According to a nationwide survey in 2011 by the Korean Gastric Cancer Association, the number of operations for gastric cancer was 14,658, and 3,783 cases (23.3%) were performed by laparoscopy in 2009. And 44.8% of the total operations for gastric cancer were performed in six large volume centers [6
]. In the report of the 13th KLGSS group, 2,836 cases of laparoscopic surgery for gastric cancer were performed in 10 large volume centers and the mean number of cases was 283.6 in 2010. These account for 74.9% according to a simple comparison with 2009 nationwide data. Many reports on laparoscopic gastric surgery have been reported and its safety is widely accepted. Additionally, most of these studies, including the KLASS group since 2008, were conducted in large volume centers [4
]. Thus, a great percentage of the operations and studies have been performed in several major hospitals. However, although the number of cases have been small for each hospital, many cases of laparoscopic assisted gastrectomy (LAG) have been performed in small volume hospitals. Therefore, to deliver better health service and increase access of local residents, hospitals that have a smaller number of surgical cases of surgery than large scale hospitals need to perform this surgery safely.
The purpose of our study was to determine the safety and feasibility of LAG in low volume hospitals. Our data shows that the total number of cases was 58 during a period of 33 months and the number of cases per year was 21.1. Compared with large volume centers (more than 280 cases per year), this is a very small number of cases but it could represent most small volume hospitals. According to a report on the KLASS group, a total of 1,485 patients underwent LAG from 1998 to 2005 by 10 surgeons. The cases were analyzed retrospectively, and the mean age and BMI were found to be 57.6 and 23.3 and stage frequency was Ia, 76.7%; Ib, 14.1%; II, 6.1%; IIIa, 2.2%; IIIb, 0.5%; and IV, 0.4%. Operation time, mean number of harvested lymph node, hospital stay, morbidity and mortality were 229 minutes, 31.9, 7-8 days (mean hospital stay not shown), 14.0% and 0.6% respectively (, ). Our results were not different or inferior to the retrospective results of the KLASS group in terms of patient demographic and surgical results except for the extent of lymph node dissection. The proportion of D2 lymph node dissection in the KLASS group was more than ours but the total number of retrieved lymph nodes was not different between the two groups. For the pathology results, the rate of T2 and N1 in the KLASS group was higher than ours because the indications for LADG included T2 tumor in the KLASS group but not in ours.
Experience with the operation could be described by the learning curve and shows the operation time of the first 10 cases declined to 235 minutes and this plateau was maintained until the 30th case, when it declined again. We thought the reason the first 10 cases took longer than the subsequent cases was that the surgeon had not yet adapted to the new operating room, instruments and surgical team. But after adaptation, the learning curve after 10 cases was shorter than that of reported cases, in which operation time improved from the 50th case and 60 to 90 cases were needed for the learning curve to reach a plateau [8
]. This reason is because the surgeon in our study was already had gained experience with LAG during his time as a clinical instructor, and therefore, his operation time after 10 cases was similar to those of the KLASS group. After reaching the plateau in the learning curve, operation time decreased constantly, and we inferred that about 20 cases of LAG per year is sufficient for the maintenance of good surgical technique in LAG.
The limitation of our study was that we compared our results with the results of the KLASS group, which had a different time of study. Operations were performed from 2009 to 2012 in our study and from 1998 to 2005 in the KLASS study. Many surgical devices including ultrasonic scissors, surgical stapler, laparoscopic camera and high-definition system are constantly evolving and this fact could have affected our data [2
]. But another report that had a similar period to our study showed similar data to ours.
Except for eight to ten high volume centers most hospital have a low volume of laparoscopic gastric surgeries and therefore, we thought our study would have meaningful results. In conclusion, laparoscopic gastric surgery in a low volume center, with about 20 cases per year, could be performed safely and the postoperative results in these centers were not different to those of high volume centers.