Development of a difficulty scoring system for laparoscopic pancreatoduodenectomy in the initial stage of the learning curve: a retrospective cohort study

It remains uncertain how surgeons can safely pass the learning curve of laparoscopic pancreatoduodenectomy (LPD) without potentially harming patients. We aimed to develop a difficulty scoring system (DSS) to select an appropriate patient for surgeons. MATERIALS AND METHODS: A total of 773 elective pancreatoduodenectomy surgeries between July 2014 and December 2019, including 346 LPD and 427 open pancreatoduodenectomy cases, were included. A 10-level DSS for LPD was developed, and an additional 77 consecutive LPD surgeries which could provide information of the learning stage I of LPD externally validated its performance between December 2019 and December 2021. RESULTS: The incidences of postoperative complications (Clavien–Dindo≥III) gradually decreased from the learning curve stage I–III (20.00, 10.94, 5.79%, P=0.008, respectively). The DSS consisted of the following independent risk factors: (1) tumor location, (2) vascular resection and reconstruction, (3) learning curve stage, (4) prognostic nutritional index, (5) tumor size, and (6) benign or malignant tumor. The weighted Cohen’s κ statistic of concordance between the reviewer’s and calculated difficulty score index was 0.873. The C-statistics of DSS for postoperative complication (Clavien–Dindo≥III) were 0.818 in the learning curve stage I. The patients with DSS<5 had lower postoperative complications (Clavien–Dindo≥III) than those with DSS≥5 (4.35–41.18%, P=0.004) in the training cohort and had a lower postoperative pancreatic fistula (19.23–57.14%, P=0.0352), delayed gastric emptying (19.23–71.43%, P=0.001), and bile leakage rate (0.00–21.43%, P=0.0368) in validation cohort in the learning curve stage I. CONCLUSION: We developed and validated a difficulty score model for patient selection, which could facilitate the stepwise adoption of LPD for surgeons at different stages of the learning curve.