Grading the Whipple’s procedure: a strategy for structured skill advancement in surgical training

The Whipple’s procedure or pancreatoduodenectomy (PD), is recognized for its technical intricacy in surgical practice. This study aims to categorize PD into four types based on procedural complexity and anticipated postoperative outcomes, intending to integrate this classification into the progressive training of surgical fellows. In this retrospective cohort study, 242 PDs, performed by a single unit across multiple centers from January 2016 to December 2022, were categorized into four types based on technical complexity and extent of surgical intervention. These types were: Type 1 (dilated duct, firm pancreas), Type 2 (as Type 1 + vascular reconstruction), Type 3 (nondilated duct, soft pancreas), and Type 4 (as Type 3 + vascular reconstruction). The study assessed patient characteristics, surgical parameters, and perioperative morbidity and mortality, comparing the outcomes of the four PD types. Type 1 PD was predominant (65.2%), with the lowest 30-day mortality (2.53%). Conversely, Type 4 PD, though least performed (3.3%), exhibited the highest mortality (25%) and major complications (25%). Statistically significant differences were noted in the incidence of clinically relevant-postoperative pancreatic fistula, delayed gastric emptying, and wound complications among the PD types, with overall surgical morbidity being higher in Types 3 and 4. In conclusion, our data compellingly links morbidity, such as postoperative pancreatic fistula, with the technical challenges of the procedure, even though not all mortality can be attributed solely to surgical factors. The implementation of this system offers a structured approach to surgical training, paving the way for trainees to adeptly navigate and proficiently perform this complex surgical technique.