Comprehensive Learning Curve of Robotic Surgery: Discovery from a Multicenter Prospective Trial of Robotic Gastrectomy

Min Seo Kim, Won Jun Kim, Woo Jin Hyung, Hyoung Il Kim, Sang Uk Han, Young Woo Kim, Keun Won Ryu, Sungsoo Park

Research output: Contribution to journalArticlepeer-review

78 Citations (Scopus)


Objective:To evaluate the complication-based learning curve and identify learning-Associated complications of robotic gastrectomy.Summary Background Data:With the increased popularity of robotic surgery, a sound understanding of the learning curve in the surgical outcome of robotic surgery has taken on great importance. However, a multicenter prospective study analyzing learning-Associated morbidity has never been conducted in robotic gastrectomy.Methods:Data on 502 robotic gastrectomy cases were prospectively collected from 5 surgeons. Risk-Adjusted cumulative sum analysis was applied to visualize the learning curve of robotic gastrectomy on operation time and complications.Results:Twenty-five cases, on average, were needed to overcome complications and operation time-learning curve sufficiently to gain proficiency in 3 surgeons. An additional 23 cases were needed to cross the transitional phase to progress from proficiency to mastery. The moderate complication rate (CD ≥ grade II) was 20% in phase 1 (cases 1-25), 10% in phase 2 (cases 26-65), 26.1% in phase 3 (cases 66-88), and 6.4% in phase 4 (cases 89-125) (P < 0.001). Among diverse complications, CD ≥ grade II intra-Abdominal bleeding (P < 0.001) and abdominal pain (P = 0.01) were identified as major learning-Associated morbidities of robotic gastrectomy. Previous experience on laparoscopic surgery and mode of training influenced progression in the learning curve.Conclusions:This is the first study suggesting that technical immaturity substantially affects the surgical outcomes of robotic gastrectomy and that robotic gastrectomy is a complex procedure with a significant learning curve that has implications for physician training and credentialing.

Original languageEnglish
Pages (from-to)949-956
Number of pages8
JournalAnnals of surgery
Issue number5
Publication statusPublished - 2021 May 1
Externally publishedYes

Bibliographical note

Funding Information:
From the *Korea University College of Medicine, Seoul, Republic of Korea; †Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea; zDepartment of Surgery, Ajou University College of Medicine, Seoul, Republic of Korea; §Center for Gastric Cancer, National Cancer Center, Seoul, Republic of Korea; and ôDivision of Upper Gastroin-testinal Surgery, Department of Surgery, Korea University College of Medi-cine, Seoul, Republic of Korea. Y This manuscript has been seen and approved by all authors. All information and materials in the manuscript are original. Clinical trials identification: NCT01309256. This work is supported by a grant from the National R&D Program for Cancer Control, Ministry of Health & Welfare, Republic of Korea (1020410) and Korea University Grant. The authors report no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site ( Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/19/27305-0949 DOI: 10.1097/SLA.0000000000003583

Publisher Copyright:
© 2021 Lippincott Williams and Wilkins. All rights reserved.


  • complication
  • learning curve
  • operation time
  • robotic gastrectomy
  • robotic surgery

ASJC Scopus subject areas

  • Surgery


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