Overcoming the Arduous Transition for Robotic Hepatopancreatobiliary Cases: A Multi‐Procedure Learning Curve Study Utilizing CUSUM Analysis

Abstract

Background/objective Quick optimization and mastery of a new technique is an important part of procedural medicine, especially in the field of minimally invasive surgery. Complex surgeries such as robotic pancreaticoduodenectomies (RPD) and robotic distal pancreatectomies (RDP) have a steep learning curve; therefore, findings that can help expedite the burdensome learning process are extremely beneficial. This single‐surgeon study aims to report the learning curves of RDP, RPD, and robotic Heller myotomy (RHM) and to review the results’ implications for the current state of robotic hepatopancreaticobiliary (HPB) surgery. Study design This is a retrospective case series of a prospectively maintained database at a non‐university tertiary care center. Total of 175 patients underwent either RDP, RPD, or RHM with the surgeon (DRJ) from January 2014 to January 2020. Results Statistical significance of operating room time (ORT) was noted after 47 cases for RDP (p < 0.05), 51 cases for RPD (p < 0.0001), and 18 cases for RHM (p < 0.05). Mean ORT after the statistical mastery of the procedure for RDP, RPD, and RHM was 124, 232, 93 min, respectively. No statistical significance was noted for estimated blood loss or length of stay. Conclusions Robotic HPB procedures have significantly higher learning curves compared to non‐HPB procedures, even for an experienced HPB surgeon with extensive laparoscopic experience. Our RPD curve, however, is quicker than the literature average. We suggest that this is because of the simultaneous implementation of HPB (RDP and RPD) and non‐HPB robotic surgeries with a shorter learning curve—especially foregut procedures such as RHM—into an experienced surgeon's practice. This may accelerate the learning process without compromising patient safety and outcomes.

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

“…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.…”

“…A total of 27 studies were included with 1618 DPs 28,37,43,45,49–54,19,55–57,20,21,58–61,22,62–64,23,65,66 . A classical DP with splenectomy was performed in 51.1% of the patients.…”

“…A total of 27 studies were included with 1618 DPs . 28,37,43,45,[49][50][51][52][53][54]19,[55][56][57]20,21,[58][59][60][61]22,[62][63][64]23,65,66 A classical DP with splenectomy was performed in 51.1% of the patients. In patients undergoing spleen-preserving DP (48.9%), a Warshaw procedure (resecting the splenic vessels) was performed in 309 cases (23.8%) 67 and a Kimura procedure (preserving the splenic vessel) in the remaining 324 cases (25%).…”