BackgroundRobotic-assisted laparoscopic surgery (RALS) is evolving as an important surgical approach in the field of colorectal surgery. We aimed to evaluate the learning curve for RALS procedures involving resections of the rectum and rectosigmoid.MethodsA series of 50 consecutive RALS procedures were performed between August 2008 and September 2009. Data were entered into a retrospective database and later abstracted for analysis. The surgical procedures included abdominoperineal resection (APR), anterior rectosigmoidectomy (AR), low anterior resection (LAR), and rectopexy (RP). Demographic data and intraoperative parameters including docking time (DT), surgeon console time (SCT), and total operative time (OT) were analyzed. The learning curve was evaluated using the cumulative sum (CUSUM) method.ResultsThe procedures performed for 50 patients (54% male) included 25 AR (50%), 15 LAR (30%), 6 APR (12%), and 4 RP (8%). The mean age of the patients was 54.4 years, the mean BMI was 27.8 kg/m2, and the median American Society of Anesthesiologists (ASA) classification was 2. The series had a mean DT of 14 min, a mean SCT of 115.1 min, and a mean OT of 246.1 min. The DT and SCT accounted for 6.3% and 46.8% of the OT, respectively. The SCT learning curve was analyzed. The CUSUMSCT learning curve was best modeled as a parabola, with equation CUSUMSCT in minutes equal to 0.73 × case number2 − 31.54 × case number − 107.72 (R = 0.93). The learning curve consisted of three unique phases: phase 1 (the initial 15 cases), phase 2 (the middle 10 cases), and phase 3 (the subsequent cases). Phase 1 represented the initial learning curve, which spanned 15 cases. The phase 2 plateau represented increased competence with the robotic technology. Phase 3 was achieved after 25 cases and represented the mastery phase in which more challenging cases were managed.ConclusionsThe three phases identified with CUSUM analysis of surgeon console time represented characteristic stages of the learning curve for robotic colorectal procedures. The data suggest that the learning phase was achieved after 15 to 25 cases.

Most diverticular bleeding in the elderly is well tolerated using nonoperative management. Success and safety of treatment does not seem to depend on a history of previous diverticular bleeding, initial hemoglobin, or amount of blood transfused. The majority of patients are treated nonoperatively. Surgical intervention seems to be well tolerated.

Single-incision laparoscopic colectomy is a safe and feasible procedure for benign and malignant diseases of the colon. This modality can be successfully applied for various colorectal procedures without conversion to open surgery, resulting in a short length of hospital stay and a minimal short-term complication rate.

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Discussion | The VA uses the O to E ratio method, which estimates performance by using group-level data that produces an O to E ratio that almost always has a value greater than 0. When comparing patient-level outcomes, the ability to adjust for risk using the O to E ratio is limited for patients for whom no complications occurred, and the curve is more dependent on the number of events in a short time span, rather than being dependent on each patient's outcome related to presurgical risk.The visual presentation of the risk-adjusted cumulative summation chart (O − E) allows for an examination of the process in control events, in better-than-expected performance, and in out-of-control events. The use of real-time cumulative summation (O − E) complements the existing O to E ratio method to provide an informative, real-time visual representation of ongoing surgical performance. It may provide a more intuitive presentation of the process of care to health care providers and administrators.