A Modern Approach to Teaching Pancreatic Surgery Stepwise Pancreatoduodenectomy for Trainees

Pancreatoduodenectomy (PD) has always been regarded as one of the most technically demanding abdominal procedures, even when carried out in high-volume centers by experienced surgeons. The reduction in higher surgical trainees working hours has led to reduced exposure, and consequently less experience in operative procedures. Furthermore, trainees have also become victims as health care systems striving for operating room efficiency, have attempted to reduce procedure duration by encouraging consultant led procedures at the expense of training. A strategy therefore needs to be developed to match the ability of the trainee with the complexity of the surgical procedure. As a PD can be deconstructed into a number of different steps, it may indeed be an ideal training operation for varying levels of ability. We describe our technique for PD and break it down to nine steps of varying technical ability making it suitable for many different stages of surgical training. The complexity and variety of steps required to perform a PD makes it an ideal training operation from the junior surgical trainee to the most senior fellow, allowing the development of a wide range of skill sets. Since the introduction of reduced working hours (48 h per week in Europe and 80 h per week in the USA) the apprenticeship model of surgical training has shifted towards a time-limited program with greater emphasis on supervision. Due to the complexity of surgery, and the perception of diminished levels of trainees' competency, a PD is often viewed as a consultant level operation. We believe that PD is an excellent model as it provides opportunities for trainees with varying levels of operative experience so that a PD could be considered the ideal teaching case. Breaking down PD into a number of different steps may help building up surgical expertise more quickly while maintaining patients' safety and allowing the surgery to be expedited in a timely manner.