Training and learning curves in minimally invasive pancreatic surgery: from simulation to mastery

Abstract

Background: Minimally invasive pancreatic surgery (MIPS) has developed over the last 3 decades and is nowadays experiencing an increased interest from the surgical community. With increasing awareness of both the public and the surgical community on patient safety, optimization of training has gained importance. For implementation of MIPS we propose 3 training phases. The first phase focuses on developing basic skills and procedure specific skills with the help of simulation, biotissue drills, video libraries, live case observations, and training courses. The second phase consists of index procedures, fellowships, and proctoring programs to ensure patient safety during the first procedures. During the third phase the surgeons aim is to safely implement the procedure into standard practice while minimizing learning curve related excess morbidity and mortality. Case selection, skills assessment, feedback, and mentoring are important methods to optimize this phase. The residual learning curve can reach up to 100 cases depending on the surgeons’ previous experience, selection of cases, and definition of the parameters used to assess the learning curve. Adequate training and high procedural volume are key to implementing MIPS safely.

Learning Curves in Open, Laparoscopic, and Robotic Pancreatic Surgery

“…Most often used parameters to define learning curves were operative time (n = 51), blood loss (n = 17), and complications (n = 10). The number of procedures to surpass a first phase of learning curve was 30 for open PD, 39 for laparoscopic PD, 25 for robotic PD (P = 0.521), 16 (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17) for laparoscopic DP, and 15 for robotic DP (P = 0.914). In a three-phase model, intraoperative parameters improved earlier (first to second phase: operating time -15%, blood loss -29%) whereas postoperative parameters improved later (second to third phase: complications -46%, postoperative pancreatic fistula -48%).…”

“…have been described so far. [5][6][7][8][9][10][11][12] Looking at the available surgical approaches (open, laparoscopic, and robotic), these numbers vary even further. The learning curve of a surgical procedure represents an important and underrepresented bias in clinical studies and is often neglected even in randomized controlled trials (RCT).…”

Surgical training model and safe implementation of robotic pancreatoduodenectomy in Japan: a technical note

“…As RPD requires advanced surgical techniques, the optimization of training should play an important role. A recent notable review proposed a pyramid demonstrating three training phases for the implementation of minimally invasive pancreatic surgery [ 12 ]. In the first phase, the surgeon should develop basic skills and procedure-specific skills using the following tools: simulation, biotissue drills, video libraries, live case observations, and training courses.…”

“…The Miami evidence-based guidelines encourage participation in a structured training program including virtual reality simulation, biotissue training to practice dissection and anastomoses, surgical video review, and on-site proctoring [ 1 ]. Furthermore, a recent interesting review suggested the importance of the structured multimodality training system for the safe implementation of minimally invasive pancreatic surgery [ 12 ]. Therefore, a multicenter structured training system should be established for surgeons and centers to introduce RPD in Japan.…”

Development and validity evidence of an objective structured assessment of technical skills score for minimally invasive linear-stapled, hand-sewn intestinal anastomoses: the A-OSATS score

“…Irrespective of the technique used (stapled, hand-sewn, mixed), the creation of intestinal anastomoses is considered an advanced surgical skill [3]. This results in prolonged learning curves of minimally invasive surgical procedures involving intestinal anastomoses [4][5][6], increasing the risk for complications. Recent studies have shown increased complication rates and decreased oncological outcomes depending on the surgeon's level of technical skills [7,8].…”