Mentorship in Training of Minimally Invasive Pancreatoduodenectomy

Abstract

Introduction: Laparoscopic pancreatoduodenectomy (LPD)is one of the most challenging minimally invasive procedures; training is not standardized. We sought to evaluate immediate postoperative outcomes of three surgeons performing LPD in the same institution, compared according to their training: self-learned, instructor-led and on-site proctoring. Methods: From 2007-2021, three different surgeons performed 404 LPD(43.5%male, median age 62(29-82)years, median ASA score 2.3(2-3),median Charlson score 1.7 (1-2)).The first surgeon started total LPD without a previous specific training program (self-learned). The second assisted the first surgeon for 50 procedures before performing his first 10 procedures under the mentoring of the first surgeon. The third surgeon was trained by on-site proctoring and performed the procedure by a hybrid technique. Morbidity was evaluated according to Clavien-Dindo. The critical slope of operative time, morbidity and blood loss was measured during the first 40 consecutive LPDs analyzed by CUSUM methodology and compared by the Mann-Whitney test. The Kwiatkowski-Phillips-Schmidt-Shin(KPSS)test was used to evaluate the stationarity. Results: The number of procedures performed was 257, 120 and 43, respectively. The cut-off (learning plateau) values(60 min forCUSUM methodology)for the three parameters was 19, 9and7, respectively. The p value for KPSS was 0.01. Median operative time was 492(423-571),497(408-615)and515(448-581)minutes, respectively(p = 0.322).Severe morbidity(grades 3a - 5)was 24%, 45% and 47% (p = 0.33),respectively. Intraoperative blood loss was 525(237-900),200(100-300)and200(100-300)ml(p = 0.01),respectively. The only statistically significant difference in perioperative data among the 3 surgeons was intraoperative blood loss. Conclusion: On-site proctoring resulted in less intraoperative blood loss during LPD during training.On-site proctoring should be further evaluated and included in training program for LPD.