Association of Mentorship and a Formal Robotic Proficiency Skills Curriculum With Subsequent Generations’ Learning Curve and Safety for Robotic Pancreaticoduodenectomy
Authors: MaryJoe K. Rice, Jacob C. Hodges, Johanna Bellon, Jeffrey Borrebach, Amr I. Al Abbas, Ahmad Hamad, L. Mark Knab, A. James Moser, Amer H. Zureikat, Herbert J. Zeh, Melissa E. Hogg
Journal: JAMA Surgery (2020)

<h3>Importance</h3> Learning curves are unavoidable for practicing surgeons when adopting new technologies. However, patient outcomes are worse in the early stages of a learning curve vs after mastery. Therefore, it is critical to find a way to decrease these learning curves without compromising patient safety. <h3>Objective</h3> To evaluate the association of mentorship and a formal proficiency-based skills curriculum with the learning curves of 3 generations of surgeons and to determine the association with increased patient safety. <h3>Design, Setting, and Participants</h3> All consecutive robotic pancreaticoduodenectomies (RPDs) performed at the University of Pittsburgh Medical Center between 2008 and 2017 were included in this study. Surgeons were split into generations based on their access to mentorship and a proficiency-based skills curriculum. The generations are (1) no mentorship or curriculum, (2) mentorship but no curriculum, and (3) mentorship and curriculum. Univariable and multivariable analyses were used to create risk-adjusted learning curves by surgical generation and to analyze factors associated with operating room time, complications, and fellows completing the full resection. The participants include surgical oncology attending surgeons and fellows who participated in an RPD at University of Pittsburgh Medical Center between 2008 and 2017. <h3>Main Outcomes and Measures</h3> The primary outcome was operating room time (ORT). Secondary outcomes were postoperative pancreatic fistula and Clavien-Dindo classification higher than grade 2. <h3>Results</h3> We identified 514 RPDs completed between 2008 and 2017, of which 258 (50.2%) were completed by first-generation surgeons, 151 (29.3%) were completed by the second generation, and 82 (15.9%) were completed by the third generation. There was no statistically significant difference between groups with respect to age (66.3-67.3 years;<i>P</i> = .52) or female sex (n = 34 [41.5%] vs n = 121 [46.9%];<i>P</i> = .60). There was a significant decrease in ORT (<i>P</i> &lt; .001), from 450.8 minutes for the first-generation surgeons to 348.6 minutes for the third generation. Additionally, across generations, Clavien-Dindo classification higher than grade 2 (n = 74 [28.7%] vs n = 30 [9.9%] vs n = 12 [14.6%];<i>P</i> = .01), conversion rates (n = 18 [7.0%] vs n = 7 [4.6%] vs n = 0;<i>P</i> = .006), and estimated blood loss (426 mL vs 288.6 mL vs 254.7 mL;<i>P</i> &lt; .001) decreased significantly with subsequent generations. There were no significant differences in postoperative pancreatic fistula. <h3>Conclusions and Relevance</h3> In this study, ORT, conversion rates, and estimated blood loss decreased across generations without a concomitant rise in adverse patient outcomes. These findings suggest that a proficiency-based curriculum coupled with mentorship allows for the safe introduction of less experienced surgeons to RPD without compromising patient safety.