• Maurice J W Zwart, Bram van den Broek, Nine de Graaf, José A Suurmeijer, Simone Augustinus, Wouter W Te Riele, Hjalmar C van Santvoort, Jeroen Hagendoorn, Borel RinkesInne H MIHMDepartment of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands., Jacob L van Dam, Kosei Takagi, Khé T C Tran, Jennifer Schreinemakers, George van der Schelling, Jan H Wijsman, Roeland F de Wilde, Sebastiaan Festen, Freek Daams, Misha D Luyer, de HinghIgnace H J TIHJTDepartment of Surgery, Catharina Hospital, Eindhoven, the Netherlands., Jan S D Mieog, Bert A Bonsing, Daan J Lips, Mohamed Abu Hilal, Olivier R Busch, Olivier Saint-Marc, Herbert J Zeh, Amer H Zureikat, Melissa E Hogg, Bas G Koerkamp, Isaac Q Molenaar, Marc G Besselink, and Dutch Pancreatic Cancer Group.
• Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands.
• Ann. Surg. 2023 Dec 1; 278 (6): e1232e1241e1232-e1241.

ObjectiveTo assess the feasibility, proficiency, and mastery learning curves for robotic pancreatoduodenectomy (RPD) in "second-generation" RPD centers following a multicenter training program adhering to the IDEAL framework.BackgroundThe long learning curves for RPD reported from "pioneering" expert centers may discourage centers interested in starting an RPD program. However, the feasibility, proficiency, and mastery learning curves may be shorter in "second-generation" centers that participated in dedicated RPD training programs, although data are lacking. We report on the learning curves for RPD in "second-generation" centers trained in a dedicated nationwide program.MethodsPost hoc analysis of all consecutive patients undergoing RPD in 7 centers that participated in the LAELAPS-3 training program, each with a minimum annual volume of 50 pancreatoduodenectomies, using the mandatory Dutch Pancreatic Cancer Audit (March 2016-December 2021). Cumulative sum analysis determined cutoffs for the 3 learning curves: operative time for the feasibility (1) risk-adjusted major complication (Clavien-Dindo grade ≥III) for the proficiency, (2) and textbook outcome for the mastery, (3) learning curve. Outcomes before and after the cutoffs were compared for the proficiency and mastery learning curves. A survey was used to assess changes in practice and the most valued "lessons learned."ResultsOverall, 635 RPD were performed by 17 trained surgeons, with a conversion rate of 6.6% (n=42). The median annual volume of RPD per center was 22.5±6.8. From 2016 to 2021, the nationwide annual use of RPD increased from 0% to 23% whereas the use of laparoscopic pancreatoduodenectomy decreased from 15% to 0%. The rate of major complications was 36.9% (n=234), surgical site infection 6.3% (n=40), postoperative pancreatic fistula (grade B/C) 26.9% (n=171), and 30-day/in-hospital mortality 3.5% (n=22). Cutoffs for the feasibility, proficiency, and mastery learning curves were reached at 15, 62, and 84 RPD. Major morbidity and 30-day/in-hospital mortality did not differ significantly before and after the cutoffs for the proficiency and mastery learning curves. Previous experience in laparoscopic pancreatoduodenectomy shortened the feasibility (-12 RPDs, -44%), proficiency (-32 RPDs, -34%), and mastery phase learning curve (-34 RPDs, -23%), but did not improve clinical outcome.ConclusionsThe feasibility, proficiency, and mastery learning curves for RPD at 15, 62, and 84 procedures in "second-generation" centers after a multicenter training program were considerably shorter than previously reported from "pioneering" expert centers. The learning curve cutoffs and prior laparoscopic experience did not impact major morbidity and mortality. These findings demonstrate the safety and value of a nationwide training program for RPD in centers with sufficient volume.Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.

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