Robotic hiatus hernia surgery: learning curve and lessons learned

Vol.:(0123456789)
Jou nal o Robo ic Su ge y (2025) 19:51
h ps://doi.o g/10.1007/s11701-024-02191-3
RESEARCH
Robo ic hia us he nia su ge y: lea ning cu e andlessons lea ned
ElisendaGa so 1,2 · Geo ginaCompany‑Se3· A an xaCla ell1· Ma aViciano1· Ch is ianHe e o1·
LexaNescola de3
Recei ed: 28 Sep embe 2024 / Accep ed: 5 Decembe 2024
© The Au ho (s) 2024
Abs ac
New p ocedu es like he obo ic app oach equi e p o iciency o ensu e pa ien sa e y and sa is ac o y unc ional esul s.
Hia al he nia su ge y se es as a sui able aining p ocedu e o uppe gas oin es inal ac su geons ansi ioning o he
obo ic app oach. This s udy aims o e alua e he ou comes o implemen ing he obo ic app oach in hia al he nia su ge y a a
e ia y hospi al and o assess he associa ed lea ning cu e. A e ospec i e e iew was conduc ed on 54 pa ien s (58 su ge -
ies) be ween June 2019 and Ma ch 2024, including bo h p ima y and e ision obo ic an i e lux su ge ies. The s udy ocused
on pe iope a i e ou comes, symp om esolu ion, and he su gical lea ning cu e, assessed using Cumula i e Sum analysis.
The esul s showed ha global su gical ime a e aged 124 ± 57 (54–350)min, 127 ± 38 (116–139) o P ima y Su ge y and
164 ± 84 (115–212)min o Re isional Su ge y. The e we e no con e sions o lapa oscopic o open app oach. The global
median o hospi al s ay was 2days (2 o P ima y Su ge y and 3 o Re isional Su ge y) and h ee pa ien s equi ed eadmis-
sion (2 o P ima y Su ge y and 1 o Re isional Su ge y). Pos ope a i e complica ions occu ed in 3 pa ien s. Symp om
esolu ion was achie ed in 90% o P ima y Su ge y g oup and 85.7% o Re isional Su ge y g oup. Lea ning cu e desc ibed
h ee phases: 1- aining (case 1 o 14), 2-pla eau (15 o 25) and 3-expe ise phase (25 onwa ds). The obo ic app oach in
hia al he nia su ge y is easible wi h minimal mo bidi y, sho hospi al s ays, and excellen unc ional esul s. Wi h p e i-
ous expe ience in lapa oscopic app oach and esophagogas ic su ge y he lea ning cu e can be educed o 14 p ocedu es.
Keywo ds Hia al he nia· Robo ic su ge y· Re isional su ge y· Lea ning cu e
In oduc ion
The lapa oscopic app oach is conside ed he gold s anda d
o he su gical ea men o hia al he nia and e lux disease
[2] sa is ac o y esul s in 85–90% o ea ed pa ien s, wi h
less pos ope a i e pain and as e eco e y, sho e han open
su ge y [3, 4]. The in oduc ion o obo -assis ed su ge y
sys ems has allowed su geons o ans e hei skills om
open su ge y o minimally in asi e p ocedu es mo e easily
han con en ional lapa oscopy [5]. The ole o obo -assis ed
su ge y is p omising o complex p ocedu es wi h dissec ion
ine in na ow spaces, su u ing and ying, as in undoplica-
ion, and has special in e es in Re isional Su ge y (RS), o
which a high mo bidi y a e o up o 50% wi h po en ially
a al complica ions such as oesophageal pe o a ion has been
desc ibed [6]. To acqui e obo ic skills, i is essen ial o ha e
p e ious expe ience in lapa oscopic su ge y and o pe o m
he i s p ocedu es in a p oc o ed manne [7]. This has made
i possible o minimize he isks associa ed wi h he lea n-
ing cu e. In esophagogas ic su ge y, undoplica ion is
The e a e no examina ions and complemen a y p ocedu es
condi ioned by he s udy. To ca y ou he su gical p ocedu es, he
4 c i ical s eps epo ed by DeMees e published in he jou nal o
Su gical Lapa oscopic and pe cu aneous echniques in 2013 ha e
been ollowed [1].
* Elisenda Ga so
[email p o ec ed]
1 Depa men o Su ge y, Facul y o Medicine, Uni e si a
Au onoma de Ba celona, Campus UAB, Bella e a,
08913Ba celona, Spain
2 Depa men o Gene al andDiges i e Su ge y, Hospi al
Uni e si a i Ge mans T ias I Pujol, Ca e e a del Canye S/N,
Badalona, 08916Ba celona, Spain
3 Elec onic andBiomedical Ins umen a ion G oup,
Depa men o Elec onic Enginee ing, Uni e si a
Poli ècnica de Ca alunya, C/ Jo di Gi ona, 1-3, Edi ici C4,
08034Ba celona, Spain
Jou nal o Robo ic Su ge y (2025) 19:51 51 Page 2 o 8
conside ed one o he p ocedu es o choice o he beginning
o his app oach [8]. E en so, unde s anding he implica ion
o any lea ning cu e and he associa ed impac on pa ien
ou comes du ing he adop ion phase o a no el p ocedu e
is c ucial o ensu e he e hical and sa e in oduc ion o new
echnologies in o su gical p ac ice.
In he pas , new su gical app oaches we e adop ed wi h-
ou o malized aining pa hways, esul ing in a po en ial
nega i e impac on pa ien ou comes. Howe e , oday i
is inc easingly accep ed ha he in oduc ion o s anda d-
ized aining plans wi h a supe ised in oduc ion o he
echnique can be c ucial o imp o e he lea ning cu e [9].
Recen ly, S aa man e al. published esul s om a high-
olume cen e and es ablished ha he lea ning cu e o
obo ic undoplica ion can be as ew as 7 o 15 cases as long
as a u o ed aining p og am is es ablished ha a oids ha m-
ul ou comes and ensu es pa ien sa e y [7]. And no only
ha , bu su geons who lea ned unde u o ing wi h o he
expe su geons on he same eam had much sho e lea n-
ing cu es.
The aims o his s udy a e: (1) To analyze he implemen-
a ion o he obo ic app oach in an esophagogas ic su ge y
uni and (2) To pe o m an analysis o he g oup’s lea ning
cu e and compa e he esul s wi h he o he s udies ound
in li e a u e.
Ma e ials andme hods
This is an obse a ional, e ospec i e, longi udinal s udy
based on da a p ospec i ely collec ed om pa ien s who
unde wen hia al he nia su ge y be ween June 2019 and
Ma ch 2023.
Pa icipan s
A o al o 58 pa ien s who unde wen hia al he nia epai
and/o an i e lux su ge y wi h a obo ic app oach we e e al-
ua ed. The p ocedu es we e pe o med by a single su geon
wi h ex ensi e expe ience in lapa oscopic and esophago-
gas ic su ge y un il he 30 h p ocedu e, a which poin wo
addi ional su geons joined. Lea ning p ocedu e began wi h
online heo e ical aining, ollowed by p ac ice on an animal
model. This was supplemen ed by mo e han 20h o simu-
la ion, and inally, he i s wo p ocedu es we e supe ised
and au ho ized by an expe su geon. Hia al he nia su ge y
was used as he ini ial p ocedu e o human aining, and 20
consecu i e su gical sessions we e pe o med, each in ol -
ing 1 o 2 obo ic undoplica ions. Subsequen ly, new sim-
ple p ocedu es, such as Helle myo omy and pa ial gas ic
esec ions o gas oin es inal s omal umo s (GIST), we e
in oduced. Mo e complex p ocedu es, such as oncological
su ge y, ha e been p og essi ely in oduced.
All pa ien s unde going P ima y Su ge y (PS) and RS
we e included, wi h p eope a i e, in aope a i e, and pos -
ope a i e da a collec ed om elec onic pa ien eco ds.
P eope a i e s udy
The diagnos ic e alua ion included a de ailed his o y, ib o-
gas oscopy, esophagogas oduodenal ansi , high- esolu-
ion esophageal manome y, pHme y, and, occasionally,
ho aco-abdominal compu ed omog aphy. Addi ionally, in
he case o RS, he de ails o he p e ious su ge y we e ana-
lyzed o ensu e he co ec selec ion o bo h he p ocedu e
and he pa ien .
Su ge y echnique inp ima y su ge y
The Da Vinci Xi o X pla o m (In ui i e Su gical Inc., Sun-
ny ale, CA) was used in all cases. The pa ien was placed in
a supine posi ion wi h a ms by hei sides and in an in e ed
T endelenbu g posi ion. The obo was docked om he
pa ien ’s le side o head. The oca s we e placed in a linea
ashion as ollows: one 8mm oca a he sup aumbilical
le el, wo 10mm and 8mm po s 8cm apa o he le o
he midline, and one 8mm po o he igh o he midline
(Fig.1). A li e e ac o was used o hold he le lobe o
he li e , in oduced h ough a 5mm hole a he subxiphoid
le el.
The i s s ep was he opening o he gas ohepa ic
ligamen , iden i ica ion o he diaph agma ic pilla s, and
educ ion o he he nial con en s in o he abdominal ca -
i y. The he nial sac was hen dissec ed and emo ed. Once
he dis al esophagus had been dissec ed o achie e a su i-
cien in a-abdominal leng h wi hou ension (5–7cm), he
Fig. 1 T oca posi ion
Jou nal o Robo ic Su ge y (2025) 19:51 Page 3 o 8 51
diaph agma ic pilla s we e closed using a con inuous ba bed
non-abso bable su u e o loose s i ches o non-abso bable
b aided ilamen . The nex s ep in ol ed sec ioning he sho
essels and p epa ing a 270º o 360º undoplica ion based on
he symp oms desc ibed by he pa ien and p e ious mano-
me ic pa ame e s.
The placemen o ein o cing mesh was almos always an
in aope a i e decision based on he size o he hia us, he
consis ency o he pilla s and he need o an e io closu e
o he oesophageal hia us.
Su ge y echnique in e isional su ge y
The placemen o he po s in RS was he same as ha
desc ibed o PS. The i s s eps included adhesiolysis and
iden i ica ion o s uc u es. The su gical echnique chosen
depended on he cause o ailu e: in some cases, a new lax
Nissen was necessa y, while mo e o en, a 270° pa ial pos-
e io Toupe undoplica ion was he bes op ion, especially
in cases o pos ope a i e dysphagia. Mesh was occasionally
used o c u al ein o cemen and ixed o p e en p ema-
u e mig a ion o displacemen . In selec ed cases o ex eme
dysphagia, a widening o he hia us was pe o med wi hou
c ea ing a new undoplica ion.
Da a analysis
A sepa a e analysis o he RS g oup and he PS g oup was
conduc ed o iden i y po en ial di e ences ha migh a ec
he lea ning cu e. This analysis aimed o de e mine whe he
he complexi ies associa ed wi h RS, such as mo e ex en-
si e dissec ion and highe mo bidi y a es, had a signi ican
impac on he o e all lea ning p ocess compa ed o PS.
By isola ing hese g oups, we sough o be e unde s and
he dis inc challenges each p esen ed and hei espec i e
con ibu ions o he p og ession h ough he lea ning cu e
phases.
The desc ip i e s a is ics o quali a i e a iables a e
exp essed as he equency o he a iable and he pe cen -
age wi h espec o he o al sample. Fo quan i a i e a i-
ables, he no mali y o he dis ibu ion was de e mined using
he Shapi o–Wilk es . No mally dis ibu ed a iables a e
p esen ed as he mean ± s anda d de ia ion (SD) and he
95% con idence in e al o he mean (lowe limi and uppe
limi ). The non-pa ame ic a iables a e exp essed as he
median (in e qua ile ange) and (minimum–maximum).
To de e mine s a is ically signi ican di e ences in ca -
ego ical a iables, he chi-squa e es was used. Fo quan i a-
i e a iables, he S uden ’s T- es was used o pa ame ic
a iables and he Mann–Whi ney U es was used o non-
pa ame ic a iables.
IBMⓇSPSSⓇ e sion 24.0 s a is ical so wa e (IBM
Co p, A monk, NY, Uni ed S a es) was used o analyze he
da a. The le el o s a is ical signi icance was se a p < 0.05.
CUSUM analysis
A cumula i e sum (CUSUM) analysis was pe o med o
e alua e he lea ning cu e o obo ic hia al he nia su ge y
in a o al o 58 pa ien s. Because o he low a e o ad e se
pe iope a i e ou comes, ope a i e ime was used as a su -
oga e o skill acquisi ion, a he han clinical ou comes,
which is ypical in such analyses. The ope a ion ime was
de ined as he o al ime be ween he i s su gical incision
and skin closu e, including he obo docking ime.
The CUSUM me hod, wi hin he quali y con ol cha s,
is possibly he bes adap ed and mos used o moni o ing
clinical-ca e p ocesses, especially o low-incidence e en s,
whe e ob aining a sample and a long ollow-up ime is nec-
essa y. This is also why i is use ul o s udying lea ning
cu es, he in oduc ion o new echnologies and, in gen-
e al, o e alua ing he quali y o he esul s hemsel es, as
i s p o ile is sensi i e o e y sub le changes in endsThe
CUSUM is he cumula i e o al o di e ences be ween he
indi idual da a poin s and he mean o each o he wo da a
g oups (p ima y su ge y and e isional su ge y), o de ing
he cases ch onologically. I is desc ibed by he ollowing
equa ion:
To calcula e he de ia ion in each ope a ion, wo means
a e conside ed: one o he PS g oup (mean = 127min) and
ano he o he RS g oup (mean = 163min).
Resul s
Basal cha ac e is ics
A o al numbe o 58 pa ien s ha e been analyzed, di ided
in 44 PS and 14 RS. The global acking ime o he pa ien s
is 15(0–57) mon hs, 14(0–57) o PS and 17(10–24) o RS.
45 (77.6%) pa ien s we e emale, and he mean age was 63
(61–66) yea s. The a e age Body Mass Index (BMI) was
29.17 (27.8–30.5), wi h 46.55% o pa ien s conside ed
obese. The as majo i y o pa ien s (87.9%), p esen ed
wi h ypical symp oms ela ed o gas oesophageal e lux
o obs uc i e issues. Likewise, 82.8% (84.1% o PS and
78.57% o RS) unde wen a comp ehensi e assessmen ,
including adiological, endoscopic, and unc ional s udies.
Table1 shows he baseline cha ac e is ics o all pa ien s,
as well as o each o he wo de ined g oups (PS and RS).
CUSUM
=
N
∑
I=1
su ge y ime(i)−
meano heg oup
Jou nal o Robo ic Su ge y (2025) 19:51 51 Page 4 o 8
Su gical esul s
The ope a ion was comple ed wi h obo ic assis ance in
all pa ien s. A Nissen undoplica ion was pe o med in 42
(72.4%) pa ien s and a Toupe undoplica ion in 16 (27.6%)
pa ien s. In one pa ien om each g oup, he su ge y was
combined wi h ano he p ocedu e (a cholecys ec omy in he
PS g oup and an incisional he nia epai in he RS g oup). A
mesh was placed in 12% o he se ies bu in 35.7% o he RS
g oup. The su gical ime was 123.5 (54–350)min, including
obo ic se up ime (d aping o he obo a ms, su gical ca
posi ioning, and ins umen se up), 127 (115.56–138.62)min
o PS and 163.5 (115.13–211.87)min o RS, wi h no s a-
is ically signi ican di e ences be ween he g oups. The e
we e no con e sions o lapa oscopic o open app oach. Two
pa ien s in he RS g oup expe ienced in aope a i e e en s
(acciden al pleu al opening and gas ic pe o a ion), which
we e success ully managed du ing he p ocedu e and no
conside ed pos ope a i e complica ions. The e was only one
majo complica ion in he PS g oup, which was an ea ly
ecu ence ha equi ed u gen su gical in e en ion. The
PS g oup had wo eadmissions: he pa ien who equi ed
eope a ion and ano he o gas bloa synd ome managed
conse a i ely. The RS g oup had one eadmission o a
pleu al e usion, which was also managed conse a i ely.
The median hospi al s ay o he o e all g oup was 2days,
wi h a sligh ly longe s ay o he RS g oup, showing a s a is-
ically signi ican di e ence. Wi h espec o symp om eso-
lu ion, he o e all se ies achie ed a sa is ac ion a e o close
o 95%. Table2 shows he o e all su gical esul s, as well
as he desc ip i e su gical esul s o he PS and RS g oups.
CUSUM cu e
Figu e2 shows he CUSUM analysis ob ained a e 58
ope a ions. The poin s show he su gical imes ob ained in
each o he in e en ions (g een: PS and ed: RS). The black
line shows he CUSUM cu e once an in e pola ion p ocess
has been ca ied ou , which de ails he accumula ed sum o
de ia ions om he mean. The blue do s show he de ia ion
alue o each o he eal ope a ions. Finally, he e ical
blue lines show he h ee iden i ied zones o he lea ning
cu e (zone 1: om ope a ion 1 o 14; zone 2: om ope a-
ion 15 o 25; and zone 3: om p ocedu e 26 onwa ds).
Discussion
This s udy aims o e alua e he ou comes o he ini ial 58
cases o hia al he nia su ge y pe o med using a obo ic
app oach, assess he sa e y o implemen ing his echnique,
and secondly, analyze he lea ning cu e o he su gical
eam.
Rega ding he desc ip i e analysis o baseline cha ac e is-
ics (Table1), i is no ewo hy ha nea ly 50% o he pa ien s
had a BMI g ea e han 30kg/m2. Addi ionally, mo e han
70% o he pa ien s had a pa aesophageal he nia. Bo h con-
di ions a e di ec ly associa ed wi h he nia ecu ence [10,
11].
Pos ope a i e esul s
Rega ding he mo bidi y associa ed wi h he obo ic ech-
nique, p e ious s udies ha e demons a ed i s sa e y and
e ec i eness in an i e lux p ocedu es, wi h pos ope a i e
complica ion a es a 30days anging om 15 o 23% and
mo ali y a es o 0% o 2.5% [12, 13]. In he cu en se ies,
he e was only one majo complica ion in he PS g oup
(Table2), which occu ed in he i s pa ien ope a ed on.
This e en is likely a ibu able o he ini ial lack o expe i-
ence o he su gical eam.
In con as , RS, which o en in ol es mo e ex ensi e
and challenging dissec ion, has his o ically been associ-
a ed wi h highe mo bidi y and con e sion a es [14]. In
Table 1 Desc ip i e o he baseline cha ac e is ics o he o e all
pa ien and baseline cha ac e is ics o p ima yand e isional su ge y
pa ien s
Global
N = 58
P ima y
N = 44
Re isional
N = 14
Age 63 ± 11
(61–66)
65 (14)
(36–79)
64 ± 12
(56–71)
Sex
Woman 45 (77.60%) 35 (79.50%) 10 (71.43%)
Man 13 (22.40%) 9 (20.50%) 4 (28.57%)
BMI 29.17 ± 5.07
(27.84–30.50)
30.33 (6.4)
(20.93–44.7)
26.97 ± 3.86
(24.75–29.20)
Popula ion wi h
BMI ≥ 30
27 (46.55%) 23 (52.27%) 4 (28.57%)
ASA Classi ica ion
I 4 (6.90%) 4 (9.10%) 0 (0%)
II 39 (67.20%) 29 (65.90%) 10 (71.43%)
III 13 (22.40%) 9 (20.50%) 4 (28.57%)
IV 1 (1.70%) 1 (2.30%) 0 (0%)
Missing 1 (1.70%) 1 (2.30%) 0 (0%)
Pa aesophageal he nia
No 16 (27.60%) 12 (27.30%) 4 (28.57%)
Yes 42 (72.40%) 32 (72.70%) 10 (71.43%)
P e ious lapa o omy
No 42 (72.40%) 32 (72.70%) 10 (71.43%)
Yes 16 (27.60%) 12 (27.30%) 4 (28.57%)
Reason o ReIQ
Dysphagia 8 (57.14%)
Re lux 4 (28.57%)
O he 2 (14.29%)
Jou nal o Robo ic Su ge y (2025) 19:51 Page 5 o 8 51
lapa oscopic app oach, mo bidi y and con e sion a es
each up o 20–30% and 12%, espec i ely [9, 15]. Robo ic
su ge y appea s o ha e imp o ed upon hese ou comes.
Me ens e al. epo ed a pos ope a i e complica ion a e
o 10.6%, wi h 2.6% being majo complica ions [16]. In
ou se ies (Table2), wo pa ien s in he RS g oup expe-
ienced in aope a i e e en s (acciden al opening o he
pleu a and gas ic pe o a ion) ha we e success ully man-
aged du ing he p ocedu e. Due o he mo e complex dis-
sec ion in ol ed, such e en s a e mo e equen in RS [17].
The e was only one eadmission in RS g oup due o symp-
oma ic pleu al e usion managed conse a i ely. No s a-
is ical di e ences we e ound be ween g oups (p = 0.702).
Thus, in he RS g oup, he e we e no majo complica ions
associa ed wi h he p ocedu e, aligning hese esul s mo e
closely wi h se ies such as ha o Sowa ds e al., which
epo ed e en lowe a es o pos ope a i e mo bidi y (1%
o PS and 0% o RS) [18].
The leng h o hospi al s ay has also shown a iabili y in
di e en se ies wi h he in oduc ion o obo ic app oaches
[19, 20] anging om 2 o 7days [21]. In ou se ies, hospi-
al s ay a e aged 2days, sligh ly longe in RS compa ed o
PS (3 s 2days), wi h s a is ical signi icance (P = 0.005),
bu simila o o he epo ed se ies [21]. Elmously e al.
ha e desc ibed e en sho e hospi al s ays and ha e a ib-
u ed his o he implemen a ion o ea ly discha ge p o-
g ams a he han he ype o su gical app oach.
Table 2 Desc ip i e analysis
o o e all su gical esul s
and di ided be ween g oups
(p ima y su ge y and e isional
su ge y)
Global
N = 58
P ima y
N = 44
Re isional
N = 14
P
Nissen s Toupe
Nissen 42(72.40%) 37 (84.10%) 5 (35.71%)
Toupe 16(27.60%) 7 (15.90%) 9 (64.29%)
Mesh
No 51(87.90%) 42 (95.50%) 9 (64.29%)
Yes 7 (12.10%) 2 (4.50%) 5 (35.71%)
Su gical ime 123.5 (57)
(54–350)
127.09 ± 37.93
(115.56–138.62)
163.5 ± 83.77
(115.13–211.87)
−1.576 0.136
Mo bidi y
No 55 (94.8%) 43 (97.70%) 12 (85.71%)
Yes 3 (5.20%) 1 (2.30%) 2 (14.29%)
Cla ien χ
IIIB 2 (3.40%) 1 (2.30%) 0 (0%) 0.757 0.384
No 56 (96.60%) 43 (97.70%) 14 (100%)
U
Hospi al s ay 2 (1)
(2–7)
2 (1)
(2–4)
3 (2)
(2–7)
2.785 0.005
Resolu ion χ
No 3 (5.17%) 1 (2.27%) 2 (14.29%) 4.382 0.112
Pa ial 8 (13.80%) 5 (11.36%) 3 (21.43%)
Yes 47(81.03%) 35 (86.37%) 9 (64.29%)
Recu ence χ
1: Symp oma ic 10 (17.24%) 8 (18.18%) 2 (14.29%) 3.522 0.318
2: Radiologic 6 (10.35%) 3 (6.82%) 3 (21.42%)
3: Symp oma ic + Radiologic 5 (8.62%) 3 (6.82%) 2 (14.29%)
No 28 (63.79%) 30 (68.18%) 7 (50.00%)
Re-admission χ
No 55(94.80%) 42 (95.50%) 13 (92.86%) 0.146 0.702
Yes 3 (5.20%) 2 (4.50%) 1 (7.14%)
Reason o ailu e
1: Slipped bandage wi h hia us he nia 6 (42.85%)
2: Only HH 4 (28.57%)
3: In e up ed w apping 2 (14.29%)
4: Fib osis 2 (14.29%)

Jou nal o Robo ic Su ge y (2025) 19:51 51 Page 6 o 8
Wi h espec o symp om esolu ion (Table2), he o e all
se ies achie ed a sa is ac ion a e o o e 85%. Al hough
he e alua ion me hod is subjec i e, i is commonly used by
o he au ho s who epo simila da a, compa able o ou -
comes seen wi h con en ional lapa oscopic su ge y [22].
Howe e , he e a e limi ed s udies p esen ing sa is ac ion
esul s alongside quali y o li e, e lux, o dysphagia assess-
men s. None heless, sa is ac ion a es emain consis en ly
high a 82% [20, 23]. Thus, he e was no s a is ically sig-
ni ican di e ence obse ed be ween PS and RS g oups
(p = 0.31).
Lea ning cu e
Hia al he nia su ge y ep esen s a c i ical p ocedu e in
benign obo ic su ge y o he uppe gas oin es inal ac ,
demanding a ange o in ica e skills such as issue manipu-
la ion, hia us dissec ion, and in aco po eal su u ing. The
mas e y o hese skills has posi ioned his p ocedu e as a
s epping s one o mo e complex esophagogas ic oncologic
su ge ies.
The adop ion o new su gical echnologies ine i ably
en ails a lea ning cu e. One o he c ucial insigh s om
lea ning cu e analyses sough by su geons is de e mining
he equisi e case expe ience needed o o e come his cu e.
To e alua e he lea ning cu e in ou s udy, we ocused on
su gical ime due o he low mo bidi y obse ed, employing
he CUSUM me hod o i s abili y o isually depic he e o-
lu ion o lea ning and iden i y c i ical u ning poin s [24].
This me hod aids in pinpoin ing when he lea ning phase has
been su passed, po en ially sho ening he cu e o mo e
complex p ocedu es such as oncologic su ge y [25].
In ou se ies, he a e age su gical ime was 121min, com-
pa able o s udies by Mo ino e al. (131min) [26] Nakadi
e al. (137min) [27] and lowe han o he s [17, 28]. How-
e e , many au ho s ha e epo ed longe su gical imes com-
pa ed o con en ional app oaches [27, 29], o en a ibu ed
o obo se up ime, hough his is no uni e sally con i med
[30].
Ou analysis iden i ied h ee dis inc phases based on
he in lec ion poin s o he CUSUM cu e (Fig.2). Phase
1 exhibi s he expec ed lea ning cu e slope, ep esen ing
he aining phase (ope a ions 1 o 14). Phase 2 shows a
pla eau, signi ying he beginning o he imp o emen phase
(ope a ions 15 o 25), whe e he su geon begins o demon-
s a e inc eased p o iciency wi h accumula ed expe ience.
Phase 3 displays a decline in he pla eau, indica ing he
expe ise pe iod (ope a ions 26 onwa ds), consis en wi h
ypical lea ning cu e pa e ns [31]. The mino luc ua ions
obse ed wi hin each phase o ou s udy we e a ibu ed o
a ying complexi ies o he nia cases, pa icula ly he in o-
duc ion o RS s a ing om he 10 h case (ma ked by ed
spo s). Addi ionally, he upwa d end seen om he 43 d
case onwa ds was associa ed wi h inc eased case complex-
i y, including wo RS cases, and he in ol emen o wo new
su geons in he p ocedu es.
Recen esea ch on he lea ning cu e o obo ic hia al
he nia epai and undoplica ion indica ed mas e y was
achie ed a e 85 cases, wi h a lea ning cu e obse ed
o e 40 cases. This s udy no ed dec eases in a e age su gical
ime, blood loss, and hospi al s ay ac oss di e en lea ning
phases, al hough hese imp o emen s did no co ela e wi h
educed mo bidi y [32]. Simila ly, Cundy e al. iden i ied
h ee dis inc phases in hei lea ning cu e o pedia ic
Fig. 2 CUSUM analysis
Jou nal o Robo ic Su ge y (2025) 19:51 Page 7 o 8 51
pa ien s, wi h aining concluding a ound he 37 h case and
mas e y a e he 48 h case [8].
In con as , ano he s udy on obo ic o egu su ge y
epo ed a longe lea ning cu e ex ending up o 86 cases,
encompassing a ious su gical p ocedu es [33]. These s ud-
ies, conduc ed wi hou p oc o ed eams, achie ed mas e y
much la e compa ed o ou indings. Con e sely, he s udies
employing a p oc o ed pa hway ha e demons a ed po en ial
educ ions in he lea ning cu e [7], hough se e al ac o s
in luence his p ocess, such as p io expe ience in lapa o-
scopic echniques, backg ound in esophagogas ic su ge y,
su geon skill, and p ocedu al complexi y.
We ha e demons a ed ha he lea ning cu e may be as
sho as 14 cases and a p oc o ed pa hway in ol ing simu-
la ion-based aining, a mul i-day we lab cou se, ollowed
by obo ic p ocedu es o e seen by obo ic uppe GI expe s,
may be he way o educe o nea ly elimina e his lea ning
cu e.
This s udy has limi a ions. I is a e ospec i e analysis
p o iding da a om a single ins i u ion and a single expe-
ienced su geon. I includes di e en ypes o su ge y (p i-
ma y and e isional), undoplica ion (pa ial and comple e),
and o he modi ica ions o he echnique such as he place-
men o mesh in some cases. These a iables could al e he
e olu ion o he su gical ime and, consequen ly, he lea ning
cu e. The e o e, ex apola ing he esul s o o he cen e s
mus be app oached wi h cau ion due o he mix o pa ien
cases and su geon- ela ed a iables. This me hodology o
e alua ing he lea ning cu e migh be mo e sui able o
sel -e alua ion o esul s a he han es ablishing a cu -o
poin o s a egic decisions.
Addi ionally, he s udy is limi ed by he lack o objec i e
e idence du ing ollow-up, which a ec s he ela i e alidi y
o he sa is ac ion esul s.
Conclusions
Hia al he nia su ge y is a complex p ocedu e, bu i can be
aluable o aining in he obo ic app oach. Ou esul s
sugges ha he implemen a ion has been p og essi e and
sa e, wi h minimal mo bidi y a es. As a as we know, he e
is only one p e ious s udy ha analyses he lea ning cu e o
he obo ic app oach in hia al he nia su ge y in adul s using
his me hodology, es ablishing cu -o poin s ha iden i y
he di e en phases o he cu e. We demons a e ha a sin-
gle su geon can achie e a le el o mas e y wi h h ee imes
ewe cases.
Au ho con ibu ions E.R. and G.C w o e he main manusc ip
ex , G.C. p epa ed Fig.2 and ables1–2. All au ho s e iewed he
manusc ip .
Funding Open Access Funding p o ided by Uni e si a Au onoma de
Ba celona. This esea ch did no ecei e any speci ic g an om und-
ing agencies in he public, comme cial, o no - o -p o i sec o s.
Da a a ailabili y No da ase s we e gene a ed o analysed du ing he
cu en s udy.
Decla a ions
Con lic o in e es The au ho s decla e no compe ing in e es s.
E hical app o al This wo k in ol ed human subjec s o animals in i s
esea ch.
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ju isdic ional claims in published maps and ins i u ional a ilia ions.