Multicentre study evaluating the surgical learning curve for posterior retroperitoneoscopic adrenalectomy

Vrielink, Otis M.; Engelsman, Anton F.; Hemmer, Patrick H. J.; Vries, Julius de; Vorselaars, Wessel M. C. M.; Vriens, M. R.; Karakatsanis, Andreas; Hellman, Per; Sywak, Mark; Leeuwen, Barbara L. van; Moumni, Mostafa El; Kruijff, Schelto

doi:10.1002/bjs.10740

Cited by 30 publications

(21 citation statements)

References 27 publications

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“…Several minimally invasive laparoscopic approaches have been described for adrenalectomies, including transperitoneal, lateral retroperitoneal, and posterior retroperitoneal approaches [15]. In our center, the first laparoscopic procedure was performed in 1995 with the use of the lateral transabdominal approach, which in turn formed the basis of education and training.…”

Section: Discussionmentioning

confidence: 99%

“…Being a high-volume center for laparoscopic operations played a contributory role in improving the technique, as well. Vrielink et al emphasized the importance of the volume of procedures performed in a surgical unit and pointed out the difficulty in achieving competency in the setting of an annual case-volume insufficient to complete the learning curve [15]. Approximately 20–40 procedures are required to reach the learning curve in order to gain sufficient experience and proficiency [16–18].…”

Section: Discussionmentioning

confidence: 99%

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Experience of an endocrine surgeon in laparoscopic transperitoneal adrenalectomy

2019

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Background Laparoscopic adrenalectomy (LA) is currently recognized as the gold standard for the treatment of most adrenal lesions, with a high safety and feasibility profile. This study aimed to present the extensive experience of a specialized endocrine surgeon in LA in a relatively large series of patients. Methods A total of 116 LAs performed from June 2009 to 2018 were evaluated in terms of adrenal pathologies, perioperative management, complications, conversions, tumor size, operative time, and learning curve. The learning curve was assessed using the cumulative sum (CUSUMOT) technique. Results Of 116 LAs, 107 (92.2%) were completed successfully, 77 (72%) of which were for Cushing’s syndrome (n = 43, 55.8%), pheochromocytoma (n = 26, 33.8%), and Conn’s syndrome (n = 8, 10.4%). Conversion was required in 9 cases (7.8%), the most common cause being limited space complicating dissection (n = 3). The mean operative time for successful LAs (unilateral 85, bilateral 22) was 74.7 min (range 40–210 min) and the mean hospital stay was 1.7 days (range 1–5 days). Gender, tumor size and body mass index were found to have no significant relationship with the operative time (p > 0.05). Postoperative normalization in hormone profiles was obtained in all patients but one. Aside from grade-I port-site infections in four patients (3.7%), no postoperative major complications and 30-day mortality were observed. On the CUSUMOT graph, the learning period covered the first 34 operations. Conclusions Laparoscopic adrenalectomy is safe and advantageous, but requires a dedicated team involving experienced endocrine surgeons who have achieved competency after completion of the learning curve.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Experience of an endocrine surgeon in laparoscopic transperitoneal adrenalectomy

2019

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“…All centres have access to diagnostic, biochemical and imaging facilities relevant to adrenal diseases and routinely carried out minimally invasive adrenal surgery, with particular expertise in retroperitoneoscopy. Surgical experience in retroperitoneoscopy of the attending surgeons who performed PRA was investigated and used in the propensity matching; 42 procedures being required to fulfil the training requirements to perform this surgery [16].We classified surgeons into two groups (< 42 vs. ≥ 42 procedures performed) at the beginning of observation period or when they were included in the centre's team. There is now robust evidence showing that, with expertise in abdominal surgery and more than 500 minimally invasive surgery (MIS) procedures done, only the experience in PRA can be relevant for the specific outcome investigated in our series [16,17].…”

Section: Study Design and Settingmentioning

confidence: 99%

“…Surgical experience in retroperitoneoscopy of the attending surgeons who performed PRA was investigated and used in the propensity matching; 42 procedures being required to fulfil the training requirements to perform this surgery [16].We classified surgeons into two groups (< 42 vs. ≥ 42 procedures performed) at the beginning of observation period or when they were included in the centre's team. There is now robust evidence showing that, with expertise in abdominal surgery and more than 500 minimally invasive surgery (MIS) procedures done, only the experience in PRA can be relevant for the specific outcome investigated in our series [16,17]. Therefore, as all participating surgeons have performed more than 500 MIS procedures and had an experience of at least 10 years in abdominal surgery, we divided them according to the number of PRAs performed (< 42 vs. ≥ 42 procedures) and matched only in this respect.…”

Section: Study Design and Settingmentioning

confidence: 99%

Insufflation pressure above 25 mm Hg confers no additional benefit over lower pressure insufflation during posterior retroperitoneoscopic adrenalectomy: a retrospective multi-centre propensity score-matched analysis

et al. 2020

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Background Insufflation pressures of or in excess of 25 mm Hg CO 2 are routinely used during posterior retroperitoneoscopic adrenalectomy (PRA) in most centres. A critical analysis of the surgical literature provides limited evidence to support this strategy. Objective To determine whether high pressure (≥ 25 mm Hg) compared with lower pressure (< 25 mm Hg) retroperitoneoscopy reduces operating time and complications. Methods A multi-centre retrospective cohort study was performed using data collected over a period of almost one decade (1st November 2008 until 1st February 2018) from surgical centres in Germany. A total of 1032 patients with benign adrenal tumours were identified. We compared patients undergoing PRA with insufflation pressures of < 25 mm Hg (G20 group) versus ≥ 25 mm Hg (G25 group). A propensity score matching analysis was performed using BMI, tumour size and surgeon's experience as independent variables. The main outcomes were (1) the incidence of perioperative complications and (2) the length of operating time. Results The baseline patient characteristics were similar in both groups, with the exception of tumour size, BMI and surgeon's experience in PRA. After propensity score matching, perioperative outcomes, especially perioperative complications (3.7% vs. 5.5% in G20 and G25, respectively; p = 0.335) and operation duration (47 min vs. 45 min in G20 and G25, respectively; p = 0.673), did not significantly differ between the groups. Conclusion Neither patient safety nor operative success was compromised when PRA was performed with insufflation pressures below 25 mm Hg. Prospective studies are required to determine whether an optimal insufflation pressure exists that maximizes patient safety and minimizes the risks of post-surgical complications. Nevertheless, our results call for a careful re-evaluation of the routine use of high insufflation pressures during PRA. In the absence of prospective data, commencing PRA with lower insufflation pressures, with the option of increasing insufflation pressures to counter intraoperative bleeding or exposition difficulties, may represent a reasonable strategy. Keywords Adrenalectomy • Retroperitoneal space • Minimally invasive surgical procedures • Surgery Abbreviations PRA Posterior retroperitoneoscopic adrenalectomy mm Hg Used for mm Hg CO 2 IQR InterQuartile range SD Standard deviation ASA American Society of Anaesthesiologists PaCO2 Partial pressure of carbon dioxide in the arterial blood Minimally invasive surgery is considered to be the gold standard for the surgical removal of benign functioning and non-functioning adrenal tumours [1-3]. Since its first description [4], minimally invasive adrenal surgery has

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“…The learning curve is not easy to define based on a set number as local and personal/individual factors might induce significant variability. For example, in a report from four surgical teams from university centers in three different countries who analyzed their first 181 consecutive posterior retroperitoneoscopic adrenalectomies, competency was achieved after a range of 24-42 procedures [36].…”

Section: Impact Of Involving Trainees In Adrenal Surgerymentioning

confidence: 99%

Training in endocrine surgery

Gimm

Barczyński

Mihai

et al. 2019

Langenbecks Arch Surg

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Background/purpose In Europe, the Division of Endocrine Surgery (DES) determines the number of operations (thyroid, neck dissection, parathyroids, adrenals, neuroendocrine tumors of the gastro-entero-pancreatic tract (GEP-NETs)) to be required for the European Board of Surgery Qualification in (neck) endocrine surgery. However, it is the national surgical boards that determine how surgical training is delivered in their respective countries. There is a lack of knowledge on the current situation concerning the training of surgical residents and fellows with regard to (neck) endocrine surgery in Europe. Methods A survey was sent out to all 28 current national delegates of the DES. One questionnaire was addressing the training of surgical residents while the other was addressing the training of fellows in endocrine surgery. Particular focus was put on the numbers of operations considered appropriate. Results For most of the operations, the overall number as defined by national surgical boards matched quite well the views of the national delegates even though differences exist between countries. In addition, the current numbers required for the EBSQ exam are well within this range for thyroid and parathyroid procedures but below for neck dissections as well as operations on the adrenals and GEP-NETs.Conclusions Training in endocrine surgery should be performed in units that perform a minimum of 100 thyroid, 50 parathyroid, 15 adrenal, and/or 10 GEP-NET operations yearly. Fellows should be expected to have been the performing surgeon of a minimum of 50 thyroid operations, 10 (central or lateral) lymph node dissections, 15 parathyroid, 5 adrenal, and 5 GEP-NET operations.

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Multicentre study evaluating the surgical learning curve for posterior retroperitoneoscopic adrenalectomy

Abstract: In specialized endocrine surgical centres between 24 and 42 procedures are required to fulfil the entire surgical learning curve for the posterior retroperitoneoscopic adrenalectomy.

Cited by 30 publications

References 27 publications

Experience of an endocrine surgeon in laparoscopic transperitoneal adrenalectomy

Experience of an endocrine surgeon in laparoscopic transperitoneal adrenalectomy

Insufflation pressure above 25 mm Hg confers no additional benefit over lower pressure insufflation during posterior retroperitoneoscopic adrenalectomy: a retrospective multi-centre propensity score-matched analysis

Training in endocrine surgery

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