Quantitative assessment of the learning curve for cleft lip repair using LC-CUSUM

The first step in cleft lip repair is the precise positioning of anatomical landmarks and tracing of the incisions on the patient's lip at the beginning of the procedure. The aim of this study was to evaluate progress made in learning cleft lip repair tracing using a quantitative assessment of learning curves: LC-CUSUM (learning curve - cumulative sum). Eight surgical residents were enrolled and asked to trace lip repair incisions on five cases of unilateral left cleft lip over 5 consecutive weeks. Results were compared to a reference tracing based on the positioning of nine anatomical landmarks and assessed using LC-CUSUM. Competence was defined as the accurate positioning of the nine landmarks (less than 1.4mm deviation from the reference positions, with an accepted 15% failure rate). After five tracing sessions, competence was not achieved evenly for all trainees, or for all landmarks, underlining differences in inter-individual learning ability even with similar training. However, despite an initial marked lack of theoretical and practical training in lip repair techniques, repeated drawings of cleft lip incisions allowed a satisfactory level of competence to be reached for most landmarks and most trainees. Nevertheless it was found that not all landmarks are understood by students with similar ease, and that landmark positioning reveals significant inter-individual differences. This approach allowed a global assessment of the teaching of cleft repair and will help to focus training on specific problematic points for which competence was not obtained according to the LC-CUSUM test.