Learning curves in laparoscopic distal pancreatectomy: a different experience for each generation

BACKGROUND: Learning curves of laparoscopic distal pancreatectomy (LDP) are mostly based on 'self-taught' surgeons who acquired sufficient proficiency largely through self-teaching. No learning curves have been investigated for 'trained' surgeons who received training and built on the experience of the 'self-taught' surgeons. This study compared the learning curves and outcome of LDP between 'self-taught' and 'trained' surgeons in terms of feasibility and proficiency using short-term outcomes. MATERIALS AND METHODS: Data of consecutive patients with benign or malignant disease of the left pancreas who underwent LDP by four 'self-taught' and four 'trained' surgeons between 1997 and 2019 were collected, starting from the first patient operated by a contributing surgeon. Risk-adjusted cumulative sum (RA-CUSUM) analyses were performed to determine phase-1 feasibility (operative time) and phase-2 proficiency (major complications) learning curves. Outcomes were compared based on the inflection points of the learning curves. RESULTS: The inflection points for the feasibility and proficiency learning curves were 24 and 36 procedures for 'trained' surgeons compared to 64 and 85 procedures for 'self-taught' surgeons, respectively. In 'trained' surgeons, operative time was reduced after completion of the learning curves (230.5-203 min, P= 0.028). In 'self-taught' surgeons, operative time (240-195 min, P ≤0.001), major complications (20.6-7.8%, P= 0.008), and length of hospital stay (9-5 days, P ≤0.001) reduced after completion of the learning curves. CONCLUSION: This retrospective international cohort study showed that the feasibility and proficiency learning curves for LDP of 'trained' surgeons were at least halved as compared to 'self-taught' surgeons.