Herein, we reported the outcomes of initial 108 patients who underwent LRYGB over a 4-yr period in a low-volume hospital, indicating LC. Comparing the results among the 3 groups; significant improvements in the operation time and LOS with an acceptably low rate of complications was observed after the initial 36 cases (group A). The present study demonstrated that the LC of LRYGB can be safely reduced to 30 + cases in the modern era under a unique setting.
Because of increasingly complex techniques and the dependence on advanced instruments, the acquisition of new laparoscopic skills is considered to be difficult. When conducting LRYGB in morbidly obese patients, there are likely several other inherent technical barriers, such as body habitus, multistep reconstructive procedures that involve multi-abdominal quadrants and laparoscopic suturing and knot tying skills. Therefore, it was once rated as a 9.5 on a difficulty scale of 10, indicating substantial technical difficulty. These skill-related prerequisites can result in adverse consequences in the early phase of practice, especially in a low-volume practice . Traditionally, various educational programs, such as workshops, bariatric fellowships and systematic training programs, have been available to facilitate this process. In recent years, new-era platforms have emerged, providing another kind of auxiliary training approach. Their popularity among medical professionals has been increasing, as they generally enable more visual and auditory interactions than journals or text books . A systematic review for the impact of e-learning demonstrates significant gains in knowledge compared with traditional teaching patterns . In our self-learning process, apart from traditional learning methods, these online multimedia materials provide considerable references and guidance despite the lack of objective tools for gauging their impact.
Considering a single surgeon’s perspective, we retrieved comparative data in the literature discussing the relevant process by a single surgeon (Table 3). Among them, variability in surgical techniques exists. Moreover, several modifications of traditional methods have occurred, such as retro-colic placement of the Roux limb [12, 13] or a circular-stapled anastomosis [12, 14, 15] had largely been fall out of favor. Meanwhile, there are differences among studies in terms of backgrounds, annual hospital volumes or former laparoscopic/bariatric experience levels. Though with undisputable importance and heightened awareness for proper fellowship training , there is no standard approach of teaching provided and accredited bariatric programs are not globally available. For example, while carried out during different periods, some hospitals conduct other laparoscopic bariatric procedures [27, 28] or perform open bariatric surgeries beforehand , others just started after complete with fellowship training [14, 16] or are based solely on advanced laparoscopic skills [12, 15, 29]. Additionally, there were with considerably different case selection criteria. In general, fellowship trained bariatric surgeons or those conduct after preceding bariatric experience appears to have a shorter LC and implement a more efficient practice. For instance, after completing a month-long mini-fellowship, Shen et al. achieved a considerably decreased complication rate and proficiency after only 30 cases . In particular, they utilized the case selection criteria following IFSO Asian-Pacific guidelines, similar to our research . However, they reported an initial complication rate of 26.7%, which included a 6.7% conversion, 10% reoperation and 5% leakage rate. While surgeons at high-volume hospitals often have the opportunity to master the procedure in a short period of time with preferable results , Shin et al. participated as assistants in 30 surgeries and conducted the first few surgeries under proctoring. They analyzed their first one hundred cases within 5 months and concluded that the LC plateaued after 50 surgeries . While they realize with marked decreasing operation times (113 min pre-LC and 73 min post-LC), they indicated that there was no further notable reduction in complications after the LC. With particularly vast prior experience in LAP BAND ®, Ballesta-Lopez et al. also published a large series with marked decreased operative time and LOS after the first 100 surgeries. Particularly, as one of only two studies, in addition to that by Andrew et al. , which were conducted with totally hand-sewn gastrojejunostomy, they reported a no negligible leakage rate of up to 9%, a 5.1% reoperation rate (mostly for leakage) and a 29.2% complication rate. In other studies with only prior advanced laparoscopic experience [12, 15, 29], the LC took slightly longer, and there was a substantially prolonged operation time compared with studies involving surgeons who completed a fellowship [14, 16, 27]. For instance, Oliak et al. reported a series with the highest mean BMI of 51 kg/m2 and proposed that the LC plateaued after 75 surgeries. Surgeons’ operative times decreased substantially from 189 min during the first 75 cases and then decreased gradually. Notably, the perioperative complication rates were substantial among all studies both before (32%) and after LC (15%). Nguyen et al. evaluated 150 consecutive cases, with the longest mean operation time of 250 min before LC; they too observed that an initial lack of experience (< 75 cases) was a major factor associated with major complications and an increased reoperation rate . On the other hand, with advanced laparoscopic skills and preemptive bariatric experience; Agrawal et al. suggest that LRYGB can be performed safely with minimal complications of only 1.4% and effectively without any LC required. It is noticeable that our initial result stabilized after just 36 surgeries and we had a low initial 30-day complication rate of 2.8%. Only the difference is their research was after completion of fellowship training. However, concordant with these forenamed studies, a sharp improvement in terms of operation time was observed in current study after LC. As findings of Shin et al., we observed no further decrease in the complication rate after LC. Only one patient presented with stenosis, and two other patients presented with hemorrhagic complications: one with hematemesis and one with melena. Considering the reported stenosis rate between 2.2% and 10% [12, 14, 16, 29] and the hemorrhagic complication rate ranges from 1–3.3% during the learning process [14, 15, 29], we deemed our initial results to be acceptable. Furthermore, there was no mortality, leakage, conversion or other major complications. While prolonged hospital stay is not uncommon after such a procedure. Nguyen et al. noted that 11% of their cases had LOS over 4 days , and the LOS is reported to range between 6 to 6.4 days before the LC and 4.8 to 5 days after the LC[16, 29]. We observed a notably shorter LOS, with a mean of 2.9 days before the LC and 2.2 days thereafter. In addition, only 2.8% of our patients required hospitalization for more than 3 days. Our LC and timespan to reach competency are in line with findings from a systemic review that reported between 30–70 surgeries . It is worth mention that the consistent outcome obtained in group B and group C can be considered an early achievement of proficiency because we reached this goal within less than 70 accumulative surgeries, while historically, it usually takes between 70–150 surgeries.
There are likely many factors contributing to our early desirable results. First, in contrast to most studies with an unselective patient approach [13–15, 28, 29], patients with a BMI > 50 were preferably offered alternative treatment modalities considering safety and long-term effectiveness [18, 32]. As a result of this selective approach, the mean BMI of 36.1 kg/m2 in our series was significantly lower than former studies, which ranged from 43 to 51 kg/m2 [12, 29]. Second, as guidelines regarding tailored per-operative care were established in 2016 , a pragmatic enhanced recovery protocol was gradually adopted in our unit ever since. Furthermore, our preceding experience in OAGB-MGB may transferred to subsequent LRYGB and increase its safety . Likewise, comprehensive care and improved techniques have been demonstrated in other studies across different periods . Because only two aforementioned studies included cases after 2010[16, 27], we believe that general improvements further contribute to this desirable result.