Incorporating New Technology into a Surgical Technique: The Learning Curve of a Single Surgeon's Stereo-Electroencephalography Experience

BACKGROUND: Technological improvements frequently outpace the publication of randomized, controlled trials in surgical patients. This makes the application of new surgical techniques difficult as surgeons solely use clinical experience to guide changes in their practice. OBJECTIVE: To quantitatively examine the learning curve of incorporating new technology into a surgical technique and discuss the clinical significance of incorporating this new technology into daily practice. To identify areas of improvement for operative efficiency and safety. METHODS: A retrospective observational study examining quantitative measures of operative efficiency and safety from 2009 to 2017 in 454 consecutive patients undergoing stereo-electroencephalography depth electrode implantations. RESULTS: The transition to a new robotic technique significantly improved operative times (196 min [95% CI 173-219] vs 115 min [95% CI 111-118], P <. 0001). Cumulative sum (CUSUM) analysis demonstrated that mastery of the robotic technique took much longer than the frame-based technique (operative time peak at case 75 vs case 25, plateau of 150 vs 10 cases). Although hemorrhage rates using different vascular imaging techniques did not appear to differ using traditional statistical analysis (magnetic resonance imaging, MRI 22.3%, computed tomography angiography, CTA 17.9%, angiogram 18.1%, likelihood ratio χ² = 4.84, P =. 30), CUSUM analysis suggested MRI as the vascular imaging modality leading to higher hemorrhage and symptomatic hemorrhage rates at our center. CONCLUSION: This experience demonstrates an improvement in operative efficiency through a series of changes made using clinical experience and intuition while transitioning to a completely new paradigm. CUSUM analysis identified potential areas for improvement in both operative efficiency and safety if used in a prospective manner.