Learning Curve in Surgery: Possibilities and Limits

Abstract

The learning curve is a graphic representation of the relationship between the experience of a surgeon and one or more performance indicators. The operation time alone is an insufficient indicator to assess the performance of a surgeon. The procedure time has to be set in relation to the complication rate and in laparoscopic surgery to the conversion rate. Techniques to visualize the changes over time are the moving average method for the operation time and the Cusum method for dichotomous outcomes, like the conversion and the complication rates. At the time when the learning curve reaches the plateau phase this representation can be used to assess the quality of a surgeon or a team in one hospital. As far as there is no validated complexity scale for laparoscopic procedures available it is difficult to compare patient populations between different hospitals. Out of this reason the learning curve is no legitimate instrument to rank surgeons or different hospitals.

Excision of vestibular schwannomas – is there a learning curve and how best to demonstrate it?

“…mortality or facial nerve preservation) across sequences of operations. [12][13][14]55 It is important to highlight the previous experiences and difficulties encountered in the demonstration of learning curves in vestibular schwannoma surgery. In 1989, Hardy et al 35 reported their results on a consecutive series of 100 translabyrinthine operations for removal of acoustic neuromas.…”

The Learning Curve of Unilateral Biportal Endoscopic (UBE) Spinal Surgery by CUSUM Analysis

“…According to the formula, the operation time of most cases before the highest point of the parabola is longer than the average operation time, and the operation time of most cases after the highest point is < the average operation time. There is no need for artificial subjective grouping in the study of the CUSUM method, which is more objective and accurate than the grouping method (34)(35)(36). According to the highest point of the CUSUM curve (Figure 3), there were 1-24 cases in the early stage of this study and 25-97 cases in the later stage.…”

The Learning Curve in Foraminal Endoscopic Discectomy: Experience Needed to Achieve a 90% Success Rate

“…The learning curve is steep (see the slope 14 of the learning curve in Figures 1 and 2 ) because of the complexity of the surgical endoscopic technique. Patient selection also improved as the surgeon became more experienced in correlating the interpretation of magnetic resonance imaging with the endoscopic visualized pathoanatomy such as annular tears, foraminal osteophytes, and lateral recess stenosis, which is easy to miss and difficult to approach with traditional transcanal surgery.…”