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PubMed1999

Learning curve in endoscopic sinus surgery.

The existence of a long learning curve for endoscopic sinus surgery has been proposed as a reason for rigorous and extensive training to prepare physicians to perform this surgery. In this article, the author--who participated in this type of training program--examines his experience over a 5-year period to assess the effect of rigorous training on the learning curve for endoscopic sinus surgery. Beginning with the first day of practice after training, 5 years with 393 cases were evaluated for complications and the need for revision surgery. The results were analyzed in 100-case groups. The results show no difference in major and serious complications or revision surgery rates. However, a statistically significant difference in the minor-complication rate, specifically frontal-sinus stenosis, was found from the first half to the second half of the experience. These findings show that, with rigorous training of the physician, the learning curve can largely be completed during residency training, allowing the new practitioner to perform endoscopic sinus surgery safely and with good results.

Education, Medical↗

PubMed2004

Learning curves and impact of psychomotor training on performance in simulated colonoscopy: a randomized trial using a virtual reality endoscopy trainer.

BACKGROUND: The aim of this study was to analyze the learning curve for the GI Mentor II endoscope trainer and to determine whether psychomotor training can contribute to an improvement in the performance of virtual colonoscopy. METHODS: To analyze the learning curve, 28 subjects were divided into three groups on the basis of their experience with gastrointestinal (GI) endoscopy: experienced surgeons (group 1, performed > 200 endoscopic procedures, (n = 8)) residents (group 2, performed < 50 endoscopic procedures, (n = 10)); and medical students (group 3, never performed GI endoscopy, (n = 10)). The participants were tested on the GI Mentor II virtual reality simulator 10 consecutive times. Assessment of the learning curve was based on the following three parameters: time used, number of punctured balloons, and number of wall collisions. In the second part of the study, 20 subjects who had never performed GI endoscopy were included. After performing a virtual colonoscopy, they were randomized to a group that received psychomotor training and a control group. Finally, all subjects performed a virtual colonoscopy. Assessment of endoscopic skills during the colonoscopy was based on nine parameters dealing with psychomotor skills. RESULTS: The learning curve for time expended reached a plateau after the second repetition for group 1 (Friedman's test, p < 0.05), after the fifth repetition for group 2 (p < 0.05), and after the seventh repetition for group 3 (p < 0.05). Experienced surgeons did not improve their scores for regarding number of balloons punctured or number of wall collisions (p > 0.05), indicating the absence of a learning curve for these parameters. Group 2 improved their scores up to the fourth and fifth repetitions, respectively (p < 0.05), and group 3 up to the fifth and seventh repetitions, respectively (p < 0.05). Experienced surgeons achieved the best performance, followed by group 2 and then group 3. The surgeons who had received psychomotor training performed the second virtual colonoscopy significantly faster than the control group (Mann-Whitney test, p < 0.001) and made significantly greater improvement in all other parameters as well. CONCLUSIONS: There were different learning curves for surgeons depending on their endoscopic background. The familiarization rate on the simulator was proportional to the endoscopic experience of the surgeons. Psychomotor training had a significant effect on the performance of a simulated colonoscopy.

Clinical Competence↗

PubMed2002

[The learning curve in surgery: possibilities and limits of this method].

The learning curve is a graphic representation of the relationship between the experience of a surgeon and one or more performance indicators. The operation time alone is an insufficient indicator to assess the performance of a surgeon. The procedure time has to be set in relation to the complication rate and in laparoscopic surgery to the conversion rate. Techniques to visualize the changes over time are the moving average method for the operation time and the Cusum method for dichotomous outcomes, like the conversion and the complication rates. At the time when the learning curve reaches the plateau phase this representation can be used to assess the quality of a surgeon or a team in one hospital. As far as there is no validated complexity scale for laparoscopic procedures available it is difficult to compare patient populations between different hospitals. Out of this reason the learning curve is no legitimate instrument to rank surgeons or different hospitals.

Clinical Competence↗

PubMed2006

Mastering the antegrade femoral artery access in patients with symptomatic lower limb ischemia: learning curve, complications, and technical tips and tricks.

BACKGROUND: Antegrade femoral access is fraught by technical challenges and steeper learning curve, in comparison with retrograde contralateral femoral access. We appraised learning curve, complications, and technical aspects inherent in the adoption of antegrade approach. METHODS: Consecutive cases in which antegrade access was attempted by a cardiologist experienced in retrograde access, but inexperienced in antegrade, under supervision of an operator with anterograde expertise, were collected. The primary end-point was the occurrence of antegrade access failure or local complications. Major complications were defined as those life-threatening, requiring transfusion, percutaneous, or surgical repair. RESULTS: Anterograde access was attempted in 120 patients. The primary end-point occurred in 14 (11.6%) cases, but according to the learning curve, in 12 (20%) for first 60 cases vs 2 (3.3%) for the last 60 cases (P = 0.008). Access failure in the hands of the in-training operator was similarly found in all cases but one during the first 60 cases. No major complications occurred, while minor complications were found in 9 (7.5%) patients, again with all but two of them occurring in the first 60 cases. These included peri-adventitial extravasation in 8 patients (6.7%), and perforation of a small branch in one (0.8%); all these complications were conservatively and successfully managed. Obesity was the only significant predictor of access failure/complication (P = 0.004). CONCLUSIONS: This work, the first to report on the learning curve of the antegrade approach, supports the feasibility and safety of this access site even for an in-training operator, if supervised. A minimum caseload of 60 procedures is likely needed to master this technique.

Aged↗

PubMed2026

Clinical Efficacy and Learning Curve of Far-Lateral Approach (FLA) in Uni-Portal Non-Coaxial Spinal Endoscopic Surgery (UNSES) in the Treatment of Lumbar Degenerative Diseases: A Prospective Study.

BACKGROUND: Uniportal non-coaxial spinal endoscopic surgery (UNSES) via far-lateral approach (FLA) is an innovative minimally invasive procedure for lumbar degenerative diseases, particularly far-lateral disc herniation and foraminal stenosis. However, complex lateral lumbar anatomy and strict endoscope-instrument coordination create a distinct learning curve that may compromise early surgical efficiency and safety. This study aimed to evaluate the efficacy and safety, quantify the learning curve, and to provide clinical guidance for the standardized promotion and application of this technology. METHODS: A total of 40 consecutive patients with lumbar degenerative diseases who underwent UNSES via FLA by a single surgeon between January 2025 and December 2025 were included. All data were analyzed using SPSS 26.0 statistical software (IBM, USA). Primary outcomes included operation time, blood loss, fluoroscopy frequency, and intraoperative complication rate. Secondary outcomes were VAS, ODI, and modified Macnab criteria at 1, 3, and 6 months postoperatively. The learning curve and the inflection point of the learning curve was determined using cumulative sum (CUSUM) analysis. The differences in clinical indicators between early and proficient stage were compared. RESULT: Operation time, blood loss, and fluoroscopy times decreased significantly with case accumulation (p < 0.05). CUSUM identified an inflection point at the 16th case, after which operation time stabilized at (55.3 ± 8.6) min, much shorter than the early phase (89.5 ± 10.3) min (p < 0.001). Before the 16th case, the curve was in an upward trend; after the 16th case, the curve tended to be flat, indicating the proficiency stage. Postoperative VAS and ODI improved significantly than those before surgery at each follow-up time (p < 0.05). There was no significant difference in postoperative VAS score and ODI between the two groups at each follow-up time point (p > 0.05). The total complication rate was 12.5% (5/40), were cured by conservative treatment. The total excellent-good rate was 90.0% (36/40). L5/S1 and Bertolotti's syndrome were independent factors affecting the learning curve. CONCLUSION: UNSES via FLA is a safe and effective minimally invasive technique for treating complex lumbar degenerative diseases. It has a certain learning curve, and the inflection point is about the 16th case. After mastering the key techniques such as anatomical positioning, endoscopic manipulation and hemostasis, the surgeon can gradually reach the proficiency stage, with significantly improved surgical efficiency and clinical efficacy, and controllable complications. This study provides a theoretical basis for the clinical training and technology promotion of UNSES via FLA.

Humans↗

PubMed1995

Visual estimation of ejection fraction by two-dimensional echocardiography: the learning curve.

Our purpose was to determine the learning curve of visual estimation of ejection fraction (EF) by echocardiography. Sixty consecutive patients, who had clinically indicated echocardiography and radionuclide ventriculography (RVG) within 1 month were selected. Five standard views were reviewed independently by a first-year cardiology fellow, a private cardiologist, and an experienced echocardiographer. Observers were given feedback of the RVG EFs immediately after estimating the EF on each study. To assess the effect of learning, the echocardiographic studies were divided into three groups of 20 and were read successively by each observer. A statistical comparison of the two methods was performed for each group. The correlation between the two techniques for the first group of studies was marginal. There was a significant improvement in the correlation with subsequent groups. The correlation did not change significantly with the last group of studies compared with the second group. In conclusion, visual estimation of EF by two-dimensional echocardiography can be learned, with a learning curve of approximately 20 studies if immediate feed-back is available.

Echocardiography↗

PubMed1984

Learning curve for percutaneous transluminal coronary angioplasty: skill, technology or patient selection.

As with all sophisticated techniques, operators who perform PTCA show a learning curve. It can best be visualized by observing changes in success rate with growing numbers of patients. Thus, the current success rate and complication rate of a particular operator may permit an estimate of the accumulated number of patients treated by that operator. Most likely, the learning curve is also reflected in the rate of long-term success, although it may be obscured by other factors in the variable natural course of CAD. The initial steep upslope of the learning curve is mainly caused by the growing skill of the particular operator. The later, flatter part appears to be secondary to improvements in technical equipment, which take more time. Patient selection has 2 effects on the learning curve that may be self-compensating. If lessons from the past are used for selection and conservatism is preserved, the learning curve will become more pronounced.

Angioplasty, Balloon↗

PubMed1996

A learning curve for laparoscopic fundoplication. Definable, avoidable, or a waste of time?

OBJECTIVE: The objective of this study was to determine whether a learning curve for laparoscopic fundoplication can be defined, and whether steps can be taken to avoid any difficulties associated with it. SUMMARY BACKGROUND DATA: Although early outcomes after laparoscopic fundoplication have been promising, complications unique to the procedure have been described. Learning curve problems may contribute to these difficulties. Although training recommendations have been published by some professional bodies, there is disagreement about what constitutes adequate supervised experience before the solo performance of laparoscopic antireflux surgery, and the true length of the learning curve. METHODS: The outcome of 280 laparoscopic fundoplications undertaken by 11 surgeons during a 46-month period was assessed prospectively. The experience was analyzed in three different ways: 1) by an assessment of the overall learning experience within chronologically arranged groups, 2) by an assessment of all individual experiences grouped according to the experience of individual surgeons, and 3) by a comparison of early outcomes of operations performed by the surgeons who initiated laparoscopic fundoplication with the early experience of surgeons beginning laparoscopic fundoplication later in the overall institutional experience. RESULTS: The complication, reoperation, and laparoscopic to open conversion rates all were higher in the first 50 cases performed by the overall group, and in the first 20 cases performed by each individual surgeon. These rates were even higher in the initial first 20 cases, and the first 5 individual cases. However, adverse outcomes were less likely when surgeons began fundoplication later in the overall experience, when experienced supervision could be provided. CONCLUSIONS: A learning curve for laparoscopic fundoplication can be defined. Experienced supervision should be sought by surgeons beginning laparoscopic fundoplication during their first 20 procedures. This should minimize adverse outcomes associated with an individual's learning curve.

Clinical Competence↗

PubMed2004

Hand-assisted laparoscopic nephrectomy: prospective evaluation of the learning curve.

PURPOSE: Laparoscopic nephrectomy (LN) has recently become an emerging standard for extirpative surgery of the kidney. LN has historically proven to have a steep learning curve with longer operative times until a surgeon gains adequate laparoscopic experience. Hand-assisted laparoscopic nephrectomy (HALN) is fast becoming a commonly used procedure to remove kidneys as it may have a reduced learning curve compared to standard LN. To date no prospective studies have evaluated the learning curve of HALN with regard to improvements in operative times and technical difficulty. We prospectively evaluated the learning curve for HALN in a residency training program as it compares to open nephrectomy. MATERIALS AND METHODS: HALN was performed in 30 consecutive patients for various indications. The senior urology resident functioned as the primary surgeon and the same attending surgeon was present throughout all cases. All participating residents had to have performed at least 15 open nephrectomies to serve as an internal, personal reference. Difficulty scores were obtained at the completion of the case from the resident surgeon comparing HALN to open nephrectomy, which ranged from 1 to 5. Operative times, estimated blood losses and lengths of stay were obtained at the time of surgery and hospitalization. RESULTS: Median difficulty score was equivalent to open nephrectomy for the first case but decreased significantly by case 4 (p = 0.0006). Median operative times decreased significantly from 178 minutes in the first cases to 85 minutes by case 6 (p = 0.0002). Estimated blood loss and length of hospitalization did not differ significantly. CONCLUSIONS: HALN has a relatively short learning curve reflected by the rapid decrease in difficulty scores and operative times by case 4. Similar results may be expected when training practicing urologists to perform HALN.

Adult↗

PubMed2006

Decision-making and technical factors account for the learning curve in complex surgery.

INTRODUCTION: The general public, the legal profession, patients and relatives expect best practice and have difficulty with the concept of a learning curve in surgical interventions. However, it is improbable that technical and innovative skills can be developed, or optimized, without some aspects of learning by experience and indeed 'risk taking'. PATIENTS AND METHOD: A single surgeon experience with a novel, complex, surgical procedure for peritoneal malignancy is described and compared with recent literature reports on the surgical learning curve. In total, 100 of 242 (41%) patients referred underwent a laparotomy. The 100 were divided into three numerically equal groups of 33, 33 and 34 cases, and the proportions undergoing surgery, mortality and major morbidity rates for the three groups were analysed. RESULTS: The numbers undergoing surgery were 33/54 (61%), 33/96 (34%) and 34/92 (37%). The mortality was 6/33 (18%), 1/33 (3%) and 1/33 (3%), and the major morbidity rates were 9/33 (27%), 2/33 (6%) and 0/34 (0%) in the three groups. CONCLUSIONS: The main components of the learning curve were considered to be decision-making and technical factors. A mechanism to reduce the surgical learning curve is suggested involving teamwork, and at least two experienced surgeons involved in all major surgical interventions. Decision-making and technical factors account for the learning curve in complex surgery.

Benchmarking↗

PubMed2005

Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections.

OBJECTIVE: To provide a multidimensional analysis of the learning curve in major laparoscopic colonic and rectal surgery and compare outcomes between right-sided versus left-sided resections. SUMMARY BACKGROUND DATA: The laparoscopic learning curve is known to vary between surgeons, may be influenced by the patient selection and operative complexity, and requires appropriate case-mix adjustment. METHODS: This is a descriptive single-center study using routinely collected clinical data from 900 patients undergoing laparoscopic surgery between November 1991 and April 2003. Outcome measures included operation time, conversion rate (CR), and readmission and postoperative complication rates. Multifactorial logistic regression analysis was used to identify patient-, surgeon-, and procedure-related factors associated with conversion of laparoscopic to open surgery. A risk-adjusted Cumulative Sum (CUSUM) model was used for evaluating the learning curve for right and left-sided resections. RESULTS: The conversion rate for right-sided colonic resections was 8.1% (n = 457) compared with 15.3% for left-sided colorectal resections (n = 443). Independent predictors of conversion of laparoscopic to open surgery were the body mass index (BMI) (odds ratio [OR] = 1.07 per unit increase), ASA grade (OR = 1.63 per unit increase), type of resection (left colorectal versus right colonic procedures, OR = 1.5), presence of intra-abdominal abscess (OR = 5.0) or enteric fistula (OR = 4.6), and surgeon's experience (OR 0.9 per 10 additional cases performed). Having adjusted for case-mix, the CUSUM analysis demonstrated a learning curve of 55 cases for right-sided colonic resections versus 62 cases for left-sided resections. Median operative time declined with operative experience (P<0.001). Readmission rates and postoperative complications remained unchanged throughout the series and were not dependent on operative experience. CONCLUSIONS: Conversion rates for laparoscopic colectomy are dependent on a multitude of factors that require appropriate adjustment including the learning curve (operative experience) for individual surgeons. The laparoscopic model described can be used as the basis for performance monitoring between or within institutions.

Adult↗

PubMed2005

Characterizing the learning curve for a basic laparoscopic drill.

BACKGROUND: The psychomotor challenges inherent in laparoscopic surgery are evident by the steep procedural "learning curves" documented throughout the literature. Few methods have been described to evaluate learning curves. The cumulative summation (CUSUM) method is a criterion-based evaluation of the learning process. The purpose of this study is to describe the CUSUM learning curves for a simple task for individuals and for a group of novice laparoscopists. METHODS: Sixteen medical students undertook four weekly sessions of 10 laparoscopic pegboard transfers in the MISTELS system. Their performance was scored and recorded for each trial. CUSUM learning curves were constructed based on the goal of achieving mean scores for senior, intermediate, or junior laparoscopists >or=95% of the time. RESULTS: Based on senior criteria, one student achieved the goal by the 40th peg transfer trial. Based on intermediate criteria, three students achieved the goal by their 40th trial (trials 21 and 36), and for junior criteria, 10 students achieved the acceptable success rate by their 40th trial (range, 26-40). CONCLUSION: CUSUM analysis suggests criterion-based practice is useful for novice laparoscopists. It allows educators to track the progress of an individual toward target criteria for each MISTELS task, to more logically allocate time for training and set attainable goals, to objectively evaluate trainee acquisition of basic laparoscopic skills, and to identify trainees who need remediation.

Clinical Competence↗

PubMed2004

Statistical evaluation of learning curve effects in surgical trials.

Randomized controlled trials (RCTs) in surgery have been impeded by concerns that improvements in the technical performance of a new technique over time (a "learning curve") may distort comparisons. The statistical assessment of learning curves in trials has received little attention. In this paper, we discuss what a learning curve effect is, the factors which effect it, how to display it, and how to incorporate the learning effect into the trial analysis. Bayesian hierarchical models are proposed to adjust the trial results for the existence of a learning curve effect. The implications for trial evaluation and data collection are considered.

Bayes Theorem↗

PubMed2000

Assessment of the learning curve in health technologies. A systematic review.

OBJECTIVE: We reviewed and appraised the methods by which the issue of the learning curve has been addressed during health technology assessment in the past. METHOD: We performed a systematic review of papers in clinical databases (BIOSIS, CINAHL, Cochrane Library, EMBASE, HealthSTAR, MEDLINE, Science Citation Index, and Social Science Citation Index) using the search term "learning curve." RESULTS: The clinical search retrieved 4,571 abstracts for assessment, of which 559 (12%) published articles were eligible for review. Of these, 272 were judged to have formally assessed a learning curve. The procedures assessed were minimal access (51%), other surgical (41%), and diagnostic (8%). The majority of the studies were case series (95%). Some 47% of studies addressed only individual operator performance and 52% addressed institutional performance. The data were collected prospectively in 40%, retrospectively in 26%, and the method was unclear for 31%. The statistical methods used were simple graphs (44%), splitting the data chronologically and performing a t test or chi-squared test (60%), curve fitting (12%), and other model fitting (5%). CONCLUSIONS: Learning curves are rarely considered formally in health technology assessment. Where they are, the reporting of the studies and the statistical methods used are weak. As a minimum, reporting of learning should include the number and experience of the operators and a detailed description of data collection. Improved statistical methods would enhance the assessment of health technologies that require learning.

Biomedical Technology↗

PubMed2006

Operative time is a poor surrogate for the learning curve in laparoscopic colorectal surgery.

BACKGROUND: Previous studies have relied on conversion rate and operative time for construction of learning curves in laparoscopic colorectal surgery. The authors hypothesized that conversion rate and operative time were less important than complication and readmission rates in defining good outcomes and hence the learning curve. METHODS: A database of 287 consecutive laparoscopic colorectal resections from a single tertiary referral center was analyzed. Outcome measures included operative time, conversion rate, major and minor complications, length of hospital stay, and the 15- and 30-day hospital readmission rate. Data were analyzed both by surgeons and by quartile case numbers. RESULTS: A total of 151 right colectomies and 136 left colectomies were performed between 1995 and 2005. For both right and left colectomies, the conversion rate decreased in each of the first three quartiles, reaching a nadir of 0% for right colectomies and 3% for left colectomies in the third quartile. The conversion rates increased slightly in the fourth quartile. The operative time remained stable for three quartiles, then increased slightly in the fourth quartile. Two surgeons managed 199 of the 287 cases. Analysis of the two high-volume surgeons demonstrated that for left-sided resections, the surgeon with the shorter operative times had the higher major complication rate (13% vs 2%), overall complication rate (22% vs 2%), 30-day readmission rate (13% vs 0%), and length of stay (3.8 vs 3.1 days) (p < 0.05 for all comparisons). CONCLUSIONS: In this series, operative time failed to decrease with experience, and shorter operative times did not correlate with better clinical outcomes. The failure of operative time to decline with experience often reflects surgeons' willingness to attempt more difficult cases rather than an accurate representation of a "learning curve." Therefore, complication and readmission rates are more important than operative time and conversion rates for evaluating the learning curve and quality of laparoscopic colorectal surgery.

Adult↗

PubMed2005

Laparoscopic vascular anastomoses: does robotic (Zeus-Aesop) assistance help to overcome the learning curve?

BACKGROUND: Considerable training is necessary to master laparoscopic suturing and knot-tying. Robotic systems are assumed to facilitate these skills and shorten the learning curve. The effect of laparoscopic experience and robotic assistance on the learning curve of vascular anastomoses was studied. METHODS: A laparoscopically experienced surgeon and a laparoscopically inexperienced surgeon made alternating laparoscopic vascular anastomoses and robot-assisted laparoscopic vascular anastomoses using a Zeus-Aesop surgical robotic system with various prosthetic conduits and suture materials in a laparoscopic training box. RESULTS: Neither laparoscopic method influenced the quality score or leakage rate, but with laparoscopic experience, significantly fewer failures were made. Suturing and knot-tying were faster with laparoscopic experience both with and without the robotic system, and fewer stitch actions and knot actions were performed. The learning curves of both surgeons were not improved by the robotic system. CONCLUSIONS: Experience is the most important factor in the performance of laparoscopic vascular anastomoses. The robotic system was not helpful in shortening the learning curve.

Anastomosis, Surgical↗

PubMed2003

Holmium laser enucleation for prostatic adenoma: analysis of learning curve over the course of 70 consecutive cases.

PURPOSE: We elucidate the learning curve, efficacy and safety of holmium laser enucleation of prostatic adenomas. MATERIALS AND METHODS: We retrospectively reviewed data on 70 patients who had undergone holmium laser enucleation for prostatic adenoma. All patients were assessed preoperatively and at an interval of 6 months postoperatively based on the International Prostate Symptom Score, quality of life index, peak urinary flow rate and post-void residual urine measurement. All complications were noted. The relationship between the number of procedures performed and treatment efficacy was analyzed. The learning curve with regard to efficiency for tissue enucleation and morcellation was assessed. RESULTS: Holmium laser enucleation of the prostate resulted in a significant improvement in subjective symptoms and urodynamic parameters. The ratio of improvement in the preoperative-to-postoperative peak urinary flow rate, post-void residual urine, International Prostate Symptom Score and quality of life index did not change significantly as experience increased. However, the efficiency of enucleation increased significantly as experience increased. Complications included short-term stress urinary incontinence in 8 cases and postoperative urethral stricture in 5. Bladder injury during morcellation was observed in 2 cases. CONCLUSIONS: Holmium laser enucleation of the prostate is an effective treatment option for benign prostatic adenoma, providing good treatment efficacy and minimal bleeding even if the surgeon has minimal experience. It requires more time to perform than traditional surgery but there is a learning curve for the enucleation technique as experience increases. Technical improvement in tissue morcellation may be necessary if the prevalence of this treatment is to increase dramatically.

Aged↗

PubMed2007

The surgical learning curve in aural atresia surgery.

OBJECTIVE: The objective of this retrospective case review is to examine the effect of surgical learning on hearing outcomes and complications in congenital aural atresia surgery. PATIENTS: Sixty-four consecutive ears (in 60 patients) operated on during the period of 1994 to 2004 at a tertiary referral center were studied. INTERVENTION(S): Intervention consisted of aural atresiaplasty through an anterior approach by the same surgeon (C.S.). MAIN OUTCOME MEASURE(S): Hearing outcomes and complication rates were compared between four temporally sequential groups of 16 ears. Acceptable hearing and complication rate outcomes were defined as results comparable to larger series in the literature. RESULTS: Hearing results, in the short term, comparable to larger series were achieved during the first group of ears (nos. 1-16). A plateau in the learning curve for short-term hearing outcomes was achieved after the first two groups, that is, after 32 ears. Hearing outcomes, in the long term (>1 year) comparable to larger series, were achieved in the second group of ears (nos. 16-32). The learning curve for long-term hearing demonstrated a significant improvement in outcomes in the final group of 16 ears compared with the first 48 ears. Long-term hearing results for the final group show closure of the postoperative air-bone gap to less than 30 dB in 94% of cases. Postoperative complication rates were equivalent to larger series in the first group of 16 ears and showed no statistically significant difference between the four groups. There was one patient with sensorineural hearing loss after surgery; there were no anacoustic ears and no facial palsies in the study group. CONCLUSIONS: A learning curve of at least 32 ears was required to achieve stable short-term hearing results. To achieve stable long-term hearing results required a learning curve of at least 48 patients in our series. Complication rates remained stable throughout the study period.

Adolescent↗