Robotic surgery is becoming increasingly utilized in HPB surgery with an enlarging pool of evidence suggesting improvements in clinical outcomes [6-8]. A majority of results from HPB surgery come from established surgeons who implemented robotics into existing practices. Limited guidance is available to new faculty members with a focused practice utilizing the robotic platform in HPB surgery. Throughout the initial years of a new faculty practice, we found a wide breadth of HPB cases were feasible with the robotic platform, with perioperative outcomes that mirrored established benchmarks. These findings suggest that with the appropriate institutional environment and comprehensive training, safe and successful implementation of a robotic HPB practice is feasible.
Operative time is often used as the best measure of proficiency, as safely and efficiently moving through a complex operation suggests mastery of the technical skills necessary to complete the procedure. Studies investigating the learning curve for robotic surgery utilize this metric to monitor progression over time, often demonstrating a large decrease in operative times with early experience, followed by a more gradual plateau. The optimized benchmark for proficiency based on the last 100 RPDs from a series of 500 RPD operative times is 415 minutes [19]. In this study, we demonstrate a median operative time below this benchmark at 360 minutes during year 1. Similarly, the optimized operative time for a distal pancreatectomy has been reported as 290 minutes, whereas this study demonstrated an operative time of 195 minutes in year 1 [21]. Moreover, operative times were consistent across the first three years of practice, suggesting minimal learning curve throughout the experience. Average operative times for hepatic resections vary, but a recent meta-analysis showed an average operative time of 283 minutes [22]. During year 1 our operative time was 172 minutes with a small decrease seen during year 2.
Safety is of the utmost importance to all providers, but especially for junior faculty when starting a new practice. In this experience, we had low perioperative mortality and found the rate of major complications to be similar to previously reported outcomes. Additionally, there were no significant differences in complication rates between practice years. In particular, 24% of year 1 RPDs had a Clavien Dindo grade 3 or above complications, comparable to the 25% reported in a large series [19]. The same findings were seen with length of stay. However, 30 and 90-day readmission rates for all HPB robotic operations were elevated to 41% and 44%, respectively, during year 1 compared to 12.5% in subsequent years. The 30 and 90-day readmission rates for RPD during year 1, specifically, were both 47% with only 3 patients admitted for a Clavien Dindo complication of 3 or above. Larger series of RPDs have found 90-day readmission rates to range from 25 to 37 percent which is similar to those seen in years 2 and 3 in this study [11, 17, 19, 23]. These findings may suggest a heightened sense of alertness and greater degree of caution for a new faculty member, resulting in a lower threshold for readmission and may not be indicative of the robotic approach itself.
Patient selection is frequently cited as a key to success for early adopters of robotics. Previous authors have recommended the gradual implementation of robotics into a new HPB practice with cautious case selection [17]. However, with the advancement of formal training programs built into residency and fellowship programs, this may be less critical to early success. Over selection may limit the ability for patients to benefit from a minimally invasive approach when feasible and restricts the knowledge and experience gained from persevering through challenging cases. The current cohort includes a complex patient population with high rates of prior intra-abdominal operations, malignancy, and CCI present even in year 1, suggesting the avoidance of strict selection criteria for robotic utilization, even for junior faculty. This is important to acknowledge when interpreting our results. Our approach was to utilize the robot for as long as safely possible at the outset of an operation, even with a high index of suspicion for the eventual need to convert to an open procedure based on adhesive disease or vascular involvement. This approach resulted in successful robotic completion for several patients with prior major foregut surgery. Additionally, operating on patients with portal vein abutment prompted us to obtain complete vasculature control of the portal vein with laparoscopic bulldog clamps during the uncinate dissection very early in the experience (4th RPD), which is a valuable technical skill to have for these procedures.
We believe several factors are critical to implementation of a successful robotic HPB surgery program especially for new attending surgeons, as demonstrated in the current work:
- Comprehensive formal training in robotics during residency and fellowship – this provides necessary technical skills, operative knowledge and prior faculty mentors who offer ongoing remote advice and support, all of which offer a strong foundation for future success.
- Highly supportive department and institutional environment – while only a handful of robotic HPB cases were done at the institution prior to 2018, the hospital already established programs in robotic cardiac, thoracic, head and neck, gynecologic and urologic surgery. New and experienced robot surgeon colleagues offered excitement and support of the program expanding to include HPB cases. The surgeon in this study was given dedicated robotic block time and a highly Functioning team.
- Two Attending Approach – while perhaps not required for success, we strongly encourage surgeons implementing a new robot HPB program to use a two-surgeon approach for the critical part of major procedures. The second attending offers technical help from more experienced hands during critical portions or challenging dissections, discusses details of the case as it unfolds, supports operative decision making, and represents a team approach for the culture of patient safety. Further, the bedside attending can effectively teach advanced laparoscopic skills to senior level residents and fellows much more directly than the other surgeon calling out instruction from the robot console.
- Dedicated Robot HPB Operative Team – a dedicated robotic operative team, including circulator and surgical assistant, is indispensable.[24] We are also fortunate to have robotic physician assistants on the surgical oncology team who are able to assist with patient positioning, docking and undocking, passing robotic instruments, and troubleshooting the robot itself.
This study does have numerous limitations. Importantly, this is a retrospective study examining the experience of a single surgeon at a single institution. These results may not be replicable across surgeons or institutions and should be interpreted with caution. The outcomes reported were the result of the surgeon being highly trained with a renowned, comprehensive robotics training program during residency and fellowship. Institutional support for the robotics program is critical to early success, and institutional resources and support vary significantly across centers. For instance, we utilized a two-surgeon approach for the majority of the major HPB cases, which may not be feasible at all hospitals. Furthermore, training resources for operative team members may differ. Despite these limitations, these results do provide a framework for safe and successful robotic surgery implementation.
Overall, we found the initiation of a new, predominantly robotic HPB practice was feasible with optimized operative times and complication rates seen within the first year of practice despite a complex and diverse patient population. We attribute this to the formal robotic training completed during residency and fellowship which allowed a diminished to absent additional learning curve during the initial years of practice. Additionally, substantial institutional support allowing for two faculty surgeon participation and a dedicated operative team is a critical component that made these results possible.