The learning curve of single-incision pediatric endosurgery

Background Single incision pediatric endosurgery (SIPES) has been established in some pediatric surgery centers for certain operations. A concern in implementing these technically challenging procedures is the associated learning curve. This study describes the learning curve associated with the 3 most common procedures appendectomy, cholecystectomy, and pyloromyotomy. Methods All SIPES appendectomies, cholecystectomies, and pyloromyotomies performed by an academic pediatric surgeon in the first 14 months of performing SIPES were chronologically divided into thirds of equal number, groups A (first), B (middle), and C (last). The learning curve for each operation was assessed by comparing operating times, conversion rates (defined as adding additional trocars) and complication rates among these groups. Results During the study period, 183 appendectomies, 51 cholecystectomies, and 49 pyloromyotomies using SIPES technique were performed. With increasing experience, operating times (mean±standard deviation) decreased significantly for all 3 operations (42±14 to 36±13 minutes for appendectomies, p=0.015; 78±20 to 59±18 for cholecystectomies, p=0.004; 26±7.7 to 20±5.5 minutes for pyloromyotomies, p=0.015). The number of additional trocars placed during appendectomies declined steadily from 21% in group A to 0% in group C (p<0.001). There were more complications during appendectomy in groups A versus B (8% versus 0%, p=0.03), but no other differences in complication rates were found. Conclusion Operating times for all SIPES operations declined throughout the study period. With experience, the need for additional trocars and the complication rate during appendectomy approaches zero. We have shown that it is feasible to safely and effectively transition to the new surgical technique.