Impact of a Nationwide Training Program in Minimally Invasive Distal Pancreatectomy (LAELAPS)
Abstract: A nationwide MIDP training program was feasible and followed by a steep increase in the use of MIDP, also in patients with pancreatic cancer, and decreased conversion rates. Future studies should determine whether such a training program is applicable in other settings.
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Cited by 107 publications
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Robot-assisted surgery has been developed to overcome limitations of conventional laparoscopy aiming to further optimize minimally invasive surgery. Despite the fact that robotics already have been widely adopted in urology, gynecology, and several gastro-intestinal procedures, like colorectal surgery, pancreatic surgery lags behind. Due to the complex nature of the procedure, surgeons probably have been hesitant to apply minimally invasive techniques in pancreatic surgery. Nevertheless, the past few years pancreatic surgery has been catching up. An increasing number of procedures are being performed laparoscopically and robotically, despite it being a highly complex procedure with high morbidity and mortality rates. Since the complex nature and extensiveness of the procedure, the start of a robotic pancreatic program should be properly prepared and should comply with several conditions within high-volume centers. Robotic training plays a significant role in the preparation. In this review we discuss the different aspects of preparation when working towards the start of a robotic pancreas program against the background of our nationwide experience in the Netherlands. a 3D, magnified view of the operative field with intraabdominal articulating instruments, thereby increasing surgical dexterity (8). Potentially, the use of the robotic system enables a larger proportion of pancreatic surgeries to be performed minimally invasively, since the technical benefits of the robot may especially be advantageous in reconstructing anastomoses during a Whipple procedure. Moreover, ergonomics are improved and the use of robotics in minimally invasive surgery potentially shortens the learning curve compared to conventional laparoscopy, as previously shown in different procedures (9,10).Still, pancreatic surgery remains highly complex and is associated with significant morbidity and mortality rates (11-13). Therefore, when starting a robotic program for pancreatic surgery, it should be well prepared and several conditions must be met prior to performing the first procedures. Training of a dedicated multidisciplinary team should play a key-role in the setup. However, specific training programs for teams performing robotic pancreatic surgery are still scarce.In the Netherlands, surgeons have been performing laparoscopic pancreatic surgery sporadically for over ten years (1). In 2012, the first robot-assisted distal pancreatectomies were performed and last year the first robot-assisted pancreatoduodenectomies were performed in the University Medical Center Utrecht (UMC Utrecht) after following the University of Pittsburgh Medical Center (UPMC) training program. Next, this program made available nationwide by the Dutch Pancreatic Cancer Group, similar as was done previously for laparoscopic pancreatic surgery (1). Other centers, including the Erasmus Medical Center Rotterdam, recently followed the program. In this review we discuss the steps we took on our road to our first successful robot-assisted pancreatoduodenectomy. T...
Robot-assisted surgery has been developed to overcome limitations of conventional laparoscopy aiming to further optimize minimally invasive surgery. Despite the fact that robotics already have been widely adopted in urology, gynecology, and several gastro-intestinal procedures, like colorectal surgery, pancreatic surgery lags behind. Due to the complex nature of the procedure, surgeons probably have been hesitant to apply minimally invasive techniques in pancreatic surgery. Nevertheless, the past few years pancreatic surgery has been catching up. An increasing number of procedures are being performed laparoscopically and robotically, despite it being a highly complex procedure with high morbidity and mortality rates. Since the complex nature and extensiveness of the procedure, the start of a robotic pancreatic program should be properly prepared and should comply with several conditions within high-volume centers. Robotic training plays a significant role in the preparation. In this review we discuss the different aspects of preparation when working towards the start of a robotic pancreas program against the background of our nationwide experience in the Netherlands. a 3D, magnified view of the operative field with intraabdominal articulating instruments, thereby increasing surgical dexterity (8). Potentially, the use of the robotic system enables a larger proportion of pancreatic surgeries to be performed minimally invasively, since the technical benefits of the robot may especially be advantageous in reconstructing anastomoses during a Whipple procedure. Moreover, ergonomics are improved and the use of robotics in minimally invasive surgery potentially shortens the learning curve compared to conventional laparoscopy, as previously shown in different procedures (9,10).Still, pancreatic surgery remains highly complex and is associated with significant morbidity and mortality rates (11-13). Therefore, when starting a robotic program for pancreatic surgery, it should be well prepared and several conditions must be met prior to performing the first procedures. Training of a dedicated multidisciplinary team should play a key-role in the setup. However, specific training programs for teams performing robotic pancreatic surgery are still scarce.In the Netherlands, surgeons have been performing laparoscopic pancreatic surgery sporadically for over ten years (1). In 2012, the first robot-assisted distal pancreatectomies were performed and last year the first robot-assisted pancreatoduodenectomies were performed in the University Medical Center Utrecht (UMC Utrecht) after following the University of Pittsburgh Medical Center (UPMC) training program. Next, this program made available nationwide by the Dutch Pancreatic Cancer Group, similar as was done previously for laparoscopic pancreatic surgery (1). Other centers, including the Erasmus Medical Center Rotterdam, recently followed the program. In this review we discuss the steps we took on our road to our first successful robot-assisted pancreatoduodenectomy. T...
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 MEASURESThe primary outcome was operating room time (ORT). Secondary outcomes were postoperative pancreatic fistula and Clavien-Dindo classification higher than grade 2. RESULTSWe 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 RELEVANCEIn 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.
ImportanceUnderstanding the learning curve of a new complex surgical technique helps to reduce potential patient harm. Current series on the learning curve of minimally invasive distal pancreatectomy (MIDP) are mostly small, single-center series, thus providing limited data.ObjectiveTo evaluate the length of pooled learning curves of MIDP in experienced centers.Design, Setting, and ParticipantsThis international, multicenter, retrospective cohort study included MIDP procedures performed from January 1, 2006, through June 30, 2019, in 26 European centers from 8 countries that each performed more than 15 distal pancreatectomies annually, with an overall experience exceeding 50 MIDP procedures. Consecutive patients who underwent elective laparoscopic or robotic distal pancreatectomy for all indications were included. Data were analyzed between September 1, 2021, and May 1, 2022.ExposuresThe learning curve for MIDP was estimated by pooling data from all centers.Main Outcomes and MeasuresThe learning curve was assessed for the primary textbook outcome (TBO), which is a composite measure that reflects optimal outcome, and for surgical mastery. Generalized additive models and a 2-piece linear model with a break point were used to estimate the learning curve length of MIDP. Case mix–expected probabilities were plotted and compared with observed outcomes to assess the association of changing case mix with outcomes. The learning curve also was assessed for the secondary outcomes of operation time, intraoperative blood loss, conversion to open rate, and postoperative pancreatic fistula grade B/C.ResultsFrom a total of 2610 MIDP procedures, the learning curve analysis was conducted on 2041 procedures (mean [SD] patient age, 58 [15.3] years; among 2040 with reported sex, 1249 were female [61.2%] and 791 male [38.8%]). The 2-piece model showed an increase and eventually a break point for TBO at 85 procedures (95% CI, 13-157 procedures), with a plateau TBO rate at 70%. The learning-associated loss of TBO rate was estimated at 3.3%. For conversion, a break point was estimated at 40 procedures (95% CI, 11-68 procedures); for operation time, at 56 procedures (95% CI, 35-77 procedures); and for intraoperative blood loss, at 71 procedures (95% CI, 28-114 procedures). For postoperative pancreatic fistula, no break point could be estimated.Conclusion and RelevanceIn experienced international centers, the learning curve length of MIDP for TBO was considerable with 85 procedures. These findings suggest that although learning curves for conversion, operation time, and intraoperative blood loss are completed earlier, extensive experience may be needed to master the learning curve of MIDP.
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