Ann Surg Treat Res.  2024 Jul;107(1):27-34. 10.4174/astr.2024.107.1.27.

Analysis of the learning curve for laparoscopic pancreaticoduodenectomy based on a single surgeon’s experience: a retrospective observational study

• Kim HJ
• Cho CK

• KMID: 2557577
• DOI: http://doi.org/10.4174/astr.2024.107.1.27

Abstract

Purpose
Laparoscopic pancreaticoduodenectomy (LPD) is a highly challenging procedure, which prevents its widespread adoption despite its advantages of being a minimally invasive procedure. This study analyzed the learning curve for LPD based on a single surgeon’s experience.
Methods
We retrospectively analyzed the medical records of 111 consecutive patients who underwent LPD by a single surgeon between March 2014 and October 2022. The learning curve was assessed using cumulative summation (CUSUM) and risk-adjusted CUSUM (RA-CUSUM) methods. Surgical failure was defined as conversion to an open procedure or the occurrence of severe complications (Clavien-Dindo grade ≥III). Based on the learning curve analysis, we divided the learning curve into the early and late phases and compared the operative outcomes in each phase.
Results
Based on the CUSUM analysis, the operation time decreased after the first 33 cases. Based on the RA-CUSUM analysis, the LPD technique stabilized after the 44th case. In the late phase, operation time, length of stay, and incidence of delayed gastric emptying, severe complications, and surgical failure were significantly lower than in the early phase.
Conclusion
Our results indicate that 44 cases are required for stabilization of the LPD technique and improvement of operative outcomes.

Keyword

Laparoscopy; Learning curve; Pancreaticoduodenectomy

Figure

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  Fig. 1 Trocar placement and operator’s position. (A) In the resection phase, the operator stands on the patient’s right side. (B) In the pancreatico-jejunostomy (PJ) phase, the operator stands between the patient’s legs considering the direction of the instrument for PJ. (C) In the hepatico-jejunostomy phase, the operator stands on the patient’s left side.

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  Fig. 2 Number of cases and indications by year. AoV, ampulla of Vater; IPMN, intraductal papillary mucinous neoplasm.

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  Fig. 3 Cumulative summation graph for the operation time. The peak point was observed at the 33rd case.

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  Fig. 4 Risk-adjusted cumulative summation graph for surgical failure in laparoscopic pancreaticoduodenectomy. The surgical failure rate gradually decreased after the 44th case. Therefore, the evaluation period was classified as early or late phase as before or after the 44th case, respectively.

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