Total laparoscopic pancreaticoduodenectomy in patients with periampullary tumors: a learning curve analysis

Background: With continued technical advances in surgical instruments and growing expertise, many surgeons have safely performed laparoscopic pylorus-preserving pancreaticoduodenectomies (LPDs) with good results, and the laparoscopic approach is being performed more frequently. However, this complex procedure requires a relatively long training period to ensure technical competence. The present study aimed to analyze the learning curve for LPD. Methods: From September 2012 to May 2019, LPDs were performed for 171 patients at the Yonsei University Severance Hospital by a single surgeon. We retrospectively analyzed the demographic and surgical outcomes. The learning curve for LPD was evaluated using both the cumulative sum (CUSUM) and risk-adjusted CUSUM (RA-CUSUM) methods. All variables among the learning curve phases were compared. Results: Based on the CUSUM and the RA-CUSUM analyses, the learning curve for LPD was grouped into three phases: phase I was the initial learning period (cases 1–40), phase II represented the technical competence period (cases 41–100), and phase III was regarded as the challenging period (cases 101–171). Conclusions: According to the learning curve analysis, 40 cases are required to achieve technical competence in LPD and 100 cases are required to address highly challenging cases.