Robotic-assisted versus laparoscopic pancreaticoduodenectomy: oncological outcomes

Minimally Invasive Pancreas Surgery: Is There a Benefit?

Minimally invasive procedures minimize trauma to the human body while maintaining satisfactory therapeutic results. Minimally invasive pancreas surgery (MIPS) was introduced in 1994, but questions regarding its efficacy compared to an open approach were widespread. MIPS is associated with several perioperative advantages while maintaining oncological standards when performed by surgeons with a robust training regimen and frequent practice. Future research should focus on addressing learning curve discrepancies while identifying factors associated with shortening the time needed to attain technical proficiency.

Implementation and outcome of minimally invasive pancreatoduodenectomy in Europe: a registry-based retrospective study - a critical appraisal of the first 3 years of the E-MIPS registry

BACKGROUND

International multicenter audit-based studies focusing on the outcome of minimally invasive pancreatoduodenectomy (MIPD) are lacking. The European Registry for Minimally Invasive Pancreatic Surgery (E-MIPS) is the E-AHPBA endorsed registry aimed to monitor and safeguard the introduction of MIPD in Europe.

MATERIALS AND METHODS

A planned analysis of outcomes among consecutive patients after MIPD from 45 centers in 14 European countries in the E-MIPS registry (2019-2021). The main outcomes of interest were major morbidity (Clavien-Dindo grade ≥3) and 30-day/in-hospital mortality.

RESULTS

Overall, 1336 patients after MIPD were included [835 robot-assisted (R-MIPD) and 501 laparoscopic MIPD (L-MIPD)]. Overall, 20 centers performed R-MIPD, 15 centers L-MIPD, and 10 centers both. Between 2019 and 2021, the rate of centers performing L-MIPD decreased from 46.9 to 25%, whereas for R-MIPD this increased from 46.9 to 65.6%. Overall, the rate of major morbidity was 41.2%, 30-day/in-hospital mortality 4.5%, conversion rate 9.7%, postoperative pancreatic fistula grade B/C 22.7%, and postpancreatectomy hemorrhage grade B/C 10.8%. Median length of hospital stay was 12 days (IQR 8-21). A lower rate of major morbidity, postoperative pancreatic fistula grade B/C, postpancreatectomy hemorrhage grade B/C, delayed gastric emptying grade B/C, percutaneous drainage, and readmission was found after L-MIPD. The number of centers meeting the Miami Guidelines volume cut-off of ≥20 MIPDs annually increased from 9 (28.1%) in 2019 to 12 (37.5%) in 2021 ( P =0.424). Rates of conversion (7.4 vs. 14.8% P <0.001) and reoperation (8.9 vs. 15.1% P <0.001) were lower in centers, which fulfilled the Miami volume cut-off.

CONCLUSION

During the first 3 years of the pan-European E-MIPS registry, morbidity and mortality rates after MIPD were acceptable. A shift is ongoing from L-MIPD to R-MIPD. Variations in outcomes between the two minimally invasive approaches and the impact of the volume cut-off should be further evaluated over a longer time period.

The Revo-i Robotic Surgical System in Advanced Pancreatic Surgery: A Second Non-Randomized Clinical Trial and Comparative Analysis to the da Vinci™ System

PURPOSE

Numerous robot-assisted pancreatic surgery are being performed worldwide. This study aimed to evaluate the feasibility and safety of the Revo-i robot system (Meerecompany, Seoul, Republic of Korea) for advanced pancreatic surgery, and also compare this new system with the existing da Vinci™ robot system (Intuitive Surgical, Sunnyvale, CA, USA) in the context of robot-assisted pancreaticoduodenectomy (RPD).

MATERIALS AND METHODS

This study was a one-armed prospective clinical trial that assessed the Revo-i robot system for advanced pancreatic surgery. Ten patients aged 30 to 73 years were enrolled between December 2019 and August 2020. Postoperative outcomes were retrospectively compared with those of the da Vinci™ surgical system. From March 2017 to August 2020, a total of 47 patients who underwent RPD were analyzed retrospectively.

RESULTS

In the prospective clinical trial, pancreaticoduodenectomy was performed in nine patients and one patient underwent central pancreatectomy. Among the 10 study participants, the incidence of major complications was 0% in hospital stay. There were eight postoperative pancreatic fistula (POPF) biochemical leaks (80%). In the retrospective analysis that compared the Revo-i and da Vinci™ robotic systems, 10 patients underwent Revo-i RPD and 37 patients underwent da Vinci™ RPD, with no significant differences in complication or POPF incidence rates between the two groups (p=0.695, p=0.317).

CONCLUSION

In this single-arm prospective study with short-term follow-up at a single institution, the Revo-i robotic surgical system was safe and effective for advanced pancreatic surgery. Revo-i RPD is comparable to the da Vinci™ RPD and is expected to have wide clinical application.

Role of minimally invasive surgery in the management of localized pancreatic ductal adenocarcinoma: a review

Pancreatic ductal adenocarcinoma (PDAC) remains a highly lethal malignancy with a minority of patients eligible for curative-intent surgical intervention. Pancreatic resections are technically demanding operations associated with considerable morbidity and mortality. Minimally invasive pancreatic resections (MIPRs), which include laparoscopic and robotic approaches, may enhance postoperative outcomes by lessening physiological impact of open surgery. A limited number of randomized-controlled trials as well as numerous retrospective reports have focused on MIPR outcomes and role in management of a variety of tumors, including PDAC. Today, MIPRs are generally considered acceptable alternatives to open surgery as a trend towards improved short-term metrics is observed. However, several questions remain regarding the oncological adequacy of MIPR's as long-term experience is less extensive compared to open techniques. This review aims to summarize existing evidence on MIPRs with a focus on PDAC.

Impact of surgical approach on short- and long-term outcomes in gastroenteropancreatic neuroendocrine carcinomas

BACKGROUND

Literature is lacking on the impact of advancements in minimally invasive surgery (MIS) on outcomes for patients with gastroenteropancreatic neuroendocrine carcinomas (GEP-NECs). Herein, we compared perioperative and oncologic outcomes among patients with GEP-NECs undergoing open, laparoscopic, and robotic resection.

METHODS

Patients with GEP-NECs diagnosed 2010-2019 were identified from the National Cancer Database (NCDB). We used the inverse probability of treatment weighting method to account for selection bias. Patients were stratified by surgical approach; and pairwise comparisons were conducted by analyzing short- and long-term outcomes.

RESULTS

Receipt of MIS increased from 34.2% in 2010 to 67.5 % in 2019. Altogether, 6560 patients met study criteria: 3444 (52.5%) underwent open resection, 2783 (42.4%) underwent laparoscopic resection and 333 (5.1%) underwent robotic resection. Compared with open resection, laparoscopic or robotic resection were associated with shorter post-operative length of stay, reduced 30-day and 90-day post-operative mortality, and prolonged overall survival (OS). Compared with laparoscopic resection, robotic resection was associated with reduced 90-day post-operative mortality, however, there was no significant difference in OS.

CONCLUSION

This NCDB analysis demonstrates that MIS approaches for treating GEP-NECs have become more common, with improved perioperative mortality, shorter post-operative length of stay and favorable OS, compared with open resection.

Laparoscopic pancreaticoduodenectomy and laparoscopic pancreaticoduodenectomy with robotic reconstruction: single-surgeon experience and technical notes

Purpose

Despite the increasing number of robotic pancreaticoduodenectomies, laparoscopic pancreaticoduodenectomy (LPD) and LPD with robotic reconstruction (LPD-RR) are still valuable surgical options for minimally invasive pancreaticoduodenectomy (MIPD). This study introduces the surgical techniques, tips, and outcomes of our experience with LPD and LPD-RR.

Methods

Between March 2014 and July 2021, 122 and 48 patients underwent LPD and LPD-RR respectively, at CHA Bundang Medical Center in Korea. The operative settings, procedures, and trocar placements were identical in both approaches; however, different trocars were used. We introduced our techniques of retraction methods for Kocherization and uncinate process dissection, pancreatic reconstruction, pancreatic division, and protection using the round ligament. The perioperative surgical outcomes of LPD and LPD-RR were compared.

Results

Baseline demographics of patients in the LPD and LPD-RR groups were comparable, but the LPD group had older age (65.5 ± 11.6 years vs. 60.0 ± 14.1 years, p = 0.009) and lesser preoperative chemotherapy (15.6% vs. 35.4%, p = 0.008). The proportion of malignant disease was similar (LPD group, 86.1% vs. LPD-RR group, 83.3%; p = 0.759). Perioperative outcomes were also comparable, including operative time, estimated blood loss, clinically relevant postoperative pancreatic fistula (LPD group, 9.0% vs. LPD-RR group, 10.4%; p = 0.684), and major postoperative complication rates (LPD group, 14.8% vs. LPD-RR group, 6.2%; p = 0.082).

Conclusion

Both LPD and LPR-RR can be safely performed by experienced surgeons with acceptable surgical outcomes. Further investigations are required to evaluate the objective benefits of robotic surgical systems in MIPD and establish widely acceptable standardized MIPD techniques.

Minimally Invasive Pancreatectomy: Robotic and Laparoscopic Developments

Minimally invasive pancreatectomy is increasingly used. Although offering potential advantages over open approaches, minimally invasive pancreatectomy has many challenges to maintain high-quality of oncologic resection. Multiple patient and surgical factors should be considered in planning laparoscopic or robotic resection, including the learning curve required to produce proficiency. For pancreaticoduodenectomy, distal pancreatectomy, and other pancreatic resections, a safe, margin-negative resection remains the goal. National and societal guidelines for the adoption of minimally invasive pancreatectomy are ongoing and will continue to be important as these techniques are further adopted.

A duct-to-mucosa pancreaticojejunostomy for small main pancreatic duct and soft pancreas in minimally invasive pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is often associated with significant morbidity and mortality after the Whipple operation. Patient-related factors associated with POPF include soft pancreatic texture and a small main pancreatic duct (MPD). The traditional duct-to-mucosa anastomosis was modified to be easily performed. The aim of the study was to evaluate the simplified pancreaticojejunostomy (PJ) method in the prevention of POPF after minimally invasive pancreaticoduodenectomy (PD).

METHODS

Ninety-eight patients who underwent laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD) with a simplified PJ procedure containing only two duct-to-mucosa sutures and four penetrating-sutures to anastomose the pancreatic parenchyma and jejunal seromuscular layer in our center were retrospectively studied. Demographics and clinical short-term safety were assessed.

RESULTS

All LPD and RPD procedures were successfully performed. The median time of PJ was 17 min, and the median blood loss was 60 mL, with only one patient requiring transfusion. Four patients (4.1%) suffered from clinically relevant POPF (CR-POPF), including four grade B cases and no grade C cases. For patients with an MPD diameter of 3 mm or less, POPF was noted in two (4%) of the fifty patients, with all cases being grade B. Of the patients with a soft pancreas, only two (4.5%) patients suffered from grade B POPF. One patient (1.0%) experienced a 90-day mortality. Neither the main pancreatic diameter nor pancreatic texture had an impact on postoperative outcomes.

CONCLUSIONS

Our technique is a simple, safe and efficient alternative to prevent POPF after LPD and RPD. This method is suitable for almost all pancreatic conditions, including cases with a small main pancreatic duct and soft pancreas, and has the potential to become the preferred procedure in low-volume pancreatic surgery centers. Our modified duct-to-mucosa PJ, which contains only two duct-to-mucosa sutures and four penetrating-sutures to anastomose the pancreatic parenchyma and jejunal seromuscular layer, is ideal for small MPD and soft pancreas when performing minimally invasive PD and has a low rate of POPF. PJ pancreaticojejunostomy, MPD main pancreatic diameter, PD pancreaticoduodenectomy, POPF postoperative pancreatic fistula.

Robotic versus open pancreaticoduodenectomy, comparing therapeutic indexes; a systematic review

BACKGROUND

Pancreaticoduodenectomy (PD) is a challenging procedure with peri-operative complications. Robotic surgery offers improved dexterity, visibility, and accessibility. Recently, many centres have reported improved clinical outcomes for robotic PD. We reviewed the safety and efficacy of robotic PD in comparison to open PD using 'Therapeutic Index' (TI).

METHODS

A systematic review of the literature was conducted in various databases. Articles published between January 2010 and March 2021 reporting totally-robotic and open PD were included, according to the PRISMA and AMSTAR-2 guidelines. The Cochrane tool was used for risk of bias assessment. We compared 30-day mortality rates (MR₃₀), lymphadenectomy rates (LR), R0 resection rates (R₀RR) and therapeutic index (TI). STATA 16.1 was used for statistical analysis.

RESULTS

The four studies that met inclusion criteria included 5090 PDs, out of which 617 were totally-robotic (RPD) and 4473 were open (OPD). Variance ratio tests demonstrated a)Higher TI for RPD versus OPD (1807.42 vs 1723.37, p = 0.86), b)Significantly smaller MR₃₀ (2.50 vs 19.00, p = 0.0004), c)Significantly lower R₀RR (130.50 vs 939.25, p = 0.00) and d)No significant difference in LR between RPD and OPD (35.63 vs 38.25, p = 0.81). Meta-regression analysis showed a significantly higher TI coefficient of RPD than OPD (0.66 vs -0.40, p = 0.08, α = 0.1).

CONCLUSION

Our study suggests that robotic PD is safe and not inferior to open PD and our analysis RPD demonstrated a higher therapeutic index than OPD. Randomised controlled trials are required to establish the efficacy of robotic PD. Also, standardisation of reporting mortality, survival and oncological outcomes is needed for the effective calculation of TI.

Robotic Versus Laparoscopic Pancreaticoduodenectomy: An Up-To-Date System Review and Meta-Analysis

Background

Although minimally invasive pancreaticoduodenectomy has gained worldwide interest, there are limited comparative studies between two minimally invasive pancreaticoduodenectomy techniques. This meta-analysis aimed to compare the safety and efficacy of robotic and laparoscopic pancreaticoduodenectomy (LPD), especially the difference in the perioperative and short-term oncological outcomes.

Methods

PubMed, China National Knowledge Infrastructure (CNKI), Wanfang Data, Web of Science, and EMBASE were searched based on a defined search strategy to identify eligible studies before July 2021. Data on operative times, blood loss, overall morbidity, major complications, vascular resection, blood transfusion, postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), conversion rate, reoperation, length of hospital stay (LOS), and lymph node dissection were subjected to meta-analysis.

Results

Overall, the final analysis included 9 retrospective studies comprising 3,732 patients; 1,149 (30.79%) underwent robotic pancreaticoduodenectomy (RPD), and 2,583 (69.21%) underwent LPD. The present meta-analysis revealed nonsignificant differences in operative times, overall morbidity, major complications, blood transfusion, POPF, DGE, reoperation, and LOS. Alternatively, compared with LPD, RPD was associated with less blood loss (p = 0.002), less conversion rate (p < 0.00001), less vascular resection (p = 0.0006), and more retrieved lymph nodes (p = 0.01).

Conclusion

RPD is at least equivalent to LPD with respect to the incidence of complication, incidence and severity of DGE, and reoperation and length of hospital stay. Compared with LPD, RPD seems to be associated with less blood loss, lower conversion rate, less vascular resection, and more retrieved lymph nodes.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier CRD2021274057

Advanced Robotic Surgery: Liver, Pancreas, and Esophagus - The State of the Art?

Background

The trend in performing robotic-assisted operations in visceral surgery has been increasing in the last decade, also reaching the challenging field of hepatic, pancreatic, and esophageal surgery. Nevertheless, solid data about advantages and disadvantages of the robotic approach are still missing. The aim of this review is to analyze the benefit and impact of robotic surgery in the field of hepatic, pancreatic, and esophageal surgery, focusing on the comparison with the conventional laparoscopic or open approach.

Summary

The well-known advantages of laparoscopic surgery in comparison to the open approach are also valid for robotic surgery, with the addition of a 3D-view camera, wristed instrumentation, and an ergonomic console. On the other hand, the use of a robotic system leads to longer operating time and higher costs. Randomized controlled trials comparing the robotic approach with the laparoscopic one are still missing.

Key Message

Recent meta-analyses show promising results of the usage of robotic systems in advanced surgical procedures, like hepatic, pancreatic, and esophageal resections. Further randomized studies are needed to validate the postulated benefit.

Surgery for pancreatic cancer: current controversies and challenges

Two areas that remain the focus of improvement in pancreatic cancer include high post-operative morbidity and inability to uniformly translate surgical success into long-term survival. This narrative review addresses specific aspects of pancreatic cancer surgery, including neoadjuvant therapy, vascular resections, extended pancreatectomy, extent of lymphadenectomy and current status of minimally invasive surgery. R0 resection confers longer disease-free survival and overall survival. Vascular and adjacent organ resections should be undertaken after neoadjuvant therapy, only if R0 resection can be ensured based on high-quality preoperative imaging, and that too, with acceptable post-operative morbidity. Extended lymphadenectomy does not offer any advantage over standard lymphadenectomy. Although minimally invasive distal pancreatectomies offers some short-term benefits over open distal pancreatectomy, safety remains a concern with minimally invasive pancreatoduodenectomy. Strict adherence to principles and judicious utilization of surgery within a multimodality framework is the way forward.

Minimally Invasive Surgery and Surgical Volume-Specific Survival and Perioperative Outcome: Unmet Need for Evidence in Gynecologic Malignancy

This study examined the effect of hospital surgical volume on oncologic outcomes in minimally invasive surgery (MIS) for gynecologic malignancies. The objectives were to assess survival outcomes related to hospital surgical volume and to evaluate perioperative outcomes and examine non-gynecologic malignancies. Literature available from the PubMed, Scopus, and the Cochrane Library databases were systematically reviewed. All surgical procedures including gynecologic surgery with hospital surgical volume information were eligible for analysis. Twenty-three studies met the inclusion criteria, and nine gastro-intestinal studies, seven genitourinary studies, four gynecological studies, two hepatobiliary studies, and one thoracic study were reviewed. Of those, 11 showed a positive volume–outcome association for perioperative outcomes. A study on MIS for ovarian cancer reported lower surgical morbidity in high-volume centers. Two studies were on endometrial cancer, of which one showed lower treatment costs in high-volume centers and the other showed no association with perioperative morbidity. Another study examined robotic-assisted radical hysterectomy for cervical cancer and found no volume–outcome association for surgical morbidity. There were no gynecologic studies examining the association between hospital surgical volume and oncologic outcomes in MIS. The volume–outcome association for oncologic outcome in gynecologic MIS is understudied. This lack of evidence calls for further studies to address this knowledge gap.

Minimally Invasive Techniques for Pancreatic Resection

There is increasing interest in the role of minimally invasive surgery (MIS) for pancreatectomy. Prospective data indicate significant advantages for MIS when performed for left-sided pancreatic pathologies and may be deemed as the standard of care. However, there is reluctance in implementing this technique to pancreaticoduodenectomy because of the complexity of the operation and the mixed results from randomized trials. A detailed description of the technical aspects of robotic pancreaticoduodenectomy and distal pancreatectomy is presented in this article in addition to a summary of the most important prospective and cohort studies. We also provide insights into patient selection and the learning curve of MIS surgery for pancreatectomy.

Assessing the perioperative complications and outcomes of robotic pancreaticoduodenectomy using the National Cancer Database: is it ready for prime time?

Robotic pancreaticoduodenectomy has generated significant interest in recent years. Our study aimed to evaluate the difference in surgical, oncological, and survival outcomes after pancreaticoduodenectomy (PD) by either a robotic (RPD) or open approach (OPD). Using the National Cancer Database, we identified patients from 2010 and 2017 diagnosed with pancreatic adenocarcinoma and underwent pancreaticoduodenectomy by either robotic PD or open approach. Patients who underwent robotic PD during 2010 were compared to patients receiving the same procedure in 2017. In addition, a secondary analysis was performed to assess outcomes of robotic PD to open PD for the 2017 patient cohorts. Our primary outcomes included 30-day and 90-day mortality, length of stay, as well as 30-day readmission. Secondary outcome measures were surgical margins, lymph node yield, and adjuvant chemotherapy initiation within 12 weeks of surgery. When we compared the 2017 data to 2010 data, we found that robotic pancreaticoduodenectomy had lower 30- and 90-day mortality rates in 2017 compared to 2010. Additionally, we found that the lymph node yield in robotic PD increased during the study period. When we compared robotic PD to open PD for 2017, we found no statistically significant differences in readmission rates (10.1% vs. 9.7%: p-0.4), lymph node yield, or negative margin between the groups. Outcomes of robotic PD have improved over the years. In 2017, outcomes of robotic PD were similar to open PD.

The current status and future directions of robotic pancreatectomy

Robotic surgery has emerged as an alternative to laparoscopic surgery and it has also been applied to pancreatectomy. With the increase in the number of robotic pancreatectomies, several studies comparing robotic pancreatectomy and conventional open or laparoscopic pancreatectomy have been published. However, the use of robotic pancreatectomy remains controversial. In this review, we aimed to provide a comprehensive overview of the current status of robotic pancreatectomy. Various aspects of robotic pancreatectomy and conventional open or laparoscopic pancreatectomy are compared, including the benefits, limitations, oncological efficacy, learning curves, and costs. Both robotic pancreatoduodenectomy and distal pancreatectomy have favorable or comparable outcomes to conventional procedures, and robotic pancreatectomy has the potential to be an alternative to open or laparoscopic procedures. However, there are still several disadvantages to robotic platforms, such as prolonged operative duration and the high cost of the procedure. These disadvantages will be improved by developing instruments, overcoming the learning curve, and increasing the number of robotic pancreatectomies. In addition, robotic pancreatectomy is still in the introductory period in most centers and should only be used in accordance with strict indications.

State of the art of robotic pancreatoduodenectomy

Current evidence shows that robotic pancreatoduodenectomy (RPD) is feasible with a safety profile equivalent to either open pancreatoduodenectomy (OPD) or laparoscopic pancreatoduodenectomy (LPD). However, major intraoperative bleeding can occur and emergency conversion to OPD may be required. RPD reduces the risk of emergency conversion when compared to LPD. The learning curve of RPD ranges from 20 to 40 procedures, but proficiency is reached only after 250 operations. Once proficiency is achieved, the results of RPD may be superior to those of OPD. As for now, RPD is at least equivalent to OPD and LPD with respect to incidence and severity of POPF, incidence and severity of post-operative complications, and post-operative mortality. A minimal annual number of 20 procedures per center is recommended. In pancreatic cancer (versus OPD), RPD is associated with similar rates of R0 resections, but higher number of examined lymph nodes, lower blood loss, and lower need of blood transfusions. Multivariable analysis shows that RPD could improve patient survival. Data from selected centers show that vein resection and reconstruction is feasible during RPD, but at the price of high conversion rates and frequent use of small tangential resections. The true Achilles heel of RPD is higher operative costs that limit wider implementation of the procedure and accumulation of a large experience at most single centers. In conclusion, when proficiency is achieved, RPD may be superior to OPD with respect to CR-POPF and oncologic outcomes. Achievement of proficiency requires commitment, dedication, and truly high volumes.

National Trends in Robotic Pancreas Surgery

BACKGROUND

Robotic pancreatic surgery is expanding throughout centers across the country. We investigated national trends in the use and outcomes for robotic-assisted pancreaticoduodenectomy (RPD) and distal pancreatectomy (RDP) for primary pancreatic tumors.

METHODS

The National Cancer Database was queried for RPD and RDP performed during three time periods: 2010-2012, 2013-2014, and 2015-2016. These time periods were compared for patient and center factors as well as surgical outcomes.

RESULTS

The use of robotic surgery increased during the study period. Most centers performed a low volume of robotic surgery (RPD, 82% of centers averaged < 1 case/year; RDP, 87% averaged < 1 case/year). From the first to last time period, the proportion of cases performed at academic centers decreased (RPD, 83% to 56%; RDP, 77% to 58%, p < 0.001) while patient characteristics remained largely unchanged. For RPD, improvements in mortality (6.7 to 1.8%, p = 0.013) and lymphadenectomy (18 to 21 nodes, p = 0.035) were observed, with no changes in conversion to open surgery, negative margin resections, or readmissions. For RDP, length of stay decreased (7 to 6 days, p = 0.048), but there were no changes in other outcomes. Compared with academic centers, non-academic centers had equivalent rates of conversion to open surgery, negative margins, and 90-day mortality. On multivariate analysis, there was no difference in survival between academic and non-academic centers.

DISCUSSION

Robotic pancreas surgery is expanding to a greater variety of centers nationwide with preservation of key surgical outcomes. These findings support the continued rigorous training and proliferation of qualified robotic pancreas surgeons going forward.

Minimally invasive pancreatic surgery—will robotic surgery be the future?

Due to the complexity of the procedures and the texture of the organ itself, pancreatic surgery remains a challenge in the field of visceral surgery. During the past decade, a minimally invasive approach to pancreatic surgery has gained distribution in clinical routine, extending from left-sided procedures to pancreatic head resections. While a laparoscopic approach has proven beneficial for many patients with left-sided pancreatic pathologies, the complex reconstruction in pancreas head resections remains worrisome with the laparoscopic approach. The robotic technique was established to overcome such technical constraints while preserving the advantages of the laparoscopic approach. Even though robotic systems are still in development, especially in pancreatoduodenectomy, the current literature demonstrates the feasibility of this approach and stable clinical and oncological outcomes compared to the open technique, albeit only under the condition of such operations being performed by specialist teams in a high-volume setting (>20 robotic pancreaticoduodenectomies per year). The aim of this review is to analyze the current evidence regarding a minimally invasive approach to pancreatic surgery and to review the potential of a robotic approach. Presently, there is still a scarcity of sound evidence and long-term oncological data regarding the role of minimally invasive and robotic pancreatic surgery in the literature, especially in the setting of pancreaticoduodenectomy.

Essential updates 2018/2019: Current topics in the surgical treatment of pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is highly malignant. While cancers in other organs have shown clear improvements in 5-year survival, the 5-year survival rate of pancreatic cancer is approximately 10%. Early relapse and metastasis are not uncommon, making it difficult to achieve an acceptable prognosis even after complete surgical resection of the pancreas. Studies have been performed on various treatments to improve the prognosis of PDAC, and multidisciplinary approaches including non-surgical treatments have led to gradual improvement. In the present literature review, we have described the significance of anatomical and biological resectability criteria, the concept of R0 resection in surgical treatment, the feasibility of minimally invasive surgery, the remarkable development of perioperative chemotherapy, the effectiveness of conversion surgery for unresectable PDAC, and ongoing challenges in PDAC treatment. We also provide an essential update on these subjects by focusing on recent trends and topics.

Systematic review and updated network meta-analysis comparing open, laparoscopic, and robotic pancreaticoduodenectomy

The treatment of periampullary and pancreatic head neoplasms is evolving. While minimally invasive Pancreaticoduodenectomy (PD) has gained worldwide interest, there has been a debate on its related outcomes. The purpose of this paper was to provide an updated evidence comparing short-term surgical and oncologic outcomes within Open Pancreaticoduodenectomy (OpenPD), Laparoscopic Pancreaticoduodenectomy (LapPD), and Robotic Pancreaticoduodenectomy (RobPD). MEDLINE, Web of Science, PubMed, Cochrane Central Library, and ClinicalTrials.gov were referred for systematic search. A Bayesian network meta-analysis was executed. Forty-one articles (56,440 patients) were included; 48,382 (85.7%) underwent OpenPD, 5570 (9.8%) LapPD, and 2488 (4.5%) RobPD. Compared to OpenPD, LapPD and RobPD had similar postoperative mortality [Risk Ratio (RR) = 1.26; 95%CrI 0.91–1.61 and RR = 0.78; 95%CrI 0.54–1.12)], clinically relevant (grade B/C) postoperative pancreatic fistula (POPF) (RR = 1.12; 95%CrI 0.82–1.43 and RR = 0.87; 95%CrI 0.64–1.14, respectively), and severe (Clavien-Dindo ≥ 3) postoperative complications (RR = 1.03; 95%CrI 0.80–1.46 and RR = 0.93; 95%CrI 0.65–1.14, respectively). Compared to OpenPD, both LapPD and RobPD had significantly reduced hospital length-of-stay, estimated blood loss, infectious, pulmonary, overall complications, postoperative bleeding, and hospital readmission. No differences were found in the number of retrieved lymph nodes and R0. OpenPD, LapPD, and RobPD seem to be comparable across clinically relevant POPF, severe complications, postoperative mortality, retrieved lymphnodes, and R0. LapPD and RobPD appears to be safer in terms of infectious, pulmonary, and overall complications with reduced hospital readmission We advocate surgeons to choose their preferred surgical approach according to their expertise, however, the adoption of minimally invasive techniques may possibly improve patients’ outcomes.

Does center or surgeon volume influence adoption of minimally invasive versus open pancreatoduodenectomy? A systematic review and meta-regression

BACKGROUND

There has been increasing uptake of minimally invasive pancreatoduodenectomy during the past decade, but it remains a highly specialized procedure as benefits over open pancreatoduodenectomy remain contentious. This study aimed to evaluate current evidence on minimally invasive pancreatoduodenectomy versus open pancreatoduodenectomy in terms of impact of center volume on outcomes.

METHODS

A systematic review of articles on comparative cohort and registry studies on minimally invasive pancreatoduodenectomy versus open pancreatoduodenectomy published until 31st December 2019 were identified, and meta-analyses were performed. Primary endpoints were International Study Group on Pancreatic Fistula grade B/C postoperative pancreatic fistula and 30-day mortality.

RESULTS

After screening 7,390 studies, 43 comparative cohort studies (8,755 patients) with moderate methodological quality and 3 original registry studies (43,735 patients) were included. For the cohort studies, the median annual hospital minimally invasive pancreatoduodenectomy volume was 10. No significant differences were found in grade B/C postoperative pancreatic fistula (odds ratio: 0.98, 95% confidence interval: 0.78-1.23) or 30-day mortality (odds ratio: 1.14, 95% confidence interval: 0.65-2.01) between minimally invasive pancreatoduodenectomy when compared with open. No publication biases were present and meta-regression identified no confounding for grade B/C postoperative pancreatic fistula, center volume or 30-day mortality. Minimally invasive pancreatoduodenectomy was only strongly associated with significantly lower rates of postoperative pulmonary complications and surgical site infection, shorter length of stay, and significantly higher rates of R0 margin resections.

CONCLUSION

Minimally invasive pancreatoduodenectomy remains noninferior to open pancreatoduodenectomy for grade B/C postoperative pancreatic fistula but is strongly associated with significantly lower rates of postoperative pulmonary complications and surgical site infection. Minimally invasive pancreatoduodenectomy can be adopted safely with good outcomes irrespective of annual center resection volume.

[Robot-assisted operations in visceral surgery]

BACKGROUND

Although only a low percentage of abdominal surgical interventions are performed using a robotic platform, the total number has significantly increased in recent years and robotic surgery (RS) is no longer limited only to university hospitals. Despite the increasing popularity and many innovations in the field of robotic surgery with new devices, the data situation is confusing.

OBJECTIVE

This review deals with the current areas of application of robotic devices in abdominal surgery and whether there are any advantages compared to laparoscopic surgery (LS).

MATERIAL AND METHODS

The current international literature was evaluated and is critically discussed with a particular focus on clinical trials.

RESULTS

While the disadvantages include high costs and longer times of surgery, the advantages are a stable optical platform and the high mobility even in confined spaces; however, no high-quality, randomized controlled trial in abdominal surgery is currently available that could demonstrate an advantage of RS compared to LS.

CONCLUSION

Although no clear advantages of RS for the patients could so far be demonstrated, it seems to be at least equivalent to LS. Undisputed is the level of comfort for the surgeon. Once the costs of RS can be reduced, LS will probably be replaced for most indications.

Robotic-assisted pancreaticoduodenectomy with vascular resection. Description of the surgical technique and analysis of early outcomes

BACKGROUND

Despite the potential benefits, the adoption of the minimally invasive surgery for the treatment of borderline resectable pancreatic cancer is still in the initial phase. We investigated the safety and feasibility of the robotic pancreaticoduodenectomy with venous resection/reconstruction (RPD SMV/PV).

METHODS

Since March 2013 to October 2019, a total of 73 RPD and 10 RPD SMV/PV were performed. The two groups were case-matched according to the preoperative characteristics.

RESULTS

Mean operative times and estimated blood loss were less in the RPD group in comparison to that in the RPD with SMV-PV group (525 vs 642 min, p = 0.003 and 290 vs 620 ml, p = 0.002, respectively). The mean length of hospital stay was similar in the RPD group in comparison to that in the RPD with SMV-PV group (10 days vs 13 days, p = 0.313). The two groups had similar overall postoperative morbidity rate (57.5% vs 60%, p = 0.686), although the severe complication rate was lower in the RPD group (11% vs 40%, p = 0.004).

CONCLUSIONS

RPD with SMV-PV is associated with increased operative time, estimated blood loss, higher major complication rate compared with RPD.

Oncological outcomes of robotic-assisted versus open pancreatoduodenectomy for pancreatic ductal adenocarcinoma: a propensity score-matched analysis

Background

Robotic-assisted minimally invasive surgery is associated with worse oncologic outcomes for some but not other types of cancers. We conducted a propensity score-matched analysis to compare oncologic outcomes of robotic-assisted laparoscopic (RPD) vs. open pancreatoduodenectomy (OPD) for pancreatic ductal adenocarcinoma (PDAC).

Methods

Treatment-naïve PDAC patients undergoing either RPD or OPD at our hospital between January 2013 and December 2017 were included. Propensity score matching was conducted at a ratio of 1:2. The primary outcome was disease-free survival (DFS) and overall survival (OS).

Results

A total of 672 cases were identified. The propensity score-matched cohort included 105 patients receiving RPD and 210 patients receiving OPD. The 2 groups did not differ in the number of retrieved lymph nodes [11 (7–16) vs. 11 (6–17), P = 0.622] and R0 resection rate (88.6% vs. 89.0%, P = 0.899). There was no statistically significant difference in median DFS (14 [95% CI 11–22] vs. 12 [95% CI 10–14] months (HR 0.94; 95% CI 0.87–1.50; log-rank P = 0.345) and median OS (27 [95% CI 22–35] vs. 20 [95% CI 18–24] months (HR 0.77; 95% CI 0.57–1.04; log-rank P = 0.087) between the two groups. Multivariate COX analysis showed that RPD was not an independent predictor of DFS (HR 0.90; 95% CI 0.68–1.19, P = 0.456) or OS (HR 0.77; 95% CI 0.57–1.05, P = 0.094).

Conclusion

Comparable DFS and OS were observed between patients receiving RPD and OPD. This preliminary finding requires further confirmation with prospective randomized controlled trials.

Robotic Whipple for pancreatic ductal and ampullary adenocarcinoma: 10 years experience of a US single-center

BACKGROUND

There is currently ample consensus about the safety and feasibility of robotic pancreaticoduodenectomy (RPD). However, few studies are available on the long-term oncological outcomes of this procedure. We present a long-term survival analysis (up to 10 years) of our series of RPD carried out for ductal and ampullary adenocarcinoma.

METHODS

A retrospective analysis of a prospectively collected approved database was carried out including 39 patients who underwent RPD for pancreatic ductal and ampullary adenocarcinomas.

RESULTS

The 5-year overall survival for ductal and ampullary carcinoma was 41% with an estimated median and mean survival of 27 and 52 months. The ampullary group had significantly longer 5-year survival (68%) than the ductal group (30%).

CONCLUSION

Our data show, within the limitations of their retrospective nature, that robotic pancreaticoduodenectomy provides similar short- and long-term survival outcomes compared to open technique in the treatment of pancreatic ductal and ampullary adenocarcinoma.

Safety and oncologic efficacy of robotic compared to open pancreaticoduodenectomy after neoadjuvant chemotherapy for pancreatic cancer

BACKGROUND

Emerging data from multi-institutional and national databases suggest that robotic pancreaticoduodenectomy is safe and feasible for pancreatic adenocarcinoma. Nevertheless, there are limited reports evaluating its safety and oncologic efficacy following neoadjuvant chemotherapy.

METHOD

This is a retrospective study from the 2010-2016 National Cancer Database comparing the postoperative, pathological and long-term oncologic outcomes between robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD) for pancreatic adenocarcinoma following neoadjuvant chemotherapy.

RESULTS

We identified 155 (5%) RPD and 3329 (95%) OPD following neoadjuvant chemotherapy. The use of the robot increased from 3 cases in 2010 to 50 cases in 2016. RPD patients were more likely to receive adjuvant chemotherapy and to be treated at academic centers. After adjustment, RPD was associated with a higher proportion of adequate lymphadenectomy, receipt of adjuvant chemotherapy, decreased rate of prolonged length of stay, and similar 90-day mortality. There was no difference in median overall survival between RPD and OPD (25.6 months vs. 27.5 months, Log Rank p = 0.879). The 1-, 3- and 5-year overall survival rates for RPD were 83%, 36% and 22% and for OPD were 86%, 38% and 22%. After adjustment, the use of robotic surgery was associated with similar overall survival compared to the open approach (HR 1.011, 95% confidence interval (CI) 0.776-1.316).

CONCLUSIONS

Following neoadjuvant chemotherapy, RPD is associated with similar short- and long-term mortality with the advantage of shorter length of stay, higher proportion of adequate lymphadenectomy and receipt of adjuvant chemotherapy.

The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection

OBJECTIVE

The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019).

SUMMARY BACKGROUND DATA

MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking.

METHODS

The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology.

RESULTS

After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety.

CONCLUSION

The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery.

Long-term oncologic outcomes of robotic and open pancreatectomy in a national cohort of pancreatic adenocarcinoma

BACKGROUND

Robotic pancreatectomy is gaining momentum; however, limited data exist on the long-term survival of this approach for pancreatic ductal adenocarcinoma (PDAC). The objective of this study is to compare the long-term oncologic outcomes of robotic pancreaticoduodenectomy (RPD) and robotic distal pancreatectomy (RDP) to open surgery in patients with PDAC.

STUDY DESIGN

Robotic and open pancreatectomy for stages I-III PDAC were obtained from the 2010 to 2016 National Cancer Database.

RESULTS

We identified 17 831 pancreaticoduodenectomies and 2718 distal pancreatectomies of which 626 (4%) and 332 (12%) were robotic, respectively. There was no difference in median overall survival between RPD (22.0 months) and open pancreatoduodenectomy (21.8 months; logrank P = .755). The adjusted hazard ratio [HR] was 1.014 (95% confidence interval [CI]: 0.903-1.139). The median overall survival for RDP (35.3 months) was higher than open distal pancreatectomy (ODP) (24.9 months; logrank P = .001). The adjusted HR suggests a benefit to RDP compared to ODP (HR, 0.744; 95% CI: 0.632-0.868) CONCLUSION: In a national cohort of resected pancreatic adenocarcinoma, the robotic platform was associated with similar long-term survival for pancreaticoduodenectomy, but improved survival for distal pancreatectomy.

Hybrid pancreatoduodenectomy in laparoscopic and robotic surgery: a single-center experience in China

BACKGROUND

Minimally invasive surgery is beneficial for pancreatic surgery, and the indication has been expanded to pancreatoduodenectomy (PD). The aim of this study was to share our experiences with hybrid PD in laparoscopic and robotic surgery.

METHODS

Sixty-four patients underwent hybrid PD in which specimen resection and gastrojejunostomy were performed through the laparoscopic route and pancreatojejunostomy and hepaticojejunostomy were performed via a robotic approach by the same surgeon at a single institution between July 2016 and June 2019. The primary endpoint was complications; secondary endpoints were operative time (OT), the length of hospital stay, and blood loss. The data for the patients were retrospectively obtained from electrical medical records.

RESULTS

All patients underwent surgery with the hybrid procedure. The mean OTs and estimated blood loss (EBL) were 309.7 ± 77.6 min (range 17-620 min), 160 ± 31.7 mL (range 50-800 mL). The mean number of lymph nodes retrieved was 7.3 ± 6.7 (range 0-37), and that among 45 malignant cases was 8.42 ± 6.7 (range 1-37). The average length of postoperative stay in the hospital was 11.14 ± 7.03 days (range 6-47 days). Clinically relevant postoperative pancreatic fistulas (POPFs) occurred in 39 (60.9%) cases, and most were biochemical leak POPF (29 cases, 45.3%); only 10 (15.6%) cases were grade B/C (8 cases were Grade B and 2 cases were Grade C treated with digital subtraction angiography). Bile leakage occurred in 2 (3.1%) patients. One (1.5%) patient had a gastric fistula, and 3 (4.7%) developed postoperative delayed gastric emptying categorized as International Study Group of Pancreatic Surgery (ISGPS) Grade A. Three (4.7%) patients were readmitted for postoperative bleeding, and 2 (3.1%) died within 30 days.

CONCLUSION

Hybrid PD with laparoscopic and robot surgery is safe and feasible. OT can be reduced by switching from the laparoscopic approach to the robotic procedure at the appropriate timepoint.

A systematic review and network meta-analysis of different surgical approaches for pancreaticoduodenectomy

BACKGROUND

Minimally invasive pancreaticoduodenectomy (MIPD) is a demanding surgical procedure, thus explaining its slow expansion and limited popularity amongst Hepato-Pancreatico-Biliary (HPB) surgeons. However, three main advantages of robotic assisted pancreaticoduodenectomy (PD) including improved dexterity, 3D vision less surgical fatigue, may overcome some of the hurdles and ultimately lead to a wider adoption. This systematic review and network meta-analysis aims to evaluate the current literature on open and MIPD.

METHODS

A systematic literature search was conducted for studies reporting robotic, laparoscopic and open surgery for PD. Network meta-analysis of intraoperative (operating time, blood loss, transfusion rate), postoperative (overall and major complications, pancreatic fistula, delayed gastric emptying, length of hospital stay) and oncological outcomes (R0 resection, lymphadenectomy) were performed.

RESULTS

Sixty-one studies including 62,529 patients were included in the network meta-analysis, of which 3% (n = 2131) were totally robotic (TR) and 10% (n = 6514) were totally laparoscopic (TL). There were no significant differences between surgical techniques for major complications, overall and grade B/C fistula, biliary leak, mortality and R0 resections. Transfusion rates were significantly lower in TR compared to TL and open. Operative time for TR was longer compared with open and TL. Both TL and TR were associated with significantly lower rates of wound infections, pulmonary complications, shorter length of stay and higher lymph nodes examined when compared to open. TR was associated with significantly lower conversion rates than TL.

CONCLUSION

In summary, this network meta-analysis highlights the variability in techniques within MIPD and compares other variations to the conventional open PD. Current evidence appears to demonstrate MIPD, both laparoscopic and robotic techniques are associated with improved rates of surgical site infections, pulmonary complications, and a shorter hospital stay, with no compromise in oncological outcomes for cancer resections.

Robotic versus conventional laparoscopic pancreaticoduodenectomy a systematic review and meta-analysis

BACKGROUND

Robotic pancreaticoduodenectomy (RPD) offers theoretical advantages to conventional laparoscopic surgery including improved instrument dexterity, 3D visualization and better ergonomics. This review aimed to determine if these theoretical advantages translate into improved patient outcomes comparing patients having either robotic pancreaticoduodenectomy or laparoscopic (LPD) equivalent.

METHOD

A systematic literature search was conducted for studies reporting minimally invasive surgery for pancreaticoduodenectomy either robotic assisted or totally laparoscopic. Meta-analysis of intra-operative (blood loss, operating times, conversion and R0 resections) and postoperative outcomes (overall complications, pancreatic fistula, length of hospital stay) was performed using a random effects model.

RESULT

This review identified 44 studies, of which six were non-randomised comparative studies including 3462 patients (1025 robotic and 2437 laparoscopic). Intraoperatively, RPD was associated with significantly lower conversion rates (OR 0.45, p < 0.001) and transfusion rates (OR: 0.60, p = 0.002) compared to LPD. However, no significant difference in blood loss (mean: 220 vs 287 mL, p = 0.1), operating time (mean: 405 vs 418 min, p = 0.3) was noted. Postoperatively RPD was associated with a shorter hospital stay (mean: 12 vs 11 days, p < 0.001) but no significant difference was noted in postoperative complications, incidence of pancreatic fistulae and R0 resection rates.

CONCLUSION

RPD appears to offer some advantages compared to conventional laparoscopic surgery, although both approaches appear to offer equivalent clinical outcomes. Importantly, the quality of evidence is generally limited to cohort studies and a high-quality randomised trial comparing both techniques is needed.

Laparoscopic pancreaticoduodenectomy: are the best times coming?

Background

The introduction of laparoscopic technology has greatly promoted the development of surgery, and the trend of minimally invasive surgery is becoming more and more obvious. However, there is no consensus as to whether laparoscopic pancreaticoduodenectomy (LPD) should be performed routinely.

Main body

We summarized the development of laparoscopic pancreaticoduodenectomy (LPD) in recent years by comparing with open pancreaticoduodenectomy (OPD) and robotic pancreaticoduodenectomy (RPD) and evaluated its feasibility, perioperative, and long-term outcomes including operation time, length of hospital stay, estimated blood loss, and overall survival. Then, several relevant issues and challenges were discussed in depth.

Conclusion

The perioperative and long-term outcomes of LPD are no worse and even better in length of hospital stay and estimated blood loss than OPD and RPD except for a few reports. Though with strict control of indications, standardized training, and learning, ensuring safety and reducing cost are still and will always the keys to the healthy development of LPD; the best times for it are coming.

Pitfalls of minimally invasive pancreatoduodenectomy

Minimally invasive approaches to abdominal surgical procedures have provided superior outcomes when compared to the open approach and thus have become the standard of care. However, minimally invasive pancreatoduodenectomy (MIPD) presents unique difficulties for both laparoscopic and robotic platforms and remains controversial. Ongoing concerns continue about the minimally invasive approach creating meaningful benefit when system-wide data may suggest MIPD results in increased morbidity and mortality during the learning curve. This treatise explores the current state of MIPD, reviewing the volume and quality of data that supports benefit while contrasting the benefits to the unique challenges associated with MIPD that may lead to unacceptable rates of complications and death. We conclude that in a handful of centers, MIPD confers an iterative but not transformative benefit. Significant barriers to the wide-spread acceptance of MIPD are apparent and persist, including: lack of high level data confirming clinical benefit, well defined patient selection criteria, formal education programs that address challenges of the learning curve, and ultimately value.

Robotic resection of the uncinate process of the pancreas

Since the development of the robotic platform, the number of robotic-assisted surgeries has significantly increased. Robotic surgery has gained growing acceptance in recent years, expanding to pancreatic resection. Here, we report a total robotic resection of the uncinate process of the pancreas performed in a patient with a cystic neuroendocrine tumor. To our knowledge, this is the first report of a robotic resection of the uncinate process of the pancreas. A 46-year-old man with no specific medical history was diagnosed with a neuroendocrine tumor after undergoing routine imaging. Biopsy guided by echoendoscopy revealed a well-differentiated neuroendocrine tumor. We decided to perform a robotic resection of the uncinate process of the pancreas after obtaining informed consent for the procedure. According to preoperative echoendoscopy and magnetic resonance imaging, there was a safe margin between the neoplasm and the main pancreatic duct. The technique uses five ports. The duodenum is fully mobilized, and Kocher maneuver is carefully performed. The uncinate process of the pancreas is then identified. The resection of the uncinate process begins with the division of small arterial branches from the inferior pancreaticoduodenal artery in its inferior portion, followed by control of venous tributaries to the superior mesenteric vein. Intraoperative localization of the ampulla of Vater is performed using indocyanine green enhanced fluorescence, thus defining the superior margin of the uncinate process. The pancreatic division is made about 5 mm below its upper margin for safety. Surgical specimen is then retrieved through the umbilical port inside a plastic bag. The raw pancreatic area is covered with hemostatic tissue and drained. The total operation time was 215 min. The docking time was 8 min and console time was 180 min. Blood loss was minimum, estimated at less than 50 mL. The postoperative period was uneventful, except for hyperamylasemia in the drain fluid. The patient was discharged on the 3rd postoperative day. The final pathological report confirmed well-differentiated pancreatic neuroendocrine tumor. Robotic resection of the uncinate process of the pancreas is safe and feasible, providing parenchymal conservation in a minimally invasive setting. Robotic resection should be considered for patients suffering from low-grade pancreatic neoplasms located in this part of the pancreas.