Multidimensional assessment of the learning curve of intracorporeal anastomosis during laparoscopic right colectomy

Purpose: After resection during a laparoscopic right colectomy (LRC), reconstruction can be conducted with an intracorporeal (IA) or extracorporeal anastomosis. Although IA benefits are well documented, its implementation has been slow due to a steep learning curve (LC) mainly associated with intracorporeal suturing. The aim of this study is to assess the LC of IA in LRC.

Methods: Consecutive patients undergoing a LRC with IA between January 2016 and June 2023 were included. Clinical, perioperative, and histopathological variables were collected. Correlation and cumulative sum (CUSUM) analyses between the operating time and case number were performed. 'Surgical success' as a composite outcome was also analysed by performing a CUSUM plot. Completion LC case number was determined based on these analyses. Pre-LC and post-LC perioperative outcomes were compared.

Results: Two-hundred-and-ninety patients underwent a LRC during the study period. Sixty-seven met inclusion criteria. Correlation analysis identified a significant operating time reduction with increasing case numbers (p = 0.034). Total complications during implementation period were 25,3%, with 6% of severe complications. Operative time CUSUM analysis identified a consistent downwards trend after case 36 and surgical success CUSUM analysis after case 37. Two phases were established: pre-LC (case 0-37th) and post-LC (38th-67). Pre-LC and post-LC revealed a significant decrease in operative time (187vs177.8 min;p = 0.016), and length of stay (4vs3 days;p < 0.001). No difference between overall complications, severe complication, or reoperation rates were detected.

Conclusion: The LC of laparoscopic IA can be achieved after 37 cases in centres with experience in advanced laparoscopic surgery. Further studies will be required to confirm these results.