The Learning Curve of Robot-Assisted Laparoscopic Surgery

Abstract

Endoscopic surgery has proven to be beneficial to the patient with regard to reduction of hospital stay, postoperative pain and earlier return to daily activities. After its introduction, development of new instrumentation improved and facilitated endoscopic performance Despite this development, laparoscopic procedures have been limited by fixed distances, restricted freedom of motion of the surgical instruments, impaired visualization and small working space With the introduction of surgical robotic systems an attempt was made to overcome these technical difficulties. Many conventional laparoscopic procedures have been duplicated with assistance of a surgical robotic system. Endoscopic cardiac procedures, that were not feasible before applying conventional laparoscopic techniques, are currently performed robotically-assisted. Several advantages of robotic surgery compared to conventional laparoscopy have been identified: additional degrees of freedom of motion, downscaling of movements, enhanced stability (both of visualization and surgical instrumentation), restoration of the eye-hand target axis, elimination of the fulcrum effect and improved ergonomics for the surgeon. These features are supposed to enhance surgical performance by improved accuracy, dexterity and visualization. Consequently, it can be expected that endoscopic surgical skills are more easily mastered and the learning curve is shortened. The learning curve can be defined as the amount of practice (in time or number of repetitions) necessary to achieve a consistency of a specified parameter. A time-action analysis, the time to complete a task, the number of actions required and the number of errors made, are parameters used to evaluate the learning curve for a specific task. In daily practice, other parameters viz. conversion rate, operating time, blood loss, morbidity and hospital stay are used to assess the learning curve for a specific procedure. Most advanced endoscopic procedures are characterized by a long learning curve. Learning curves are associated with prolonged operative times, increased patient morbidity and higher costs. These difficulties might delay further implementation of advanced endoscopic techniques. Although a surgical robotic system might impose as the ideal endoscopic instrument, most clinical studies have not shown benefit with regard to operative time compared to conventional endoscopy. The objective of this study is to systematically review the available literature to evaluate the impact of a surgical robotic system on the learning curve of endoscopic procedures compared to conventional endoscopy.