Association of Mentorship and a Formal Robotic Proficiency Skills Curriculum With Subsequent Generations’ Learning Curve and Safety for Robotic Pancreaticoduodenectomy

Abstract

IMPORTANCE Learning curves are unavoidable for practicing surgeons when adopting new technologies. However, patient outcomes are worse in the early stages of a learning curve vs after mastery. Therefore, it is critical to find a way to decrease these learning curves without compromising patient safety.OBJECTIVE To evaluate the association of mentorship and a formal proficiency-based skills curriculum with the learning curves of 3 generations of surgeons and to determine the association with increased patient safety. DESIGN, SETTING, AND PARTICIPANTS All consecutive robotic pancreaticoduodenectomies (RPDs) performed at the University of Pittsburgh Medical Center between 2008 and 2017 were included in this study. Surgeons were split into generations based on their access to mentorship and a proficiency-based skills curriculum. The generations are (1) no mentorship or curriculum, (2) mentorship but no curriculum, and (3) mentorship and curriculum. Univariable and multivariable analyses were used to create risk-adjusted learning curves by surgical generation and to analyze factors associated with operating room time, complications, and fellows completing the full resection. The participants include surgical oncology attending surgeons and fellows who participated in an RPD at University of Pittsburgh Medical Center between 2008 and 2017. MAIN OUTCOMES AND MEASURESThe primary outcome was operating room time (ORT). Secondary outcomes were postoperative pancreatic fistula and Clavien-Dindo classification higher than grade 2. RESULTSWe identified 514 RPDs completed between 2008 and 2017, of which 258 (50.2%) were completed by first-generation surgeons, 151 (29.3%) were completed by the second generation, and 82 (15.9%) were completed by the third generation. There was no statistically significant difference between groups with respect to age (66.3-67.3 years; P = .52) or female sex (n = 34 [41.5%] vs n = 121 [46.9%]; P = .60). There was a significant decrease in ORT (P < .001), from 450.8 minutes for the first-generation surgeons to 348.6 minutes for the third generation. Additionally, across generations, Clavien-Dindo classification higher than grade 2 (n = 74 [28.7%] vs n = 30 [9.9%] vs n = 12 [14.6%]; P = .01), conversion rates (n = 18 [7.0%] vs n = 7 [4.6%] vs n = 0; P = .006), and estimated blood loss (426 mL vs 288.6 mL vs 254.7 mL; P < .001) decreased significantly with subsequent generations. There were no significant differences in postoperative pancreatic fistula. CONCLUSIONS AND RELEVANCEIn this study, ORT, conversion rates, and estimated blood loss decreased across generations without a concomitant rise in adverse patient outcomes. These findings suggest that a proficiency-based curriculum coupled with mentorship allows for the safe introduction of less experienced surgeons to RPD without compromising patient safety.

State of the art of robotic pancreatoduodenectomy

“…Under appropriate conditions, RPD facilitates safe implementation of minimally invasive PD [14] and reduces the learning curve of this procedure, when compared to LPD [28]. Availability of mentorship and implementation a proficiency-based curriculum further facilitate safe implementation of RPD [27].…”

“…Excluding one article defining the simultaneous learning curve of two surgeons at 80 procedures [21], the number of cases required to overcome the learning curve for a single surgeon ranged between 20 and 40 RPDs [22][23][24][25][26]. Implementation of mentorship and a proficiency-based curriculum could not affect POPF rate, but was shown to reduce operating times, conversion rates, severe post-operative complications, and estimated blood loss [27]. A recent systematic review on the learning curve of LPD and RPD showed that the learning curve of a single surgeon was considerably longer for LPD [ 21.0 (95% CI 17.5-25.0)] although the difference was not statistically significant [28].…”

Formal robotic training diminishes the learning curve for robotic pancreatoduodenectomy: Implications for new programs in complex robotic surgery

“…Besides formal training, ongoing mentorship positively impacts the early outcomes of outcomes with each generation of surgeons demonstrating improved outcomes in their early experience. 26 These studies, when combined with the current analysis, suggest that formal robotic training and access to expert robotic surgeons facilitates a smoother transition with improved outcomes for new robotic pancreatic surgeons.…”

Educational note: teaching and training in robotic surgery. An opinion of the Minimally Invasive and Robotic Surgery Committee of the Brazilian College of Surgeons

“…As in the "real simulation", criteria based on specific time and errors can be used for each exercise or Global Rate Scale (GRS) assessment model such as GOALS 19 or GEARS 20,21 . In structuring and developing curricula, the surgeonpreceptor becomes necessary to achieve a high level of results in adapting the beginner to robotic procedures, providing an evaluative feedback throughout the training process 10,22,33 .…”