Learning curve in robotic transabdominal preperitoneal (rTAPP) ventral hernia repair: a cumulative sum (CUSUM) analysis
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ORIGINAL ARTICLE
Learning curve in robotic transabdominal preperitoneal (rTAPP) ventral hernia repair: a cumulative sum (CUSUM) analysis O. Y. Kudsi1 · F. Gokcal1 · N. Bou‑Ayash1 · A. S. Crawford2 · S. K. Chung2 · K. Chang1 · D. Litwin2 Received: 15 April 2020 / Accepted: 25 May 2020 © Springer-Verlag France SAS, part of Springer Nature 2020
Abstract Purpose rTAPP-VHR is a novel technique which may be added to a surgeon’s armamentarium. We aim to evaluate the robotic transabdominal preperitoneal ventral hernia repair (rTAPP-VHR) learning curve based on operative times while accounting for peritoneal flap integrity. Methods We performed a retrospective analysis of a database collected over a 7-year period. Patients with primary ventral hernias were included and a cumulative sum analysis(CUSUM) was used to create learning curves for three subsets of operative times. A risk-adjusted CUSUM (RA-CUSUM) accounted for repair quality based on peritoneal flap completeness. The flap was considered as incomplete when peritoneal gaps were unable to be closed. Results 105 patients undergoing rTAPP-VHR were included. Learning curves were created for skin-to-skin, console, and off-console times. Patients were divided into three phases. In terms of skin-to-skin times, both phase 2&3 had a mean 11 min shorter than that of phase 1 (p = 0.0498, p = 0.0245, respectively), with a steady decrease after forty-six cases. An incomplete peritoneal flap was noted in 25/36 patients in phase 1, as compared to 5/24 and 5/45 patients in phase 2&3, respectively. When risk-adjusted for peritoneal flap completeness, gradually decreasing skin-to-skin times were observed after sixty-one cases. In terms of off-console times, the mean across three phases was 14 min, with marked improvement after forty-three cases. Conclusions Forty-six cases were needed to achieve steadily decreasing operative times. We can assume that ensuring goodquality repairs, through maintenance of peritoneal flap integrity, was gradually improved after sixty-one cases. Moreover, familiarization with port placements and robotic docking was accomplished after forty-three cases. Keywords Robotic ventral hernia repair · Learning curve · Transabdominal preperitoneal · TAPP
Introduction Ventral hernia repair (VHR) has evolved and ranged from open to minimally invasive techniques with adjuncts including various mesh placements. Laparoscopic ventral hernia repair (LVHR) was initially performed as a bridging intraperitoneal onlay mesh technique (IPOM) in the 1990s [1]. The preliminary results of this paper were presented as an oral presenation in the INSAC—Natural and Health Sciences 2020 congress (Turkey). * O. Y. Kudsi [email protected] 1
Department of Surgery, Good Samaritan Medical Center, Tufts University School of Medicine, One Pearl Street, Brockton, MA 02301, USA
Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
2
Other mesh positions and techniques gradually arose, such as transabdominal preperitoneal (TAPP) repair,
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