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J Vet Clin 2023; 40(6): 438-444

https://doi.org/10.17555/jvc.2023.40.6.438

Published online December 31, 2023

Learning Curve of a Low-Volume Veterinary Surgeon for Laparoscopic Salpingectomy in Asiatic Black Bear (Ursus thibetanus)

Dongwook Heo1 , Seong-Min Kim2 , Dae-Yoen Hwang3 , Ill-Hwa Kim2 , Hyun-Gu Kang2,*

1Incheon General Animal Hospital, Incheon 22551, Korea
2Laboratory of Veterinary Theriogenology, College of Veterinary Medicine, Chungbuk National University, Cheongju 28644, Korea
3Department of Biomaterials Science, College of Natural Resources and Life Science/Life and Industry Convergence Research Institute, Pusan National University, Miryang 50463, Korea

Correspondence to:*kang6467@chungbuk.ac.kr

Received: November 22, 2023; Revised: December 4, 2023; Accepted: December 5, 2023

Copyright © The Korean Society of Veterinary Clinics.

The aim of this study was to analyze the learning curve of a low-volume veterinary surgeon for laparoscopic salpingectomy of Asiatic black bear. A total of 66 Asiatic black bears (Ursus thibetanus) were presented for sterilization using laparoscopic salpingectomy. These 66 bears were divided into three groups of 22 bears according to the order of surgery (A, B, and C groups, 22 bears per group). One veterinarian performed laparoscopic salpingectomy. There was no significant difference in age, body weight, or crown-rump length between groups. The hazard of completion for salpingectomy by 5 minutes was higher (p < 0.0001) in B and C groups than A group, whereas the hazard was not significant different between B and C groups. The factor that affected the hazard of completing salpingectomy by 5 minutes was heart rate, not age or weight. Operation time was 12.61 ± 8.04 minutes for group A, 5.35 ± 4.38 minutes for group B, and 2.80 ± 1.16 minutes for group C. The operation time for salpingectomy shortened over time. However, significant difference in operation time was present only between groups A and C (p = 0.001). The operation time for laparoscopic salpingectomy decreased rapidly for the first 7 bears (p < 0.05). It then decreased gradually until the 66th case. Operation time of laparoscopic salpingectomy was significantly decreased and stabilized after 33 cases (p < 0.05). As a result, the number of bears required for a low-volume veterinary surgeon to be proficient in laparoscopic salpingectomy is 33 or more.

Keywords: laparoscopy, salpingectomy, Asiatic black bear, learning curve

In East and Southeast Asia, large numbers of bears are privately raised to collect their bile (15). There are animal welfare and ethical issues with bear breeding for the purpose of collecting bear bile. Thus, there is a need to terminate breeding by stopping their pregnancy (11). There are many options for population control and for prevention and treatment of reproductive diseases of females, including contraception, pessaries, ovariohysterectomy, medication, intra vaginal device, salpingectomy, and ligation of uterine tube (2,13,18,38,41,42).

Bears are wild animals. When performing surgeries for bears using general surgical methods, it is difficult to control them (42). In addition, there is a possibility of self-injury at the surgical site. Thus, a method that can minimize the surgical site must be selected. A less invasive method using laparoscope has many advantages such as shorter hospitalization period, better operating field visualization, fewer surgical wound complications, less postoperative pain, and less invasiveness (3,12,16,18).

Laparoscopic surgery requires new training methods and a certain volume of surgical procedures before surgeons can reach an acceptable level of expertise based on outcome parameters (24). The length of this learning curve is proportional to the complexity of the procedure (24). A learning curve is a graphical representation of the number of times a particular procedure must be repeated before one acquires skills necessary to perform the procedures in an appropriate and safe manner (24,30). The learning curve of laparoscopy is more complex, slower, and more error-prone than that of an open surgery (30). This can be explained by a variety of factors, including lack of appropriate procedures for training purposes, difficulties with image-eye-hand coordination, loss of three dimensions and tactile sensations, and fulcrum effects that can reverse the movement of instrument and increase tremor (17). In order to acquire skills necessary for a laparoscopic surgery, there must be an appropriate training method. Training methods that can improve proficiency include using models to improve operation of surgical instruments (20,30) and increasing surgical cases in actual clinical practice (6,24). Laparoscopic proficiency should be evaluated the time required for surgery, bleeding, mortality rate, and side effects (33). In humans, various surgeries using laparoscopy are being performed and many studies are being conducted on learning curve in laparoscopic surgery (6,17,24,30). However, there are no reports on proficiency in laparoscopic salpingectomy in veterinary practice. Therefore, this study aimed to determine the number of surgeries needed to reach a stable operation time and examine the learning curve for a low-volume veterinary surgeon performing laparoscopic salpingectomy in 66 Asiatic black bears.

Animals and management

This study was performed at a domestic bear farm located in Dangjin gun, Chungnam province, South Korea (36°56’N, 126°43’E). Sixty-six female adults of Asiatic black bear were used in this study. Their mean age, body weight, and crown rump length at the beginning of the study were 12.17 ± 3.57 years, 89.91 ± 35.08 kg, and 125.33 ± 18.71 cm, respectively (Table 1). Each bear was housed individually or 5 to 10 bears in a small or large captive pen with a cement or steel-barred floor. They were fed acorns, chest nuts, fruits, vegetables, sweet potatoes, and commercial feed (Omnivore diet dry, Zupreem®, KC, USA) twice a day based on seasonal calorie requirement.

Table 1 Age, body weight and crown rump length (CRL) of 66 Asiatic black bears (mean ± SD)

GroupNo. of bearsAge (year)Body weight (kg)CRL (cm)
A2213.18 ± 2.5994.01 ± 48.59123.45 ± 13.23
B2211.00 ± 4.4886.23 ± 31.39123.23 ± 26.43
C2212.32 ± 3.1789.41 ± 20.74129.32 ± 13.58
Total6612.17 ± 3.5789.91 ± 35.08125.33 ± 18.71


Bears were divided into three groups according to the order of surgery for prospective analysis. Group A consisted of the first 22 bears. Group B had bears numbered from 23 to 44. The final 22 bears were included in Group C.

Surgeon

A single surgeon specialized in obstetrics carried out all surgeries in this study. The surgeon could handle a laparoscopic instrument proficiently. However, the surgeon never performed laparoscopic salpingectomy before.

Anesthesia

Bears were fasted for more than 24 h before anesthesia. Initially, anesthetic agent doses were calculated by grossly estimating the body weight of each bear. The anesthetic was administered by darting using a blowgun. Bears were anesthetized with a combination of tiletamine–zolazepam (2 mg/kg; Zoletile 50® Virvac, Carros, France) and xylazine (1.5 mg/kg; Xyzine®, SF, Ansan, Korea). After anesthesia induction, bears were blindfolded and transported to the operating room on a cart for laparoscopic salpingectomy. In the operating room, bears were weighed on an electronic balance. Next, they were restrained on an operating table, tilted down at a 10° angle by placing them in a foot-up and head-down position in dorsal recumbency, and supplied with in 100% oxygen (4 L/min) through the nose. After completing all procedures in the operating room, bears were moved to the recovery room. Yohimbine (0.2 mg/kg, Xyverse®; SF), a xylazine antagonist, was then administered intravenously at a dose similar to that of the initial xylazine.

Laparoscopic salpingectomy

To direct abdominal organs toward the diaphragm, bear’s hind legs were lifted toward the chest three times. The surgical-site was prepared antiseptically using povidone and alcohol. First, a guide opening for Veress needle (2 mm, length 120 mm, MGB, Germany) should be made. Thus, a 2 cm skin incision was made toward the head from the umbilicus. After that, the surgeon made a stay suture to prevent intestinal damage. Holding a stay suture, the surgeon placed a Veress needle in the abdominal cavity along the ventral midline. This Veress needle was soon connected with a sterile tube that supplied CO2 gas of 12 mmHg pressure into the abdominal cavity from an insufflator (Fencer, MGB). If additional room was made perfectly, the Veress needle was pulled out and a 5 mm trocar with a 5.5-mm trocar sleeve with cannula was inserted in the same place. Connecting a cannula with a sterile CO2 supplying tube, the trocar removed slowly. A 30° laparoscope (5 mm, MGB) was put in the sleeve portal to examine the abdominal cavity. This laparoscope later helped the surgeon put a second trocar and a third trocar in a way to make a light guide. The veterinary surgeon inserted the second and third trocars in the same way, 15 cm right-caudo-lateral and 15 cm left-caudo-lateral to the umbilical cord. All surgical preparations were considered complete when the instruments were properly inserted into the three ports (for laparoscopy, atraumatic grasper, and coagulation forceps). The oviduct placed on the left ovary was identified by a laparoscope. An atraumatic grasper was inserted through the right-sided portal and grasped the proper ligament to suspend the left ovary. A coagulation forceps was used to seal and cut the oviduct and mesosalpinx. The right-sided salpingectomy was performed in the manner described for the left-sided salpingectomy. The abdominal cavity was deflated and each portal was sutured. The time taken for a laparoscopic salpingectomy was from the time all instruments entered the abdominal cavity until the laparoscopic salpingectomy was performed and instruments were removed. During the postoperative period, the bear was monitored for appetite, abnormal behavior, mortality, and wound hemorrhage.

Statistical analysis

The Cox proportional hazards model (Cox regression) was used to compare the duration of completing a salpingectomy within 300 seconds among Groups A, B, and C. Age, body weight, and the group categories of bears were included in the model as explanatory variables. The PHREG procedure within SAS software (SAS version 9.1, SAS Institute Inc., Cary, NC, USA) was used for this purpose. Kaplan-Meier curves were fitted for each group using MedCalc software (version 11.1, MedCalc Software, Mariakerke, Belgium). Differences between the survival curves were statistically examined using the log-rank test with the LIFETEST procedure in SAS software. Differences were considered statistically significant at p value of less than 0.05.

Results of surgeon’s operation time are presented in Table 2. The operation time for groups A, B, and C were 12.61 ± 8.04 minutes, 5.35 ± 4.38 minutes, and 2.80 ± 1.16 minutes, respectively. The surgeon’s operation time was significantly shortened over time (Fig. 1). The operation time for laparoscopic salpingectomy decreased rapidly for the first 7 bears (p < 0.05). It then decreased gradually until the 66th case. Operation time of laparoscopic salpingectomy was significantly decreased and stabilized after 33 cases (p < 0.05).

Table 2 Operation time (time to complete) for laparoscopic salpingectomy in Asiatic black bear

GroupsNo. of bearsOperation time (time to complete)
Mean ± SDRange
A2212.61 ± 8.04a2.43-34.53
B225.35 ± 4.38b1.25-19.25
C222.80 ± 1.16b0.85-4.74
Total666.92 ± 6.710.85-34.53

Group B had a significantly shorter operation time than group A (p = 0.01), and group C had a significantly shorter operation time than group A (p = 0.001). No significant difference was recognized between group B and group C (p > 0.05).



Figure 1.Number of repetitions required for proficiency. The laparoscopic salpingectomy time decreased rapidly up to the 7th repetition (arrow, p < 0.05) and gradually decreased thereafter. The number of repetitions that could stably complete the laparoscopic salpingectomy within 5 minutes was 33.

Table 3 shows factors affecting the hazard of completing salpingectomy by 5 minutes. Heart rate of bear had a significant effect on the hazard (p = 0.0001), whereas age and body weight of bears did not affect the hazard (p > 0.05). The hazard for completing salpingectomy was higher (p = 0.0001) in B (HR: 7.74) and C (HR: 19.37) groups than in the A group as shown by survival curves (Fig. 2). However, the hazard of completing salpingectomy by 5 minutes was not statistically different between B and C groups (p > 0.05).

Table 3 Factors affecting the hazard of completion for salpingectomy by 5 minutes analyzed by PHREG procedure

VariableHR95% CIp-value
Heart rate group
AReference
B7.742.227-26.885< 0.005
C19.375.555-67.568< 0.0001
Age> 0.05
Body weight> 0.05

HR, hazard ratio; CI, confidence interval.



Figure 2.Survival curves for the completion for salpingectomy by 5 minutes in the A, B and C groups. The hazard of completion for salpingectomy by 5 minutes was higher (p = 0.0001) in B and C groups than in the A group, whereas the hazard was not different between B and C groups (p > 0.05).

Ovariohysterectomy is a surgical method commonly used for the treatment and prevention of reproductive diseases in animals as well as for neutering (2,13,18,21,38,41,42). It is commonly performed through either a ventral midline or a lateral flank approach (14,22,28,35,43). Although the ventral midline approach is preferable to the lateral flank approach in ovariohysterectomy, each method has its advantages and disadvantages (22,28,35,43). In large wild animals, the ventral midline approach may result in delayed wound healing at the surgical site and increased risk of potential rupture (9,27,31,34). Bears are wild animals that are dangerous and difficult to manage. Laparotomy to treat reproductive diseases in wild animals can cause various complications (8,27,34). For this reason, laparoscopy may be used to limit reproduction in female bears. In this study, laparoscopic salpingectomy was selected because the only purpose was to limit reproduction in captive bears.

Veterinarians with little experience in a skill should receive appropriate training to acquire that skill (39). The term “learning curve” as currently employed in surgery means that inexperienced surgeons have not only a longer operating time, but also a higher complication rate (1). Proficiency is assessed by a learning curve. The learning curve varies greatly depending on the complexity and difficulty of the surgery (26). Because the learning curve varies depending on the type of surgery and instruments used, surgeons need a new learning curve when using a new surgical method (19). In general, the definition of a learning curve has been proposed as “the number of cases required to become proficient for performing various surgical procedures”. Learning curves are currently being analyzed using various parameters (7,8,40). In laparoscopic surgery, proficiency is evaluated by bleeding, mortality rate, reoperation, and operation time (30,33). In this study, skill level was assessed by the time required for laparoscopic salpingectomy.

In the literature, the learning curve is given as 30 procedures for laparoscopic cholecystectomy (4,25), 60 procedures for endoscopic inguinal hernia repair (5), 100 procedures for laparoscopic gastric bypass (32), 110 cases for laparoscopic prostectomy (24), 88-152 procedures for laparoscopic colorectal surgery (23), and 200-250 procedures for prostate cancer surgery (36). Factors that can impede rapid skill acquisition in laparoscopic surgery include small number of cases suitable for surgical training, difficulties with video eye-hand coordination, altered perception of depth, and laparoscopic suturing (30). A study on learning curves of surgeons and students demonstrated that students required more repetitions to achieve curve stabilization than surgeons and that surgical experience reduced the learning curve (30). Therefore, the learning curve could be greatly influenced by the operator’s clinical experience and the number of repetitions of the surgery. In the present study, the operation time decreased rapidly up to 7 cases and continued to decrease until 66 cases. After 33 cases, the surgery was stably completed within 5 minutes. This reduction in time was due to the fact that surgeons gradually became accustomed to handling the instrument over time and had the ability to easily locate target abdominal organs. This stable skill level varies greatly depending on the complexity of the surgery, location of organs, and size of the patient. Therefore, as shown in this study, it is necessary to achieve a minimum level of proficiency even in the most basic laparoscopic surgery. It is reasonable to consider these results in a basic education program for veterinarians who want to perform a laparoscopic surgery.

In the clinical field, veterinarians must learn diagnostic skills to diagnose various causes. In human medicine, a learning curve is set for various diagnostic technologies and the minimum number of repetitions required to use the technology (10,44). Especially in the surgical field, more repetitive learning is needed depending on the complexity of the surgery and anatomical location (29). In the veterinary field, various equipment is being developed. At the same time, high-difficulty surgeries are being required. Thus, there is a need to establish a learning curve for each technology. Developing training programs of progressively increasing complexity, supported by learning aids such as simulators, cadaver workshops, and training case presentations, is pivotal in minimizing complications associated with the learning curve (1,17,37,44).

For sterilization of bears, laparoscopic salpingectomy is less invasive and more effective than a conventional surgical approach. Operation time of laparoscopic salpingectomy was significantly decreased for the first 7 bears. It then decreased gradually until the 66th case. The number of bears required for a low-volume veterinary surgeon to be proficient in laparoscopic salpingectomy is 33 or more. In laparoscopic surgery, it is necessary to achieve a minimum level of proficiency in order to minimize complications resulting from surgery. Thus, it is necessary to establish a basic training program for veterinarians who wish to perform a laparoscopic surgery.

This work was funded by an academic research program of Chungbuk National University in 2022.

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Article

Original Article

J Vet Clin 2023; 40(6): 438-444

Published online December 31, 2023 https://doi.org/10.17555/jvc.2023.40.6.438

Copyright © The Korean Society of Veterinary Clinics.

Learning Curve of a Low-Volume Veterinary Surgeon for Laparoscopic Salpingectomy in Asiatic Black Bear (Ursus thibetanus)

Dongwook Heo1 , Seong-Min Kim2 , Dae-Yoen Hwang3 , Ill-Hwa Kim2 , Hyun-Gu Kang2,*

1Incheon General Animal Hospital, Incheon 22551, Korea
2Laboratory of Veterinary Theriogenology, College of Veterinary Medicine, Chungbuk National University, Cheongju 28644, Korea
3Department of Biomaterials Science, College of Natural Resources and Life Science/Life and Industry Convergence Research Institute, Pusan National University, Miryang 50463, Korea

Correspondence to:*kang6467@chungbuk.ac.kr

Received: November 22, 2023; Revised: December 4, 2023; Accepted: December 5, 2023

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The aim of this study was to analyze the learning curve of a low-volume veterinary surgeon for laparoscopic salpingectomy of Asiatic black bear. A total of 66 Asiatic black bears (Ursus thibetanus) were presented for sterilization using laparoscopic salpingectomy. These 66 bears were divided into three groups of 22 bears according to the order of surgery (A, B, and C groups, 22 bears per group). One veterinarian performed laparoscopic salpingectomy. There was no significant difference in age, body weight, or crown-rump length between groups. The hazard of completion for salpingectomy by 5 minutes was higher (p < 0.0001) in B and C groups than A group, whereas the hazard was not significant different between B and C groups. The factor that affected the hazard of completing salpingectomy by 5 minutes was heart rate, not age or weight. Operation time was 12.61 ± 8.04 minutes for group A, 5.35 ± 4.38 minutes for group B, and 2.80 ± 1.16 minutes for group C. The operation time for salpingectomy shortened over time. However, significant difference in operation time was present only between groups A and C (p = 0.001). The operation time for laparoscopic salpingectomy decreased rapidly for the first 7 bears (p < 0.05). It then decreased gradually until the 66th case. Operation time of laparoscopic salpingectomy was significantly decreased and stabilized after 33 cases (p < 0.05). As a result, the number of bears required for a low-volume veterinary surgeon to be proficient in laparoscopic salpingectomy is 33 or more.

Keywords: laparoscopy, salpingectomy, Asiatic black bear, learning curve

Introduction

In East and Southeast Asia, large numbers of bears are privately raised to collect their bile (15). There are animal welfare and ethical issues with bear breeding for the purpose of collecting bear bile. Thus, there is a need to terminate breeding by stopping their pregnancy (11). There are many options for population control and for prevention and treatment of reproductive diseases of females, including contraception, pessaries, ovariohysterectomy, medication, intra vaginal device, salpingectomy, and ligation of uterine tube (2,13,18,38,41,42).

Bears are wild animals. When performing surgeries for bears using general surgical methods, it is difficult to control them (42). In addition, there is a possibility of self-injury at the surgical site. Thus, a method that can minimize the surgical site must be selected. A less invasive method using laparoscope has many advantages such as shorter hospitalization period, better operating field visualization, fewer surgical wound complications, less postoperative pain, and less invasiveness (3,12,16,18).

Laparoscopic surgery requires new training methods and a certain volume of surgical procedures before surgeons can reach an acceptable level of expertise based on outcome parameters (24). The length of this learning curve is proportional to the complexity of the procedure (24). A learning curve is a graphical representation of the number of times a particular procedure must be repeated before one acquires skills necessary to perform the procedures in an appropriate and safe manner (24,30). The learning curve of laparoscopy is more complex, slower, and more error-prone than that of an open surgery (30). This can be explained by a variety of factors, including lack of appropriate procedures for training purposes, difficulties with image-eye-hand coordination, loss of three dimensions and tactile sensations, and fulcrum effects that can reverse the movement of instrument and increase tremor (17). In order to acquire skills necessary for a laparoscopic surgery, there must be an appropriate training method. Training methods that can improve proficiency include using models to improve operation of surgical instruments (20,30) and increasing surgical cases in actual clinical practice (6,24). Laparoscopic proficiency should be evaluated the time required for surgery, bleeding, mortality rate, and side effects (33). In humans, various surgeries using laparoscopy are being performed and many studies are being conducted on learning curve in laparoscopic surgery (6,17,24,30). However, there are no reports on proficiency in laparoscopic salpingectomy in veterinary practice. Therefore, this study aimed to determine the number of surgeries needed to reach a stable operation time and examine the learning curve for a low-volume veterinary surgeon performing laparoscopic salpingectomy in 66 Asiatic black bears.

Materials and Methods

Animals and management

This study was performed at a domestic bear farm located in Dangjin gun, Chungnam province, South Korea (36°56’N, 126°43’E). Sixty-six female adults of Asiatic black bear were used in this study. Their mean age, body weight, and crown rump length at the beginning of the study were 12.17 ± 3.57 years, 89.91 ± 35.08 kg, and 125.33 ± 18.71 cm, respectively (Table 1). Each bear was housed individually or 5 to 10 bears in a small or large captive pen with a cement or steel-barred floor. They were fed acorns, chest nuts, fruits, vegetables, sweet potatoes, and commercial feed (Omnivore diet dry, Zupreem®, KC, USA) twice a day based on seasonal calorie requirement.

Table 1 . Age, body weight and crown rump length (CRL) of 66 Asiatic black bears (mean ± SD).

GroupNo. of bearsAge (year)Body weight (kg)CRL (cm)
A2213.18 ± 2.5994.01 ± 48.59123.45 ± 13.23
B2211.00 ± 4.4886.23 ± 31.39123.23 ± 26.43
C2212.32 ± 3.1789.41 ± 20.74129.32 ± 13.58
Total6612.17 ± 3.5789.91 ± 35.08125.33 ± 18.71


Bears were divided into three groups according to the order of surgery for prospective analysis. Group A consisted of the first 22 bears. Group B had bears numbered from 23 to 44. The final 22 bears were included in Group C.

Surgeon

A single surgeon specialized in obstetrics carried out all surgeries in this study. The surgeon could handle a laparoscopic instrument proficiently. However, the surgeon never performed laparoscopic salpingectomy before.

Anesthesia

Bears were fasted for more than 24 h before anesthesia. Initially, anesthetic agent doses were calculated by grossly estimating the body weight of each bear. The anesthetic was administered by darting using a blowgun. Bears were anesthetized with a combination of tiletamine–zolazepam (2 mg/kg; Zoletile 50® Virvac, Carros, France) and xylazine (1.5 mg/kg; Xyzine®, SF, Ansan, Korea). After anesthesia induction, bears were blindfolded and transported to the operating room on a cart for laparoscopic salpingectomy. In the operating room, bears were weighed on an electronic balance. Next, they were restrained on an operating table, tilted down at a 10° angle by placing them in a foot-up and head-down position in dorsal recumbency, and supplied with in 100% oxygen (4 L/min) through the nose. After completing all procedures in the operating room, bears were moved to the recovery room. Yohimbine (0.2 mg/kg, Xyverse®; SF), a xylazine antagonist, was then administered intravenously at a dose similar to that of the initial xylazine.

Laparoscopic salpingectomy

To direct abdominal organs toward the diaphragm, bear’s hind legs were lifted toward the chest three times. The surgical-site was prepared antiseptically using povidone and alcohol. First, a guide opening for Veress needle (2 mm, length 120 mm, MGB, Germany) should be made. Thus, a 2 cm skin incision was made toward the head from the umbilicus. After that, the surgeon made a stay suture to prevent intestinal damage. Holding a stay suture, the surgeon placed a Veress needle in the abdominal cavity along the ventral midline. This Veress needle was soon connected with a sterile tube that supplied CO2 gas of 12 mmHg pressure into the abdominal cavity from an insufflator (Fencer, MGB). If additional room was made perfectly, the Veress needle was pulled out and a 5 mm trocar with a 5.5-mm trocar sleeve with cannula was inserted in the same place. Connecting a cannula with a sterile CO2 supplying tube, the trocar removed slowly. A 30° laparoscope (5 mm, MGB) was put in the sleeve portal to examine the abdominal cavity. This laparoscope later helped the surgeon put a second trocar and a third trocar in a way to make a light guide. The veterinary surgeon inserted the second and third trocars in the same way, 15 cm right-caudo-lateral and 15 cm left-caudo-lateral to the umbilical cord. All surgical preparations were considered complete when the instruments were properly inserted into the three ports (for laparoscopy, atraumatic grasper, and coagulation forceps). The oviduct placed on the left ovary was identified by a laparoscope. An atraumatic grasper was inserted through the right-sided portal and grasped the proper ligament to suspend the left ovary. A coagulation forceps was used to seal and cut the oviduct and mesosalpinx. The right-sided salpingectomy was performed in the manner described for the left-sided salpingectomy. The abdominal cavity was deflated and each portal was sutured. The time taken for a laparoscopic salpingectomy was from the time all instruments entered the abdominal cavity until the laparoscopic salpingectomy was performed and instruments were removed. During the postoperative period, the bear was monitored for appetite, abnormal behavior, mortality, and wound hemorrhage.

Statistical analysis

The Cox proportional hazards model (Cox regression) was used to compare the duration of completing a salpingectomy within 300 seconds among Groups A, B, and C. Age, body weight, and the group categories of bears were included in the model as explanatory variables. The PHREG procedure within SAS software (SAS version 9.1, SAS Institute Inc., Cary, NC, USA) was used for this purpose. Kaplan-Meier curves were fitted for each group using MedCalc software (version 11.1, MedCalc Software, Mariakerke, Belgium). Differences between the survival curves were statistically examined using the log-rank test with the LIFETEST procedure in SAS software. Differences were considered statistically significant at p value of less than 0.05.

Results

Results of surgeon’s operation time are presented in Table 2. The operation time for groups A, B, and C were 12.61 ± 8.04 minutes, 5.35 ± 4.38 minutes, and 2.80 ± 1.16 minutes, respectively. The surgeon’s operation time was significantly shortened over time (Fig. 1). The operation time for laparoscopic salpingectomy decreased rapidly for the first 7 bears (p < 0.05). It then decreased gradually until the 66th case. Operation time of laparoscopic salpingectomy was significantly decreased and stabilized after 33 cases (p < 0.05).

Table 2 . Operation time (time to complete) for laparoscopic salpingectomy in Asiatic black bear.

GroupsNo. of bearsOperation time (time to complete)
Mean ± SDRange
A2212.61 ± 8.04a2.43-34.53
B225.35 ± 4.38b1.25-19.25
C222.80 ± 1.16b0.85-4.74
Total666.92 ± 6.710.85-34.53

Group B had a significantly shorter operation time than group A (p = 0.01), and group C had a significantly shorter operation time than group A (p = 0.001). No significant difference was recognized between group B and group C (p > 0.05)..



Figure 1. Number of repetitions required for proficiency. The laparoscopic salpingectomy time decreased rapidly up to the 7th repetition (arrow, p < 0.05) and gradually decreased thereafter. The number of repetitions that could stably complete the laparoscopic salpingectomy within 5 minutes was 33.

Table 3 shows factors affecting the hazard of completing salpingectomy by 5 minutes. Heart rate of bear had a significant effect on the hazard (p = 0.0001), whereas age and body weight of bears did not affect the hazard (p > 0.05). The hazard for completing salpingectomy was higher (p = 0.0001) in B (HR: 7.74) and C (HR: 19.37) groups than in the A group as shown by survival curves (Fig. 2). However, the hazard of completing salpingectomy by 5 minutes was not statistically different between B and C groups (p > 0.05).

Table 3 . Factors affecting the hazard of completion for salpingectomy by 5 minutes analyzed by PHREG procedure.

VariableHR95% CIp-value
Heart rate group
AReference
B7.742.227-26.885< 0.005
C19.375.555-67.568< 0.0001
Age> 0.05
Body weight> 0.05

HR, hazard ratio; CI, confidence interval..



Figure 2. Survival curves for the completion for salpingectomy by 5 minutes in the A, B and C groups. The hazard of completion for salpingectomy by 5 minutes was higher (p = 0.0001) in B and C groups than in the A group, whereas the hazard was not different between B and C groups (p > 0.05).

Discussion

Ovariohysterectomy is a surgical method commonly used for the treatment and prevention of reproductive diseases in animals as well as for neutering (2,13,18,21,38,41,42). It is commonly performed through either a ventral midline or a lateral flank approach (14,22,28,35,43). Although the ventral midline approach is preferable to the lateral flank approach in ovariohysterectomy, each method has its advantages and disadvantages (22,28,35,43). In large wild animals, the ventral midline approach may result in delayed wound healing at the surgical site and increased risk of potential rupture (9,27,31,34). Bears are wild animals that are dangerous and difficult to manage. Laparotomy to treat reproductive diseases in wild animals can cause various complications (8,27,34). For this reason, laparoscopy may be used to limit reproduction in female bears. In this study, laparoscopic salpingectomy was selected because the only purpose was to limit reproduction in captive bears.

Veterinarians with little experience in a skill should receive appropriate training to acquire that skill (39). The term “learning curve” as currently employed in surgery means that inexperienced surgeons have not only a longer operating time, but also a higher complication rate (1). Proficiency is assessed by a learning curve. The learning curve varies greatly depending on the complexity and difficulty of the surgery (26). Because the learning curve varies depending on the type of surgery and instruments used, surgeons need a new learning curve when using a new surgical method (19). In general, the definition of a learning curve has been proposed as “the number of cases required to become proficient for performing various surgical procedures”. Learning curves are currently being analyzed using various parameters (7,8,40). In laparoscopic surgery, proficiency is evaluated by bleeding, mortality rate, reoperation, and operation time (30,33). In this study, skill level was assessed by the time required for laparoscopic salpingectomy.

In the literature, the learning curve is given as 30 procedures for laparoscopic cholecystectomy (4,25), 60 procedures for endoscopic inguinal hernia repair (5), 100 procedures for laparoscopic gastric bypass (32), 110 cases for laparoscopic prostectomy (24), 88-152 procedures for laparoscopic colorectal surgery (23), and 200-250 procedures for prostate cancer surgery (36). Factors that can impede rapid skill acquisition in laparoscopic surgery include small number of cases suitable for surgical training, difficulties with video eye-hand coordination, altered perception of depth, and laparoscopic suturing (30). A study on learning curves of surgeons and students demonstrated that students required more repetitions to achieve curve stabilization than surgeons and that surgical experience reduced the learning curve (30). Therefore, the learning curve could be greatly influenced by the operator’s clinical experience and the number of repetitions of the surgery. In the present study, the operation time decreased rapidly up to 7 cases and continued to decrease until 66 cases. After 33 cases, the surgery was stably completed within 5 minutes. This reduction in time was due to the fact that surgeons gradually became accustomed to handling the instrument over time and had the ability to easily locate target abdominal organs. This stable skill level varies greatly depending on the complexity of the surgery, location of organs, and size of the patient. Therefore, as shown in this study, it is necessary to achieve a minimum level of proficiency even in the most basic laparoscopic surgery. It is reasonable to consider these results in a basic education program for veterinarians who want to perform a laparoscopic surgery.

In the clinical field, veterinarians must learn diagnostic skills to diagnose various causes. In human medicine, a learning curve is set for various diagnostic technologies and the minimum number of repetitions required to use the technology (10,44). Especially in the surgical field, more repetitive learning is needed depending on the complexity of the surgery and anatomical location (29). In the veterinary field, various equipment is being developed. At the same time, high-difficulty surgeries are being required. Thus, there is a need to establish a learning curve for each technology. Developing training programs of progressively increasing complexity, supported by learning aids such as simulators, cadaver workshops, and training case presentations, is pivotal in minimizing complications associated with the learning curve (1,17,37,44).

Conclusions

For sterilization of bears, laparoscopic salpingectomy is less invasive and more effective than a conventional surgical approach. Operation time of laparoscopic salpingectomy was significantly decreased for the first 7 bears. It then decreased gradually until the 66th case. The number of bears required for a low-volume veterinary surgeon to be proficient in laparoscopic salpingectomy is 33 or more. In laparoscopic surgery, it is necessary to achieve a minimum level of proficiency in order to minimize complications resulting from surgery. Thus, it is necessary to establish a basic training program for veterinarians who wish to perform a laparoscopic surgery.

Acknowledgements

This work was funded by an academic research program of Chungbuk National University in 2022.

Conflicts of Interest

The authors have no conflicting interests.

Fig 1.

Figure 1.Number of repetitions required for proficiency. The laparoscopic salpingectomy time decreased rapidly up to the 7th repetition (arrow, p < 0.05) and gradually decreased thereafter. The number of repetitions that could stably complete the laparoscopic salpingectomy within 5 minutes was 33.
Journal of Veterinary Clinics 2023; 40: 438-444https://doi.org/10.17555/jvc.2023.40.6.438

Fig 2.

Figure 2.Survival curves for the completion for salpingectomy by 5 minutes in the A, B and C groups. The hazard of completion for salpingectomy by 5 minutes was higher (p = 0.0001) in B and C groups than in the A group, whereas the hazard was not different between B and C groups (p > 0.05).
Journal of Veterinary Clinics 2023; 40: 438-444https://doi.org/10.17555/jvc.2023.40.6.438

Table 1 Age, body weight and crown rump length (CRL) of 66 Asiatic black bears (mean ± SD)

GroupNo. of bearsAge (year)Body weight (kg)CRL (cm)
A2213.18 ± 2.5994.01 ± 48.59123.45 ± 13.23
B2211.00 ± 4.4886.23 ± 31.39123.23 ± 26.43
C2212.32 ± 3.1789.41 ± 20.74129.32 ± 13.58
Total6612.17 ± 3.5789.91 ± 35.08125.33 ± 18.71

Table 2 Operation time (time to complete) for laparoscopic salpingectomy in Asiatic black bear

GroupsNo. of bearsOperation time (time to complete)
Mean ± SDRange
A2212.61 ± 8.04a2.43-34.53
B225.35 ± 4.38b1.25-19.25
C222.80 ± 1.16b0.85-4.74
Total666.92 ± 6.710.85-34.53

Group B had a significantly shorter operation time than group A (p = 0.01), and group C had a significantly shorter operation time than group A (p = 0.001). No significant difference was recognized between group B and group C (p > 0.05).


Table 3 Factors affecting the hazard of completion for salpingectomy by 5 minutes analyzed by PHREG procedure

VariableHR95% CIp-value
Heart rate group
AReference
B7.742.227-26.885< 0.005
C19.375.555-67.568< 0.0001
Age> 0.05
Body weight> 0.05

HR, hazard ratio; CI, confidence interval.


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Vol.41 No.2 April 2024

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