A commentary on ‘Learning curves in laparoscopic distal pancreatectomy: a different experience for each generation (Int J Surg. 2023;109(6):1648–55)’

Dear Editor,

Over the last three decades, laparoscopic and robotic technologies have radically transformed the surgical landscape. Cucchetti reported the first description of laparoscopic pancreatic resection in 1994; a few years later, Gagner published his initial experience of laparoscopic distal pancreatectomy (LDP) with spleen preservation in eight cases¹. Indeed, LDP is now accepted worldwide for tumors of the body and tail of the pancreas.

We read with great interest the results of the study by van Ramshorst et al.², which was recently published in the International Journal of Surgery. This article contributes to understanding the learning curves in LDP and the impact of training and proctoring on these curves. They found that the learning curves for LDP were at least halved among ‘trained’ surgeons as compared to ‘self-taught’ surgeons. However, we would like to discuss some of our concerns. The concept and method of LDP have continuously evolved, including with respect to surgical position, spleen preservation method, location of orifices needed for approaching the pancreas, the extent of the resection, and the technique used for the parenchymal transection³. Whether the outcomes in this study were affected by these changes is worth exploring. Therefore, the selection of ‘self-taught’ surgeons as Idea, Development, Exploration, Assessment, and Long-term Study (IDEAL) stage 2 operators should be carefully considered because the surgeons are still improving their technique and skills during this period. At the same time, whether the advancement of surgical instruments also facilitated the operation process, reduced the difficulty of operation, and improved postoperative recovery, is another pertinent question. Second, there are no statistics on the surgeon’s experience of open distal pancreatectomy (ODP) before they started performing LDP. Whether the experience of OPD has any influence on LPD performance is worthy of further analysis⁴. Different teaching methods, concepts, and the subjective tendency of teaching doctors may also affect the learning curve of ‘trained’ surgeons for LDP. This aspect is also worthy of discussion. Third, regarding the outcomes for ‘trained’ surgeons, failure rates of spleen preservation significantly increased during the learning curve phases. Is this related to the selection of patients? In previous studies, patients with less extensive cancer underwent LDP, while those with more extensive cancer underwent ODP⁴. For the ‘trained’ surgeons, was there are tendency for selection of more complex patients (such as those receiving neoadjuvant chemotherapy or radiation and those with larger tumors) with the increase in surgical proficiency? Whether this can potentially explain this result needs to be assessed in a larger sample.

Despite these problems, this study shows the importance of education and training in the implementation of novel techniques and suggests that learning curves must be considered flexible curves that are dependent on many factors (including time) and that the obtained learning curves may be adopted in the design of future surgical trials. Nonetheless, we cannot ignore the innovative and exploratory spirit of surgeons in the first-generation phase of laparoscopic and robotic technologies. Their contribution and struggle in minimally invasive surgery need to be inherited and carried forward.

Ethical approval

This is a commentary; no ethical approval is needed.

Consent

None.

Sources of funding

None.

Author contribution

M.W.: writing; Y.L.: revision; J.W.: design and final revision.

Conflicts of interest disclosure

The authors declare that they have no conflicts of interest.

Research registration unique identifying number (UIN)

None.

Guarantor

Jianfeng Wei.

Data availability statement

This is a commentary; no data statement is needed.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Assistance with the study

None.