The Impact Of Three Dimensional Endoscopy On The Learning Curve Of Minimally Invasive Mitral Valve Surgery
Sumi Westhofen1, Christian Detter1, Ewaldas Girdauskas1, Tobias Deuse2, Hendrik Treede3, Hermann Reichenspurner1, Lenard Conradi1.
1University Heart Center Hamburg, Hamburg, Germany, 2Division of Cardiothoracic Surgery, UCSF, San Francisco, CA, USA, 3Department of Cardiac Surgery, Comprehensive Heart Center, Halle (Saale), Germany.
Objective: Minimally-invasive mitral valve surgery (MIMVS) has become the routine approach at many centers. Use of three-dimensional (3D) endoscopy is the latest step of continuous technical refinement. We analyzed the impact of 3D endoscopy on learning MIMVS.
Methods: From 2010-2016 a total of 362patients underwent MIMVS. Of these, 243 were treated using standard 2D endoscopy (group1) and 119 were treated using 3D endoscopy (group2). These procedures were performed by 6 surgeons with similar individual caseloads but at different stages of training. Individual and cumulative learning curves regarding operation times and perioperative complications were assessed for 3D-endoscopy-guided procedures.Operation times, complications and functional results of both groups were comparatively assessed.
Results: Age was 55.3±12.4years (group1) vs. 57.7±10.6years (group2;p=0.07), 31.3% vs. 31.1%(p=0.91) were female, respectively. Bileaflet prolapse was seen in 21.4% (group1) versus 14.3% (group2;P=0.11). Complexity and number of repair techniques performed were not significantly different for both groups. We did not observe an obvious overall or individual learning curve regarding operation times for 3D-endoscopy-guided procedures. Surgeons in earlier training stages did not show significantly longer operation times than experienced surgeons. Individual and cumulative learning curves regarding perioperative complications did also show no obvious learning effect. Operation times were 263.34±62.48min vs. 262.59±52.13min in group 1 and 2 respectively (p=0.91). Re-exploration for bleeding was performed in 1.6% vs. 1.7%(p=0.98), conversion to sternotomy was performed in 1.6% vs. 0.8% (p=0.49). Impaired wound-healing was not seen in group2, but in 1.6% of group1 (p<0.01). Discharge echocardiography showed excellent results in both groups with 1.6% vs. 0.8% >mild recurrent regurgitation in groups 1 and 2 respectively (p=0.49).
Conclusion: In our early experience of 3D-endoscopic MI-MVR we could not identify typical learning curve patterns, operation times were stable from the beginning for each surgeon. Compared to the established group1-procedure we found lower complication rates, equal functional results and equal operation times. Therefore we think that the use of 3D endoscopy can support learning minimally invasive surgery by increasing orientation and depth perception.
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