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Results for “Learning Curve”

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PubMed2002

[Evaluation of the learning curve of a new intubation technique: intubating laryngeal mask].

OBJECTIVE: Assessment of the learning curve of a new device for blind orotracheal intubation: Intubating laryngeal mask. STUDY DESIGN: Prospective clinical study. METHODS: Ten persons practicing anaesthesia (specialist, fellow, nurse) underwent videotape learning and manikin training required with the device. Each person had to carry out a tracheal intubation in ten consecutive patients undergoing scheduled surgery. No patient presented history or clinical sign of difficult airway management. Results were expressed as mean +/- SD. Main percentages were provided with their 95% confidence interval; the percentage comparison were performed using Chi 2 test. The significance level for overall analysis was p < 0.05. RESULTS: One hundred patients were included. The overall success rate of tracheal intubation with the intubating laryngeal mask was 88%. An easy learning curve was obtained according to the low failure rate that was observed. No failure was noticed after eight procedures. Significant diminution of the delay for tube insertion was observed during the practice (3 +/- 1.30 min for the first procedure and 1.16 +/- 0.60 min for the tenth procedure). Circumstances of the oral intubation were improved with muscle relaxation. Finally, all failure with the intubating laryngeal mask were followed by successful intubation using direct laryngoscopy. CONCLUSION: The intubating laryngeal mask is a new device for blind orotracheal intubation with an easy learning curve in patients without difficulty in airway management, even for non-selected operators.

Aged↗

PubMed2004

Generating a learning curve for penile block in neonates, infants and children: an empirical evaluation of technical skills in novice and experienced anaesthetists.

BACKGROUND: Literature concerning learning curves for anaesthesiological procedures in paediatric anaesthesia is rare. The aim of this study was to assess the number of penile blocks needed to guarantee a high success rate in children. METHODS: At a teaching hospital, the technical skills of 29 residents in anaesthesiology who performed penile blocks under the supervision of two staff anaesthesiologists were evaluated during a 12-month period using a standardized self-evaluation questionnaire. At the start of the study period, the residents had no prior experience in paediatric anaesthesia or in performing penile block. All residents entered the paediatric rotation after a minimum of 1-year training in adult general and regional anaesthesia. The blocks were rated using a binary score. For comparison, the success rates of the two supervising staff anaesthesiologists were collected during the same period using the same self-evaluation questionnaire. Statistical analyses were performed by generating individual and institutional learning curves by using the pooled data. The learning curves were calculated with the aid of a least square fit model. A 95% CI were estimated by a Monte Carlo procedure with a bootstrap technique. RESULTS: In a total number of 392 blocks performed, the overall success rate was 92.1%. There was no statistical difference between the success rate of the two staff members (success rate: 96.3%) and the overall success rate of the 29 residents performing a total of 339 blocks. The total success rate for this group was 91.5%. The failure rate for the first 10 blocks performed by the residents was 8.82% (95% CI: 5.0-14.14%), it was 4.12% (95% CI: 1.13-10.22%) for the next 10 blocks and from blocks 21 to 40 it was 6.5% (95% CI: 2.65-12.9%). For blocks 41-60, the failure rate was 4.4% (95% CI 0.54-15.15%). CONCLUSIONS: Penile block in children is easily learned by residents. A steep learning curve was found. The success rate was over 93.5% after more than 40 blocks.

Adult↗

PubMed2006

Decline in urinary retention incidence in 805 patients after prostate brachytherapy: the effect of learning curve?

PURPOSE: To evaluate the incidence and factors predictive of acute urinary retention (AUR) in 805 consecutive patients treated with prostate brachytherapy monotherapy and to examine the possible effect of a learning curve. METHODS AND MATERIALS: Between July 1998 and November 2002, 805 patients were treated with prostate brachytherapy. Low-risk patients (Gleason Score (GS) < or = 6; prostate specific antigen (PSA) < or = 10, and < or = T2b [UICC 1997]) received implant alone. Patients with prostate volume of 50 cc or more, GS = 7, or PSA = 10 to 15 received 6 months of androgen suppression (AS) with brachytherapy. Patient, treatment, and dosimetric factors examined include baseline prostate symptom score (IPSS), diabetes, vascular disease, PSA, Gleason score, clinical stage, AS, ultrasound planning target volume (PUTV), postimplant prostate volume (obtained with "Day 30" postimplant CT), CT:PUTV ratio (surrogate for postimplant edema), number of seeds, number of needles, number of seeds per needle, dosimetric parameters (V100, V150, and D90), date of implant (learning curve), and implanting oncologists. Univariate and multivariate analyses were carried out. RESULTS: Acute urinary retention in the first 200 patients was 17% vs. 6.3% in the most recently treated 200 patients (p = 0.002). Overall AUR was 12.7%, and prolonged urinary obstruction incidence (> 20 days) was 5%. On multivariate analysis, factors predictive of any AUR include baseline IPSS (p = < 0.004), CT:PUTV ratio (p = < 0.001), PUTV (p = < 0.001), and implant order (learning curve) (p = 0.001). Factors predictive for "prolonged" catheterization (> 20 days) on multivariate analysis include IPSS (p < 0.01), number of needles (p < 0.001), diabetes mellitus (p = 0.048), and CT:PUTV ratio (p < 0.001) CONCLUSION: Over the years, our AUR rate has fallen significantly (from 17% to 6.3%). On multivariate analysis, highly significant factors include IPSS, PUTV, CT:PUTV ratio (i.e., degree of prostate edema), and order of implant (learning curve). Over the course of the program, we have deliberately reduced the number of needles and OR time per patient, which have potentially minimized intraoperative trauma and may have contributed to less toxicity. A learning curve in prostate brachytherapy programs affect not only the outcome but also the toxicity from the treatment.

Acute Disease↗

PubMedDate not supplied

Establishing learning curves for surgical residents using Cumulative Summation (CUSUM) Analysis.

BACKGROUND: The assessment of technical proficiency is of paramount importance in the training of surgical residents. The fact that technical proficiency is underrepresented in the context of the ACGME outcomes project is evidenced in that proficiency skills comprise less than 5% of all assessments that evaluate residents. In this study, we use Cumulative Summation Analysis (CUSUM) as a visual objective analytic tool to determine performance accuracy and establish learning curves for PGY-1s in surgery. METHODS: From April 2001 to May 2002, 11 surgical residents completed a 1-month anesthesia rotation. Each resident was asked to complete a preoperative airway assessment followed by endotracheal intubation with induction of anesthesia. Airway assessment was performed independently by a resident and a licensed anesthesiologist or certified anesthetist with the modified Mallampati Score. Data were sequentially collected and plotted for summated successes and failures. RESULTS: The average intern required approximately 19 intubation attempts to complete the learning curve experience. There was no learning curve for airway assessment. CONCLUSIONS: The CUSUM analysis is an effective objective tool to define learning curves for technical skills. Vital information is provided for surgical programs that place residents in positions to manage airways, and limitless potential for defining the learning curves for technical skills is provided.

Adult↗

PubMed2000

Learning curves for transperitoneal laparoscopic and extraperitoneal endoscopic paraaortic lymphadenectomy.

STUDY OBJECTIVE: To compare learning curves for paraaortic lymphadenectomy by extraperitoneal endoscopic approach with those for transperitoneal laparoscopy. DESIGN: Randomized, long-term study (Canadian Task Force classification I). SETTING: Animal laboratory. SUBJECTS: Sixty-six pigs. INTERVENTION: Laparoscopic and endoscopic paraaortic lymphadenectomy, 33 pigs in each group, performed by two surgeons competent in laparoscopic surgery but without experience in endoscopic paraaortic lymphadenectomy. MEASUREMENTS AND MAIN RESULTS: The duration of the procedure, number of lymph nodes removed, and number of residual nodes revealed learning curves that stabilized after the tenth procedure for each surgeon and for each approach. Vascular trauma depended on experience, occurring during the first 10 procedures for each surgeon. Efficacy and operative morbidity were comparable for the two procedures. CONCLUSION: Endoscopic extraperitoneal lymphadenectomy has a steep learning curve similar to that for transperitoneal laparoscopy.

Animals↗

PubMed2005

Robotic-assisted laparoscopic prostatectomy: what is the learning curve?

Although equipment for performance of robotic-assisted laparoscopic prostatectomy (RALP) is becoming more widely available, few surgeons have acquired the skill and experience necessary to master RALP. A significant issue has been the requisite training and experience (ie, the "learning curve") necessary for a qualified surgeon to become an expert at RALP. The senior author (J.A.S.) has experience with > 2500 radical retropubic prostatectomy (RRP) and > 350 RALP procedures. He assessed his learning curve in achieving expertise with RALP. Because there are no objective measures to define expertise with RALP, achievement of expert status depends on the surgeon's comfort, experience, and results with alternative approaches. Surgeons with extensive experience with open approaches may "set the bar" higher for the learning curve because of expectations. RALP results comparable to those obtained routinely with RRP were not achieved until after > or = 150 procedures. Surgeon comfort and confidence comparable to that with RRP did not occur until after 250 RALP procedures. Defining the learning curve for RALP as the point at which a surgeon could provide outcomes comparable to those obtainable with alternative surgical approaches means that the point varies, depending on the experience and expertise of the surgeon. Surgeons whose sole or dominant experience is with laparoscopic or robotic approaches may have a different perception of the learning curve compared with an experienced open surgeon.

Clinical Competence↗

PubMed2004

Prospective evaluation of the learning curve of laparoscopic-assisted vaginal hysterectomy in a university hospital.

STUDY OBJECTIVE: To prospectively analyze the learning curve of laparoscopic-assisted vaginal hysterectomy (LAVH) in a surgical team and evaluate if length of surgery can be reduced safely. DESIGN: Prospective observational study (Canadian Task Force classification II-2). SETTING: Department of obstetrics and gynecology in a university-affiliated hospital. PATIENTS: One hundred and sixty consecutive women undergoing LAVH performed between January 1, 1998 and April 30, 2001. INTERVENTION: LAVH (AAGL Classification System for Laparoscopic Hysterectomy III-B-3). MEASUREMENTS AND MAIN RESULTS: The primary parameter evaluated was length of surgery. Patients were grouped in cohorts of 10, in order to perform a time curve that would assist us in evaluation of the learning process. Once the plateau was reached, we evaluated the process before and after this plateau (groups 1 [learning stage] and 2 [second stage], respectively). Average length of surgery was 126 minutes (range, 60-260). Length of surgery was 138 minutes (range, 75-260) in the learning stage (first 80 cases) and 112 minutes (range, 60-225) in the second stage (p <.0001). Total rate of complications was 11.6%. There were three major complications, and they occurred before the plateau. There were 15 minor complications (9.67%), 8 during the first stage and 7 in the second stage, (p =.9; NS). A second learning curve excluding LAVH with associated surgeries was obtained. The average length of surgery for the first stage was 133 minutes (range, 75-205) and 102 minutes for the second stage (range, 60-130) (p >.0001). CONCLUSION: Analysis of the learning curve demonstrated that the length of surgery in LAVH could be reduced without increasing the number of complications.

Adult↗

PubMedDate not supplied

Learning curves in health care.

This article explores the uses of learning curve theory in medicine. Though effective application of learning curve theory in health care can result in higher quality and lower cost, it is seldom methodically applied in clinical practice. Fundamental changes are necessary in the corporate culture of medicine in order to capitalize maximally on the benefits of learning.

Algorithms↗

PubMed2005

The learning curve measured by operating times for laparoscopic and open gastric bypass: roles of surgeon's experience, institutional experience, body mass index and fellowship training.

BACKGROUND: Surgeons must overcome a substantial learning curve before mastering laparoscopic Roux-en-Y gastric bypass (LRYGBP). This learning curve can be defined in terms of mortality, morbidity or length of surgery. The aim of this study was to compare the learning curves in terms of surgical time for the first 3 surgeons performing LRYGBP in our hospital with the length of surgery for open gastric bypass (CONTROLS). METHODS: We compared 494 primary LRYGBPs performed by 3 surgeons (393 by 1st SURGEON, 57 by 2nd SURGEON and 44 by 3rd SURGEON) to 159 open vertical banded gastroplasty-Roux-en-Y gastric bypasses (CONTROLS). Data for LRYGBP patients were prospectively obtained. Factors that significantly affected the length of surgery were identified by univariate and multivariate linear regression analysis. RESULTS: LRYGBP and CONTROL patients were similar in age, height, weight and BMI, although more CONTROLS were male. Median time for the 1st SURGEON performing LRYGBP dropped for each subsequent 100 operations: 1st 100 - 190 min, 2nd 100 - 135 min, 3rd 100 - 110 min and 4th 100 - 100 min. Median time for 2nd SURGEON performing LRYGBP was 120 min, 3rd SURGEON 173 min and CONTROLS 64 min. Length of surgery significantly correlated with surgical experience in terms of numbers of operations and BMI of patient. Times for 2nd SURGEON, a fellowship trained laparoscopic surgeon, started significantly faster than 1st SURGEON's, but did not significantly improve with experience. 3rd SURGEON's initial times were similar to 1st SURGEON's, but his times improved more rapidly with experience. Times for CONTROLS were significantly faster than all laparoscopic groups and did not correlate with operation number or patient BMI. CONCLUSIONS: The length of surgery for LRYGBPs continued to shorten beyond 400 operations for the first surgeon performing LRYGBP in our hospital. Previous fellowship training in LRYGBP shortened surgical times during initial clinical experience as an attending for the second surgeon. The learning curve was truncated because of the already established LRYGBP program.

Adult↗

PubMed2006

Intensive laparoscopic training: the impact of a simplified pelvic-trainer model for the urethrovesical anastomosis on the learning curve.

We prospectively evaluated the learning curve (LC) for laparoscopic urethrovesical anastomosis (L-UVA) in an operator-training model and program using an innovative simplified pelvic-trainer model. Over a period of 12 months, 30 LRP were performed by one urologist skilled in open surgery but inexperienced in laparoscopy. During the first 15 procedures no systematic training was done. Consequentially, a systematic simplified daily program was performed on the pelvic trainer with a videolaparoscopic unit. The training lesson consisted of intracorporal knotting and suturing, linear and circular interrupted suture anastomosis. At the end of each lesson, time and performance error scores were recorded and progression curve was plotted for each task. The performances of each training tasks were plotted against the performance of L-UVA during the LRP. The significance of progression was evaluated using logarithmic regression analysis. A steady improvement in time and accuracy of performance skill was shown during the first 20 lessons (p<0.001). These improved skill acquisitions were proportionally correlated with the time and the accuracy (water-tight) of L-UVA performance during the last 15 L-RPE. Compared to the first 15 L-RPE, where no systematic training was performed, time and accuracy of L-UVA performance in the last 15 L-RPE were improved from a mean 51 (median 48, range: 38-75) to 26 (median 24, range 18-33) min (p<0.001) and from 10 to 15 watertight anastomoses (p<0.001), respectively. Using a continuing, systematic, simplified training model the LC of L-UVA can be improved significantly in a short time.

Humans↗

PubMed2005

Learning curve: the surgeon as a prognostic factor in colorectal cancer surgery.

The individual surgeon is an independent prognostic factor for outcome in colorectal cancer surgery. The surgeon's learning curve is therefore directly related to the patient's outcome. The exact shape of the learning curve, however, is unknown. The present study reviewed supervision, training/teaching, specialization, surgeon's caseload, and hospital's caseload as the five main surgeon- and hospital-related confounding factors for outcome, and examined their influence on the learning curve as well as their interactions and prognostic significance. All five confounding factors were related to outcome. The highest degree of evidence, however, was found for training/teaching (introduction of total mesorectal excision), specialization in colorectal surgery (special interest, board-certification, specialized colorectal cancer units), and the surgeon's caseload. Five surgeon- and hospital-related factors directly influence the surgeon's learning curve and are therefore rightly considered predictors of outcome in colorectal cancer surgery. Improvements in supervision, training/teaching, specialization, the surgeon's caseload, and the hospital's caseload will therefore translate into enhanced patient outcome.

Certification↗

PubMed2005

Examining the learning curve of laparoscopic fundoplications at an urban community hospital.

BACKGROUND: Laparoscopic fundoplication for gastroesophageal reflux disease is a procedure associated with specific complications, especially in a surgeon's early experience. The learning curve of this procedure was examined at a tertiary community institution. METHODS: A retrospective review of the first 100 cases performed at Royal Columbian Hospital was conducted. Two surgeons performed the majority of cases and routinely assisted each other. Patients were grouped chronologically with the first 50 cases defined as early institutional experience and a surgeon's first 20 cases defined as early personal experience. RESULTS: Operative time was longer in both the early institutional (117.8 versus 91.3 minutes, P < .001) and personal experience (126.8 versus 89.7 minutes, P < .001). The rate of dysphagia requiring intervention was higher during the early institutional (22% versus 4%, P = .017) but not personal experience (19% versus 8%, P = not significant). The conversion rate was 0%, reoperation rate was 1%, mean length of stay was 2.5 +/- 1.4 days, and the readmission rate was 5%; these outcomes were unaffected by the learning curve. CONCLUSIONS: There is a definable learning curve in laparoscopic fundoplication in terms of operative time. However, an acceleration of the personal learning curve in terms of dysphagia was observed with a two-surgeon collaborative approach. With careful patient selection conversion, reoperation, readmission, and complication rates equivalent to experienced centers can be achieved in the community setting early in the personal and institutional experience.

Adult↗

PubMed2006

Laparoscopic colon resection early in the learning curve: what is the appropriate setting?

INTRODUCTION: Laparoscopic colon resection (LCR) is a safe and effective treatment of benign and malignant colonic lesions. There is little question that a steep learning curve exists for surgeons to become skilled and proficient at LCR. Because of this steep learning curve, debate exists regarding the appropriate hospital setting for LCR. We hypothesize that outcomes of LCR performed early in the learning curve at a regional medical center (New Hanover Regional Medical Center; NHRMC) and a university medical center (Baylor College of Medicine; BCM) would not be significantly different. METHODS: The first 50 consecutive LCRs performed at each institution between August 2001 and December 2003 were reviewed. Age, mean body mass index (BMI), gender, history of previous abdominal surgery (PAS), operative approach [laparoscopic (LAP) versus hand/laparoscopic assisted (HAL)], conversions (Conv), operative time (OR time), pathology (benign vs. malignant), lymph nodes (LN) harvested in malignant cases, length of stay (LOS), morbidity and mortality were obtained. Continuous data were expressed as mean +/- SD. Data were analyzed by chi, Fisher exact test, or t test. RESULTS: NHRMC patients were on average older females with a higher incidence of PAS. A LAP approach was more frequently performed at BCM (86%), whereas HAL was used more frequently at NHRMC (24%). Conversions to open were similar at both institutions (12%). Benign disease accounted for the majority of operations at both institutions. In cases of malignancy, more LN were harvested at BCM. OR time and LOS were shorter at NHRMC. Complication rates were similar between institutions. There were no anastomotic leaks or deaths. CONCLUSIONS: LCR can be performed safely and with acceptable outcomes early in the learning curve at regional medical centers and university medical centers. Outcomes depend more on surgeons possessing advanced laparoscopic skills and adhering to accepted oncologic surgical principles in cases of malignancy, than on the size or location of the healthcare institution.

Clinical Competence↗

PubMed2005

Vitreous loss during phacoemulsification learning curve performed by third-year residents.

OBJECTIVES: To assess the resident's phacoemulsification learning curve as a risk factor for vitreous loss and to determine the incidence of vitreous loss among the residents performing phacoemulsification. DESIGN: Retrospective matched case-control study MATERIAL AND METHOD: A case-control study comparing all consecutive cases of attempted phacoemulsification with intraocular lens (IOL) implantation from January 1st, 1998 to December 31st, 1999. The surgeon variable will be categorized into two groups, the third year ophthalmology residents, representing resident's phacoemulsification learning curve, and faculty staffs. The study group consisted of eyes that had had intraoperative complication of vitreous loss. The control group consisted of eyes that had not had vitreous loss. Continuous variables were compared with the 2-sided unpaired t-test. Categorical variables were compared between groups using analytical matched case-control study with relative risk or odd ratio, Mc Nemar's (Marginal) o 2 test and 95% confident interval of relative risk. RESULTS: The odds that the eyes in the resident group would have an intraoperative complication of vitreous loss were 4 times the odds that the eyes in the faculty staff group would have such complication (P = 0.0052, 95% confidential interval (CI) of relative risk (RR) = 1.516-10.556). The incidence of vitreous loss among residents was 6.93% (28/404) and 2.06% (28/1358) among the faculty staffs. The overall incidence of vitreous loss was 3.18% (56/1762). CONCLUSION: The incidence of intraoperative complication of vitreous loss, the relative risk of such complication performed by the learning curve surgeon in the present study serve as benchmarks for residents-in-training, beginning and surgeon-in-practice converting to phacoemulsification.

Case-Control Studies↗

PubMed2005

Psoas compartment block (PCB) in children: Part II--generation of an institutional learning curve with a new technique.

BACKGROUND: Literature concerning institutional learning processes for anesthesia procedures in pediatric anesthesia is rare. Until recently only small series of psoas compartment blocks (PCB) in children have been reported. We report on a series of 100 consecutive blocks using new landmarks and the institutional learning process. METHODS: In 100 consecutive children (5.9-106 kg) PCB was performed using a nerve stimulator. In the lateral position, the needle was inserted between the medial 2/3 and the lateral 1/3 on a line from the spinous process of L4 to the posterior superior iliac spine. Residents unfamiliar with PCB were instructed by one single staff member without manual intervention. Failure was defined as a bloody tap, more than one skin perforation with the needle or relinquishing the procedure to senior staff. To evaluate the institutional learning process the cumulative sum (CUSUM) statistical technique was used. CUSUM analysis was performed using an acceptable failure rate of 10%. A learning curve using a bootstrap technique and a least square fit model was also used. RESULTS: Although all blocks were clinically successful, only in 64% was a single attempt sufficient. In 16% vascular puncture occurred. Surprisingly the CUSUM analysis showed a clear institutional learning phenomenon. Applying a strict definition for a successful block, more than 100 PCB in an institution may be necessary. Using the generated learning curve, for a success rate of 70% a case load of at least 55 attempts is required. CONCLUSIONS: Although the described new technique had a very high success rate with a low complication rate, PCB in children is not easily implemented into clinical practice when strict criteria of success were used, despite a well-controlled environment. Training programs could use CUSUM to track the progress of their institutional learning in order to guarantee adequate experience.

Anesthesia, Epidural↗

PubMed1990

Learning curve for radial keratotomy.

I prospectively evaluated my own learning curve for radial keratotomy (RK) by comparing the results achieved in two groups: 20 consecutive eyes on which I performed RK without having had previous experience with the procedure (group 1); and 20 other eyes, matched for age, sex, and preoperative refractive error, on which I performed RK after I had performed the procedure 250 times (group 2). Although there were nine microperforations in group 1 and none in group 2, the postoperative refractions and uncorrected visual acuities were similar in both groups. Since the microperforations had no adverse effect on the visual results, it is reasonable to conclude that there was, in effect, no learning curve involved in my experience with RK.

Adult↗

PubMed2005

Comparison of 25 and 27 gauge needle in spinal anesthesia learning curve for anesthesia residency training.

BACKGROUND AND RATIONALE: Size of spinal needle may be a factor which influences the success rate of spinal anesthesia. OBJECTIVES: To compare learning curves of using 25G and 27G quincke spinal needle for spinal anesthesia. SETTING: Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital. DESIGN: Prospective randomized control trial. MATERIAL AND METHOD: Ten new first year anesthesia residents were randomized to 2 groups: Group I (n = 5) used 25G Quincke spinal needle, Group II (n = 5) used 27G Quincke spinal needle to perform 200 consecutive cases of spinal anesthesia. Number of success and failure was recorded by each individual resident anonymously. The learning curves of plotted by cumulative sum of success rate revealed an initial rapid improvement of success during the first 20 cases in both groups. The overall success rate of group I was 84% (95CI, 66.5-100) and group II was 87% (95%CI, 61.5-100); p = 0.89. The widest difference between the 2 learning curves at 20 attempts intervals was at the twentieth attempts with a success rate of 76.0% VS 65.0% in group I and group II respectively; p = 0.54. CONCLUSION: The learning curves of spinal anesthesia using 25G and 27G Quincke spinal needle showed rapid improvement of success rate at the first 20 spinal block and high overall success rate with no significant difference between the groups.

Adult↗

PubMed2002

[Follow-up results and learning curve in laparoscopic gastrofundoplications].

AIM OF THE STUDY: To analyze the postoperative results and the learning curve of laparoscopic gastrofundoplications by postoperative clinical monitoring of consequences and self-evaluation of complaints 12 months after surgery. METHODS: One hundred patients (58 female and 42 male) were operated at the Department of Surgery, Hospital of Kaunas University of Medicine, from April 1998 to January 2001 because of hiatal hernias, complicated with gastroesophageal reflux (in 59 cases sliding axial non-fixed, in 38 cases sliding axial fixed, and in 3 cases paraesophageal hernias were found). 89 Nissen and 11 Toupet fundoplications were performed. Patients were distributed into five groups (20 patients in each). Operation time, number of postoperative complications, postoperative hospital stay were analyzed. RESULTS: The mean operation time was 198 min in the 1 st group, 105 min in the 2 nd group, 110 min in the 3 rd group, 124 min in the 4 th group and 120 min in the 5 th group. Conversion to laparotomy was necessary in two cases (the 1 st and the 2 nd groups). The number of postoperative complications decreased from 5 in the 1 st group to 2 in the 2 nd group, and to 1 in the 3 rd and 4 th groups; no complications were noted in the 5 th group. According patient's opinion, successful results were received in 87 %. CONCLUSIONS: Laparoscopy is a good approach for surgical management of hiatal hernias complicated with gastroesophageal reflux, but laparoscopic gastrofundoplication needs advanced skills to be performed safely. The learning curve in terms of operation time covered initial 20 procedures and remained stable afterwards, the number of postoperative complications decreased after initial 20 operations, but dangerous complications occurred until the 60 th procedure. Other conventional elective surgical procedures of medium extent can be successfully performed simultaneously with laparoscopic fundoplication without affecting the outcome. The true learning curve of laparoscopic fundoplication can be drawn by careful follow-up and analysis of long-term postoperative results; this enables to improve operative techniques.

Adult↗