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Follow-up Study Comparing Open Hysterectomy of Expert Surgeon and Laparoscopic Approach (Learning Curve)
            was demonstrated. These finding might be due to more complex     4.  Mán E, Németh T, et al. Learning curve after rapid introduction of
            and high risk patients accepted by expert surgeons. Another study   laparoscopic appendectomy: are there any risks in surgical resident
            confirmed that the effect of change in the character of patients,   participation? World J Emerg Surg 2016. DOI: 10.1186/s13017-016-
                                                          17
            tendency of complicated cases accepted by expert surgeons.    0074-5.
               The main reason for the conversion rate is usually a complication.     5.  Raja RJ. The Impact of the Learning Curve in Laparoscopic
                                                                    Surgery. World J Laparoscopic Surg 2008;1(1):56–59. DOI: 10.5005/
            So, conversion and complication rate are more in learning curve in   jp-journals-10007-1048.
            the present study. There was no case of conversion to open surgery     6.  Terzi H, Biler A, et al. Total laparoscopic hysterectomy: Analysis of the
            in laparoscopy patients.                                surgical learning curve in benign conditions. Int J Surg November
                                                                    2016;35:51–57. DOI: 10.1016/j.ijsu.2016.09.010.
            Learning Curve                                        7.  Perino A, Cucinella G, et al. Total laparoscopic hysterectomy versus
            Transfusion                                             total abdominal hysterectomy: an assessment of the learning curve in
            In the present study, transfusion during and after surgery did   a prospective randomized study. Human Reprod 1999;14:2996–2999.
                                                                    DOI: 10.1093/humrep/14.12.2996.
            not differ significantly between the laparoscopy and laparotomy     8.  Lirk P, Thiry J, et al. Pain management after laparoscopic hysterectomy:
            groups. In the laparoscopic surgery, blood loss is expected to be   systematic review of literature and PROSPECT recommendations. BMJ
            less than open surgery. A study in the laparoscopic and laparotomy   Feb 2019. DOI: 10.1136/rapm-2018-100024.
            hysterectomy showed that bleeding during laparoscopic surgery     9.  Chapron C, Dubuisson JB, et al. Total laparoscopic hysterectomy:

            was less than open surgery (p < 0.001). The average intraoperative   preliminary results. Hum Reprod 1994;9:2084–2089. DOI: 10.1093/
            blood loss was lower in laparoscopic hysterectomy than in   oxfordjournals.humrep.a138398.
                                       17
            abdominal hysterectomy (p ≤ 0.001).                  10.  Chapron C, Fauconnier A, et al. Laparoscopic surgery is not inherently

                                                                    dangerous for patients presenting with benign gynaecologic
                                                                    pathology. Results of a meta-analysis. Hum Reprod 2002;17:
            conclusIon                                              1334–1342. DOI: 10.1093/humrep/17.5.1334.
                                                                 11.  www.hkcog.org.hk/hkcog/Download/endo_levels_July2006.pdf.
            In the present study, hysterectomy patients were operated on in two     12.  Mishra RK. Text book of Practical Laparoscopic Surgery. In: Mishra RK.
            groups of laparoscopy (learning curve) and open surgery of expert   ed. Role of Training in Minimal Access Surgery, 3rd ed., New Delhi:
            and radical surgeon, which did not differ in terms of complications,   Jaypee Brothers Medical Publisher (P) Ltd; 2013. pp. 532–539.
            transfusion, duration of hospitalization, and readmission. However,     13.  Papachristofi O, Jenkins D, et al. Assessment of learning curves in
            the surgical time was significantly longer in the laparoscopy group.   complex surgical interventions: a consecutive case-series study. BMS
            This study encourages starting laparoscopy method instead of   Series June 2016. DOI: 10.1186/s13063-016-1383-4.
            open surgery, even in setting of expert open surgeons, and even     14.  Michel LA. Epistelogy of evidence-based medicine. Surg Endosc
                                                                    2007;21(2):146. DOI: 10.1007/s00464-006-0905-7.
            in advanced (level 4) surgery such as hysterectomy.    15.  Verdaasdonk EGG, Stassen LPS, et al. Problems with technical
               In the present study, the surgeon was a gyneco-oncologist   equipment during laparoscopic surgery. Surg Endosc 2007;21:
            and was very familiar to pelvic anatomy and an expert in open   275–279. DOI: 10.1007/s00464-006-0019-2.
            surgery. Probably, equal complication, transfusion, hospital stay,     16.  Mavrona R, Radosa JC, et al. Learning curves for laparoscopic
            and readmission of laparoscopic hysterectomy in her learning   hysterectomy after implementation of minimally invasive surgery.
            curve in comparison to her open surgery were due to prolonged   Researchgate May 2016.
            experience in radical surgeries and might not be the case of every     17.  Bozkurt N, Yildiz S, et al. Total Laparoscopic Hysterectomy: Learning
            open surgeon.                                           Curve of a Single Surgeon with 40 Cases. The journal of minimally
                                                                    invasive Gynecology. November–December, 2013;20(6):S150.
               Another point is no attention and data collection regarding     18.  Graves N, Janda M, et al. The cost-effectiveness of total laparoscopic
            patient satisfaction with her operation and work return delay after   hysterectomy compared to total abdominal hysterectomy for the
            each method of surgery, laparoscopy and open, which are the main   treatment of early stage endometrial cancer. J Health Econ 2012.
            advantages of laparoscopic surgery.                  19.  Marana R, Busacca M, et al. Laparoscopically assisted vaginal
                                                                    hysterectomy versus total abdominal hysterectomy: a prospective,
                                                                    randomized, multicenter study. Am J Obstet Gynecol 1999;180:
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              2.  Hurd W, Rivlin ME. Gynecologic Laparoscopy. emedicine.medscape.    21.  Torng PL, Pan SP, et al. Learning curve in concurrent application
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             8    World​Journal​of​Laparoscopic​Surgery,​Volume​12​Issue​1​(January–April​2019)
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