An analysis of the impact of previous laparoscopic hysterectomy experience on the learning curve for robotic hysterectomy

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1 J Robotic Surg (2013) 7: DOI /s ORIGINAL ARTICLE An analysis of the impact of previous laparoscopic hysterectomy experience on the learning curve for robotic hysterectomy A. Eddib N. Jain M. Aalto S. Hughes A. Eswar M. Erk C. Michalik V. Krovi P. Singhal Received: 18 October 2012 / Accepted: 21 November 2012 / Published online: 27 February 2013 Ó Springer-Verlag London 2013 Abstract To analyze and compare the safety and perioperative outcomes of newly trained robotic surgeons with previous laparoscopic hysterectomy experience (TLH Exp) and those without previous laparoscopic hysterectomy experience (Non-TLH Exp). The purpose is to determine the effect of previous advanced laparoscopic skills on the performance in robotic assisted laparoscopic surgery. We will also compare the perioperative outcomes between the total laparoscopic hysterectomies (TLH), and robotic assisted laparoscopic hysterectomies (RALH) of a single experienced (TLH Exp) robotic surgeon. The purpose is to determine benefits and/or risks, if any, of one approach over the other in the hands of an experienced laparoscopic surgeon. Prospective data were collected on the first consecutive series of RALH performed by (TLH Exp) and (Non-TLH Exp) surgeons, with perioperative outcomes and morbidity being evaluated. In addition, retrsopective data were collected on a consecutive series of patients in a TLH group and compared with the outcomes in the robotic A. Eddib (&) M. Aalto S. Hughes A. Eswar M. Erk P. Singhal Department of Obstetrics and Gynecology, University at Buffalo, Buffalo, NY, USA abeereddib@hotmail.com N. Jain Department of Neurosciences, University of Rochester, Rochester, NY, USA C. Michalik Kaleida Health, Millard Fillmore Suburban Hospital, Williamsville, NY, USA V. Krovi Department of Mechanical and Aerospace Engineering, University at Buffalo, Buffalo, NY, USA group for benign hysterectomies by the same surgeon. The parameters that were analyzed for associations with these two groups were estimated blood loss (EBL), Hb drop, length of hospital stay (LOS), procedure time, pain medication use, and complications. The (TLH Exp) group had 64 patients, and the (Non-TLH Exp) group had 72 patients. When comparing patients in the (TLH Exp) group with patients in (Non-TLH Exp) group, the mean age was 44 and 45 (P = 0.8), mean BMI was 27.7 and 29.5 kg/m 2 (P = 0.2), mean procedure time was 121 and 174 min (P \ 0.05), mean console time was 70 and 119 min (P \ 0.05), mean EBL was 64 and 84 ml (P = 0.3), with a Hb drop 1.7 and 1.33 (P = 0.2), uterine weight was 192 and 205 gms (P = 0.7), and length of stay was 1.07 and 1.33 days (P = 0.2), respectively. The (TLH Exp) surgeons had a lower OR, procedure and console time, but a higher hemoglobin drop, with no difference in EBL. There were no operative deaths, or conversions in either group. Morbidity occurred in two patients (3 %) in each group, with no statistically significant difference between the groups. In the (TLH Exp) group it included a blood transfusion and a readmission for a postoperative ileus. In the (Non-TLH Exp), the complications included a blood transfusion and a return to the OR for a vaginal cuff dehiscence. When comparing a single (TLH Exp) surgeon s own TLH versus RALH, there were 64 RALH and 49 TLH cases. There was a statistically significant difference in the mean procedure time versus 88.8 min (P \ 0.05), mean Hb drop 1.7 versus 2.3 (P \ 0.05), and mean EBL 64.2 versus 158 ml (P \ 0.05), respectively. The RALH group had a longer procedure time, but lower Hb drop, and less estimated blood loss. There were no operative deaths, or conversions in either group. Morbidity occurred in 2 patients in the robotic group, and included one blood transfusion, and one postoperative ileus. There

2 296 J Robotic Surg (2013) 7: were no complications noted in the laparoscopic hysterectomy group. Previous advanced laparoscopic skills appear to only significantly impact the length of the procedure, but not other variables. Robotic surgery may level the playing field between the basic and advanced laparoscopic surgeon for robotic assisted laparoscopic hysterectomy. In comparing the outcomes of RALH versus TLH by a single surgeon, the robotic assistance appeared to lengthen the procedure time, but reduce the amount of blood loss. Robotic surgery may offer a benefit of reduced blood loss at the expense of longer operating time. Similar studies including different surgeons are needed to validate these points, and thereby determine the risk benefit balance between the two approaches for benign simple hysterectomies. Keywords Experience Background Robotic Hysterectomy Laparoscopic Hysterectomy is one of the most commonly performed surgical procedures in the US, with approximately 600 thousand procedures performed annually [1, 2]. Minimally invasive surgical methods are becoming more common in the treatment of gynecologic conditions. However, despite the documented benefits of the minimally invasive approach in patients, due to the steep learning curve, and technical difficulties, this has been slow to gain acceptance [2]. More than two-thirds of hysterectomies are being performed through an abdominal incision [1]. The instruments of laparoscopy offer surgeons limited precision and poor ergonomics, and the amount of time and energy required to develop and maintain such advanced laparoscopic skills is substantial. Robotic surgery may allow all laparoscopic surgeons regardless of their level of experience to perform advanced laparoscopic procedures with greater ease. The potential advantages of surgical robotic systems include making advanced laparoscopic surgical procedures accessible to surgeons who do not have advanced laparoscopic experience and expanding the scope of surgical procedures that can be performed using the laparoscopic method. The increasing popularity of robotic surgery has sparked interest in the acquisition of the skills needed to perform robotic surgery safely. For benign gynecology, many studies suggest that robotic and conventional laparoscopic hysterectomy have comparable surgical and clinical outcomes [3 5]. A Cochrane database review recently concluded that there is no benefit for benign gynecologic diseases in regards to effectiveness and safety [6]. Since the role of robotic surgery is not to convert the advanced laparoscopic surgeon to a robotic surgeon; but to convert a surgeon who previously did mainly laparotomies to a minimally invasive surgeon via robotics, we need to determine if robotic assisted laparoscopic surgeries requires advanced laparoscopic skills. Because the majority of these studies did not control for the laparoscopic level of experience for the surgeons, our issue is: Can the general gynecologist with less than advanced laparoscopic skills duplicate these favorable study results for robotic hysterectomy? Several laboratory studies suggest that laparoscopic experience seems to be the strongest predictor of performance with the da Vinci surgical system [7]. However, clinical evidence for this is limited. The purpose of this study was to determine whether skills are transferred between conventional laparoscopy and robotically assisted surgery in the clinical setting. We will try to determine the influence of previous laparoscopic experience on robotic assisted surgery outcomes, and will also try to determine the benefits and/or risks, if any, of one approach over the other in the hands of a single experienced laparoscopic surgeon. Our expectation is that previous advanced laparoscopic skills have minimal impact on the performance in robotic assisted laparoscopic surgery. Methods To evaluate the impact of previous laparoscopic experience on robotic surgery, our study design included two cohorts. In the first cohort, we compared the learning curve for robotic assisted laparoscopic hysterectomies (RALH) in newly trained robotic surgeons with previous laparoscopic hysterectomy experience (TLH Exp) and those without previous laparoscopic hysterectomy experience (Non-TLH Exp). In the second cohort, we compared the total laparoscopic hysterectomies (TLH) and robotic hysterectomies (RALH) of a single experienced advanced laparoscopic surgeon (TLH Exp). We attempted to use a surgeon s previous TLH experience as a surrogate for advanced laparoscopic skills. We considered the TLH experienced surgeon as a surgeon with advanced laparoscopic skills, whereas the surgeon that only performed laparoscopic adnexal surgery or less complicated procedures as an intermediate laparoscopic surgeon. Our study did not evaluate the role of lack of previous laparoscopic experience, i.e., novices, since few gynecologists meet this definition. The majority of practicing gynecologists perform some degree of laparoscopy such as tubal ligations, ectopic pregnancies, and adnexal surgery, which we consider intermediate laparoscopic surgeons, i.e., Non- TLH experienced surgeons for the purpose of our study. To evaluate the learning curve between the two groups in each cohort we compared operative time, and

3 J Robotic Surg (2013) 7: perioperative outcomes. Prospective data were collected on the first consecutive series of (RALH) performed by (TLH Exp) and (Non-TLH Exp) surgeons. In addition, retrospective data were collected on a consecutive series of patients in a TLH group and compared to the prospectively collected data on RALH for the same surgeon. Multiple perioperative variables and outcomes were evaluated. The parameters that were analyzed included age, BMI, procedure time, estimated blood loss (EBL), Hb drop, length of hospital stay (LOS), uterine weight (ut wt), pain medication use, and complications. All robotic surgeries were performed on the da Vinci Surgical System (Intuitive Surgical, Sunnydale, CA) using a four-arm robot. The study population includes a consecutive series of RALH, and TLH patients between May 2010 and March The types of procedures were hysterectomy with or without adnexal excision (RAH ± BSO). Pain medication use was standardized among patients by converting all narcotic medications to the dose equivalent in milligrams of morphine in a 24-h period. Operative times and duration of each step were recorded and included: mean total operative time (from patient in OR till patient out of OR), console time, closing time (from undocking till port site fascia closure), and procedure time (skin incision to dressing). The complications reported were collected from patient charts and included a hospital wide electronic query of any patients re-admitted within 30 days of the surgery. Data analysis was performed using SAS 9.3 (Cary, NC). Descriptive statistics were initially performed followed by statistical analysis with Student s t test to compare means between the two groups. Significance was set at P \ procedure and console time, but a higher hemoglobin drop, with no increase in documented EBL. There were no operative deaths, or conversions in either group. Morbidity occurred in two patients (3 %) in each group, there was no statistically significant difference between the groups. In the (TLH Exp) group it included a blood transfusion and a readmission for a postoperative ileus. In the (Non-TLH Exp), the complications included a blood transfusion and a return to the OR for a vaginal cuff dehiscence. Previous advanced laparoscopic skills appear to only significantly impact the length of the procedure, but not other variables. In the second cohort, looking at a single surgeon s experience, we compared the total laparoscopic hysterectomies (TLH) and robotic hysterectomies (RALH) (Table 2). Comparing a single (TLH Exp) surgeon s own TLH versus RALH, there were 64 RALH and 49 TLH consecutive cases (Table 1). There was a statistically significant difference in the mean procedure time versus 88.8 min (P \ 0.05), in the mean Hb drop 1.7 versus 2.3 (P \ 0.05), and in the mean EBL 64.2 versus 158 ml (P \ 0.05), respectively. The RALH group had a longer procedure time, but the TLH group had a higher Hb drop, and more blood loss. There was no statistically significant difference in LOS 1.07 versus 1.1 (P = 0.6), uterine weight versus gms (P = 0.49) or pain med use 74.9 versus 69.4 mg morphine, (P = 0.7) between the RALH, and the TLH. There were no operative deaths, or conversions in either group. Morbidity occurred in two patients in the robotic group, and included one blood transfusion, and one postoperative ileus. There were no complications noted in the laparoscopic hysterectomy Results In this study, there were two groups in each cohort. For the 1st Cohort, we compared the learning curve for robotic assisted laparoscopic hysterectomies (RALH) in newly trained robotic surgeons with previous laparoscopic hysterectomy experience (TLH Exp) and those without previous laparoscopic hysterectomy experience (Non-TLH Exp) (Table 1). The (TLH Exp) group had 64 patients, and the (Non-TLH Exp) group had 72 patients. When comparing patients in the (TLH Exp) group with patients in (Non-TLH Exp) group, the mean age was 44 and 45 (P = 0.8), mean BMI was 27.7 and 29.5 kg/m 2 (P = 0.2), mean procedure time was 121 and 174 min (P \ 0.05), mean console time 70 and 119 min (P \ 0.05), mean EBL was 64 and 84 ml (P = 0.3), Hb drop was 1.7 and 1.33 (P = 0.2), uterine weight was 192 and 205 g (P = 0.7), pain med use 74.9 and 68.8 mg morphine (P = 0.83), and length of stay was 1.07 and 1.35 days (P = 0.29), respectively. The (TLH Exp) surgeons had a lower OR, Table 1 Comparison of perioperative variables between (TLH Exp), and (Non-TLH Exp) robotic assisted laparoscopic hysterectomies Variable (TLH Exp) (Non-TLH Exp) P value N Age BMI EBL Hb drop \0.05 LOS Ut wt Time to dock Console time \0.05 Prep time Closing time Procedure time \0.05 OR time \0.05 Complications 2 (3 %) 2 (2.7 %) N/A Pain medication

4 298 J Robotic Surg (2013) 7: Table 2 Comparison of perioperative variables between robotic assisted, and non-robot assisted laparoscopic hysterectomies Variable Robotic Non-robotic P value N N/A Age BMI EBL (ml) \0.05 Hb drop (g/dl) \0.05 LOS (days) Ut wt (grams) Procedure time (min) \0.05 OR time (min) \0.05 Complications 2 (3 %) 0 N/A Pain meds (mg morphine) group. The robotic assistance appeared to lengthen the procedure time, but reduce the amount of blood loss. Discussion Despite significant advances in conventional laparoscopic techniques, the majority of gynecological procedures are still performed through major abdominal incisions, which are associated with higher surgical morbidity [8]. The benefit of the minimally invasive approach is well documented, however, due to the steep learning curve, and technical difficulties, this has been slow to gain acceptance. Limitations associated with traditional laparoscopic surgery can be overcome with robotics by offering better ergonomics, wristed instruments, increased dexterity, as well as improved visualization via 3-dimensional highdefinition camera systems. Thus, with the recent adoption of the da Vinci Surgical System for robotic surgery, the percentage of patients that undergo a minimally invasive approach has increased. As interest in robotic assisted surgery continues to grow, more and more surgeons are embracing this technology [9]. Because gynecologic surgeons vary in their skill and experience level as it pertains to laparoscopic surgery, the impact of previous laparoscopic experience on the learning curve is difficult to determine. Accordingly, studies that compare the impact of previous laparoscopic experience on the learning curve for robotics in the clinical setting are lacking. The learning curve for robotics has been evaluated in different studies [10 12], using parameters such as operative time, and outcome measures such as blood loss, intraoperative complications and conversion rates. Hence, to evaluate the learning curve for TLH experienced surgeons versus Non-TLH experienced surgeons, we used similar parameters. The influence of previous laparoscopic experience on the adaptation to robotic surgery, has been evaluated in studies; however, these were mainly done in a laboratory setting [13 16]. For example, Jayaraman et al. [17] in a study used an ex vivo model for a complex minimally invasive surgical (MIS) procedure performed by three surgeons with graduated MIS expertise: surgeon A (MIS? robotics), surgeon B (experienced MIS), and surgeon C (basic MIS). They found that da Vinci improves time to completion and quality of a complex minimally invasive surgical (MIS) procedure over laparoscopy in an ex vivo bench model. This advantage is more pronounced in the hands of surgeons with less MIS experience. They concluded that robotics might allow less experienced surgeons to perform more complex operations without first developing advanced laparoscopic skills. Since very little study has been done regarding the transfer of skills between conventional laparoscopy and robotically assisted surgery in the clinical setting, the purpose of this study was to determine whether skills are transferred between these two approaches in the clinical setting. We therefore sought to compare an advanced laparoscopic surgeon s learning curve with that of an intermediate (noncomplicated laparoscopic surgeon and no laparoscopic hysterectomy experience). Our findings suggest that there appears to be limited transference of skills between conventional laparoscopy and robotically assisted surgery. We say limited transference of skills, because previous advanced laparoscopic skills appear to only significantly impact the length of the procedure, but not other variables. Since this limited transference does not appear to significantly impact other outcomes, previous advanced laparoscopic experience may not be necessary to perform robotic surgery. Therefore, robotic surgery may very well level the playing field between the basic and advanced laparoscopic surgeon for robotic assisted laparoscopic hysterectomy. The second purpose of our study was to assess the learning curve and difference in outcome between conventional laparoscopy and robotic hysterectomy for the same surgeon, to control for inter-surgeon variability. Multiple studies have been done that grouped single or multi-institution benign hysterectomy outcomes, and even meta-analysis of these studies, most showing reduced blood loss, fewer conversions, and longer operative time [18, 19]. The majority of these studies, however, did not control for the laparoscopic skill of the surgeon, which is an inherently difficult and controversial parameter to measure. We therefore sought to try to control for this potential bias by looking at a single experienced laparoscopic surgeon s outcomes. In comparing the outcomes of RALH versus TLH by a single surgeon, the robotic assistance appeared to lengthen the procedure time, but reduce the amount of blood loss. Our study suggests that robotic

5 J Robotic Surg (2013) 7: surgery may offer a benefit of reduced blood loss at the expense of longer operating time. This longer operating time noted with robotic cases may level off or plateau with more robotic cases, since in our study this may be attributed to the early part of the learning curve for the robotic adoption phase. Whether in the advanced laparoscopic surgeon s hands robotic surgery risk benefit balance favors conventional laparoscopy or robotics will need to be further evaluated. Conclusions Previous advanced laparoscopic skills appear to only significantly impact the length of the procedure, but not other variables. Robotic surgery may level the playing field between the basic and advanced laparoscopic surgeon for robotic assisted laparoscopic hysterectomy. And in comparing the outcomes of a robotic approach versus a conventional laparoscopic approach by a single surgeon, the robotic assistance appeared to lengthen the procedure time, but reduce the amount of blood loss. Robotic surgery may offer a benefit of reduced blood loss at the expense of longer operating time. Similar studies including different surgeons with different levels of laparoscopic skills are needed to validate these points, and thereby determine the risk benefit balance between the two approaches for benign simple hysterectomies. We are concerned that the advanced laparoscopic surgeons are the ones that are embracing robotics, and the nonadvanced laparoscopic surgeons are still doing exploratory laparotomies for their hysterectomies, and thus exchanging the same rate of minimally invasive surgery with a more expensive tool. For robotic surgery to have a significant impact on minimally invasive surgery rates more nonadvanced laparoscopic surgeons should embrace it. Our study promotes this and agrees with previous studies in that new robotic surgeons may not need previous exposure to laparoscopic surgery to start using the robotic system. Conflict of interest References None. 2. Wu JM et al (2007) Hysterectomy rates in the United States, Obstet Gynecol 110(5): Sarlos D et al (2010) Robotic hysterectomy versus conventional laparoscopic hysterectomy: outcome and cost analyses of a matched case-control study. Eur J Obstet Gynecol Reprod Biol 150(1): Sarlos D, Kots LA (2011) Robotic versus laparoscopic hysterectomy: a review of recent comparative studies. Curr Opin Obstet Gynecol 23(4): Pasic RP et al (2010) Comparing robot-assisted with conventional laparoscopic hysterectomy: impact on cost and clinical outcomes. J Minim Invasive Gynecol 17(6): Liu H et al (2012) Robotic surgery for benign gynaecological disease. Cochrane Database Syst Rev 2:CD Hagen ME et al (2009) Impact of IQ, computer-gaming skills, general dexterity, and laparoscopic experience on performance with the da Vinci surgical system. Int J Med Roboti Comput Assist Surg MRCAS 5(3): Matthews CA (2010) Applications of robotic surgery in gynecology. Journal of Women s Health 19(5): Matthews CA et al (2010) Evaluation of the introduction of robotic technology on route of hysterectomy and complications in the first year of use. Am J Obstet Gynecol 203(5):499.e1 499.e5 10. Kho RM (2011) Comparison of robotic-assisted laparoscopy versus conventional laparoscopy on skill acquisition and performance. Clin Obstet Gynecol 54(3): Lenihan JP Jr, Kovanda C, Seshadri-Kreaden U (2008) What is the learning curve for robotic assisted gynecologic surgery? J Minim Invasive Gynecol 15(5): Lowe MP et al (2009) A multiinstitutional experience with robotic-assisted hysterectomy with staging for endometrial cancer. Obstet Gynecol 114(2 Pt 1): Stefanidis D et al (2010) Robotic assistance improves intracorporeal suturing performance and safety in the operating room while decreasing operator workload. Surg Endosc 24(2): Chandra V et al (2010) A comparison of laparoscopic and robotic assisted suturing performance by experts and novices. Surgery 147(6): Obek C et al (2005) Robotic versus conventional laparoscopic skill acquisition: implications for training. J Endourol 19(9): Blavier A et al (2007) Comparison of learning curves and skill transfer between classical and robotic laparoscopy according to the viewing conditions: implications for training. Am J Surg 194(1): Jayaraman S et al (2010) Does robotic assistance improve efficiency in performing complex minimally invasive surgical procedures? Surg Endosc 24(3): Payne TN, Dauterive FR (2008) A comparison of total laparoscopic hysterectomy to robotically assisted hysterectomy: surgical outcomes in a community practice. J Minim Invasive Gynecol 15(3): Payne TN, Pitter MC (2011) Robotic-assisted surgery for the community gynecologist: can it be adopted? Clin Obstet Gynecol 54(3): Merrill RM (2008) Hysterectomy surveillance in the United States, 1997 through Med Sci Monit 14(1):24 31

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