Safe implementation of a minimally invasive hepatopancreatobiliary program, a narrative review and institutional experience

Laparoscopic and robotic‐assisted approaches to hepatopancreatobiliary (HPB) operations have expanded worldwide. As surgeons and medical centers contemplate initiating and expanding minimally invasive surgical (MIS) programs for complex HPB surgical operations, there are many factors to consider. This review highlights the key components of developing an MIS HPB program and shares our recent institutional experience with the adoption and expansion of an MIS approach to pancreaticoduodenectomy.

to several perceived advantages of the technology including improved three-dimensional optics, wristed articulation, improved ergonomics, and diminished surgeon fatigue.Although an in-depth review of the literature comparing approaches is beyond the scope of this review, numerous reports have demonstrated superior short-term outcomes of MIS approaches compared to open surgery in select patients. 6,10,19,20However, these factors must be weighed against the limitations including high costs, prolonged learning curves, need for experienced teams, and lack of benefit in certain patients. 21,22S HPB surgical procedures are complex and require meticulous attention to detail as adverse outcomes can have dramatic consequences for the patient.Therefore, adopting these procedures safely requires a multidisciplinary approach with commitment from multiple stakeholders, including surgeons, anesthesiologists, nursing staff, and hospital administrators.Formalization of an institutional program in MIS HPB surgery should be strongly considered to facilitate building an expert operating room team that adheres to standardized protocols and procedures, securing institutional support for staff training, specialized equipment, and facilities, and fostering a culture of patient safety, focusing on quality assurance and improvement.

| WHO SHOULD BUILD AN MIS HPB PROGRAM?
Surgeons and institutional leaders should consider several factors before starting an MIS HPB program.Some of these include a sufficient volume of cases, human resources to build an expert surgical team, and financial resources to support simulation, training, and continuous process improvement.
4][25][26][27][28][29] Published learning curve rates are variable but demonstrate that outcomes improve as experience accumulates in both MIPR and MIH. 13,23For example, in laparoscopic distal pancreatectomy, a reduction in operating room time (OR time), estimated blood loss (EBL), and open conversion rates was observed after completion of 10-40 cases, 30,31 while a reduction in OR time, EBL, postoperative pancreatic fistula for a robotic pancreaticoduodenectomy was observed after 15-80 cases. 32,33In the largest single institution series of robotic pancreatoduodenectomies, improvements in EBL, OR time, and morbidity was observed within the first 240 cases. 18In MIH, studies suggest that learning curves for robotic hepatectomy are shorter than laparoscopic hepatectomy, with one study demonstrating a learning curve of 16 operations compared to 29 for robotic and laparoscopic hepatectomy, respectively. 34For robotic major hepatectomy, a single institution study using cumulative sum operation time model indicated that the learning curve can be divided into three phases, initial (15 cases), intermediate (25 cases), and mature (52 cases) with shorter OR time observed after completion of phase one and reduced EBL after phase two. 35Given the extensive experience needed to improve outcomes in MIS HPB operations, it is important for prospective programs to ensure they have the patient volume and sufficient access to the robot for surgical teams to become proficient.
Building an MIS program is resource intensive.Departmental and institutional resources are needed for equipment acquisition and maintenance, purchasing procedural consumables, building and maintaining specialized facilities while hiring and training staff to assist in implementation. 36,37In many centers, two attending surgeons are often involved in every case during the early part of the learning curve.Although an MIS program can be developed under a single surgeon, a two-surgeon team ensures patient safety and can speed up the learning curve. 38Resources are also needed to fund training programs and simulation centers to develop and maintain surgeon skills, support team-based experiences for management of intraoperative adverse events and catastrophes, and fund quality improvement assessment projects to ensure patient safety. 39erefore, it is important to secure institutional and departmental support for these components for safe and effective implementation.
Surgeons interested in starting a robotic MIS HPB program come with variable backgrounds.It is important to take personal experience into the decision of whether to build an MIS program.An increasing number of surgeons are now being trained in MIS HPB techniques during fellowship, however, many do not have prior experience with these operations.It is important that surgeons contemplating starting an MIS HPB without prior experience leverage expertise from experienced colleagues, review guidelines from thought leaders and professional societies and seek out coaching models to assist in safe adoption and implementation.It is helpful to have a team that combines the experience and familiarity with both HPB and MIS.

| HOW TO BUILD AN MIS HPB PROGRAM?
Building a successful MIS HPB program necessitates a strategic and multifaceted approach that intertwines clinical expertise, standardized protocols and procedures, specialized infrastructure, and a robust culture of patient safety (Figure 1).In MIPR, several groups  It can be time consuming and difficult for a practicing surgeon to become proficient in these new practices after surgical training, and this can be a barrier to adoption.Proctoring, coaching, and formal programs exist to provide education in these technologies and are discussed below.5][46][47] The future of these MIS programs depends on a reliable, well-trained surgical workforce and it is incumbent upon training programs to formalize training in these technologies to benefit future surgeons and patients. 48S HPB operations pose unique considerations for the anesthesiologist compared to traditional open surgery.Some of these challenges include limited patient access due to patient positioning and equipment setup, increased duration of the operation, hemodynamic and respiratory effects of pneumoperitoneum, central venous pressure optimization, and management of specific intraoperative adverse events such as major vascular hemorrhage and air embolism. 49,50Intravenous fluid needs differ from laparotomy with reduced evaporative fluid loss in laparoscopic operations. 51Patients with underlying liver disease have increased risk of perioperative morbidity and benefit from an anesthesia team experienced in the management of coagulopathy, ascites, hyperbilirubinemia, and encephalopathy. 52The use of enhanced recovery protocols for liver and pancreas surgery may provide a set of best practices for perioperative management and should be considered to standardize care in these complex patients. 53,54paroscopic and robotic-assisted surgical procedures significantly alter the team dynamics of the operating room.The operations utilize complex equipment, significantly alter the physical space of the operating room, influence team communications and task management, introduce new challenges in workflow efficiency, and require different approaches to manage and rescue patients after intraoperative adverse events.Several studies have examined the effect these technologies on human performance and recommend routine interdisciplinary training, preoperative briefing, surgical checklists, and adherence to best team communication practices. 55,56urgical oncology fellows completed a three-step mastery-based robotic curriculum and 94% perceived an improvement in robotic skills after the curriculum.This curriculum is mandatory to complete before participating in live surgery at UPMC and can serve as a benchmark for other programs interested in robotic surgical training. 58,59merous online video resources and intraoperative video recordings are available to assist in training.1][62] YouTube video libraries, Facebook interest groups, X (formerly known as Twitter), SurgeOn app, blogs, and other social media platforms facilitate the dissemination of surgical videos and can be used to gain tips and tricks from other surgeons.Furthermore, there are several online communities and interest groups for surgeons to find resources and collaborate on difficult cases.Finally, individualized surgical video review and coaching are important new tools best suited for minimally invasive techniques given ease of recording.These can help to facilitate self-reflection and critique with the goal of improving one's own surgical skills. 61

| Standardization of protocols, culture of patient safety
No specific universal standards exist for defining patient selection, indications, and contraindications for MIS HPB operations.Several guidelines and consensus statements exist to help facilitate safe practices, but patient selection criteria are surgeon and institution dependent. 8,10,19,20,43As a part of the MIS HPB program, it is important for the surgical, anesthesia, and nursing team to determine appropriate criteria for patient selection.From a surgeon's standpoint, this should consider patient and tumor factors associated with increasing difficulty such as vascular involvement, recent pancreatitis, and anatomic variations.[65][66] In addition to patient selection, an MIS HPB program should foster a culture of patient safety that focuses on quality improvement and assurance.Programs should endeavor to create protocols and interdisciplinary training programs for managing adverse intraoperative events such as major hemorrhage, air embolism, cardiac arrest, and equipment failure.8][69] For example, the Barnes-Jewish Hospital/Washington University created an "Emergency Undocking Bleeding Protocol" that delineate team roles to be performed simultaneously during an emergency event. 56 At the time of publication, our group has completed 20 cases utilizing a consistent technique and have internally reviewed and published our outcomes.In our early experience, we were able to complete robotic pancreaticoduodenectomy in under 420 min.In less than 20 cases, we have shortened this in many cases to less than 360 min.These times are less than reported early experiences, which can be attributed to the team approach and previous HPB and MIS experience. 70Next steps include expanding our inclusion criteria to more challenging cases, performing single surgeon operations, increasing involvement of our surgical trainees, and adapting techniques for various steps of the operation.We look forward to continuing to build expertise in these operations and to regularly assessing our outcomes to determine which patients benefit most from these MIS approaches at our center.
have published guidelines delineating key steps for initiating a program including the Longitudinal Assessment and Realization of Pancreatic Surgery Program (LAELAPS) from the Netherlands, the Miami group, and The University of Pittsburgh robotic pancreatic surgery program among others. 5,12,19,20,23,40-43Key components include (1) acquisition of specialized equipment and facilities, (2) creating a dedicated team of nurses, surgical technologists, anesthesiologists, and surgeons with training in MIS equipment and approaches, (3) adoption of a training program that utilizes simulation and stepwise training curricula for skill development and maintenance, (4) standardizing protocols for patient selection, management of intraoperative adverse events, and (5) establishing a culture of patient safety with regular monitoring for continuous improvement.

4. 1 |
Building the team Minimally invasive procedures present unique challenges compared to traditional open surgery and require a trained surgical team for its safe implementation.The ideal surgical team should be dedicated to the HPB MIS program and include experienced HPB surgeons, anesthesiologists with expertise in the physiologic changes associated with laparoscopy and managing unique perioperative conditions of HPB surgical patients, and scrub nurses familiar with MIS technology and HPB operations.Surgeons with experience in complex HPB procedures and minimally invasive techniques are important for safe implementation.
Formal proficiency-based training curricula in MIS HPB surgery are implemented to standardize robotic surgical techniques, enhance F I G U R E 1 Key components of a minimally invasive hepatopancreatobiliary program.HPB, hepatopancreatobiliary; MIS, minimally invasive surgery.novice's surgical skills and increase the safety and feasibility of MIS. 57These programs exist primarily for fellows in advanced surgical training with the goal of shortening the learning curve and increasing participation in MIS cases during fellowship training.These curricula included mastery-based virtual reality robotic simulation, inanimate biotissue, video training libraries, and active intraoperative evaluation with feedback.At the University of Pittsburgh Medical Center, 16 By promoting open communication, continuous training, and adherence to protocols, an MIS HPB program can identify and mitigate potential risks to patients.A culture focused on patient safety will enhance patient outcomes, build confidence in robotic surgery, and lead to improved patient care, leading to a more successful and resilient MIS HPB program.5 | CITY OF HOPE EXPERIENCE, A PRACTICAL GUIDE Our group at the City of Hope (COH) National Medical Center in Duarte, California, recently developed and initiated a robotic pancreaticoduodenectomy and major hepatectomy program.Our group enjoyed some advantages in starting the program as we had multiple existing robotic systems in our operating rooms, which enabled access, in addition to a group of well trained and experienced nurses, surgical technicians, and anesthesiologists.Our departmental and institutional leadership was well informed of the technology and aware of the benefits and limitations.Although our group has extensive experience with robotic surgical techniques and complex HPB operations, they did not have specific training or experience in robotic pancreaticoduodenectomy or major hepatectomy.To initiate our program, our surgeon champions presented a program strategy, aims and objectives to the departmental and hospital leadership.After securing approval for use of the robot for these procedures, the surgeon champions were formally trained by a surgical expert at an outside institution.Subsequently, the first cases at COH were proctored by an expert surgeon utilizing their technique.During the early stage of the learning curve, we have utilized a two-surgeon technique, with an attending at the bedside and console.We have also alternated console and bedside assist time to address fatigue and to shorten the length of the operation.To ensure patient safety, inclusion and exclusion criteria were standardized including exclusion of any patients requiring vascular reconstruction, elevated body mass index, or significant medical comorbidities.
In conclusion, interest in MIS HPB operations has increased despite initial concerns about safety, efficacy, and costs.A formalized MIS HPB program should be strongly considered to facilitate the safe adoption and expansion of these technologies.Building a successful MIS HPB program requires careful consideration of factors such as case volume, expertise, adequate human and financial resources.A multidisciplinary approach involving skilled surgical teams, anesthesiologists, and nursing staff is essential for safe implementation, along with standardized protocols, rigorous training, and a strong patient safety culture to enhance patient outcomes and foster confidence in minimally invasive HPB surgery.