Post fellowship training in "new-to-them" surgical techniques: assessment of learning curve characteristics

To evaluate surgically related quality outcomes during the learning curve for board-certified or board-eligible gynecologic oncologists developing "new-to-them" surgical techniques.

The study design was a retrospective review of patients with endometrial cancer clinically limited to the uterus and/or cervix undergoing TLH-BSO or TAH-BSO, aortic and pelvic lymphadenectomy(APLNDx), peritoneal washings with/without omentectomy from May 1996 to April /2006. A "senior" surgeon taught three board-certified or board-eligible gynecologic oncologists a "new-to-them" technique to perform both TLH-BSO and TAH-BSO with APLNDx using argon beam coagulation and endoscopic staplers in patients with early-stage endometrial cancer. The main outcome measures were: a) length of surgery; b) surgical measures, e.g. lymph node count; and c) peri-operative morbidity. A comparison of outcomes with the "senior" surgeon was undertaken. The learning curve characteristics were analyzed by ANOVA and curve estimate analysis.

The mean operative times associated with learning a new technique to perform TLH-BSO with APLNDx and TAH-BSO with APLNDx were 155.39+/-26.32 and 102.28+/-34.22 min, respectively, with significant improvement after 20 cases (150.27+/-26.68 vs. 172.30+/-22.28, p=0.030) and 30 cases (93.30+/-24.97 vs. 124.63+/-29.73, p=0.030), respectively. Intra- and peri-operative morbidity and lymph node count were unaffected by experience.

While mean operative times decreased, outcome measures of surgical quality were not adversely affected during the learning curve for post-fellowship training while acquiring "new-to-them" surgical techniques. This study emphasizes the need for "senior" surgical supervision during the initial training period. The results of this study are likely transferable to fellowship-trained gynecologic oncologists learning other "new-to-them" surgical techniques and procedures.