The learning curve associated with laparoscopic total gastrectomy

Although the frequency of laparoscopic total gastrectomy (LTG) has been increasing, the procedure requires considerable experience because of its technical difficulty and the concern for oncological safety. This study intended to define the learning curve associated with the procedure. All 256 cases of LTG performed from June 2003 to December 2012 were enrolled. The cases were divided into ten groups of 25 cases based on when they occurred. The learning curve was defined using the moving average method. LTG, performed in the absence of other procedures (pure-LTG, 132 cases), was extracted from the ten groups, and the mean operative time and estimated blood loss (EBL) were compared to define the learning curve. Retrieved lymph nodes, hospital stay, and complications were compared across the phases of the learning curve. LTG with spleen resection, performed in the absence of other procedures (pure-srLTG, 53 cases), was also analyzed by the same method. A three-phase learning curve of LTG was defined: the first two groups, the following two groups, and the final six groups (mean operative time: 223.0, 244.8, and 207.8 min, respectively, p = 0.003; mean EBL: 94.6, 237.0, and 116.5 ml, respectively, p < 0.001). The rates of complications and open conversions were similar across the three phases. There were no significant differences in mean operative time, EBL, retrieved LNs, hospital stay, or complication rates between pure-LTG and pure-srLTG, after completing the respective learning curves. Experience with approximately 100 LTG cases was required to complete learning of the procedure.