A study of the learning curve for laparoscopic Nissen fundoplication procedure, focusing on operative times using cumulative sum (CUSUM) method and multiple regression analysis for patients with neuromuscular disease.

PURPOSE: The number of cases necessary to achieve proficiency in laparoscopic Nissen fundoplication (Lap-Nissen) remains unclear. We analyzed operative times using the cumulative sum (CUSUM) method to construct learning curves and estimate the required case volume. METHODS: We retrospectively reviewed patients who underwent Lap-Nissen at our institution beginning in October 2008. Learning curves for each surgeon were constructed using CUSUM analysis and divided into three phases (I-III) by piecewise linear regression. RESULTS: A total of 109 cases were analyzed. For surgeon A (n = 46), the mean operative time decreased across phases I (cases 1-8, 299.4 min), II (9-32, 217.7 min), and III (33-46, 179.6 min). Similar trends were observed for surgeon B (n = 42): I (1-5, 328.2 min), II (6-30, 204.4 min), and III (31-42, 179.5 min). Surgeon C (n = 14) delivered no clear learning curve, and surgeons D-F were excluded due to low case numbers. Multiple regression analysis identified the surgeons' experience as the strongest factor associated with operative time (β = - 0.53, p < 0.001). CONCLUSION: Phase I comprised approximately five cases, while phase II included more than 30 cases. Larger multicenter prospective studies are warranted.