Aim : Laparoscopy-assisted distal gastrectomy (LADG) with regional lymph node dissection is a treatment option for patient with early gastric cancer. However, LADG is a technically complex and advanced procedure, which is chal lenging for inexperienced surgeons. In this report, we retrospectively evaluated the learning curve for LADG of a single surgeon with no previous experience in LADG and the usefulness of direct instruction by a surgeon experienced in LADG in shortening the learning curve. Patients and Methods : This study was analyzed 80 consecutive patients, who underwent LADG by a single surgeon (first assistant in 10 cases and operator in 70 cases) between January 2008 and December 2012. Patients were divided into 3 sequential groups of 10 (training period), 30 (learning period), and 40 (operating period) cases in each group. Median operation time and estimated blood loss for these 3 groups were deter mined. Other learning indicators, including transfusion requirement, postoperative complications, number of lymph node harvested, and rate of conversion open gastrectomy, were also evaluated. Results : During the training period, me dian operation time and estimated blood loss were 219.5 min and 83.0 ml, respectively. During the learning period, the operation time was significantly longer than that of training period. In the operating period, the operation time was sig nificantly lesser than that during the learning period. However, the operation time was not different from that during the training period and reached a plateau. The estimated blood loss during the operating period was significantly lesser than that during the learning period. The difference in the number of lymph nodes retrieved between each group was not significant. Conclusions : Direct instructions by an experienced surgeon can decrease the number of cases required for learning. Because LADG is technically more complex than other laparoscopic procedures, standardization of LADG and an effective training system for performing it should be established.
KeywordsLaparoscopic-Assisted Distal GastrectomyLearningTraining System
M. Sasako, M. Saka, T. Fukagawa, H. Katai and T. Sano, “Surgical Treatment of Advanced Gastric Cancer: Japanese Perspective,” Digestive Surgery, Vol. 24, No. 2, 2007, pp. 101-107. doi:10.1159/000101896
M. Sasako, “Gastric Cancer Eastern Experience,” Surgical Oncology Clinics of North America, Vol. 21, No. 1, 2012, pp. 71-77. doi:10.1016/j.soc.2011.09.013
S. Kitano, K. Shimoda, M. Miyahara, N. Shiraishi, T. Bandoh, T. Yoshida, K. Shuto and M. Kobayashi, “Laparoscopic Approaches in the Management of Patients with Early Gastric Carcinomas,” Surgical Laparoscopy Endoscopy & Percutaneous Techniques, Vol. 5, No. 5, 1995, pp. 359-362.
H. Katai, M. Sasako, H. Fukuda, K. Nakamura, N. Hiki, M. Saka, H. Yamaue, T. Yoshikawa and K. Kojima, “Safety and Feasibility of Laparoscopy-Assisted Distal Gastrectomy with Suprapancreatic Nodal Dissection for Clinical Stage I Gastric Cancer: A Multicenter Phase II Trial (JCOG 0703),” Gastric Cancer, Vol. 13, No. 4, 2010, pp. 238-244. doi:10.1007/s10120-010-0565-0
K. Nakamura, H. Katai, J. Mizusawa, T. Yoshikawa, M. Ando, M. Terashima, S. Ito, M. Takagi, A. Takagane, M. Ninomiya, N. Fukushima and M. Sasako, “A Phase III Study of Laparoscopy-Assisted versus Open Distal Gastrectomy with Nodal Dissection for Clinical Stage IA/IB Gastric Cancer (JCOG0912),” Japanese Journal of Clinical Oncology, Vol. 43, No. 3, 2013, pp. 324-327. doi:10.1093/jjco/hys220
S. Tanimura, M. Higashino, Y. Fukunaga, M. Takemura, Y. Tanaka, Y. Fujiwara and H. Osugi, “Laparoscopic Gastrectomy for Gastric Cancer: Experience with More than 600 Cases,” Surgical Endoscopy, Vol. 22, No. 5, 2008, pp. 1161-1164. doi:10.1007/s00464-008-9786-2
K. Koeda, S. Nishizuka and G. Wakabayashi, “Minimally Invasive Surgery for Gastric Cancer: The Future Standard of Care,” World Journal of Surgery, Vol. 35, No. 7, 2011, pp. 1469-1477. doi:10.1007/s00268-011-1051-5
H. H. Kim, S. U. Han, M. C. Kim, W. J. Hyung, W. Kim, H. J. Lee, S. W. Ryu, G. S. Cho, C. Y. Kim, H. K. Yang, J. do Park, K. Y. Song, S. I. Lee, S. Y. Ryu and J. H. Lee, “Prospective Randomized Controlled Trial (Phase III) to Comparing Laparoscopic Distal Gastrectomy with Open Distal Gastrectomy for Gastric Adenocarcinoma (KLASS 01),” Journal of the Korean Surgical Society, Vol. 84, No. 2, 2013, pp. 123-130. doi:10.4174/jkss.2013.84.2.123
S. Tanimura, M. Higashino, Y. Fukunaga, S. Kishida, A. Ogata, Y. Fujiwara and H. Osugi, “Respiratory Function after Laparoscopic Distal Gastrectomy—An Index of Minimally Invasive Surgery,” World Journal of Surgery, Vol. 30, No. 7, 2006, pp. 1211-1215. doi:10.1007/s00268-005-0115-9
Y. K. Zeng, Z. L. Yang, J. S. Peng, H. S. Lin and L. Cai, “Laparoscopy-Assisted versus Open Distal Gastrectomy for Early Gastric Cancer: Evidence from Randomized and Nonrandomized Clinical Trials,” Annals of Surgery, Vol. 256, No. 1, 2012, pp. 39-52. doi:10.1097/SLA.0b013e3182583e2e
Y. W. Kim, Y. H. Baik, Y. H. Yun, B. H. Nam, D. H. Kim, I. J. Choi and J. M. Bae, “Improved Quality of Life Outcomes after Laparoscopy-Assisted Distal Gastrectomy for Early Gastric Cancer: Results of a Prospective Randomized Clinical Trial,” Annals of Surgery, Vol. 248, No. 5, 2008, pp. 721-727. doi:10.1097/SLA.0b013e318185e62e
S. Kitano, N. Shiraishi, I. Uyama, K. Sugihara and N. Tanigawa, “A Multicenter Study on Oncologic Outcome of Laparoscopic Gastrectomy for Early Cancer in Japan,” Annals of Surgery, Vol. 245, No. 1, 2007, pp. 68-72. doi:10.1097/01.sla.0000225364.03133.f8
S. W. Lee, E. Nomura, G. Bouras, T. Tokuhara, S. Tsunemi and N. Tanigawa, “Long-Term Oncologic Outcomes from Laparoscopic Gastrec-tomy for Gastric Cancer: A Single-Center Experience of 601 Consecutive Resections,” Journal of the American College of Surgeons, Vol. 211, No. 1, 2010, pp. 33-40. doi:10.1016/j.jamcollsurg.2010.03.018
S. Y. Kang, S. Y. Lee, C. Y. Kim and D. H. Yang, “Comparison of Learning Curves and Clinical Outcomes between Laparoscopy-Assisted Distal Gastrectomy and Open Distal Gastrectomy,” Gastric Cancer, Vol. 10, No. 4, 2010, pp. 247-253. doi:10.5230/jgc.2010.10.4.247
M. C. Kim, G. J. Jung and H. H. Kim, “Learning Curve of Laparoscopy-Assisted Distal Gastrectomy with Systemic Lymphadenectomy for Early Gastric Cancer,” World Journal of Gastroenterology, Vol. 11, No. 47, 2005, pp. 7508-7511.
C. Kunisaki, H. Makino, N. Yamamoto, T. Sato, T. Oshima, Y. Nagano, S. Fujii, H. Akiyama, Y. Otsuka, H. A. Ono, T. Kosaka, R. Takagawa and H. Shimada, “Learning Curve for Laparoscopy-Assisted Distal Gastrectomy with Regional Lymph Node Dissection for Early Gastric Cancer,” Surgical Laparoscopy Endoscopy & Percutaneous Techniques, Vol. 18, No. 3, 2008, pp. 236241. doi:10.1097/SLE.0b013e31816aa13f
X. Zhang and N. Tanigawa, “Learning Curve of Laparoscopic Surgery for Gastric Cancer, a Laparoscopic Distal Gastrectomy-Based Analysis,” Surgical Endoscopy, Vol. 23, No. 6, 2009, pp. 1259-1264. doi:10.1007/s00464-008-0142-3
M. Tokunaga, N. Hiki, T. Fukunaga, A. Miki, S. Ohyama, S. Miyata and T. Yamaguchi, “Learning Curve of Laparoscopy-Assisted Gastrectomy Using a Standardized Surgical Technique and an Established Educational System,” Scandinavian Journal of Surgery, Vol. 100, No. 2, 2011, pp. 86-91.
Japanese Gastric Cancer Association, “Japanese Classification of Gastric Carcinoma: 3rd English Edition,” Gastric Cancer, Vol. 14, No. 2, 2011, pp. 101-112. doi:10.1007/s10120-011-0041-5
P. A. Clavien, J. Barkun, M. L. de Oliveira, J. N. Vauthey, D. Dindo, R. D. Schulick, E. de Santibañes, J. Pekolj, K. Slankamenac, C. Bassi, R. Graf, R. Vonlanthen, R. Padbury, J. L. Cameron and M. Makuuchi, “The ClavienDindo Classification of Surgical Complications: FiveYear Experience,” Annals of Surgery, Vol. 250, No. 2, 2009, pp. 187-196. doi:10.1097/SLA.0b013e3181b13ca2
Y. Ezoe, M. Muto, N. Uedo, H. Doyama, K. Yao, I. Oda, K. Kaneko, Y. Kawahara, C. Yokoi, Y. Sugiura, H. Ishikawa, Y. Takeuchi, Y. Kaneko and Y. Saito, “Magnifying Narrowband Imaging Is More Accurate Than Conventional White-Light Imaging in Diagnosis of Gastric Mucosal Cancer,” Gastroenterology, Vol. 141, No. 6, 2011, pp. 2017-2025. doi:10.1053/j.gastro.2011.08.007
Y. Tsuji, K. Ohata, M. Sekiguchi, A. Ohno, T. Ito, H. Chiba, T. Gunji, J. Fukushima, N. Yamamichi, M. Fujishiro, N. Matsuhashi and K. Koike, “Magnifying Endoscopy with Narrow-Band Imaging Helps Determine the Management of Gastric Adenomas,” Gastric Cancer, Vol. 15, No. 4, 2012, pp. 414-418. doi:10.1007/s10120-011-0133-2
E. Otsuji, A. Toma, S. Kobayashi, H. Cho, K. Okamoto, A. Hagiwara and H. Yama-gishi, “Long-Term Benefit of Extended Lymphadenectomy with Gastrectomy in Distally Located Early Gastric Carcinoma,” The American Journal of Surgery, Vol. 180, No. 2, 2000, pp. 127-132. doi:10.1016/S0002-9610(00)00436-0
S. Nunobe, N. Hiki, S. Tanimura, K. Nohara, T. Sano and T. Yamaguchi, “The Clinical Safety of Performing Laparoscopic Gastrectomy for Gastric Cancer by Trainees after Sufficient Experience in As-sisting,” World Journal of Surgery, Vol. 37, No. 2, 2013, pp. 424-429. doi:10.1007/s00268-012-1827-2
M. Tokunaga, N. Hiki, T. Fukunaga, A. Miki, S. Ohyama, S. Miyata and T. Yamaguchi, “Learning Curve of Laparoscopy-Assisted Gastrectomy Using a Standardized Surgical Technique and an Established Educational System,” Scandinavian Journal of Surgery, Vol. 100, No. 2, 2011, pp. 86-91.
S. J. Yang, E. J. Ahn, S. H. Park, J. H. Kim and J. M. Park, “The Early Experience of Laparoscopy-Assisted Gastrectomy for Gastric Cancer at a Low-Volume Center,” Gastric Cancer, Vol. 10, No. 4, 2010, pp. 241-246. doi:10.5230/jgc.2010.10.4.241