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Defining the learning curve in laparoscopic paraesophageal hernia repair: a CUSUM analysis

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Abstract

Introduction

There are numerous reports in the literature documenting high recurrence rates after laparoscopic paraesophageal hernia repair. The purpose of this study was to determine the learning curve for this procedure using the Cumulative Summation (CUSUM) technique.

Methods

Forty-six consecutive patients with paraesophageal hernia were evaluated prospectively after laparoscopic paraesophageal hernia repair. Upper GI series was performed 3 months postoperatively to look for recurrence. Patients were stratified based on the surgeon’s early (first 20 cases) and late experience (>20 cases). The CUSUM method was then used to further analyze the learning curve.

Results

Nine patients (21%) had anatomic recurrence. There was a trend toward a higher recurrence rate during the first 20 cases, although this did not achieve statistical significance (33% vs. 13%, p = 0.10). However, using a CUSUM analysis to plot the learning curve, we found that the recurrence rate diminishes after 18 cases and reaches an acceptable rate after 26 cases.

Conclusions

Surgeon experience is an important predictor of recurrence after laparoscopic paraesophageal hernia repair. CUSUM analysis revealed there is a significant learning curve to become proficient at this procedure, with approximately 20 cases required before a consistent decrease in hernia recurrence rate is observed.

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Acknowledgments

Supported in part by an unrestricted educational grant from Covidien Canada and Steinburg-Bernstein Centre for Minimally Invasive Surgery, McGill University.

Disclosures

Dr. Allan Okrainec, Dr. Lorenzo Ferri, Dr. Liane Feldman, and Dr. Gerald Fried have no conflicts of interest or financial ties to disclose.

Author information

Authors and Affiliations

  1. Division of General Surgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada

    Allan Okrainec

  2. Department of Surgery, University of Toronto, Toronto, ON, Canada

    Allan Okrainec

  3. Steinberg-Bernstein Centre for Minimally Invasive Surgery, Montreal General Hospital, 1650 Cedar Avenue, L9-112, Montreal, QC, H3G 1A4, Canada

    Lorenzo E. Ferri

  4. Steinberg-Bernstein Centre for Minimally Invasive Surgery, Montreal General Hospital, 1650 Cedar Avenue, L9-412, Montreal, QC, H3G 1A4, Canada

    Liane S. Feldman

  5. Steinberg-Bernstein Centre for Minimally Invasive Surgery, Montreal General Hospital, 1650 Cedar Avenue, D6.136, Montreal, QC, H3G 1A4, Canada

    Gerald M. Fried

  6. Department of Surgery, McGill University, Montreal, QC, Canada

    Lorenzo E. Ferri, Liane S. Feldman & Gerald M. Fried

Authors
  1. Allan Okrainec
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  2. Lorenzo E. Ferri
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  3. Liane S. Feldman
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  4. Gerald M. Fried
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Corresponding author

Correspondence to Gerald M. Fried.

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Okrainec, A., Ferri, L.E., Feldman, L.S. et al. Defining the learning curve in laparoscopic paraesophageal hernia repair: a CUSUM analysis. Surg Endosc 25, 1083–1087 (2011). https://doi.org/10.1007/s00464-010-1321-6

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  • DOI: https://doi.org/10.1007/s00464-010-1321-6

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