Medial-to-lateral laparoscopic colon resection: a view beyond the learning curve

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Abstract
Since the authors’ report on the lateral approach to laparoscopic colon resection (LCR), medial-to-lateral (M-L) segmental resection has continued to evolve. This report analyzes their learning curve experience with a standardized three-trocar M-L technique, which demonstrates the influence of operative volume on proficiency and outcome. From January 1999 to December 2004, 100 consecutive patients underwent a standardized three-trocar M-L segmental LCR. Patient demographics, indications for surgery, operative proficiency (time), and outcome (i.e., blood loss, conversion to open surgery, length of hospital stay, morbidity, and mortality) were recorded. A learning curve analysis was performed using a t-test and analysis of variance (ANOVA). The 100 M-L LCRs included sigmoid (55%), right (34%), left (6%), and transverse (5%) approaches. Overall learning curve proficiency was influenced by increasing operative experience (p = 0.02). However, significant and consistent improvement in the learning curve occurred only after 38 LCRs (p < 0.008). Notably, all conversions to open surgery (3%) occurred during the early learning curve. Similarly, early LCR patients experienced greater morbidity (mean, 21% vs 12%) and mortality (mean, 5% vs 2%) than their later counterparts. To obtain optimum proficiency in performing LCR, a minimum of 38 M-L procedures is required. Operative and patient outcomes improve beyond the early learning curve.