Robotic Pancreaticoduodenectomy Quality Outcomes
Original Investigation Research
Invited Commentary INNOVATION IN SAFETY: SAFETY IN INNOVATION
Challenges of Minimally Invasive Pancreas Surgery Growth With Such a High Learning Curve Barish H. Edil, MD; Richard D. Schulick, MD
Minimally invasive pancreaticoduodenectomy (MIPD), defined as laparoscopic or robotic surgery, has been slow to develop compared with operations on other organs.1 Approximately 100 years after the first pancreaticoduodenectomy, Related article page 416 MIPD is found to be safe, have potential oncologic advantages, and has been a large technical advance in our abilities.2,3 Despite continued skepticism, a select group of institutions, including our own, perform MIPD 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 mile-
stones 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.
ARTICLE INFORMATION
REFERENCES
Author Affiliations: Department of Surgery, University of Colorado, Aurora.
1. Biere SS, van Berge Henegouwen MI, Maas KW, et al. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomized controlled trial. Lancet. 2012;379(9829):1887-1892.
Corresponding Author: Barish H. Edil, MD, Department of Surgery, University of Colorado, 1665 Aurora Ct, Room 3337, Aurora, CO 80045 ([email protected]). Published Online: March 11, 2015. doi:10.1001/jamasurg.2015.32. Conflict of Interest Disclosures: None reported.
jamasurgery.com
2. Croome KP, Farnell MB, Que FG, et al. Total laparoscopic pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: oncologic advantage over open approaches? Ann Surg. 2014; 260(4):633-638.
3. Kausch W. Das Carcinom der Papilla duodeni und seine radikale Entfernung. Beitrage zur Klinische Chirurgie. 1912;78:439-486. 4. Boone BA, Zenati M, Hogg ME, et al. Assessment of quality outcomes for robotic pancreaticoduodenectomy: identification of the learning curve [published online March 11, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.17.
(Reprinted) JAMA Surgery May 2015 Volume 150, Number 5
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 08/17/2015
423
Original Investigation Research
Invited Commentary INNOVATION IN SAFETY: SAFETY IN INNOVATION
Challenges of Minimally Invasive Pancreas Surgery Growth With Such a High Learning Curve Barish H. Edil, MD; Richard D. Schulick, MD
Minimally invasive pancreaticoduodenectomy (MIPD), defined as laparoscopic or robotic surgery, has been slow to develop compared with operations on other organs.1 Approximately 100 years after the first pancreaticoduodenectomy, Related article page 416 MIPD is found to be safe, have potential oncologic advantages, and has been a large technical advance in our abilities.2,3 Despite continued skepticism, a select group of institutions, including our own, perform MIPD 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 mile-
stones 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.
ARTICLE INFORMATION
REFERENCES
Author Affiliations: Department of Surgery, University of Colorado, Aurora.
1. Biere SS, van Berge Henegouwen MI, Maas KW, et al. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomized controlled trial. Lancet. 2012;379(9829):1887-1892.
Corresponding Author: Barish H. Edil, MD, Department of Surgery, University of Colorado, 1665 Aurora Ct, Room 3337, Aurora, CO 80045 ([email protected]). Published Online: March 11, 2015. doi:10.1001/jamasurg.2015.32. Conflict of Interest Disclosures: None reported.
jamasurgery.com
2. Croome KP, Farnell MB, Que FG, et al. Total laparoscopic pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: oncologic advantage over open approaches? Ann Surg. 2014; 260(4):633-638.
3. Kausch W. Das Carcinom der Papilla duodeni und seine radikale Entfernung. Beitrage zur Klinische Chirurgie. 1912;78:439-486. 4. Boone BA, Zenati M, Hogg ME, et al. Assessment of quality outcomes for robotic pancreaticoduodenectomy: identification of the learning curve [published online March 11, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.17.
(Reprinted) JAMA Surgery May 2015 Volume 150, Number 5
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 08/17/2015
423
