoscopic technique, 32–75 procedures for the robot-assisted technique and 36–54 procedures for the transanal technique. Due to the low quality of studies and a high level of heterogeneity a meta-analysis could not be performed. Heterogeneity was caused by patient-related factors, surgeon-related factors and differences in statistical methods. Conclusion Current high-quality literature regarding length of the learning curve of minimal invasive TME techniques is scarce. Available literature suggests equal lengths of the learning curves of laparoscopic, robot-assisted and transanal TME. Well-designed studies, using adequate statistical methods are required to properly assess the learning curve, while taking into account patient-related and surgeon-related factors.

Training curriculum in minimally invasive emergency digestive surgery: 2022 WSES position paper

“…Today, we refer to the process of granting adequate expertise in a given domain [ 34 ]. Particularly in surgery, it requires the repetition of a minimum number of procedures to achieve proficiency [ 13 , 35 – 37 ]. Despite the fact that this represents the basis of surgical education, there need to be more studies elucidating the process of the surgical learning curve, particularly in the emergency setting [ 38 , 39 ].…”

Nomogram for predicting the surgical difficulty of laparoscopic total mesorectal excision and exploring the technical advantages of robotic surgery

“…Following the anastomosis, a diverting ileostomy was selectively created at a distance of approximately 20 cm from the oral side of the terminal ileum. All procedures were performed by a surgeon (Shuangyi Ren) with experience performing more than 2000 laparoscopic surgeries ( 16 , 17 ).…”

Economic analysis of open versus laparoscopic versus robot-assisted versus transanal total mesorectal excision in rectal cancer patients: A systematic review

“…As differences between surgeons' experience have previously been known to confound the assessment of minimally invasive TME outcomes [41], it could be doubted whether comparing techniques performed throughout different stages of the learning curve is suitable for economic evaluation. As the learning curve is known to be associated with longer operative times [42] and added morbidity which likely confounds the reported operative costs [23]. Particularly as most of the available studies reporting on minimally invasive techniques were early experience reports with surgeons still in their learning curves.…”