title: The learning curve in robotic distal pancreatectomy.
abstract: No data are available on the learning curve in robotic distal pancreatectomy (RADP). The learning curve in RADP was assessed in 55 consecutive patients using the cumulative sum method, based on operative time. Data were extracted from a prospectively maintained database and analyzed retrospectively considering all events occurring within 90 days of surgery. No operation was converted to laparoscopic or open surgery and no patient died. Post-operative complications occurred in 34 patients (61.8%), being of Clavien-Dindo grade I-II in 32 patients (58.1%), including pancreatic fistula in 29 patients (52.7%). No grade C pancreatic fistula occurred. Four patients received blood transfusions (7.2%), three were readmitted (5.4%) and one required repeat surgery (1.8%). Based on the reduction of operative times (421.1 ± 20.5 vs 248.9 ± 9.3 min; p < 0.0001), completion of the learning curve was achieved after ten operations. Operative time of the first 10 operations was associated with a positive slope (0.47 + 1.78* case number; R (2) 0.97; p < 0.0001*), while that of the following 45 procedures showed a negative slope (23.52 - 0.39* case number; R (2) 0.97; p < 0.0001*). After completion of the learning curve, more patients had a malignant histology (0 vs 35.6%; p = 0.002), accounting for both higher lymph node yields (11.1 ± 12.2 vs 20.9 ± 18.5) (p = 0.04) and lower rate of spleen preservation (90 vs 55.6%) (p = 0.04). RADP was safely feasible in selected patients and the learning curve was completed after ten operations. Improvement in clinical outcome was not demonstrated, probably because of the limited occurrence of outcome comparators.
authors.affiliation: Division of General and Transplant Surgery, Azienda Ospedaliera Universitaria Pisana, Università di Pisa, Via Paradisa 2, 56124, Pisa, Italy, nicco.napo@gmail.com.
authors.forename: Niccolò
authors.initials: N
authors.lastname: Napoli
authors.forename: Emanuele F
authors.initials: EF
authors.lastname: Kauffmann
authors.forename: Vittorio Grazio
authors.initials: VG
authors.lastname: Perrone
authors.forename: Mario
authors.initials: M
authors.lastname: Miccoli
authors.forename: Stefania
authors.initials: S
authors.lastname: Brozzetti
authors.forename: Ugo
authors.initials: U
authors.lastname: Boggi
mesh_terms: D002983:Clinical Competence; D005260:Female; D006801:Humans; D059032:Learning Curve; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D010180:Pancreatectomy / Q000009:adverse effects / Q000379:methods*; D018579:Patient Selection; D011183:Postoperative Complications; D012086:Reoperation; D012189:Retrospective Studies; D012371:Robotics