Mitigation of robotic pancreaticoduodenectomy learning curve through a comprehensive training program

Abstract

Background: The utilization of robotic surgery for pancreaticoduodenectomy continues to increase. There is an apparent associated lag in the training for this complex operation resulting in a learning curve with the adoption of this technique. We hypothesize that the reported learning curve can be mitigated through a comprehensive graduated training protocol. Methods: Prior to robotic pancreaticoduodenectomy program implementation, all surgeons (n=3) and operating room staff at The Ohio State University underwent dedicated training. All patients who underwent an open (n=156) or robotic (n=41) pancreaticoduodenectomy following program implementation between 2015-2018 were identified. Operative and post-operative outcomes over time were analyzed. Robotic and open patients were matched 1:1 based on all measurable pre-operative patient- and tumor-specific risk factors. Results: The unplanned robotic-to-open conversion rate was 19.5% (n=8). Of the remaining 33 robotic whipple operations, operative time plateaued at 11 cases (figure); however, mean operative time did not change over time (P=0.08). Similarly, no difference over time was seen in the rate of grade B/C postoperative pancreatic fistula (POPF) (n=9.1%) or need for blood transfusion (n=4, 12,1%) (P=1.00). After matching, no difference was seen between robotic and open operations in the incidence of grade b/c POPF, delayed gastric emptying, length of stay, readmission, major complications, and death (all P>0.05). Conclusion: Through a graduated comprehensive training protocol, there was no apparent learning curve associated with the implementation of robotic pancreaticoduodenectomy as described in previous studies. Furthermore, robotic cases had similar postoperative outcomes compared to matched open cases.