Challenges of minimally invasive pancreas surgery growth with such a high learning curve.

Abstract

Minimally invasive pancreaticoduodenectomy (MIPD), defined as laparoscopic or robotic surgery, has been slow to develop compared with operations on other organs.1 Approximately100yearsafter the first pancreaticoduodenectomy, MIPD is foundtobesafe,have potential oncologic advantages, andhasbeena large technical advance inour abilities.2,3 Despite continued skepticism, a select group of institutions, including our own, performMIPD routinely. Boone et al4 found that after 20, 40, and 80 cases, there was a statistical drop in the conversion rate, estimated blood loss, and operative time, respectively. These learning curve milestones were determined after analyzing 200 robotic pancreaticoduodenectomies and highlight the challenge in training future robotic pancreatic surgeons, particularly because trainees will not even reach these milestones for open pancreaticoduodenectomy. There are several unique aspects of this article that must be kept in context before applying its findings to all MIPDs. First, the authors’ early learning curve was spent in the development of robotic techniques. This development was a significant component of our own learning curve with laparoscopic pancreaticoduodenectomy. With proper mentorship, the learning curve should no longer be an issue. However, robotic surgery adds another layer to the learning curve. Using laparoscopic techniques, in which most surgical residents are proficient, may create a more efficient training environment. These milestones will be invaluable for comparison; however, to use robotic milestones to represent all MIPDs is premature. Boone et al highlight the large number of cases required to become a proficient robotic pancreatic surgeon. How to efficiently attain expertise will be a challenge and may limit robotic pancreas surgery growth.