Learning curves for robotic pancreatic surgery-from distal pancreatectomy to pancreaticoduodenectomy

Abstract

This study sought to identify the learning curves of console time (CT) for robotic pancreaticoduodenectomy (RPD) and robotic distal pancreatectomy (RDP). Perioperative outcomes were compared between the early group of surgeries performed early in the learning curve and the late group of surgeries performed after the learning curve.Pancreaticoduodenectomy (PD) is a technically demanding and challenging procedure carrying a high morbidity.Data for RDP and RPD were prospectively collected for analysis. The learning curve was assessed by cumulative sum (CUSUM). Based on CUSUM analyses, patients were divided into the early group and the late group.There were 70 RDP and 61 RPD cases. It required 37 cases to overcome the learning curve for RDP and 20 cases for RPD. The median console time was significantly shorter in the late group for both RDP (112 minutes vs 225 minutes, P < .001) and RPD (360 minuntes vs 520 minutes, P < .001). Median blood loss was significantly less in the late group for both RDP (30 cc vs 100 cc, P = .003) and RPD (100 cc vs 200 cc, P < .001). No surgical mortality occurred in either group. Clinically relevant pancreatic fistula rate was 22.9% for RDP (32.4% in the early group vs 12.1% in the late group, P = .043), and 11.5% for RPD (0 in early group vs 17.1% in late group, P = .084).This study demonstrates that the RPD learning curve is 20 cases with prior experience of RDP and confirms the safety and feasibility of both RPD and RDP. Practice and familiarity with the robotic platform are likely to contribute to significant shortening of the learning curve in robotic pancreatic surgery, while knowledge and experience, in addition to practical skills, are also essential to minimize the potential surgical risks of RPD.

Figure 1

CUSUM analysis for robotic distal pancreatectomy (RDP). (A) Raw console time (CT) plotted for each RDP case arranged in chronological order. (B) Cumulative sum of the console time (CUSUM-CT) plotted against the chronological order of RDP cases modeled as a parabola. (C) Two phases of the learning process in RDP are identified using the CUSUM-CT curve by linear regression analysis. CT  = console time, CUSUM  = cumulative sum, RDP  = robotic distal pancreatectomy.

Figure 2

CUSUM analysis for robotic pancreaticoduodenectomy (RPD). (A) Raw console time (CT) plotted for each RPD case arranged in chronological order. (B) Cumulative sum of the console time (CUSUM-CT) plotted against the chronological order of RPD cases modeled as a parabola. (C) Two phases of the learning process in RPD are identified using the CUSUM-CT curve by linear regression analysis. CT  = console time, CUSUM  = cumulative sum, RDP  = robotic distal pancreatectomy.