Learning curve of three European centers in laparoscopic, hybrid laparoscopic, and robotic pancreatoduodenectomy

Abstract

Introduction There are limited numbers of high-volume centers performing minimally invasive pancreatoduodenectomy (MIPD) routinely. Several approaches to MIPD have been described. Aim of this analysis was to show the learning curve of three different approaches to MIPD. Focus was on determining the number of cases necessary to obtain proficient level in MIPD. Patients and methods Retrospective study wherein outcomes of 300 consecutive patients at three centers-at each center the initial 100 consecutive patients undergoing MIPD for malignant and benign tumors of the head of the pancreas and perimpullary area, performed by three experienced surgeons were collected and analyzed. Results Overall, 300 patients after MIPD were included: the three different cohorts (laparoscopic n = 100, hybrid n = 100, robotic n = 100). CUSUM analysis of operating time in each center demonstrated that the plateau for laparoscopic PD was n = 61, for hybrid PDes was n = 32 and for robotic PD was n = 68. Median operative time for laparoscopic, hybrid, and robotic approaches was 395 min, 404 min, 510 min, respectively. Intraoperative blood loss for laparoscopic PD, hybrid PD, and robotic PD was 250 ml, 250 ml, and 413 ml, respectively. Delayed gastric emptying occurred 12% in laparoscopic cohort, 10% in hybrid, and 53% in robotic cohort. Major complications (Clavien-Dindo III/IV) rate for laparoscopic PD, hybrid PD, and robotic PD was 32%, 37%, and 22% with 5% death in each cohorts, respectively. Conclusion This analysis of the learning curve of three European centers found a shorter learning curve with hybrid PD as compared to laparoscopic and robotic PD. In implementation of a MIPD program, a stepwise approach might be beneficial.

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

“…However at this institution the 250 cut‐off was shared by three operating surgeons, suggesting that approximately 80 procedures could be required to achieve proficiency in robotic PD. Indeed, in a single‐surgeon experience, results reached a plateau after robotic PDs 10 . We were not able to capture figures on individual surgeons, and more importantly to define proficiency of individual surgeons, but proficient surgeons might be fewer than high‐volume centers.…”

“…At most high‐volume institutions the vast majority of DPs are currently performed using minimally invasive techniques 3,6,7 . The diffusion of minimally invasive pancreatoduodenectomy (PD) is also increasing but at a slower pace 8–10 . This is probably due to the increased technical complexity of this procedure and the intrinsic limitations of laparoscopic instruments and view.…”

“…3,6,7 The diffusion of minimally invasive pancreatoduodenectomy (PD) is also increasing but at a slower pace. [8][9][10] This is probably due to the increased technical complexity of this procedure and the intrinsic limitations of laparoscopic instruments and view. The da Vinci Surgical System® (Intuitive Surgical) surpasses most of the technical limitations of conventional laparoscopy and could further increase diffusion and reproducibility of minimally invasive pancreatic resections.…”

Multimodal Management of Grade 1 and 2 Pancreatic Neuroendocrine Tumors

“…Laparoscopic pancreaticoduodenectomy (LPD) has seen much slower adoption than other laparoscopic procedures as it represents a true technical challenge, especially when it comes to reconstruction. Concerns remains regarding the long learning curve of LPD, potential higher morbidity and mortality rates, and the need to perform a high number of procedures (more than 40 procedures) to achieve equivalent outcomes to the open approach [ 31 ]. Since 2017, three trials and one meta-analysis have compared the short-term outcomes of LPDc versus open pancreaticoduodenectomy [ 32 , 33 , 34 ].…”

Robotische Pankreaschirurgie – Lernkurve und Etablierung

“…Vielmehr scheint die Lernkurve für die komplett robotische Pankreaskopfresektion insbesondere im Vergleich zur Hybridresektion mit laparoskopischer Resektion und Rekonstruktion über eine Minilaparotomie sogar höher zu liegen, was sicherlich durch die technisch anspruchsvolle Rekonstruktion begründet ist. Eine retrospektive Analyse von 3 europäischen High-Volume-Zentren an 300 Patienten zeigte eine Lernkurve von 68 Fällen bei der robotischen Pankreaskopfresektion, die im Vergleich mit der laparoskopischen Hybridtechnik (32 Fälle) deutlich höher lag [44]. Eine Metaanalyse aus dem Jahre 2021 fand keinen Unterschied zwischen der Lernkurve robotischer und laparoskopischer Eingriffe sowohl für die Kopf-als auch die Linksresektion [43].…”