gms | German Medical Science

Background: An increasing number of pancreas resections are performed laparoscopically. Despite identical operative procedures, laparoscopic pancreas resections however, greatly vary in their technical difficulty. This implies that surgeons have to wisely select appropriate patients according to their technical skill while they pass through their individual learning curve. With our analyses we try to identify parameters that are indicators of success during the personal learning curve using 2 independent learning curves with 30 hybrid laparoscopically assisted pancreatoduodenectomies for each surgeon.

Materials and methods: Between 2010 and 2015 106 laparoscopic hybrid pancreatoduodenectomies with open reconstruction were performed in a single center at the Clinic of General and Visceral Surgery, University of Freiburg. These operations were performed consecutively by two surgeons independently responsible for patient selection and operative procedures. Data of operative procedures and the postoperative clinical course was continuously collected in a SPSS database (SPSS, Version 22.0, SPSS Inc.,Chicago, IL, USA). Statistical significance was tested using the Mann-Whitney-U-Test, Fischer´s exact test and Chi-square tests.

Results: The first 30 operations done by each surgeon were analyzed. Analysis of histopathological diagnosis revealed a difference in patient selection with more patients with adenocarcinoma resected by one surgeon (23% vs. 43%). Patients selected by one surgeon were also significantly older (65 ± 12.5 vs. 71 ± 11.6). Mortality was low with 1 death by one surgeon (3.3%) and no lethality within the first 30 resections by the second surgeon. Perioperative complications were comparable to open procedures. Grade C POPFs (0% vs. 3.3%) were more common in one series due to the change in complication management to early conversion of high volume fistulas after pancreatojejunostomy to pancreatogastrostomy. Operation time and blood loss differed between both series with longer operation times and higher blood loss in the series with more pancreatic adenocarcinomas (operation time 381 ± 79 min vs. 454 ± 71 min p< 0.001; median blood loss 350 ml vs. 650 ml, p<0.001).

While in one surgeon operation time reduced between the first and second 15 patients (437 ± 51 min vs. 320 ± 68, p<0.001) this effect was not observed for the second surgeon. Longitudinal analysis of the first 15 versus the second 15 patients in each series however did not show different patient outcomes, patient characteristics or blood loss, indicating that these parameters are possibly not suitable do measure surgical competence during an individual learning curve.

Conclusion: During the individual learning curve, patient selection appears to be of exceptional importance. Complications, conversion rates, operative time and reoperations rates are insufficient parameters of competence since a shift in patient selection to more complicated cases probably compensates for improvement in these factors. Due to the variability in technical complexity of laparoscopic pancreatoduodenectomy even with open reconstruction, a plateau of the learning curve is not reached after 30 procedures.