Outcomes of a Multicenter Training Program in Robotic Pancreatoduodenectomy (LAELAPS-3)

Maurice J. W. Zwart*, Carolijn L. M. Nota*, Thijs de Rooij, Jony van Hilst, Wouter W. te Riele, Hjalmar C. C. van Santvoort, Jeroen Hagendoorn, Inne H. M. Borei Rinkes, Jacob L. L. van Dam, Anouk E. J. Latenstein, Kosei Takagi, Khe T. C. Tran, Jennifer Schreinemakers, George P. P. van der Schelling, Jan H. H. Wijsman, Sebastiaan Festen, Freek Daams, Misha D. D. Luyer, Ignace H. J. T. de Hingh, Jan S. D. MieogBert A. A. Bonsing, Daan J. J. Lips, Mohammed Abu Hilal, Olivier R. R. Busch, Olivier Saint-Marc, Herbert J. J. Zehl II, Amer H. H. Zureikat, Melissa E. E. Hogg, I. Quintus Molenaar, Marc G. G. Besselink, Bas Groot Koerkamp, Dutch Pancreatic Canc Grp

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

64 Citations (Web of Science)


OBJECTIVE: To assess feasibility and safety of a multicenter training program in robotic pancreatoduodenectomy (RPD) adhering to the IDEAL framework for implementation of surgical innovation.

BACKGROUND: Good results for RPD have been reported from single center studies. However, data on feasibility and safety of implementation through a multicenter training program in RPD are lacking.

METHODS: A multicenter training program in RPD was designed together with the University of Pittsburgh Medical Center, including an online video bank, robot simulation exercises, biotissue drills, and on-site proctoring. Benchmark patients were based on the criteria of Clavien. Outcomes were collected prospectively (March 2016-October 2019). Cumulative sum (CUSUM) analysis of operative time was performed to distinguish the first and second phase of the learning curve. Outcomes were compared between both phases of the learning curve. Trends in nationwide use of robotic and laparoscopic PD were assessed in the Dutch Pancreatic Cancer Audit.

RESULTS: Overall, 275 RPD procedures were performed in seven centers by 15 trained surgeons. The recent benchmark criteria for low-risk PD were met by 125 (45.5%) patients. The conversion rate was 6.5% (n = 18) and median blood loss 250 ml (IQR 150-500). The rate of Clavien-Dindo grade ≥III complications was 44.4% (n = 122), postoperative pancreatic fistula (grade B/C) rate 23.6% (n = 65), 90-day complication-related mortality 2.5% (n = 7) and 90-day cancer-related mortality 2.2.% (n = 6). Median postoperative hospital stay was 12 days (IQR 8-20). In the subgroup of patients with pancreatic cancer (n = 80), the major complication rate was 31.3% and POPF rate was 10%. CUSUM analysis for operative time found a learning curve inflection point at 22 RPDs (IQR 10-35) with similar rates of Clavien-Dindo grade ≥III complications in the first and second phase (43.4% vs 43.8%, P = 0.956, respectively). During the study period the nationwide use of laparoscopic PD reduced from 15% to 1%, whereas the use of RPD increased from 0% to 25%.

CONCLUSIONS: This multicenter RPD training program in centers with sufficient surgical volume was found to be feasible without a negative impact of the learning curve on clinical outcomes.

Original languageEnglish
Pages (from-to)e886-e895
Number of pages10
JournalAnnals of Surgery
Issue number6
Early online date1 Feb 2021
Publication statusPublished - Dec 2022

Bibliographical note

Funding Information:
M.J.W.Zwart received funding from the Amsterdam UMC for studies on safe implementation of innovative techniques in advanced pancreatic surgery.He also received funding from the Dutch Digestive Foundation, (Maag Lever Darm Stichting), for studies on the before mentioned topics (Agreement ID: I 16–05). LAELAPS-3 received a research grant from Intuitive for funding of proctoring travel. Training suturing material was provided by ETHICON, Johnson & Johnson. The other authors have nothing to disclose relevant to this study or manuscript.

Publisher Copyright:
© 2022 Lippincott Williams and Wilkins. All rights reserved.


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