The learning curve of laparoscopic, robot-assisted and transanal total mesorectal excisions: a systematic review

Thijs A Burghgraef; Daan J Sikkenk; Paul M Verheijen; Mostafa El Moumni; Roel Hompes; Esther C J Consten

doi:10.1007/s00464-022-09087-z

The learning curve of laparoscopic, robot-assisted and transanal total mesorectal excisions: a systematic review

Surg Endosc. 2022 Sep;36(9):6337-6360. doi: 10.1007/s00464-022-09087-z. Epub 2022 Jun 13.

Authors

Thijs A Burghgraef^{1

2}, Daan J Sikkenk³, Paul M Verheijen³, Mostafa El Moumni⁴, Roel Hompes⁵, Esther C J Consten^{3

4}

Affiliations

¹ Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands. ta.burghgraef@umcg.nl.
² Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands. ta.burghgraef@umcg.nl.
³ Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands.
⁴ Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands.
⁵ Department of Surgery, University Medical Center Amsterdam, Location AMC, Amsterdam, the Netherlands.

Abstract

Background: The standard treatment of rectal carcinoma is surgical resection according to the total mesorectal excision principle, either by open, laparoscopic, robot-assisted or transanal technique. No clear consensus exists regarding the length of the learning curve for the minimal invasive techniques. This systematic review aims to provide an overview of the current literature regarding the learning curve of minimal invasive TME.

Methods: A systematic literature search was performed. PubMed, Embase and Cochrane Library were searched for studies with the primary or secondary aim to assess the learning curve of either laparoscopic, robot-assisted or transanal TME for rectal cancer. The primary outcome was length of the learning curve per minimal invasive technique. Descriptive statistics were used to present results and the MINORS tool was used to assess risk of bias.

Results: 45 studies, with 7562 patients, were included in this systematic review. Length of the learning curve based on intraoperative complications, postoperative complications, pathological outcomes, or a composite endpoint using a risk-adjusted CUSUM analysis was 50 procedures for the laparoscopic technique, 32-75 procedures for the robot-assisted technique and 36-54 procedures for the transanal technique. Due to the low quality of studies and a high level of heterogeneity a meta-analysis could not be performed. Heterogeneity was caused by patient-related factors, surgeon-related factors and differences in statistical methods.

Conclusion: Current high-quality literature regarding length of the learning curve of minimal invasive TME techniques is scarce. Available literature suggests equal lengths of the learning curves of laparoscopic, robot-assisted and transanal TME. Well-designed studies, using adequate statistical methods are required to properly assess the learning curve, while taking into account patient-related and surgeon-related factors.

Keywords: Laparoscopy; Learning curve; Robot-assisted; Total mesorectal excision; Transanal.

Publication types

Review
Systematic Review

MeSH terms

Humans
Laparoscopy* / methods
Learning Curve
Postoperative Complications / epidemiology
Postoperative Complications / etiology
Postoperative Complications / surgery
Rectal Neoplasms* / pathology
Rectum / pathology
Rectum / surgery
Robotics*
Transanal Endoscopic Surgery* / methods
Treatment Outcome