Totally Laparoscopic Distal Gastrectomy after Learning Curve Completion: Comparison with Laparoscopy - Assisted Distal Gastrectomy

Purpose: The aims are to: (i) display the multidimensional learning curve of totally laparoscopic distal gastrectomy, and (ii) verify the feasibility of totally laparoscopic distal gastrectomy after learning curve completion by comparing it with laparoscopy-assisted distal gastrectomy. Materials and Methods: From January 2005 to June 2012, 247 patients who underwent laparoscopy-assisted distal gastrectomy (n= 136) and totally laparoscopic distal gastrectomy (n= 111) for early gastric cancer were enrolled. Their clinicopathological characteristics and early surgical outcomes were analyzed. Analysis of the totally laparoscopic distal gastrectomy learning curve was conducted using the moving average method and the cumulative sum method on 180 patients who underwent totally laparoscopic distal gastrectomy. Results: Our study indicated that experience with 40 and 20 totally laparoscopic distal gastrectomy cases, is required in order to achieve optimum proficiency by two surgeons. There were no remarkable differences in the clinicopathological characteristics between laparoscopy- assisted distal gastrectomy and totally laparoscopic distal gastrectomy groups. The two groups were comparable in terms of open conversion, combined resection, morbidities, reoperation rate, hospital stay and time to first flatus (P> 0.05). However, totally laparoscopic distal gastrectomy had a significantly shorter mean operation time than laparoscopy-assisted distal gastrectomy (P< 0.01). We also found that intra-abdominal abscess and overall complication rates were significantly higher before the learning curve than after the learning curve (P< 0.05). Conclusions: Experience with 20 similar to 40 cases of totally laparoscopic distal gastrectomy is required to complete the learning curve. The use of totally laparoscopic distal gastrectomy after learning curve completion is a feasible and timesaving method compared to laparoscopyassisted distal gastrectomy.