Post fellowship training in “new-to-them” surgical techniques: Assessment of learning curve characteristics

ObjectiveTo evaluate surgically related quality outcomes during the learning curve for board-certified or board-eligible gynecologic oncologists developing “new-to-them” surgical techniques.MethodsThe study design was a retrospective review of patients with endometrial cancer clinically limited to the uterus and/or cervix undergoing TLH-BSO or TAH-BSO, aortic and pelvic lymphadenectomy(APLNDx), peritoneal washings with/without omentectomy from May 1996 to April /2006. A “senior” surgeon taught three board-certified or board-eligible gynecologic oncologists a “new-to-them” technique to perform both TLH-BSO and TAH-BSO with APLNDx using argon beam coagulation and endoscopic staplers in patients with early-stage endometrial cancer. The main outcome measures were: a) length of surgery; b) surgical measures, e.g. lymph node count; and c) peri-operative morbidity. A comparison of outcomes with the “senior” surgeon was undertaken. The learning curve characteristics were analyzed by ANOVA and curve estimate analysis.ResultsThe mean operative times associated with learning a new technique to perform TLH-BSO with APLNDx and TAH-BSO with APLNDx were 155.39 +/− 26.32 and 102.28 +/− 34.22 min, respectively, with significant improvement after 20 cases (150.27 +/− 26.68 vs. 172.30 +/− 22.28, p = 0.030) and 30 cases (93.30 +/− 24.97 vs. 124.63 +/− 29.73, p = 0.030), respectively. Intra- and peri-operative morbidity and lymph node count were unaffected by experience.ConclusionWhile mean operative times decreased, outcome measures of surgical quality were not adversely affected during the learning curve for post-fellowship training while acquiring “new-to-them” surgical techniques. This study emphasizes the need for “senior” surgical supervision during the initial training period. The results of this study are likely transferable to fellowship-trained gynecologic oncologists learning other “new-to-them” surgical techniques and procedures.

Research Highlights
► The learning curve for “new-to-them” laparoscopic techniques plateaus after 20 cases.
► The learning curve for “new-to-them” laparotomy techniques plateaus after 30 cases.
► Surgical outcomes are not compromised during this post-fellowship learning period when supervised and mentored by a senior surgeon.