Robotic DIEP Flap Harvest through a Totally Extraperitoneal Approach Using a Single-Port Surgical Robotic System.

SUMMARY: Deep inferior epigastric artery perforator (DIEP) flap surgery is one of the most common techniques for breast reconstruction using abdominal tissue. Although the DIEP flap reduces donor-site morbidity when compared with the conventional free transverse rectus abdominis musculocutaneous flap, violation of the anterior rectus sheath, rectus muscle, and motor nerves cannot be avoided. To further minimize tissue damage in the donor site, the use of a surgical robotic system for DIEP flap harvest with a totally extraperitoneal approach has been suggested. This totally extraperitoneal approach has a long learning curve because of the narrow preperitoneal space and the difficulty of converting a potential space to an actual space. Thus, the authors suggest a single-port robotic system optimized for narrow surgical spaces as a feasible option for DIEP flap harvest by a totally extraperitoneal approach, which has a shorter learning curve.

Shorter operation time and improved surgical outcomes in laparoscopic donor right hepatectomy compared with open donor right hepatectomy.

BACKGROUND: Pure laparoscopic donor right hepatectomy is a complex procedure, and the safety and feasibility of this operation remain unclear. This study aimed to evaluate the clinical outcomes and learning curve of this operation performed by a single surgeon. METHODS: We retrospectively reviewed the initial 100 donors who underwent pure laparoscopic donor right hepatectomy or open donor right hepatectomy by a single surgeon from December 2012 to May 2019. Endpoints analyzed included intraoperative results, postoperative complications, and learning curve, which was evaluated using the cumulative sum method based on the operation time. We divided the pure laparoscopic donor right hepatectomy group into initial and recent groups based on the time point of overcoming the learning curve. RESULTS: The operative time was significantly shorter in the recent pure laparoscopic donor right hepatectomy group (n = 57; 181.0 ± 35.7 min) than in the open donor right hepatectomy (n = 50; 203.0 ± 37.3 min) and initial pure laparoscopic donor right hepatectomy (n = 43; 282.2 ± 59.2 min) groups (P < .001). Moreover, the length of hospital stay in the recent pure laparoscopic donor right hepatectomy group was significantly reduced compared to that in the open donor right hepatectomy group (7.7 ± 1.2 vs 5.8 ± 1.4; P < .001). The complication rate was reduced from 10% in the open donor right hepatectomy group and 8% in the initial pure laparoscopic donor right hepatectomy group to 2% in the recent pure laparoscopic donor right hepatectomy group. CONCLUSION: As technology advances, the surgical outcomes of pure laparoscopic donor right hepatectomy are comparable and the operation time of pure laparoscopic donor right hepatectomy is superior to those of open donor hepatectomy.

Perceptions of porta-celiac vascular models for hepatic surgery and their use in residency training.

BACKGROUND: Primary aspect of hepatic navigation surgery is the identification of source vascular details to preserve healthy liver which has a vascular anatomy quite challenging for the young surgeons. The purpose was to determine whether three-dimensional (3D) vascular pattern models of preoperative computed tomography (CT) images will assist resident-level trainees for hepatic surgery. METHODS: This study was based on the perception of residents who were presented with 5 different hepatic source vascular patterns and required to compare their perception level of CT, and 1:1 models in terms of importance of variability, differential of patterns and preoperative planning. RESULTS: All residents agree that models provided better understanding of vascular source and improved preplanning. Five stations provided qualitative assessment with results showing the usefulness of porta-celiac models when used as anatomical tools in preplanning (p = 0.04), simulation of interventional procedures (p = 0.02), surgical education (p = 0.01). None of the cases had scored less than 8.5. Responses related to understanding variations were significantly higher in the perception of the 3D model in all cases, furthermore 3D models were more useful for seniors in more complex cases 3 and 5. Some open-ended answers: "The 3D model can completely change the operation plan" One of the major factors for anatomical resection of liver transplantation is the positional relationship between the hepatic arteries and the portal veins. CONCLUSION: The plastic-like material presenting the hepatic vascularity enables the visualization of the origin, pattern, shape, and angle of the branches with appropriate spatial perception thus making it well-structured.

Interactive Virtual Reality Renal Models as an Educational and Preoperative Planning Tool for Laparoscopic Donor Nephrectomy.

OBJECTIVE: To evaluate the efficacy of interactive virtual reality (iVR) in providing a three-dimensional (3D) experience with the donor's anatomy for surgeons and patients, we present a retrospective, case-controlled study assessing the impact of iVR renal models prior to LDN on both surgical outcomes and patients' understanding of the procedure. MATERIALS AND METHODS: Twenty patients undergoing LDN were prospectively recruited; their contrast-enhanced CT scans were transformed into iVR models. An iVR platform allowed the surgeons to rotate and deconstruct the renal anatomy; patients could also view their anatomy as the procedure was explained to them. Questionnaires assessed surgeons' understanding of renal anatomy after CT alone and after CT+iVR. Surgeons also commented on whether iVR impacted their preoperative plan. Patients assessed their anatomical understanding and anxiety level before and after iVR. Surgical outcomes for the iVR cohort were compared to a retrospectively matched, non-iVR cohort of LDN patients. RESULTS: Surgeons altered their preoperative plan in 18 of 20 LDNs after viewing iVR models. Patients reported better understanding of their anatomy (5/5) and noted decreased preoperative anxiety (5/5) after viewing iVR. When compared to the non-iVR group, the iVR group had a 25% reduction in median operative time (P < .001). In terms of surgical outcomes, patients in the iVR group had a 40% lower median relative change in postoperative creatinine (P < .001). CONCLUSION: Preoperative viewing of iVR models altered the operative approach, decreased the operative time, and improved donor patient outcomes. iVR models also reduced patients' preoperative anxiety.

Measures to Increase Use of Multiple Arterial Grafts for Isolated Coronary Artery Bypass Grafting.

BACKGROUND: Use of multiple arterial grafts (MAGs) provides superior patency and long-term survival benefit compared with venous grafts during coronary artery bypass grafting (CABG). However, MAGs are used infrequently for CABG. We hypothesized that specific measures introduced at our institution would lead to an increase in the use of MAGs. STUDY DESIGN: Use of MAGs before and after introduction of bundled measures was compared. Measures included increased education in arterial graft harvesting, inclusion as a quality metric, and hiring of surgeon champions. Patients younger than 70 years who underwent first time, isolated CABG using at least 1 arterial graft were included. Number and type of grafts used were compared between time periods using chi-square test. Secondary outcomes included postoperative complications. Complications were compared between time periods, as well as between MAG and non-MAG recipients before and after propensity score matching using Fisher exact test and univariate logistic regression. Multivariable logistic regression was used to determine patient characteristics associated with MAG use. RESULTS: There were 2,169 patients included from 2012 to 2019. MAG use increased significantly after introduction of measures (21.1% to 41.9%; p < 0.001). Radial artery use with an internal mammary artery (0.3% to 16%; p < 0.001) and the use of triple arterial grafts increased significantly (0% to 2.4%; p < 0.001). MAG use in the entire cohort was associated with decreased 30-day mortality and postoperative cardiac arrest that was not significant after propensity matching. CONCLUSIONS: A programmatic emphasis on the use of MAGs for CABG is an effective method to increase its use.

Learning curves of minimally invasive donor nephrectomy in a high-volume center: A cohort study of 1895 consecutive living donors.

BACKGROUND: Few studies have investigated the learning curves of minimally invasive donor nephrectomy (MIDN) using the cumulative sum (CUSUM) analysis. In addition, no study has compared the learning curves of the different surgical MIDN techniques in one cohort study using the CUSUM analysis. This study aims to evaluate and compare learning curves for several MIDN using the CUSUM analysis. METHODS: A retrospective review of consecutive donors, who underwent MIDN between 1997 and 2019, was conducted. Three laparoscopic-assisted techniques were applied in our institution and included for analysis: laparoscopic (LDN), hand-assisted retroperitoneoscopic (HARP), and robot-assisted laparoscopic (RADN) donor nephrectomy. The outcomes were compared based on surgeon volume to develop learning curves for the operative time per surgeon. RESULTS: Out of 1895 MIDN, 1365 (72.0%) were LDN, 427 (22.5%) were HARP, and 103 (5.4%) were RADN. The median operative time and median blood loss were 179 (IQR, 139-230) minutes and 100 (IQR, 40-200) mL, respectively. The incidence of major complication was 1.2% with no mortality, and the median hospital stay was three (IQR, 3-4) days. The CUSUM analysis resulted in learning curves, defined by decreased operative time, of 23 cases in LDN, 45 cases in HARP, and 26 cases in RADN. CONCLUSIONS: Our study shows different learning curves in three MIDN techniques with equal post-operative complications. The LDN and RADN learning curves are shorter than that of the hand-assisted donor nephrectomy. Our observations can be helpful for informing the development of teaching requirements for fellows to be trained in MIDN.

Development and evaluation of stem cell collection procedure diagrams to support the education and recruitment of committed stem cell donors.

BACKGROUND: Diagrams which allow potential unrelated stem cell donors to visualize the stem cell collection process were hypothesized to support the recruitment and education of committed stem cell donors. STUDY DESIGN AND METHODS: A series of bone marrow and peripheral blood stem cell collection procedure diagrams were developed, featuring young adult male donors of varied ethnic backgrounds. Post-implementation, surveys were conducted to evaluate stakeholder perspective on the diagrams' utility. A quality improvement project was conducted at five stem cell drives from 2017 to 2018 at which recruiters did or did not show the diagrams to potential donors. Following the drives, registrants were invited to complete a survey exploring their experience, knowledge and attitude towards donation. RESULTS: The diagrams were implemented in Canada in 07/2016. Of 293 participating registrants (24·7% non-Caucasian males) recruited at five drives between 2017 and 2018, 76% (n = 197) were shown the diagrams. Participants who were shown the diagrams were significantly more likely to report that the recruiters appeared very knowledgeable (89% vs. 76%, P = 0·019) and to report improved self-reported knowledge of stem cell donation (P = 0·010) compared to participants not shown the diagram. Data are also shown demonstrating that stakeholders in donor recruitment used and valued the diagrams and that use of the diagrams was associated with improved donor recruitment outcomes in Canada. CONCLUSION: This report is the first evaluation of stem cell collection diagrams in the literature. The diagrams are relevant to donor registries, recruitment organizations and transplant centres worldwide, and their use may support efforts to educate and recruit committed, ethnically diverse donors.

Experimental Rat Model for Brain Death Induction and Kidney Transplantation.

Background: Experimental animal research has been pivotal in developing clinical kidney transplantation (KTx). One donor-associated risk factor with negative affect of transplantation outcome is brain death (BD). Many rat models for BD and KTx have been developed in the last decade, but no surgical guidelines have been developed for these models. Here, we describe a surgical technique for BD induction and the cuff technique for experimental KTx in rats.Methods: After intubation and mechanically ventilation of sixteen healthy adult male Sprague-Dawley rats were induction of BD performed. Animals were kept hemodynamically stable for eight hours. Then, the kidney was prepared and perfused with standard histidine-tryptophan-ketoglutarate solution. After explantation, grafts were immediately implanted in recipients using the cuff technique and reperfused. After 2 h of observation, animals were sacrificed by intravenous administration of potassium chloride.Results: In the early phase of BD, heart rate increased and mean arterial pressure decreased. Partial variations were observed in O2 partial pressure, O2 saturation, and HCO3. During the 2-h observation phase, all transplanted kidneys were sufficiently perfused macroscopically. There was no hyperacute rejection.Conclusions: It is feasible to observe BD for 8 h with maintained circulation in small experimental settings. The cuff technique for KTx is simple, the complication rate is low, and the warm ischemia time is short, therefore, this could be a suitable technique for KTx in the rat model.

Learning curve of two common Descemet membrane endothelial keratoplasty graft preparation techniques.

OBJECTIVE: To compare the learning curve of two Descemet membrane endothelial keratoplast (DMEK) graft preparation techniques. DESIGN: Experimental study. PARTICIPANTS: Twenty paired donor corneoscleral rims. METHODS: The corneas were randomized to DMEK peeling using the peripheral blunt dissection technique (n = 10) or the modified submerged cornea using backgrounds away (mSCUBA) technique (n = 10). Outcome measures included graft peeling time, surgeon's peeling difficulty grading (on a scale of 1 to 10, 1 being the easiest and 10 the hardest), number of tears, and percentage tissue loss. RESULTS: Average graft peeling time using the peripheral blunt dissection technique and the mSCUBA technique was 15.75 ± 4.01 minutes and 8.43 ± 3.26 minutes, respectively (p < 0.0005). The first 3 grafts' average peeling time was longer than the last 7 grafts: 19.14 ± 2.40 versus 14.21 ± 3.50 minutes in the peripheral blunt dissection technique (p = 0.06) and 12.36 ± 3.76 versus 6.67 ± 0.49 minutes in the mSCUBA technique (p = 0.016). In the latter, there were significantly fewer radial tears compared to the former: 1.5 ± 1.0 and 3.1 ± 1.9, respectively (p = 0.049). No tissue loss was noted in the mSCUBA group compared to one (10%) in the peripheral blunt dissection group. The average difficulty grading for the mSCUBA was significantly lower than the peripheral blunt dissection technique: 3.3 ± 1.9 and 5.8 ± 1.6, respectively (p = 0.024). CONCLUSIONS: Our study suggests a shorter learning curve with the mSCUBA technique for DMEK graft preparation, with shorter peeling time and fewer complications in comparison to the peripheral blunt dissection technique.

The learning curve in pure laparoscopic donor right hepatectomy: a cumulative sum analysis.

BACKGROUND: Although the use of pure laparoscopic donor hepatectomy (PLDH) is increasingly common, it remains limited to a few experienced centers and no data on the learning curve are currently available. The aim of this study is to evaluate the learning curve associated with the use of pure laparoscopic donor right hepatectomy (PLDRH). METHODS: Data from donors undergoing PLDRH performed by a single surgeon between November 2015 and October 2017 were retrospectively reviewed. The learning curve was evaluated using the cumulative sum (CUSUM) method based on duration of surgery. RESULTS: Of 100 donors evaluated, none required transfusion or conversion to open hepatectomy and no irreversible disability or mortality was reported. The mean operative time was 320.7 ± 51.8 min, and all grafts were successfully transplanted. The CUSUM analysis demonstrated a learning curve of approximately 60 cases of PLDRH. Estimated total liver volume > 1400 cm3 and double portal vein orifices were seen to be risk factors for longer surgery time. Having adjusted for case mix with these factors, the risk-adjusted CUSUM analysis demonstrated a learning curve of 65-70 cases of PLDRH. CONCLUSIONS: In conclusion, PLDRH is a feasible and safe procedure with a learning curve of 65-70 cases.

Initial Experience With Hand-Assisted Laparoscopic Living Donor Nephrectomy: Training and Clinical Practice as a General Surgeon.

BACKGROUND: To analyze our initial results of hand-assisted laparoscopic living donor nephrectomy, executed by a skilled gastrointestinal surgeon. METHODS: A total of 22 consecutive patients underwent the hand-assisted laparoscopic living donor nephrectomy between December 2014 and January 2017. We retrospectively analyze the patient's perioperative clinical data, which were collected prospectively. RESULTS: The right kidney was harvested in 12 patients. The mean operative time and intraoperative blood loss was 241.0 ± 43.4 minutes (range, 140-310 min) and 293.2 ± 203.1 mL (range, 50-700 mL), respectively. The mean warm ischemic time was 288.4 ± 103.4 seconds (range, 179-610 s). Postoperative complications included chyle leakage in 2 patients who were left kidney donors and oliguria in 1 patient who was a right kidney donor. All patients recovered with conservative care, and the mean hospital stay was 7.5 ± 1.7 days. The mean creatinine level was 0.7 ± 0.2 mg/dL before surgery, 1.1 ± 0.3 mg/dL at postoperative day (POD) 1, and 1.0 ± 0.2 mg/dL after discharge. The mean glomerular filtration rate was 97.9 ± 18.2 mL/min/1.73 m2 before surgery, 60.7 ± 10.4 at POD 1, and 67.3 ± 11.1 after discharge. Operation time was not associated with patient body mass index and case number. No significant differences, other than postoperative complications, were found in the perioperative data for the side of kidney donation. CONCLUSION: A skilled surgeon with experience in laparoscopic abdominal surgery (such as gastrectomy or colectomy) might safely perform hand-assisted donor nephrectomy. However, we could not identify a clear case number to complete the learning curve.

Cumulative sum analysis of the learning curve for video-assisted minilaparotomy donor nephrectomy in healthy kidney donors.

Video-assisted minilaparotomy surgery (VAMS) is a hybrid of open and laparoscopic surgical techniques, so has advantages of both approaches. Here, we examined the learning curve for this procedure.We retrospectively evaluated 50 consecutive patients who underwent VAMS donor nephrectomy performed by a single surgeon (YEY) between March 2015 and March 2016. The learning curve was evaluated using the cumulative sum (CUSUM) method. Measures of surgical performance included total operation time, warm ischemic time, and estimated blood loss.The mean patient age, body mass index, and body surface area were 43.5 years, 23.8 kg/m, and 1.7 m, respectively. The mean operation time and warm ischemic time were 160.0 minutes and 124.4 seconds. The learning curve of total operation time was best modeled as a second-order polynomial with equation CUSUMOT (minutes) = -0.3802 × case number + 20.315 × case number - 41.333 (R = 0.7707). The curve included 3 unique phases: phase 1 (the initial 17 cases), which is the initial learning curve; phase 2 (the middle 23 cases), expert competence, and phase 3 (the subsequent cases), mastery. In terms of warm ischemic time and estimated blood loss, the initial learning was achieved after 16 cases and after 9 to 10 cases, one could achieve competency.The VAMS donor nephrectomy learning curve is shorter than for laparoscopic or robotic hand-assisted donor nephrectomy. Surgeons can become familiar with the procedure and perform it without complications after approximately 16 to 17 operations.

A porcine model for robotic training harvest of the rectus abdominis muscle.

Conventional open surgical approaches for the harvesting of the rectus abdominis muscle carry a high risk of morbidity. It is possible to reduce these risks by using laparoscopy or robot-assisted techniques. This work hypothesizes that a porcine model could be used for learning the robot-assisted collection of the rectus abdominis. The rectus abdominis was taken in 3 stages in 3 pigs: installation of the robot, surgical approaches with 4 trocars, dissection and collection of the muscle. The average operating time was 1h20min and the average muscular length was 16cm. Our results showed a learning curve for the robot-assisted harvesting of the rectus abdominis on a porcine model.

Learning DMEK From YouTube.

PURPOSE: To evaluate the outcomes of the first cases of Descemet membrane endothelial keratoplasty (DMEK) performed by an anterior segment surgeon, learning the procedure, including graft preparation, primarily from watching YouTube videos. DMEK surgery was not learned during fellowship training; there was no attendance at DMEK courses, no witnessing of live surgery, and no supervision by an experienced DMEK surgeon. All graft tissue was prepared by the surgeon on the day of surgery. METHODS: This is a retrospective review of the 3-month postoperative results of the first 40 consecutive cases. The success rate of graft preparation, intraoperative and postoperative complications, spectacle-corrected visual acuity, endothelial cell density, and central corneal thickness were evaluated. RESULTS: Grafts were successfully prepared in all cases with no loss of donor tissue. DMEK surgery was successful in 39 of 40 eyes with the one failure occurring in a vitrectomized eye without an intact iris-lens diaphragm. Spectacle-corrected visual acuity was ≥6/6 in 23 of the 25 eyes without comorbidity. Mean endothelial cell density was 1515 (±474) cells/mm. Mean central corneal thickness decreased from 624 (±40) µm preoperatively to 513 (±34) µm postoperatively. CONCLUSIONS: Although formal training is desirable, good results can be obtained by an anterior segment surgeon learning DMEK, including graft preparation, without it. DMEK should no longer be considered a procedure with a long learning curve in routine cases.

An Artificial Cadaveric Leg Blood Flow System for Endoscopic Vein Harvesting Simulation.

Despite being the most common training model for endoscopic vein harvesting, cadaveric legs are limited by their absence of blood flow, resulting in a faded vascular appearance. Because the saphenous vein and the surrounding tissue seem less distinguishable, dissection of the saphenous vein and bipolar coagulation of its branches becomes increasingly inefficient and difficult. An inexpensive artificial blood flow system was developed to overcome this limitation. A cadaveric leg was thawed to a soft and yielding degree, and the saphenous vein was dissected medial and proximal to the medial malleolus. An artificial blood solution was prepared by dissolving 4% protein powder, red dye, and a contrast agent-for x-ray visualization-in saline. The solution was perfused through the saphenous vein and artery. The open ends of the vessels were temporarily clamped after the perfusion had been completed. Blood flow within the vessels was confirmed via angiography and endoscopic visualization of the leg's vessels. A bleeding effect was observed when the saphenous vein was perforated or when a vascular branch was transected. Conversely, a tight seal indicated successful bipolar coagulation of a branch, providing an objective, quantifiable assessment parameter. The artificial blood flow system helps overcome the limitations of the cadaveric leg, creating a more realistic and inexpensive model for endoscopic vein harvesting simulation training.

Evolution of Technique in Laparoscopic Donor Nephrectomy: A Single Center Experience.

BACKGROUND: Renal transplantation is the most successful therapy for improving survival and quality of life for end-stage renal disease (ESRD). Living donor kidney transplantation (LDKTx) has been used as an alternative to reduce the stay on the waiting list of patients with ESRD. Laparoscopic donor nephrectomy (LDN) has become the standard procedure for LDKTx. OBJECTIVE: This study aims to describe evolution of surgical technique with LDN at our institute. MATERIALS AND METHODS: We retrospectively analyzed our experience with LDN performed from January, 2003 to November, 2016, focusing on describing modifications of the surgical technique and devices made during those years. Demographics, operative factors, and postoperative complications of donors were reviewed. RESULTS: From the beginning of our experience with LDKTx we have performed 185 cases. From 2003 to 2016, 144 LDN were performed. Modifying our technique in response to the learning curve, complications encountered, and technological advancements, we experienced low complication rates. CONCLUSIONS: Continual refinement with LDN techniques based on intraoperative observations and technological advances is necessary to keep complication rates low and reduce donor morbidity and time for recovery.

Development of a human cadaver model for training in laparoscopic donor nephrectomy.

BACKGROUND: The organ procurement network recommends a surgeon record 15 cases as surgeon or assistant for laparoscopic donor nephrectomies (LDN) prior to independent practice. The literature suggests that the learning curve for improved perioperative and patient outcomes is closer to 35 cases. In this article, we describe our development of a model utilizing fresh tissue and objective, quantifiable endpoints to document surgical progress, and efficiency in each of the major steps involved in LDN. MATERIALS AND METHODS: Phase I of model development focused on the modifications necessary to maintain visualization for laparoscopic surgery in a human cadaver. Phase II tested proposed learner-based metrics of procedural competency for multiport LDN by timing procedural steps of LDN in a novice learner. RESULTS: Phases I and II required 12 and nine cadavers, with a total of 35 kidneys utilized. The following metrics improved with trial number for multiport LDN: time taken for dissection of the gonadal vein, ureter, renal hilum, adrenal and lumbrical veins, simulated warm ischemic time (WIT), and operative time. CONCLUSION: Human cadavers can be used for training in LDN as evidenced by improvements in timed learner-based metrics. This simulation-based model fills a gap in available training options for surgeons.

[Quality of corneal tissue procured by trained non-ophthalmologist medical personnel]. / Calidad de tejido corneal procurado por personal médico no oftalmólogo capacitado.

BACKGROUND: The cornea is the first tissue awaiting transplantation at a national level. It is imperative to train health personnel in procurement technique with excision of corneoscleral button in situ. The objective was to compare the quality of corneal tissue procured by social service medical interns and Ophthalmology residents in a third level hospital. METHODS: We performed a quasi-experimental pilot study with two groups: group 1, which included trained social service medical interns, and group 2, which included trained residents of Ophthalmology. RESULTS: 10 participants in two groups had a mean endothelial cell density of 2662.35 ± 223.92, a percentage of hexagonal cells of 53.89 ± 5.61 %, and a coefficient of variation of 0.43 ± 0.06 in group 1; also, and respectively, group 2 presented these results: 2656.44 ± 156.14, 64.15 ± 5.90 %, and 0.45 ± 0.06. The macroscopic and microscopic quality of procured corneal tissues was similar in both groups. Besides the learning curve and complications were minimal. CONCLUSION: All trained medical personnel acquired skills necessary to obtain optimal corneal tissue.

A comprehensive review on learning curve associated problems in endoscopic vein harvesting and the requirement for a standardised training programme.

Endoscopic vein harvesting is becoming one of the most favourable vein harvesting techniques in multiple bypass coronary surgery, due to its short term post-operative benefits with high patient satisfaction. However, long-term graft patency has been both supported and questioned in the literature. Graft failure can be affected by harvesting methods and operator's experience. Endoscopic vein harvesting is associated with a learning curve period, during which the incidence of vein trauma is high due to unfamiliarity with the surgical technique. There is a paucity of structured learning tools for novice practitioners, meaning that training differs significantly between hospital centres. Inconsistent training methods can lead to poor surgical technique, which can have a significant impact on vein quality and stress level of the practitioner. In turn, this can lead to increased postoperative complications and longer surgical duration. The main aim of this literature review is to understand the impact of the learning curve on the vein conduit and whether there is a requirement for a standardised training programme for the novice practitioners.