title: Defining the learning curve for team-based laparoscopic pancreaticoduodenectomy.
abstract: BACKGROUND
  The purpose of this study was to define the learning curves for laparoscopic pancreaticoduodenectomy (LPD) with and without laparoscopic reconstruction, using paired surgical teams consisting of advanced laparoscopic-trained surgeons and advanced oncologic-trained surgeons.
  
  
  METHODS
  All patients undergoing PD without vein resection at a single institution were retrospectively analyzed. LPD was introduced by initially focusing on laparoscopic resection followed by open reconstruction (hybrid) for 18 months prior to attempting a totally LPD (TLPD) approach. Cases were compared with Chi square, Fisher's exact test, and Kruskal-Wallis analysis of variance (ANOVA).
  
  
  RESULTS
  Between March 2010 and June 2013, 140 PDs were completed at our institution, of which 56 (40 %) were attempted laparoscopically. In 31/56 procedures we planned to perform only the resection laparoscopically (hybrid), of which 7 (23 %) required premature conversion before completion of resection. Following the first 23 of these hybrid cases, a total of 25 TLPDs have been performed, of which there were no conversions to open. For all LPD, a significant reduction in operative times was identified following the first 10 patients (median 478.5 vs. 430.5 min; p = 0.01), approaching open PD levels. After approximately 50 cases, operative times and estimated blood loss were consistently lower than those for open PD.
  
  
  CONCLUSIONS
  In our experience of building an LPD program, the initial ten cases represent the biggest hurdle with respect to operative times. For an experienced teaching center using a staged and team-based approach, LPD appears to offer meaningful reductions in operative time and blood loss within the first 50 cases.
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, NC, USA, paul.speicher@duke.edu.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Speicher
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Nussbaum
authors.forename: Rebekah R
authors.initials: RR
authors.lastname: White
authors.forename: Sabino
authors.initials: S
authors.lastname: Zani
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Mosca
authors.forename: Dan G
authors.initials: DG
authors.lastname: Blazer
authors.forename: Bryan M
authors.initials: BM
authors.lastname: Clary
authors.forename: Theodore N
authors.initials: TN
authors.lastname: Pappas
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Tyler
authors.forename: Alexander
authors.initials: A
authors.lastname: Perez
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D010535:Laparoscopy / Q000193:education* / Q000379:methods; D059032:Learning Curve; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D061646:Operative Time; D010190:Pancreatic Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000193:education* / Q000379:methods; D011183:Postoperative Complications; D017410:Practice Guidelines as Topic / Q000592:standards*; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate