Learning Curve From 450 Cases of Robot-Assisted Pancreaticoduocectomy in a High-Volume Pancreatic Center

Abstract

Objective: We aimed to describe our experience and the learning curve of 450 cases of robot-assisted pancreaticoduodenectomy (RPD) and optimize the surgical process so that our findings can be useful for surgeons starting to perform RPD. Summary Background Data: Robotic surgical systems were first introduced 20 years ago. Pancreaticoduodenectomy (PD) is a challenging surgery because of its technical difficulty. RPD may overcome some of these difficulties. Methods: The medical records of 450 patients who underwent RPD between May 2010 and December 2018 at the Shanghai Ruijin Hospital were retrospectively analyzed. Operative times and estimated blood loss (EBL) were analyzed and the learning curve was determined. A cumulative sum (CUSUM) analysis was used to identify the inflexion points. Other postoperative outcomes, postoperative complications, and long-term follow-up were also analyzed. Results: Operative time improved gradually over time from 405.4 AE 112.9 minutes (case 1-50) to 273.6 AE 70 minutes (case 301-350) (P < 0.001). EBL improved from 410 AE 563.5 mL (case 1-50) to 149.0 AE 103.3 mL (case 351-400) (P < 0.001). According to the CUSUM curve, there were 3 phases in the RPD learning curve. The inflexion points were around cases 100 and 250. The incidence of pancreatic leak in the last 350 cases was significantly lower than that in the first 100 cases (30.0% vs 15.1%, P ¼ 0.003). Conclusions: RPD is safe and feasible for selected patients. Operative and oncologic outcomes were much improved after experience of 250 cases. Our optimization of the surgical process may have also contributed to this. Future prospective and randomized studies are needed to confirm our results.

Current statement and safe implementation of minimally invasive surgery in the pancreas

“…Although robotic assistance during MIPD may contribute to overcoming several aspects of technical difficulty in LPD, RPD also requires enough time and experience to reach proficiency. There are still a limited number of learning curve analyses in RPD and RDP 40,43,66–68 . From these observational studies, experience with at least 20‐40 robot‐assisted pancreatic surgeries is required for the initial advance in the techniques.…”

Current Status of Laparoscopic and Robotic Pancreatic Surgery and Its Adoption in Singapore

“…As a result of the highly complex manipulations that are required during resection and anastomoses thereafter, the minimally invasive surgical approach is only performed by a few pancreatic surgeons in high-volume centres. [37][38][39][40][41][42] In 1994, Gagner et al 10 reported the first study of LPD; however, the steep learning curve of LPD led to its slow adoption compared to LDP. Even today, the practice of MIS in PD is limited and remains controversial, given the technical complexity of the procedure and lack of perceived advantages over the open approach.…”

“…A few large series of LPD and robotic pancreaticoduodenectomy (RPD) 40,41 from high-volume centres had reported excellent results associated with MIS. To the best of our knowledge, 3 RCT 19,20,22 had evaluated short-term outcomes of LPD against open PD, but with mixed results.…”

Robotergestützte Bauchspeicheldrüsenchirurgie

“…Eine retrospektive Studie von Shi et al zeigte, dass sich das operative Ergebnis sowie das onkologische Ergebnis deutlich verbessern, wenn mehr als 250 Eingriffe durchgeführt wurden [24]. Andere Daten in diesem Zusammenhang zeigen, dass die Lernkurve bereits nach etwa 40 [25] oder 80 Fällen [2,26] ein Plateau erreichen kann.…”

“…Gleiches galt für den Blutverlust, der mit zunehmender Erfahrung abnahm. Darüber hinaus zeigte diese Studie, dass die Inzidenz von POPF in den letzten 350 Verfahren gegenüber dem Mittel der ersten 100 Fälle signifikant abnahm [24]. Diese Daten lassen sich in Europa aufgrund der Fallzahl der einzelnen Pankreaszentren nur schwer extrapolieren.…”