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

Schmidt, Carl; Harris, Britney R.; Musgrove, Kelsey A.; Rao, Pavan; Marsh, J. Wallis; Thomay, Alan A.; Hogg, Melissa E.; Zeh, Herbert J.; Zureikat, Amer H.; Boone, Brian A.

doi:10.1002/jso.26284

Cited by 19 publications

(10 citation statements)

References 33 publications

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“…Some 2598 PDs were reported between July 2003 and March 2021 13–18,28–48 . Approximately two‐thirds of the patients (63.7%) received a I‐II American Society of Anesthesiologists (ASA) score, while the remaining patients (36.3%) were classified as ASA III‐IV.…”

Section: Resultsmentioning

confidence: 99%

Figures do matter: A literature review of 4587 robotic pancreatic resections and their implications on training

Sandri

Hilal

Dokmak

et al. 2022

J Hepato Biliary Pancreat

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Background:The use of robotic assistance in minimally invasive pancreatic resection is quickly growing. Methods:We present a systematic review of the literature regarding all types of robotic pancreatic resection (RPR). Our aim is to show for which procedures there is enough experience to permit safe training and provide an estimation of how many centers could serve as teaching institutions. Results:Sixty-four studies reporting on 4587 RPRs were analyzed. A total of 2598 pancreatoduodenectomies (PD) were reported by 28 centers from Europe (6/28; 21.4%), the Americas (11/28; 39.3%), and Asia (11/28; 39.3%). Six studies reported >100 robot PD (1694/2598; 65.2%). A total of 1618 distal pancreatectomies (DP) were reported by 29 centers from Europe (10/29; 34.5%), the Americas (10/29; 34.5%), and Asia (9/29; 31%). Five studies reported >100 robotic DP (748/1618; 46.2%). A total of 154 central pancreatectomies were reported by six centers from Europe (1/6; 16.7%), the Americas (2/6; 33.3%), and Asia (3/6; 50%). Only 49 total pancreatectomies were reported. Finally, 168 enucleations were reported in seven studies (with a mean of 15.4 cases per study). A single center reported on 60 enucleations (35.7%). Results of each type of robotic procedure are also presented. Conclusions:Experience with RPR is still quite limited. Despite high case volume not being sufficient to warrant optimal training opportunities, it is certainly a key component of every successful training program and is a major criterion for fellowship accreditation. From this review, it appears that only PD and DP can currently be taught at few institutions worldwide.

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Section: Resultsmentioning

confidence: 99%

Figures do matter: A literature review of 4587 robotic pancreatic resections and their implications on training

Sandri

Hilal

Dokmak

et al. 2022

J Hepato Biliary Pancreat

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“…Moreover, although the reported series was performed by surgical teams with extensive experience in pancreatic surgery, they were also in the initial phase of their robotic-assisted experience. More recent reports [ 25 , 26 ], from centers that have used the latest Xi version of the da Vinci, have certainly already identified shorter learning curves. Ryoo et al [ 25 ] included in their study two surgeons who completed a robotic training protocol before undertaking R-PDs.…”

Section: Discussionmentioning

confidence: 99%

“…The operative time of these two surgeons plateaued after 10 cases reaching the mean operating time of the series. Another study, from Schmidt et al [ 26 ] suggests that formal robotic training facilitates a safe and efficient adoption of R-PD for new programs, significantly reducing the learning curve. In fact, OT in their analysis does not have a plateau or significant decline suggesting the absence of a true learning curve.…”

Section: Discussionmentioning

confidence: 99%

Initial 50 consecutive full-robotic pancreatoduodenectomies without conversion by a single surgeon: a learning curve analysis from a tertiary referral high-volume center

et al. 2023

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Background Several studies report on a learning curve for robotic pancreatoduodenectomy (R-PD) ranging between 20 and 80 operations, with conversion rates varying between 1.1 and 35%. However, as these publications mostly refer to initial robotic experiences and do not take into account the previous surgical background in pancreatic surgery (PS) and in robotic-assisted surgery (RAS), the center’s volume, as well as the platform used, we aimed to perform a surgical outcomes analysis with a particular view to these aspects. Methods Intraoperative and perioperative outcomes of the first 50 consecutive R-PD performed with the da Vinci Xi by the same surgeon, within a tertiary referral high-volume center, between January 2018 and March 2022, were analyzed. The surgeon was previously experienced in both PS and RAS. Shewhart control chart and cumulative sum (CUSUM) analysis were used to evaluate the learning curve of R-PD. Results All the operations were performed with a full-robotic technique, without any conversion to open surgery. Twenty of 50 patients (40%) had a BMI ≥ 25 kg/m 2 , while 24/50 (48%) had undergone previous abdominal surgery. Mean console time was 276.30 ± 31.16 min. The median post-operative length of hospital stay was 10 days, while 20/50 (40%) patients were discharged within post-operative day 8. Six patients (12%) had major complications (Clavien-Dindo grade 3 or above). There was no 30-day mortality. Shewhart control chart and CUSUM analysis did not show a significant learning curve during the study period. Conclusions An extensive prior experience in both PS and RAS, within a tertiary referral high-volume center with availability of the da Vinci Xi platform, can significantly flatten the learning curve and, therefore, enable safe performance of challenging operations, i.e., pancreatoduodenectomies with a minimally invasive approach, with very low risk of conversion to open surgery, even in the first 50 operations.

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“…Regarding learning curves, in order to make robotic HPB surgery more widely available, institutions have now begun to describe structures for implementing robotics into fellowship and residency training of future HPB surgeons 58–60 . These institutions have preliminarily shown shortened learning curves for those who undergo a formal robotic training program within their fellowship or residency 60–62 . In 2020, our center developed the first completely robotic HPB surgery fellowship.…”

Section: Where Are We Going Internationally?mentioning

confidence: 99%

Current progress in robotic hepatobiliary and pancreatic surgery at a high‐volume center

McCarron,

Vrochides,

Martinie

2023

Annals of Gastroent Surgery

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There has been steady growth in the adoption of robotic HPB procedures world‐wide over the past 20 years, but most of this increase has occurred only recently. Not surprisingly, the vast majority of robotics has been in the United States, with very few, select centers of adoption in Italy, South Korea, and Brazil, to name a few. We began our robotic HPB program in 2008, well before almost all other centers in the world, with the most notable exception of Giullianotti and colleagues. Our program began gradually, with smaller cases carefully selected to optimize the strengths of the original robotic platform and included complex biliary and pancreatic resections. We performed the first reported series of choledochojejunostomy for benign biliary strictures and first series of completion cholecystectomies. We began performing robotic distal pancreatectomies and longitudinal pancreaticojejunostomies, reporting our early experience for each of these procedures. Over time we progressed to robotic pancreaticoduodenectomies. Initially, these were performed with planned conversions until we were able to optimize efficiency. Now we have performed over 200 robotic whipples, reaching a 100% robotic completion rate by 2020. Finally, we have added robotic major hepatectomies, including resections for hilar cholangiocarcinoma to our repertoire. Since the program began, we have performed over 1600 robotic HPB cases. Outcomes from our program have shown superior lymph node harvest, lower DGE rates, shorter hospitalizations, and fewer rehab admissions with similar overall complications to open and laparoscopic procedures, signifying that over time a robotic HPB program is not only feasible but advantageous as well.

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

Cited by 19 publications

References 33 publications

Figures do matter: A literature review of 4587 robotic pancreatic resections and their implications on training

Figures do matter: A literature review of 4587 robotic pancreatic resections and their implications on training

Initial 50 consecutive full-robotic pancreatoduodenectomies without conversion by a single surgeon: a learning curve analysis from a tertiary referral high-volume center

Current progress in robotic hepatobiliary and pancreatic surgery at a high‐volume center

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