Development of a difficulty scoring system for laparoscopic pancreatoduodenectomy in the initial stage of the learning curve: a retrospective cohort study.

BACKGROUND: It remains uncertain how surgeons can safely pass the learning curve of laparoscopic pancreatoduodenectomy (LPD) without potentially harming patients. We aimed to develop a difficulty scoring system (DSS) to select an appropriate patient for surgeons. MATERIALS AND METHODS: A total of 773 elective pancreatoduodenectomy surgeries between July 2014 and December 2019, including 346 LPD and 427 open pancreatoduodenectomy cases, were included. A 10-level DSS for LPD was developed, and an additional 77 consecutive LPD surgeries which could provide information of the learning stage I of LPD externally validated its performance between December 2019 and December 2021. RESULTS: The incidences of postoperative complications (Clavien-Dindo≥III) gradually decreased from the learning curve stage I-III (20.00, 10.94, 5.79%, P =0.008, respectively). The DSS consisted of the following independent risk factors: (1) tumor location, (2) vascular resection and reconstruction, (3) learning curve stage, (4) prognostic nutritional index, (5) tumor size, and (6) benign or malignant tumor. The weighted Cohen's κ statistic of concordance between the reviewer's and calculated difficulty score index was 0.873. The C -statistics of DSS for postoperative complication (Clavien-Dindo≥III) were 0.818 in the learning curve stage I. The patients with DSS<5 had lower postoperative complications (Clavien-Dindo≥III) than those with DSS≥5 (4.35-41.18%, P =0.004) in the training cohort and had a lower postoperative pancreatic fistula (19.23-57.14%, P =0.0352), delayed gastric emptying (19.23-71.43%, P =0.001), and bile leakage rate (0.00-21.43%, P =0.0368) in validation cohort in the learning curve stage I. CONCLUSION: We developed and validated a difficulty score model for patient selection, which could facilitate the stepwise adoption of LPD for surgeons at different stages of the learning curve.

Technical details of a left-side approach to the superior mesenteric artery during pancreaticoduodenectomy.

BACKGROUND AND PURPOSE: To describe the procedure for a left-side approach to the superior mesenteric artery (SMA) during pancreaticoduodenectomy (PD) in a cadaveric study. OPERATIVE PROCEDURE: After dividing the upper jejunum, the jejunal artery (JA) is followed to its origin. At the cranial side of the JA, the mesojejunum to be dissected is detached from the ventral to the dorsal side and from the peripheral to the origin side of the SMA. The inferior pancreatoduodenal artery (IPDA), which is usually the common trunk of the IPDA and the first JA, is able to be visualized at the cranio-dorsal side of the origin of the JA. After cutting the IPDA, the mesojejunum can be detached from the SMA from the dorsal aspect to the right side. Subsequently, the pancreas head is dissected easily from the right aspect of the SMA. CONCLUSION: This left-side approach to the SMA may become a standard procedure.

Learning curve of laparoscopic and robotic pancreas resections: a systematic review.

BACKGROUND: Minimally invasive pancreatic resection has been shown recently in some randomized trials to be superior in selected perioperative outcomes compared with open resection when performed by experienced surgeons. However, minimally invasive pancreatic resection is associated with a long learning curve. This study aims to summarize the current evidence on the learning curve of minimally invasive pancreatic resection and define the number of cases required to surmount the learning curve. METHODS: A systematic search was performed on PubMed, Embase, Scopus, and the Cochrane database using a detailed search strategy. Studies that did not describe the learning curve were excluded from the study. Data on the method of learning curve analysis, single surgeon versus institutional learning curve, and outcome measures were extracted and analyzed. RESULTS: A total of 32 studies were included in the pooled analysis: 12 on laparoscopic pancreatoduodenectomy, 9 on robotic pancreatoduodenectomy, 12 on laparoscopic distal pancreatectomy, and 3 on robotic distal pancreatectomy. Sample population was comparable between laparoscopic pancreatoduodenectomy and robotic pancreatoduodenectomy (median 63 vs 65). Six of 12 studies and 7 of 9 studies used nonarbitrary methods of analysis in laparoscopic pancreatoduodenectomy and robotic pancreatoduodenectomy, respectively. Operating time was used as the single outcome measure in 4 of 12 studies in laparoscopic pancreatoduodenectomy and 5 of 9 studies in robotic pancreatoduodenectomy. Overall, there was no significant difference between the number of cases required to surmount the learning curve for laparoscopic pancreatoduodenectomy versus robotic pancreatoduodenectomy (laparoscopic pancreatoduodenectomy 34.1 [95% confidence interval 30.7-37.7] versus robotic pancreatoduodenectomy 36.7 [95% confidence interval 32.9-41.0]; P = .8241) and laparoscopic distal pancreatectomy versus robotic distal pancreatectomy (laparoscopic distal pancreatectomy 25.3 [95% confidence interval 22.5-28.3] versus robotic distal pancreatectomy 20.7 [95% confidence interval 15.8-26.5]; P = .5997.) CONCLUSION: This study provides a detailed summary of existing evidence around the learning curve in minimally invasive pancreatic resection. There was no significant difference between the learning curve for robotic pancreatoduodenectomy versus laparoscopic pancreatoduodenectomy and robotic distal pancreatectomy versus laparoscopic distal pancreatectomy. These findings were limited by the retrospective nature and heterogeneity of the studies published to date.

Formal robotic training diminishes the learning curve for robotic pancreatoduodenectomy: Implications for new programs in complex robotic surgery.

INTRODUCTION: The learning curve associated with robotic pancreatoduodenectomy (RPD) is a hurdle for new programs to achieve optimal results. Since early analysis, robotic training has recently expanded, and the RPD approach has been refined. The purpose of this study is to examine RPD outcomes for surgeons who implemented a new program after receiving formal RPD training to determine if such training reduces the learning curve. METHODS: Outcomes for consecutive patients undergoing RPD at a single tertiary institution were compared to optimal RPD benchmarks from a previously reported learning curve analysis. Two surgical oncologists with formal RPD training performed all operations with one surgeon as bedside assistant and the other at the console. RESULTS: Forty consecutive RPD operations were evaluated. Mean operative time was 354 ± 54 min, and blood loss was 300 ml. Length of stay was 7 days. Three patients (7.5%) underwent conversion to open. Pancreatic fistula affected five patients (12.5%). Operative time was stable over the study and lower than the reported benchmark. These RPD operative outcomes were similar to reported surgeon outcomes after the learning curve. CONCLUSION: This study suggests formal robotic training facilitates safe and efficient adoption of RPD for new programs, reducing or eliminating the learning curve.

Evaluation of the learning curve for laparoscopic pancreatoduodenectomy by CUSUM analyses. Cohort study.

INTRODUCTION: Laparoscopic pancreatoduodenectomy (LPD) remains an extremely demanding surgery. The purpose of this study was to describe the learning curve required for its safe implementation. METHODS: Fifty consecutive patients undergoing LPD were retrospectively reviewed. The learning curve was clustered into 4 groups: A, B and C (initial phase, n = 10 each) and D (consolidation phase, n = 20). Cumulative Sum (CUSUM) analysis was applied to operative time, conversion rate and severe postoperative complications. RESULTS: No significant differences were observed among groups and phases concerning specific and general postoperative complications, oncological outcomes or mortality. The conversion rate significantly reduced from 90% (9) in Group A to 40% (4) in Group C (p < 0.01). Operative time was longer in the consolidation phase (median of 506 vs 437 min, p < 0.01). Conversely, hospital stays were shorter during the consolidation phase (8 vs 15 days, p < 0.01). CUSUM analysis identified 20-25cases as being enough to complete the learning curve if operative time and severe complications are analysed, while 40 cases would be needed for considering the conversion rate. CONCLUSIONS: The learning curve in LPD can be completed after 20-25 procedures. This information will help to design programmes for introducing new surgeons to this technique.

Outcome of robot-assisted pancreaticoduodenectomy during initial learning curve versus laparotomy.

To analyze the initial learning curve (LC) for robot-assisted pancreaticoduodenectomy (RAPD) and compare RAPD during the initial LC with open pancreaticoduodenectomy (OPD) in terms of outcome. This study is a retrospective review of patients who consecutively underwent RAPD and OPD between October 2015 and January 2020 in our hospital. 41 consecutive RAPD cases and 53 consecutive open cases were enrolled for review. Compared with OPD, RAPD required a significantly longer operative time (401.1 ± 127.5 vs. 230.8 ± 44.5 min, P < 0.001) and higher cost (194621 ± 78342 vs. 121874 ± 39973 CNY, P < 0.001). Moreover, compared with the OPD group, the RAPD group revealed a significantly smaller mean number of lymph nodes harvested in malignant cases (15.6 ± 5.9 vs 18.9 ± 7.3, P = 0.025). No statistically significant differences were observed between the two groups in terms of incidence of Clavien-Dindo grade III-V morbidities and 90-day mortality and readmission (P>0.05). In the CUSUM graph, one peak point was observed at the 8th case, after which the operation time began to decrease. LC for RAPD may be less than 30 cases, and RAPD is safe and feasible during the initial LC.

Association of Mentorship and a Formal Robotic Proficiency Skills Curriculum With Subsequent Generations' Learning Curve and Safety for Robotic Pancreaticoduodenectomy.

Importance: Learning curves are unavoidable for practicing surgeons when adopting new technologies. However, patient outcomes are worse in the early stages of a learning curve vs after mastery. Therefore, it is critical to find a way to decrease these learning curves without compromising patient safety. Objective: To evaluate the association of mentorship and a formal proficiency-based skills curriculum with the learning curves of 3 generations of surgeons and to determine the association with increased patient safety. Design, Setting, and Participants: All consecutive robotic pancreaticoduodenectomies (RPDs) performed at the University of Pittsburgh Medical Center between 2008 and 2017 were included in this study. Surgeons were split into generations based on their access to mentorship and a proficiency-based skills curriculum. The generations are (1) no mentorship or curriculum, (2) mentorship but no curriculum, and (3) mentorship and curriculum. Univariable and multivariable analyses were used to create risk-adjusted learning curves by surgical generation and to analyze factors associated with operating room time, complications, and fellows completing the full resection. The participants include surgical oncology attending surgeons and fellows who participated in an RPD at University of Pittsburgh Medical Center between 2008 and 2017. Main Outcomes and Measures: The primary outcome was operating room time (ORT). Secondary outcomes were postoperative pancreatic fistula and Clavien-Dindo classification higher than grade 2. Results: We identified 514 RPDs completed between 2008 and 2017, of which 258 (50.2%) were completed by first-generation surgeons, 151 (29.3%) were completed by the second generation, and 82 (15.9%) were completed by the third generation. There was no statistically significant difference between groups with respect to age (66.3-67.3 years; P = .52) or female sex (n = 34 [41.5%] vs n = 121 [46.9%]; P = .60). There was a significant decrease in ORT (P < .001), from 450.8 minutes for the first-generation surgeons to 348.6 minutes for the third generation. Additionally, across generations, Clavien-Dindo classification higher than grade 2 (n = 74 [28.7%] vs n = 30 [9.9%] vs n = 12 [14.6%]; P = .01), conversion rates (n = 18 [7.0%] vs n = 7 [4.6%] vs n = 0; P = .006), and estimated blood loss (426 mL vs 288.6 mL vs 254.7 mL; P < .001) decreased significantly with subsequent generations. There were no significant differences in postoperative pancreatic fistula. Conclusions and Relevance: In this study, ORT, conversion rates, and estimated blood loss decreased across generations without a concomitant rise in adverse patient outcomes. These findings suggest that a proficiency-based curriculum coupled with mentorship allows for the safe introduction of less experienced surgeons to RPD without compromising patient safety.

Robotic Pancreatoduodenectomy: Patient Selection, Volume Criteria, and Training Programs.

INTRODUCTION: There has been a rapid development in minimally invasive pancreas surgery in recent years. The most recent innovation is robotic pancreatoduodenectomy. Several studies have suggested benefits as compared to the open or laparoscopic approach. This review provides an overview of studies concerning patient selection, volume criteria, and training programs for robotic pancreatoduodenectomy and identified knowledge gaps regarding barriers for safe implementation of robotic pancreatoduodenectomy. MATERIALS AND METHODS: A Pubmed search was conducted concerning patient selection, volume criteria, and training programs in robotic pancreatoduodenectomy. RESULTS: A total of 20 studies were included. No contraindications were found in patient selection for robotic pancreatoduodenectomy. The consensus and the Miami guidelines advice is a minimum annual volume of 20 robotic pancreatoduodenectomy procedures per center, per year. One training program was identified which describes superior outcomes after the training program and shortening of the learning curve in robotic pancreatoduodenectomy. CONCLUSION: Robotic pancreatoduodenectomy is safe and feasable for all indications when performed by specifically trained surgeons working in centers who can maintain a minimum volume of 20 robotic pancreatoduodenectomy procedures per year. Large proficiency-based training program for robotic pancreatoduodenectomy seem essential to facilitate a safe implementation and future research on robotic pancreatoduodenectomy.

Lessons Learned from the Introduction of Laparoscopic Pancreaticoduodenectomy.

Introduction: Minimally invasive techniques have been suggested to achieve enhanced recovery and improved outcome after pancreaticoduodenectomy (PD). This study describes our experience and a stepwise technical implementation of the laparoscopic pancreaticoduodenectomy (LPD) during early introduction in 2016. Methods: A team of three hepatopancreaticobiliary surgeons with extensive experience in open pancreaticoduodenectomy (OPD) and with advanced laparoscopic skills started a proctor-guided program with LPD. The first 20 carefully selected cases were prospectively reviewed and compared with a matched OPD cohort. Results: In 20 months, 20 minimally invasive PDs were performed. Reviewing the first 10 LPD cases, 7 patients (70%) had anastomosis-related complications, versus 16% in OPD (P = .001). After consulting an international LPD expert, the team switched to a hybrid technique consisting of LPD followed by open reconstruction through midline minilaparotomy (LPD-OR). In the following 10 cases of LPD-OR, no anastomosis-related complications did occur (P = .342 OPD versus LPD-OR). Conclusion: Safe introduction of new techniques in minimally invasive major abdominal surgery is imperative. Based on our single-center experience, LPD-OR may be safer in the earliest phase of the learning curve of minimally invasive PD, as part of a stepwise implementation toward the fully laparoscopic technique.

Educational step-by-step surgical video about operative technique in robotic pancreaticoduodenectomy (RPD) at University of Illinois at Chicago (UIC): 17 steps standardized technique-Lessons learned since the first worldwide RPD performed in the year 2001.

BACKGROUND: RPD (Robotic pancreatoduodenectomy) was first performed by P. C. Giulianotti in 2001 (Arch Surg 138(7):777-784, 2003). Since then, the complexity and lack of technique standardization has slowed down its widespread utilization. RPD has been increasingly adopted worldwide and in few centres is the preferred apporached approach by certain surgeons. Some large retrospective series are available and data seem to indicate that RPD is safe/feasible, and a valid alternative to the classic open Whipple. Our group has recently described a standardized 17 steps approach to RPD (Giulianotti et al. Surg Endosc 32(10): 4329-4336, 2018). Herin, we present an educational step-by-step surgical video with short technical/operative description to visually exemplify the RPD 17 steps technique. METHODS: The current project has been approved by our local Institutional Review Board (IRB). We edited a step-by-step video guidance of our RPD standardized technique. The data/video images were collected from a retrospective analysis of a prospectively collected database (IRB approved). The narration and the images describe hands-on operative "tips and tricks" to facilitate the learning/teaching/evaluation process. RESULTS: Each of the 17 surgical steps is visually represented and explained to help the in-depth understanding of the relevant surgical anatomy and the specific operative technique. CONCLUSIONS: Educational videos descriptions like the one herein presented are a valid learning/teaching tool to implement standardized surgical approaches. Standardization is a crucial component of the learning curve. This approach can create more objective and reproducible data which might be more reliably assessed/compared across institutions and by different surgeons. Promising results are arising from several centers about RPD. However, RPD as gold standard-approach is still a matter of debate. Randomized-controlled studies (RCT) are required to better validate the precise role of RPD.

[The current status and future of laparoscopic pancreaticoduodenectomy].

This review focused on the progress in laparoscopic pancreaticoduodenectomy(LPD) in the past six years.With the appropriate approaches under laparoscopy, including the resection and reconstruction, LPD has been proved to be safe and feasible. In some centers, LPD has been routine with rapid growth of numbers, it not only benefit the patients with fast recovery, but also benefit the trainees with similar sights as the primary surgeon and good videos of the procedures. However, LPD is still controversial as the more complications in some centers and inconclusive oncologic outcomes. Thus, in the further, a long-time outcome monitoring of LPD is essential. A registry of a prospectively maintained database may be a need for LPD to evaluate its outcomes by multicenter randomized control trials, and real world research may be of value. Structured LPD training programs are valuable for the new surgeons.

Efectos de la curva de aprendizaje en los resultados de la duodenopancreatectomía cefálica en un hospital de nivel II / Effects of the learning curve on the results of cephalic pancreaticoduodenectomy in a level II hospital

Resumen Introducción: La duodeno pancreatectomía cefálica es una operación compleja cuyos resultados a corto plazo son multifactoriales. Objetivo: Evaluar el impacto de la curva de aprendizaje en los resultados a corto plazo de la duodenopancreatectomía cefálica en un hospital de nivel II. Materiales y Método: Se analizaron los datos obtenidos a partir de una base de datos mantenida prospectivamente desde 2005. Se definieron dos periodos de tiempo: de 2005 a 2011 y de 2012 a 2017. Se compararon la morbilidad, mortalidad y estancia postoperatoria de ambos períodos. Resultados: Durante el período de tiempo estudiado se hicieron 126 duodenopancreatectomías cefálicas, 61 durante la primera etapa y 65 durante la segunda. La tasa de transfusión intraoperatoria se redujo de 33% a 15% (p = 0,011). La tasa de transfusión postoperatoria se redujo de 39 a 23% (p = 0,021). No hubo diferencias significativas con respecto a la incidencia global de complicaciones postoperatorias (59% y 52,3%). La incidencia de abscesos intraabdominales fue significativamente menor en el segundo período (18% y 4,6%, respectivamente; p = 0,038). La tasa de reintervenciones se redujo significativamente, de 22% a 9% (p = 0,049). También se redujo significativamente la tasa de mortalidad, de 6,56% a 0% (p = 0,032). La estancia media postoperatoria disminuyó significativamente en el segundo período, pasando de 19,6 a 15,8 días (p = 0,001), con una mayor proporción de pacientes dados de alta en los 8 primeros días de postoperatorio (11,5% y 38,5%, respectivamente; p = 0,001). Conclusión: La curva de aprendizaje es un factor que permite mejorar los resultados de la duodenopancreatectomía cefálica, en un hospital de nivel II, hasta alcanzar valores similares a los de un hospital de nivel III.

Introduction: The duodenum pancreatectomy cephalic is a complex operation whose short-term results are multifactorial. Aim: To assess the impact of the learning curve on the short-term outcomes of cephalic duodenopancreatectomy at a level II hospital. Materials Method: We analyze the data obtained from a database maintained prospectively since 2005. Two time periods were defined: from 2005 to 2011 and from 2012 to 2017. The morbidity, mortality and postoperative stay of both periods were compared. Results: 126 cephalic duodenopancreatectomies were performed, 61 during the first period and 65 during the second. The intraoperative transfusion rate was reduced from 33% to 15% (p = 0.011). The postoperative transfusion rate was reduced from 39 to 23% (p = 0.021). There were no significant differences with respect to the overall incidence of postoperative complications (59% and 52.3%, respectively). However, the incidence of intra-abdominal abscesses was significantly lower in the second period (18% and 4.6%, respectively, p = 0.038). The rate of reoperations was significantly reduced, from 22% to 9% (p = 0.049). The mortality rate was also significantly reduced, from 6.56% to 0% (p = 0.032). The mean postoperative stay decreased significantly in the second period, from 19.6 to 15.8 days (p = 0.001), with a higher proportion of patients discharged in the first 8 postoperative days (11.5% and 38.5%, respectively, p = 0.001). Conclusion: The learning curve is a factor allows improving the results of cephalic pancreaticoduodenectomy, in a level II hospital, until reaching values similar to those of a level III hospital.

The learning curve for a surgeon in robot-assisted laparoscopic pancreaticoduodenectomy: a retrospective study in a high-volume pancreatic center.

BACKGROUND: Pancreaticoduodenectomy (PD) is one of the most technically difficult abdominal operations. Recent advances have allowed surgeons to attempt PD using minimally invasive surgery techniques. This retrospective study aimed to analyze the learning curve of a single surgeon who had carried out his first 100 robot-assisted laparoscopic pancreaticoduodenectomy (RPD) in a high-volume pancreatic center. METHODS: The data on consecutive patients who underwent RPD for malignant or benign pathologies were prospectively collected and retrospectively analyzed. The data included the demographic data, operative time, estimated blood loss, postoperative length of hospital stay, morbidity rate, mortality rate, and final pathological results. The cumulative sum (CUSUM) analysis was used to identify the inflexion points which corresponded to the learning curve. RESULTS: Between 2012 and 2016, 100 patients underwent RPD by a single surgeon. From the CUSUM operation time (CUSUM OT) learning curve, two distinct phases of the learning process were identified (early 40 patients and late 60 patients). The operation time (mean, 418 min vs. 317 min), hospital stay (mean, 22 days vs. 15 days), and estimated blood loss (mean, 227 ml vs. 134 ml) were significantly lower after the first 40 patients (P < 0.05). The pancreatic fistula, postoperative hemorrhage, delayed gastric emptying, and reoperation rates also decreased in the late 60 patients group (P < 0.05). Non-significant reductions were observed in the incidences of major (Clavien-Dindo Grade II or higher) morbidity, postoperative death, bile leakage, gastric fistula, wound infection, and open conversion. CONCLUSIONS: RPD was technically feasible and safe in selected patients. The learning curve was completed after 40 RPD. Further studies are required to confirm the long-term oncological outcomes of RPD.

Outcomes of a Multicenter Training Program in Laparoscopic Pancreatoduodenectomy (LAELAPS-2).

OBJECTIVE: The aim of the study was to assess feasibility and outcomes of a multicenter training program in laparoscopic pancreatoduodenectomy (LPD). BACKGROUND: Whereas expert centers have reported promising outcomes of LPD, nationwide analyses have raised concerns on its safety, especially during the learning curve. Multicenter, structured LPD training programs reporting outcomes including the first procedures are lacking. No LPD had been performed in the Netherlands before this study. METHODS: During 2014-2016, 8 surgeons from 4 high-volume centers completed the Longitudinal Assessment and Realization of Laparoscopic Pancreatic Surgery (LAELAPS-2) training program in LPD, including detailed technique description, video training, and proctoring. In all centers, LPD was performed by 2 surgeons with extensive experience in pancreatic and laparoscopic surgery. Outcomes of all LPDs were prospectively collected. RESULTS: In total, 114 patients underwent LPD. Median pancreatic duct diameter was 3 mm [interquartile range (IQR = 2-4)] and pancreatic texture was soft in 74% of patients. The conversion rate was 11% (n = 12), median blood loss 350 mL (IQR = 200-700), and operative time 375 minutes (IQR = 320-431). Grade B/C postoperative pancreatic fistula occurred in 34% of patients, requiring catheter drainage in 22% and re-operation in 2%. A Clavien-Dindo grade ≥ III complication occurred in 43% of patients. Median length of hospital stay was 15 days (IQR = 9-25). Overall, 30-day and 90-day mortality were both 3.5%. Outcomes were similar for the first and second part of procedures. CONCLUSIONS: This LPD training program was feasible and ensured acceptable outcomes during the learning curve in all centers. Future studies should determine whether such a training program is applicable in other settings and assess the added value of LPD.

Training for laparoscopic pancreaticoduodenectomy.

In recent years, laparoscopic procedures have developed rapidly, and the reports of laparoscopic pancreatic resection including laparoscopic pancreaticoduodenectomy (LPD) have increased in number. Although LPD is a complex procedure with high mortality, the training system for LPD remains unestablished. Ensuring patient safety is extremely important, even in challenging surgeries such a LPD. At present, several tools have been developed for surgical education to ensure patient safety preoperatively, such as video learning, virtual reality simulators, and cadaver training. Although LPD is reported as a safe and feasible choice, LPD is still a challenging operation. An LPD training system should be established with a board-certified system.

Learning curves for robotic pancreatic surgery-from distal pancreatectomy to pancreaticoduodenectomy.

This study sought to identify the learning curves of console time (CT) for robotic pancreaticoduodenectomy (RPD) and robotic distal pancreatectomy (RDP). Perioperative outcomes were compared between the early group of surgeries performed early in the learning curve and the late group of surgeries performed after the learning curve.Pancreaticoduodenectomy (PD) is a technically demanding and challenging procedure carrying a high morbidity.Data for RDP and RPD were prospectively collected for analysis. The learning curve was assessed by cumulative sum (CUSUM). Based on CUSUM analyses, patients were divided into the early group and the late group.There were 70 RDP and 61 RPD cases. It required 37 cases to overcome the learning curve for RDP and 20 cases for RPD. The median console time was significantly shorter in the late group for both RDP (112 minutes vs 225 minutes, P < .001) and RPD (360 minuntes vs 520 minutes, P < .001). Median blood loss was significantly less in the late group for both RDP (30 cc vs 100 cc, P = .003) and RPD (100 cc vs 200 cc, P < .001). No surgical mortality occurred in either group. Clinically relevant pancreatic fistula rate was 22.9% for RDP (32.4% in the early group vs 12.1% in the late group, P = .043), and 11.5% for RPD (0 in early group vs 17.1% in late group, P = .084).This study demonstrates that the RPD learning curve is 20 cases with prior experience of RDP and confirms the safety and feasibility of both RPD and RDP. Practice and familiarity with the robotic platform are likely to contribute to significant shortening of the learning curve in robotic pancreatic surgery, while knowledge and experience, in addition to practical skills, are also essential to minimize the potential surgical risks of RPD.

Learning curve and surgical factors influencing the surgical outcomes during the initial experience with laparoscopic pancreaticoduodenectomy.

BACKGROUND: Laparoscopic pancreaticoduodenectomy (LPD) requires sufficient laparoscopic training for optimal outcomes. Our aim is to determine the learning curve and investigate the factors influencing surgical outcomes during the learning curve. METHODS: We analyzed surgical results of 150 consecutive cases of LPD performed by three hepatopancreatobiliary surgeons during their 50 first cases. Learning curves were constructed by cumulative sum (CUSUM) analysis. Preoperative factors influencing resection time and blood loss were investigated in the introductory and stable periods. RESULTS : The learning curve could be divided into three phases: initial (1-20 cases), plateau (21-30), and stable (31-50). Resection time with lymph node dissection was significantly longer during the introductory period (initial and plateau periods) (P < 0.01) but not the stable phase (P = 0.51). Multivariate analysis revealed that patients with pancreatitis had longer resection times and massive blood loss in both the introductory and stable periods (stable phase). High visceral fat area was also significantly related to massive blood loss in the introductory period (P = 0.04). CONCLUSIONS: Hepatopancreatobiliary surgeons need more than 30 cases until LPD becomes stable. Lymph node dissection and patients with high visceral fat area and concomitant pancreatitis should be avoided during the introductory period of the learning curve.

Management and Outcomes of Pancreatic Resections Performed in High-Volume Referral and Low-Volume Community Hospitals Lead by Surgeons Who Shared the Same Mentor: The Importance of Training.

BACKGROUND: High hospital volume improves outcomes after pancreatic resection. The aim of this study was to assess if practice and outcomes differed between high- and low-volume centers across which chief surgeons shared a similar training and mentoring. METHODS: Data on patients undergoing standard pancreatic resections (2010-2013) at 7 Italian hospitals were collected. Chiefs of pancreatic surgery at each hospital had received the same training, with the same mentor. Two centers were high-volume referral hospitals for pancreatic disease, while 5 were low-volume hospitals. RESULTS: A total of 856 patients were included, with median annual volume of resections 82 at high-volume referral hospitals and 11 at low-volume hospitals. Patients at low-volume hospitals were older, had more comorbidities, and were more often referred from the emergency room. Intraoperative techniques and reconstruction methods were similar. Comparable rates of major postoperative complications (18 vs. 22%; p = 0.236) and pancreatic fistula (29 vs. 32%; p = 0.287) were achieved in both groups, with no significant increases in failure to rescue from grade B-C fistula (6.2 vs. 15.0%; p = 0.108) and mortality (2.4 vs. 4.1%; p = 0.233) in low-volume hospitals. Postoperative length of stay was shorter in high-volume referral hospitals (10 vs. 15 days; p < 0.001). CONCLUSION: Similar postoperative outcomes can be achieved across high- and low-volume centers where chief surgeons shared a similar training and mentoring. However, multidisciplinary postoperative provision more often associated with high-volume centers may also affect outcomes.

Robotic Pancreatoduodenectomy Biotissue Curriculum has Validity and Improves Technical Performance for Surgical Oncology Fellows.

OBJECTIVE: Obtaining the proficiency on the robotic platform necessary to safely perform a robotic pancreatoduodenectomy is particularly challenging. We hypothesize that by instituting a proficiency-based robotic training curriculum we can enhance novice surgeons' skills outside of the operating room, leading to a shorter learning curve. DESIGN: A biotissue curriculum was designed consisting of sewing artificial organs to simulate a hepaticojejunostomy (HJ), gastrojejunostomy (GJ), and pancreaticojejunostomy (PJ). Three master robotic surgeons performed each biotissue anastomosis to assess validity. Using video review, trainee performance on biotissue drills was evaluated for time, errors and objective structured assessment of technical skills (OSATS) by 2 blinded graders. SETTING: This study is conducted at the University of Pittsburgh Medical Center (Pittsburgh, PA), a tertiary care academic teaching hospital. PARTICIPANTS: In total, 14 surgical oncology fellows completed the biotissue curriculum. RESULTS: Fourteen fellows performed 196 anastomotic drills during the first year: 66 (HJ), 64 (GJ), and 66 (PJ). The fellows' performances were analyzed as a group by attempt. The attendings' first attempt outperformed the fellows' first attempt in all metrics for every drill (all p < 0.05). More than 5 analyzed attempts of the HJ, there was improvement in time, errors, and OSATS (all p < 0.01); however, no metric reached attending performance. For the GJ, time, errors, and OSATS all improved more than 5 attempts (all p < 0.01), whereas only errors and OSATS reached proficiency. For the PJ, errors and OSATS both improved over attempts (p < 0.01) and reached proficiency; however, time did not statistically improve nor reach proficiency. The graders scoring correlated for errors and OSATS (p < 0.0001). CONCLUSION: A pancreatoduodenectomy biotissue curriculum has face and construct validity. The curriculum is feasible and improves errors and technical performance. Time is the most difficult technical parameter to improve. This curriculum is a valid tool for teaching robotic pancreatoduodenectomies with established milestones for reaching optimum performance.