Learning and teaching advanced laparoscopic procedures: Do alternating trainees impair a laparoscopic surgeon's learning curve?

Study Objective: In this study we investigated whether teaching advanced laparoscopic procedures like laparoscopic-assisted surgical staging (LASS) for endometrial cancer negatively affects the learning curve of the attending surgeon. Design: Retrospective study (Canadian Task Force classification II-3.). Setting: Department of Obstetrics and Gynecology, University of Arizona, Tucson. Patients: One hundred twenty-four patients undergoing LASS for endometrial cancer at our institution from 1992 through 2004 were included for analysis. Interventions: Cases were classified into 3 groups. Group A comprised the initial learning phase where 2 attending gynecologic oncologists used other faculty as assistants (first 30 cases). Groups B and C comprised procedures after the learning phase involving attendings (n = 27, group B) or obstetrics and gynecology residents (n = 67, group C) as trainees. Groups were compared with respect to general outcome parameters and disease-free survival. Measurements and Main Results: Patients within all groups were comparable with respect to age and height or body mass index. In the subgroup analysis, a decrease in blood loss and length of stay occurred mainly during the group B series. Pelvic lymph node yield reached oncologic standards during the initial learning curve (median 12-13) and remained stable during both teaching phases. Intraoperative and postoperative complications occurred in 2.4% and 13.7% of cases, respectively. Ninety percent of intraoperative and 64% of postoperative complications occurred within the first half of the series and were not correlated with type of assistance. Survival data were obtainable in 65% of cases with a median follow-up of 3.6 years. Disease free-survival was 92.5% in stage I disease and without significant difference among the groups. Conclusion: After gaining proficiency in the procedure, more or less surgically experienced trainees can be actively included without hampering the progress of the attending's learning curve.