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Page 189 Body et al. Art Int Surg 2022;2:186-94 https://dx.doi.org/10.20517/ais.2022.28

[36]
to complete “mastery” level is 4.5 to 7 h . This basic robotic simulation programme can be effectively
[38]
introduced at an early postgraduate stage of training .
During the second stage of the programme, participants use box trainers to perform a
pancreaticojejunostomy, hepato-jejunostomy and gastro-jejunostomy using bio-tissue created to mimic the
respective organs. This allows the development of a standardised technique to improve efficiency in the
operating room, and enables adjustment to the loss of haptic feedback and recognition of the level of finger
pressure required to exert the intended instrument force. Each practice anastomosis is recorded and later
video scored by trained experts. Specific scores are required before progression to the next step.

All candidates later watch live cases in addition to several recordings of procedures, divided into distinct
operative phases. The curriculum participants then progress to intra-operative performance under the
guidance of a trained mentor with a step-wise progression of the number of operative phases performed. An
evaluation of the RPD training programme showed that fellows increasingly perform the complete
[39]
procedure and outcomes improve after they complete all curricula steps .
To ensure that robotic surgery is performed safely in an experienced setting, pancreatic robotic training
should be recommended to surgeons with specific characteristics that work in centres with defined surgical
volumes. The E-AHPBA course requires that at least 50 PD per year are performed at the applicant’s centre,
robot time is secured in the theatre and at least two surgeons are trained . Morbidity and mortality in MIS
[40]
pancreatic resections is higher in low-volume centres [41,42] ; thus, the Miami guidelines recommend that
[33]
centres participating in MIS should perform more than 20 MIS pancreas resections per year . This leads to
the questions of where future training will take place, and if an organised link between low- and high-
volume centres is required .
[43]

Does HPB robotic training work?
There is a shorter learning curve for robotic surgery compared with laparoscopic surgery, with novices able
to achieve basic surgical skills, including suturing and knot tying, more quickly . Furthermore, significant
[44]
improvements in outcomes after pancreaticoduodenectomy have been shown in robotic surgery after 40
cases in comparison with 60-104 cases for LPD [6,46] .
[45]

Virtual reality participation effectively trains the novice robotic surgeon in basic surgical skills. In a recent
RCT, 20 surgical trainees and 20 medical students were randomised to either laparoscopic or robotic
training. They performed 6 h of training on the simulator and box trainer, and then the following day
performed three surgical tasks on cadavers. Videos were recorded and analysed for time to complete, global
rating score and suture errors. The robotic group consistently performed better than the laparoscopic
group, with higher scores for each task and fewer suture errors . In the US, where more surgical trainees
[44]
have proportionately had robotic simulation exposure than the UK and Ireland, over 90% of trainees go on
to perform more than 15 general surgical procedures as a console surgeon compared with only 3% of UK
trainees .
[47]

Procedural-specific training has also been shown to be effective. A Dutch pancreatic cancer group was
trained using the Pittsburgh five-step technique. In its first 275 cases, it had excellent operative outcomes,
[11]
with minimal blood loss, a conversion rate of 6.5% and a pancreatic fistula rate of 23.6% . This RPD
[48]
training protocol has also been safely implemented in Japan .