TABLE 7.
Domain 7 Implementation and Training; Questions and Recommendations on Laparoscopic (L), Robotic (R) and General (G) MIPS
| Clinical questions (CQs) | Recommendation (R) | Evidence level | Form of recommendation | |
|---|---|---|---|---|
| Topic 18: Volumes and Learning Curves | ||||
| L41 | What center volume should be maintained for the safe implementation of LPR (LPD/LDP)? | Center volume strongly affects outcomes after LPD. Morbidity, mortality, and R0 rate are better when LPD is done in centers performing at least 20 LPD procedures per year. Centers should aim to perform at least 20 LPD procedures per year; however, it may be acceptable for centers to perform a lower volume per year as long as they can demonstrate maintenance of equivalent outcomes and they have a well-trained multidisciplinary pancreas team. | Moderate | Strong |
| R41 | What center volume should be maintained for the safe implementation of RPR (RPD/RDP)? | Center volume strongly affects outcomes after RPD. Morbidity, mortality, and R0 rate are better when RPD is done in centers performing at least 20 RPD procedures per year. Centers should aim to perform at least 20 RPD procedures per year; however, it may be acceptable for centers to perform a lower volume per year as long as they can demonstrate maintenance of equivalent outcomes and they have a well-trained multidisciplinary pancreas team. | Moderate | Strong |
| L42 | What are the suggested learning curves and surgeon volumes for LPR (LPD/LDP)? | The learning curve for operative time is 16 procedures for LDP and 39 for LPD. The learning curve for postoperative complications is 25 procedures for LDP and 25–80 for LPD. During the learning curve, surgeons are recommended to participate in a structured training program and ensure that competency is reached. | Moderate | Strong |
| R42 | What are the suggested learning curves and surgeon volumes for RPR (RPD/RDP)? | The learning curve for operative time is 15 procedures for RDP and 25 for RPD. The learning curve for postoperative complications is 21 for RDP and 25–40 for RPD. During this period, surgeons are recommended to participate in a structured training program and ensure that competency is reached. | Moderate | Strong |
| Topic 19: Training | ||||
| L43 | What training and preparation should surgeons pursue before performing LPR, and what is their impact? | A potentially higher rate of severe complications suggests the need for caution in introducing LPR techniques. Procedure-specific training programs for LPR mitigated the learning curve. Formal mentorship and structured training programs, which could include virtual reality, bio tissue drills, and off-site and on-site proctoring, facilitate the safe introduction and expansion of LPR. | Moderate | Weak |
| R43 | What training and preparation should surgeons pursue before performing RPR, and what is their impact? | A potentially higher rate of severe complications suggests the need for caution in introducing RPR techniques. Procedure-specific training programs for RPR mitigated the learning curve. Formal mentorship and structured training programs, which could include virtual reality, bio tissue drills, and off- and on-site proctoring, facilitate the safe introduction and expansion of RPR. | Moderate | Weak |
| Topic 20: Registries | ||||
| G44 | What should be the role of national and international registries in the wider implementation of MIPS? | The wider implementation of MIPS should be promoted by national and international HPB associations who should strongly encourage the development, implementation, and coordination of national registries and participation in international registries, as it will enhance the position of the country in the international debate and propagate/disseminate collaborative studies, for example, snapshot studies. | Moderate | Strong |
| G45 | Should centers be asked to include patients having MIPS in registries for quality control? | For MIPS, inclusion into registries for quality control by validated national and international centralized registries should be strongly encouraged to allow for transparent analysis and discussions for surgical procedures over time and new surgical techniques. | Moderate | Strong |
| Topic 21: Cost-effectiveness | ||||
| L46 | Is the laparoscopic approach more costly than the traditional open approach? | The intraoperative costs are higher for LPR compared with OPR but may be offset by the reduction in the length of hospital stay and functional recovery time. | Moderate | Strong |
| R46 | Is the robot-assisted approach more costly than the traditional open approach? | Studies assessing costs for robot-assisted pancreatic surgery are encouraged and should include capital costs, maintenance, and training. | Low | Strong |
HPB indicates hepato-pancreato-biliary; LDP, laparoscopic distal pancreatectomy; LPD, laparoscopic pancreatoduodenectomy; LPR, laparoscopic pancreatic resections; MIPS, minimally invasive pancreatic surgery; OPR, open pancreatic resections; RDP, robot-assisted distal pancreatectomy; RPD, robot-assisted pancreatoduodenectomy; RPR, robot-assisted pancreatic resections.