Thesis etd-12082022-130206 |
Link copiato negli appunti
Thesis type
Tesi di specializzazione (5 anni)
Author
CARPENITO, CRISTINA
URN
etd-12082022-130206
Thesis title
Le prime 50 duodenocefalopancreasectomie consecutive completamente robotiche eseguite da un singolo operatore senza conversioni: analisi della curva di apprendimento in un centro ad alto volume
Department
PATOLOGIA CHIRURGICA, MEDICA, MOLECOLARE E DELL'AREA CRITICA
Course of study
CHIRURGIA GENERALE
Supervisors
relatore Prof. Morelli, Luca
Keywords
- chirurgia pancreatica
- chirurgia robotica
- conversione open
- curva di apprendimento
- da Vinci Xi
- duodenocefalopancreasectomia robotica
- learning curve
- open conversion
- pancreatic surgery
- robotic pancreatoduodenectomy
- robotic surgery
Graduation session start date
13/01/2023
Availability
Withheld
Release date
13/01/2093
Summary
L’approccio open ha sempre costituito il gold standard per la chirurgia resettiva pancreatica. I limiti della chirurgia laparoscopica (visione 2D, assenza di feedback tattile, movimento controintuitivo degli strumenti, effetto fulcro, assenza di coordinazione mano-occhio, pochi gradi di libertà, amplificazione del tremore fisiologico) non ne hanno favorito la diffusione quale approccio di scelta per la chirurgia pancreatica. L’introduzione dei sistemi robotici ha consentito di superare alcuni di questi limiti, grazie a visione 3D, 7 gradi di libertà dell’EndoWrist, eliminazione del tremore fisiologico e dell’effetto fulcro, maggiore ergonomia, possibilità di eseguire movimenti in scala. Con l’applicazione della tecnologia robotica alla chirurgia pancreatica si è assistito a riduzione delle perdite ematiche intraoperatorie e della degenza ospedaliera, con stesso outcome oncologico a breve termine, morbidità e mortalità rispetto all’approccio open. Studi in letteratura riportano una curva di apprendimento per la duodenocefalopancreasectomia robotica di 20-80 casi, con tassi di conversione dall’1.1% al 35%; tali studi però non prendono in considerazione il background chirurgico dell’operatore né il volume del Centro o la tipologia di piattaforma robotica utilizzata, facendo perlopiù riferimento a esperienze robotiche in fase iniziale. Abbiamo analizzato gli outcome intra- e perioperatori delle prime 50 DCP totalmente robotiche consecutive eseguite da un singolo operatore con pregressa esperienza sia in chirurgia pancreatica che robotica utilizzando la piattaforma da Vinci Xi in un Centro ad alto volume tra il Gennaio 2018 e il Marzo 2022. Tutti gli interventi sono stati eseguiti con tecnica totalmente robotica, senza conversione open. 20/50 pazienti (40%) presentavano BMI≥25 kg/m2, 24/50 (48%) avevano subito pregressa chirurgia addominale. Il tempo di console medio è risultato pari a 276,30±31,16 minuti. La degenza postoperatoria mediana è stata di 10 giorni: 20/50 pazienti (40%) sono stati dimessi entro l’VIII g.p.o. 6/50 pazienti (12%) hanno presentato complicanze maggiori (Clavien-Dindo ≥ III). Non vi è stata mortalità a 30 giorni. Il diagramma di controllo di Shewhart e l'analisi CUSUM non hanno dimostrato una curva di apprendimento significativa durante il periodo in esame. Una vasta esperienza in chirurgia pancreatica e in chirurgia robotica, in un Centro di riferimento terziario ad alto volume con disponibilità della piattaforma robotica da Vinci Xi, contribuiscono al significativo appiattimento della curva di apprendimento consentendo di eseguire interventi chirurgici anche complessi, come la DCP con approccio mininvasivo, con un rischio di conversione molto basso già nelle prime 50 operazioni.
The gold standard for pancreatectomies has always been the traditional open approach. The intrinsic limits of laparoscopy (2D vision, absence of haptic feedback and hand-eye coordination, counterintuitive movement of the instruments, fulcrum effect, few degrees of freedom, amplification of physiological tremor) have not favoured its diffusion as the approach of choice for pancreatic surgery. The introduction of robotic platforms, with their 3D vision, 7 degrees of freedom thanks to the EndoWrist, elimination of physiological tremor and fulcrum effect, and possibility of scale movements, allowed to overcome some of these limitations. Robot-assisted pancreatic surgery has been proved to reduce intraoperative bleeding and length of hospital stay, while providing the same short term oncological outcomes and morbidity and mortality rates as the open approach. Several studies report a learning curve for robotic pancreatoduodenectomy of 20-80 operations, with conversion rates between 1.1% and 35%; however, these studies mostly refer to initial robotic experiences, and do not consider the previous surgical background in pancreatic surgery and in robotic assisted surgery, the Center’s volume, and the type of platform used. We analysed the intra- and perioperative outcomes of our first 50 consecutive full-robotic pancreatoduodenectomies performed with the da Vinci Xi by the same surgeon, within a tertiary referral high-volume Center, between January 2018 and March 2022. No conversions to open surgery were reported. 20/50 (40%) patients had a BMI≥25 kg/m2, while 24/50 (48%) had undergone previous abdominal surgery. Mean console time was 276,30±31,16 min. The median post-operative length of stay was 10 days: 20/50 (40%) patients were discharged within POD 8. 6/50 (12%) patients had major complications (Clavien-Dindo≥3). There was no 30-day mortality. Shewhart control chart and CUSUM analysis did not show a significant learning curve during the study period. An extensive prior experience in both pancreatic and robotic surgery, within a tertiary referral high-volume Center with availability of the da Vinci Xi platform, can significantly flatten the learning curve enabling safe performance of challenging operations, i.e. pancreatoduodenectomy with a minimally invasive approach, with very low risk of conversion to open surgery even in the first 50 operations.
The gold standard for pancreatectomies has always been the traditional open approach. The intrinsic limits of laparoscopy (2D vision, absence of haptic feedback and hand-eye coordination, counterintuitive movement of the instruments, fulcrum effect, few degrees of freedom, amplification of physiological tremor) have not favoured its diffusion as the approach of choice for pancreatic surgery. The introduction of robotic platforms, with their 3D vision, 7 degrees of freedom thanks to the EndoWrist, elimination of physiological tremor and fulcrum effect, and possibility of scale movements, allowed to overcome some of these limitations. Robot-assisted pancreatic surgery has been proved to reduce intraoperative bleeding and length of hospital stay, while providing the same short term oncological outcomes and morbidity and mortality rates as the open approach. Several studies report a learning curve for robotic pancreatoduodenectomy of 20-80 operations, with conversion rates between 1.1% and 35%; however, these studies mostly refer to initial robotic experiences, and do not consider the previous surgical background in pancreatic surgery and in robotic assisted surgery, the Center’s volume, and the type of platform used. We analysed the intra- and perioperative outcomes of our first 50 consecutive full-robotic pancreatoduodenectomies performed with the da Vinci Xi by the same surgeon, within a tertiary referral high-volume Center, between January 2018 and March 2022. No conversions to open surgery were reported. 20/50 (40%) patients had a BMI≥25 kg/m2, while 24/50 (48%) had undergone previous abdominal surgery. Mean console time was 276,30±31,16 min. The median post-operative length of stay was 10 days: 20/50 (40%) patients were discharged within POD 8. 6/50 (12%) patients had major complications (Clavien-Dindo≥3). There was no 30-day mortality. Shewhart control chart and CUSUM analysis did not show a significant learning curve during the study period. An extensive prior experience in both pancreatic and robotic surgery, within a tertiary referral high-volume Center with availability of the da Vinci Xi platform, can significantly flatten the learning curve enabling safe performance of challenging operations, i.e. pancreatoduodenectomy with a minimally invasive approach, with very low risk of conversion to open surgery even in the first 50 operations.
File
Nome file | Dimensione |
---|---|
Thesis not available for consultation. |