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OBJECTIVE: To describe the pooled learning curves of Ivor Lewis totally minimally invasive esophagectomy (TMIE) in hospitals stratified by predefined hospital- and surgeon-related factors.BACKGROUND: Ivor Lewis (TMIE is known to have a long learning curve which is associated with considerable learning associated morbidity. It is unknown whether hospital and surgeon characteristics are associated with more efficient learning.METHODS: A retrospective analysis of prospectively collected data of consecutive Ivor Lewis TMIE patients in 14 European hospitals was performed. Outcome parameters used as proxy for efficient learning were learning curve length, learning associated morbidity, and the plateau level regarding anastomotic leakage and textbook outcome. Pooled incidences were plotted for the factor-based subgroups using generalized additive models and 2-phase models. Casemix predicted outcomes were plotted and compared with observed outcomes. The investigated factors included annual volume, TMIE experience, clinic visits, courses and fellowships followed, and proctor supervision.RESULTS: This study included 2121 patients. The length of the learning curve was shorter for centers with an annual volume >50 compared to centers with an annual volume CONCLUSIONS: More efficient learning was observed in centers with higher annual volume. Visiting an expert clinic, completing a fellowship, or implementation under a proctor's supervision were not associated with more efficient learning.

"Components separation technique" for the repair of large abdominal wall hernias.de Vries Reilingh TS, van Goor H, Rosman C, Bemelmans MH, de Jong D, van Nieuwenhoven EJ, van Engeland MI, Bleichrodt RP.Department of Surgery, University Medical Center, Nijmegen, Heerlen, The Netherlands.BACKGROUND: The "components separation technique" is a method for abdominal wall reconstruction in patients with large midline hernias that cannot be closed primarily. The early and late results of this technique were evaluated in 43 patients. METHODS: Records of 43 patients, 11 women and 32 men, with a mean age of 49.7 (range 22 to 78), were reviewed for body length and weight, size and cause of the hernia, intra- and postoperative mortality and morbidity, with special attention given to wound and pulmonary complications. Patients were invited to attend the outpatient clinic afterward for at least 12 months for physical examination of the abdominal wall. RESULTS: The defect resulted after elective surgery in 19 patients and after acute surgery in 24 patients. In 11 patients, the defect was a result of open treatment of generalized peritonitis, and 13 patients had a recurrent incisional hernia. One patient died on the sixth postoperative day from mesenteric thrombosis. The postoperative course was complicated in 17 patients: fascial dehiscence in one, hematoma in five, seroma in two, wound infection in six, skin necrosis in one, and respiratory insufficiency in two. Thirty-eight patients were seen for followup. After a mean followup of 15.6 months (range 12 to 30 months), a recurrent hernia was found in 12 of the 38 patients (32%). The remaining four patients had no recurrent hernia after 1, 1, 3, and 4 months, respectively. CONCLUSIONS: The "components separation technique" is useful for the reconstruction of large abdominal wall hernias, especially under contaminated conditions in which the use of prosthetic material is contraindicated. Further research is needed to reduce the relatively high reherniation rate. Copyright 2003 by the American College of Surgeons