What is the learning curve for single-port access laparoscopic-assisted vaginal hysterectomy?

Single-port access (SPA) surgery is a rapidly advancing technique in laparoscopic surgery. Currently, there is limited evidence on the learning curve and complications of performing SPA laparoscopic-assisted vaginal hysterectomies (LAVHs).

One hundred patients who initially planned to undergo a SPA-LAVH for benign indications between May 2008 and October 2009 were enrolled. All operative data were prospectively collected. Patients were arranged in order based on the date of surgery and the outcomes were compared between quartiles (cases 1-25, 26-50, 51-75, and 76-100). Proficiency was defined as the point at which the slope of the curve becomes less steep for operative time. Plateau was defined as the point at which the slope is zero. A comparison of the data on a quartile was performed. Locally weighted regression generated smoothed lines that represent operative time over the sequence of the operations.

Most SPA-LAVHs were successful, but additional ports were needed in 5 patients because of pelvic adhesions (n=3) and large uterine size (n=2). There were 3 cases with post-operative complications (hemorrhage, 1; vesicovaginal fistula, 1; and cuff abscess, 1), who were managed without sequelae. Without increased operative morbidities, the operative time decreased from a median of 133.0 min (interquartile range, 107.5-162.5 min) in the first quartile to a median of 100.0 min (interquartile range, 85.0-117.5 min) for the last quartile (p=0.011). The proficiency and plateau were determined after approximately 25 and 75 cases, respectively.

The SPA-LAVH was safe, effective, and reproducible after training, and with the current technique, had a low rate of complications.