Perioperative Outcomes of Robotic Pancreaticoduodenectomy: a Propensity-Matched Analysis to Open and Laparoscopic Pancreaticoduodenectomy

Surgical techniques to prevent delayed gastric emptying after pancreaticoduodenectomy

BACKGROUND

Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). DGE represents impaired gastric motility without significant mechanical obstruction and is associated with an increased length of hospital stay, increased healthcare costs, and a high readmission rate. We reviewed published studies on various technical modifications to reduce the incidence of DGE.

DATA SOURCES

Studies were identified by searching PubMed for relevant articles published up to December 2022. The following search terms were used: "pancreaticoduodenectomy", "pancreaticojejunostomy", "pancreaticogastrostomy", "gastric emptying", "gastroparesis" and "postoperative complications". The search was limited to English publications. Additional articles were identified by a manual search of references from key articles.

RESULTS

In recent years, various surgical procedures and techniques have been explored to reduce the incidence of DGE. Pyloric resection, Billroth II reconstruction, Braun's enteroenterostomy, and antecolic reconstruction may be associated with a decreased incidence of DGE, but more high-powered studies are needed in the future. Neither laparoscopic nor robotic surgery has demonstrated superiority in preventing DGE, and the use of staplers is controversial regarding whether they can reduce the incidence of DGE.

CONCLUSIONS

Despite many innovations in surgical techniques, there is no surgical procedure that is superior to others to reduce DGE. Further larger prospective randomized studies are needed.

The optimal choice for patients underwent minimally invasive pancreaticoduodenectomy: a systematic review and meta-analysis including patient subgroups

The aim of this meta-analysis was to evaluate the efficacy and safety of robotic pancreaticoduodenectomy (RPD) in improving perioperative aspects and postoperative complications in patients.

METHODS

We searched PubMed, Embase, Web of Science, and the Cochrane Library database systems for studies that compared RPD with laparoscopic pancreaticoduodenectomy (LPD). Meta-analysis was performed for 24 relevant outcomes, including perioperative outcomes and postoperative complications. Subsequently, a subgroup analysis based on geographical regions was conducted to investigate the impact of regional differences on the perioperative outcomes of the RPD group and the LPD group.

RESULTS

This review found 19 studies with 12,731 individuals (3539 RPD and 9192 LPD). In comparison to LPD, RPD had lower rates of Conversion (OR = 0.58, P < 0.00001), Blood Transfusion (OR = 0.59, P = 0.02), Length of Stay (MD = - 0.54, P = 0.01), postoperative complications [Pneumonia (OR = 0.31, P < 0.0001), and Wound Disruption (OR = 0.26, P = 0.0007)], and more thorough lymph node harvesting (MD = 1.25, P = 0.001). Subgroup analysis showed that Blood Transfusion (I2 = 55%, P = 0.02), Conversion (I2 = 30%, P < 0.00001), Length of Stay (I2 = 71%, P = 0.01), and Lymph Node Harvested (I2 = 87%, P = 0.001) were statistically significant. Interestingly, compared to China, other countries had lower rates of Conversion and more lymph nodes harvested for RPD surgery.

CONCLUSION

The benefits of RPD surgery over LPD surgery in terms of therapy and an optimistic short-term prognosis are clearly supported by this study. Moreover, subgroup analysis based on regional differences revealed statistically significant results for Conversion, Length of Stay (days), Number of Lymph Nodes Harvested and the rate of Blood Transfusion, indicating significant variability across regions. This study provides a solid theoretical foundation and basis for the advancement of RPD in clinical practice.

Initiation of a robotic pancreatoduodenectomy program using virtual collaboration

BACKGROUND

Adoption of robotic pancreatoduodenectomy (RPD) is growing, although there are challenges for safe introduction of this technique, including limitations in on-site expert proctoring. We developed and implemented a structured approach for safe introduction of a new RPD program using virtual collaboration.

METHODS

A structured framework for introducing a RPD program was designed; key steps included obtaining additional training, identifying required resources, establishing a dedicated team, and patient safety considerations. Virtual collaboration with a proctor for bidirectional communication was utilized for remote operative guidance. In the initial cohort, perioperative data and postoperative outcomes were extracted from a prospectively maintained database.

RESULTS

From August 2020 to December 2023, 68 patients underwent RPD. The median operative time was 407 min with an estimated blood loss of 150 mL. Median length of stay was 8 days. Negative margins were obtained in 90% of resections. Operative time was significantly shorter in the second half of cases compared to the first (380min vs 441min, p < 0.01) and rate of conversion decreased (6% vs 21%).

CONCLUSION

The safe initiation of a structured RPD program is feasible through virtual expert collaboration. With careful consideration and an appropriate environment, excellent perioperative outcomes are achievable even for initial cases.

Safety and feasibility of instituting a robotic pancreas program in the Australian setting: a case series and narrative review

BACKGROUND

Minimally invasive pancreatic resection has been gathering interest over the last decade due to the technical demands and high morbidity associated with these typically open procedures. We report our experience with robotic pancreatectomy within an Australian context.

METHODS

All patients undergoing robotic distal pancreatectomy (DP) and pancreaticoduodenectomy (PD) at two Australian tertiary academic hospitals between May 2014 and December 2020 were included.

RESULTS

Sixty-two patients underwent robotic pancreatectomy during the study period. Thirty-four patients with a median age of 68 years (range 42-84) were in the PD group whilst the DP group included 28 patients with a median age of 60 years (range 18-78). Thirteen patients (46.4%) in the DP group had spleen-preserving procedures. There were 13 conversions (38.2%) in the PD group whilst 0 conversions occurred in the DP group. The Clavien-Dindo grade ≥III complication rate was 26.4% and 17.9% in the PD and DP groups, respectively. Two deaths (5.9%) occurred within 90-days in the PD group whilst none were observed in the DP group. The median length of hospital stay was 11.5 days (range 4-56) in the PD group and 6 days (range 2-22) in the DP group.

CONCLUSION

Robotic pancreatectomy outcomes at our institution are comparable with international literature demonstrating it is both safe and feasible to perform. With improved access to this platform, robotic pancreas surgery may prove to be the turning point for patients with regards to post-operative complications as more experience is obtained.

Minimally invasive total pancreatectomy with islet autotransplantation for chronic pancreatitis: the robotic approach

INTRODUCTION

Total pancreatectomy with islet autotransplantation (TPIAT) treats refractory pain in chronic pancreatitis, prevents episodes of acute exacerbation, and mitigates postoperative brittle diabetes. The minimally invasive (MIS) approach offers a decreased surgical access trauma and enhanced recovery. Having established a laparoscopic TPIAT program, we adopted a robotic approach (R-TPIAT) and studied patient outcomes compared to open TPIAT.

METHODS

Between 2013 and 2021, 61 adult patients underwent TPIAT after a comprehensive evaluation (97% chronic pancreatitis). Pancreatic islets were isolated on-site during the procedure. We analyzed and compared intraoperative surgical and islet characteristics, postoperative morbidity and mortality, and 1-year glycemic outcomes.

RESULTS

MIS-TPIAT was performed in 41 patients (67%, 15 robotic and 26 laparoscopic), and was associated with a shorter mean length of intensive care unit stay compared to open TPIAT (2.9 vs 4.5 days, p = 0.002). R-TPIAT replaced laparoscopic TPIAT in 2017 as the MIS approach of choice and demonstrated decreased blood loss compared to open TPIAT (324 vs 843 mL, p = 0.004), similar operative time (609 vs 562 min), 30-day readmission rate (7% vs 15%), and 90-day complication rate (13% vs 20%). The glycemic outcomes including C-peptide detection at 1-year (73% vs 88%) and insulin dependence at 1-year (75% vs 92%) did not differ. The mean length of hospital stay after R-TPIAT was 8.6 days, shorter than for laparoscopic (11.5 days, p = 0.031) and open TPIAT (12.6 days, p = 0.017). Both MIS approaches had a 1-year mortality rate of 0%.

CONCLUSIONS

R-TPIAT was associated with a 33% reduction in length of hospital stay (4-day benefit) compared to open TPIAT. R-TPIAT was similar to open TPIAT on measures of feasibility, safety, pain control, and 1-year glycemic outcomes. Our data suggest that robotic technology, a new component in the multidisciplinary therapy of TPIAT, is poised to develop into the primary surgical approach for experienced pancreatic surgeons.

Robot-assisted versus laparoscopic pancreatoduodenectomy: a pan-European multicenter propensity-matched study

BACKGROUND

The use of robot-assisted and laparoscopic pancreatoduodenectomy is increasing, yet large adjusted analyses that can be generalized internationally are lacking. This study aimed to compare outcomes after robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy in a pan-European cohort.

METHODS

An international multicenter retrospective study including patients after robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy from 50 centers in 12 European countries (2009-2020). Propensity score matching was performed in a 1:1 ratio. The primary outcome was major morbidity (Clavien-Dindo ≥III).

RESULTS

Among 2,082 patients undergoing minimally invasive pancreatoduodenectomy, 1,006 underwent robot-assisted pancreatoduodenectomy and 1,076 laparoscopic pancreatoduodenectomy. After matching 812 versus 812 patients, the rates of major morbidity (31.9% vs 29.6%; P = .347) and 30-day/in-hospital mortality (4.3% vs 4.6%; P = .904) did not differ significantly between robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy, respectively. Robot-assisted pancreatoduodenectomy was associated with a lower conversion rate (6.7% vs 18.0%; P < .001) and higher lymph node retrieval (16 vs 14; P = .003). Laparoscopic pancreatoduodenectomy was associated with shorter operation time (446 minutes versus 400 minutes; P < .001), and lower rates of postoperative pancreatic fistula grade B/C (19.0% vs 11.7%; P < .001), delayed gastric emptying grade B/C (21.4% vs 7.4%; P < .001), and a higher R0-resection rate (73.2% vs 84.4%; P < .001).

CONCLUSION

This European multicenter study found no differences in overall major morbidity and 30-day/in-hospital mortality after robot-assisted pancreatoduodenectomy compared with laparoscopic pancreatoduodenectomy. Further, laparoscopic pancreatoduodenectomy was associated with a lower rate of postoperative pancreatic fistula, delayed gastric emptying, wound infection, shorter length of stay, and a higher R0 resection rate than robot-assisted pancreatoduodenectomy. In contrast, robot-assisted pancreatoduodenectomy was associated with a lower conversion rate and a higher number of retrieved lymph nodes as compared with laparoscopic pancreatoduodenectomy.

A propensity score-matched analysis of laparoscopic versus open pancreaticoduodenectomy: Is there value to a laparoscopic approach?

BACKGROUND

Laparoscopic pancreaticoduodenectomy has been found safe and associated with advantages over open pancreaticoduodenectomy in prior studies. We compared outcomes of laparoscopic pancreaticoduodenectomy versus open pancreaticoduodenectomy at a single institution after applying technical aspects and perioperative care learned from laparoscopic pancreaticoduodenectomy to the open pancreaticoduodenectomy practice.

METHODS

From January 2010 to December 2020, all patients undergoing pancreaticoduodenectomy were identified, and information was collected in a prospective fashion. Open pancreaticoduodenectomy (n = 347) and laparoscopic pancreaticoduodenectomy (n = 242) were performed using the same selection criteria, operative technique, and recovery protocols at a single institution. Propensity score matching was performed, and then perioperative data and 90-day outcomes were compared, and statistical analysis was performed.

RESULTS

A total of 589 patients underwent pancreaticoduodenectomy, including open pancreaticoduodenectomy (n = 347) and laparoscopic pancreaticoduodenectomy (n = 242). After excluding those undergoing total pancreatectomy or major vascular or concomitant organ resection, there were 497 patients (open pancreaticoduodenectomy = 301 and laparoscopic pancreaticoduodenectomy = 196). Propensity score matching was performed, and 187 open pancreaticoduodenectomy patients were matched to 187 laparoscopic pancreaticoduodenectomy patients. Operative time (475 vs 280 minutes) was longer, and estimated blood loss (150 vs 212 mL) was less for laparoscopic pancreaticoduodenectomy than open pancreaticoduodenectomy, respectively. Pancreatic fistula (18.8% vs 5.4%) and delayed gastric emptying (18.8% vs 9.7%) were higher for laparoscopic pancreaticoduodenectomy than open pancreaticoduodenectomy, respectively. Postpancreatectomy hemorrhage, major morbidity, mortality, hospital stay, and readmissions were nonsignificantly higher for laparoscopic pancreaticoduodenectomy than open pancreaticoduodenectomy. Intensive care use and overall costs were significantly higher for laparoscopic pancreaticoduodenectomy than open pancreaticoduodenectomy.

CONCLUSION

In our experience, open pancreaticoduodenectomy offers similar to improved outcomes over laparoscopic pancreaticoduodenectomy, with less use of perioperative resources, thereby offering better value to patients requiring pancreaticoduodenectomy.

Robotic versus open partial pancreatoduodenectomy (EUROPA): a randomised controlled stage 2b trial

Background

Open partial pancreatoduodenectomy (OPD) represents the current gold standard of surgical treatment of a wide range of diseases of the pancreatic head but is associated with morbidity in around 40% of cases. Robotic partial pancreatoduodenectomy (RPD) is being used increasingly, yet, no randomised controlled trials (RCTs) of RPD versus OPD have been published, leaving a low level of evidence to support this practice.

Methods

This investigator-initiated, exploratory RCT with two parallel study arms was conducted at a high-volume pancreatic centre in line with IDEAL recommendations (stage 2b). Patients scheduled for elective partial pancreatoduodenectomy (PD) for any indication were randomised (1:1) to RPD or OPD with a centralised web-based tool. The primary endpoint was postoperative cumulative morbidity within 90 days, assessed via the Comprehensive Complication Index (CCI). Biometricians were blinded to the intervention, but patients and surgeons were not. The trial was registered prospectively (DRKS00020407).

Findings

Between June 3, 2020 and February 14, 2022, 81 patients were randomly assigned to RPD (n = 41) or OPD (n = 40), of whom 62 patients (RPD: n = 29, OPD: n = 33) were analysed in the modified intention to treat analysis. Four patients in the OPD group were randomised, but did not undergo surgery in our department and one patient was excluded in the RPD group due to other reason. Nine patients in the RPD group and 3 patients in the OPD were excluded from the primary analysis because they did not undergo PD, but rather underwent other types of surgery. The CCI after 90 days was comparable between groups (RPD: 34.02 ± 23.48 versus OPD: 36.45 ± 27.65, difference in means [95% CI]: -2.42 [-15.55; 10.71], p = 0.713). The RPD group had a higher incidence of grade B/C pancreas-specific complications compared to the OPD group (17 (58.6%) versus 11 (33.3%); difference in rates [95% CI]: 25.3% [1.2%; 49.4%], p = 0.046). The only complication that occurred significantly more often in the RPD than in the OPD group was clinically relevant delayed gastric emptying. Procedure-related and overall hospital costs were significantly higher and duration of surgery was longer in the RPD group. Blood loss did not differ significantly between groups. The intraoperative conversion rate of RPD was 23%. Overall 90-day mortality was 4.8% without significant differences between RPD and OPD.

Interpretation

In the setting of a very high-volume centre, both RPD and OPD can be considered safe techniques. Further confirmatory multicentre RCTs are warranted to uncover potential advantages of RPD in terms of perioperative and long-term outcomes.

Funding

Federal Ministry of Education and Research (BMBF: 01KG2010).

What are the true benefits of robotic pancreaticoduodenectomy for patients with pancreatic cancer?

INTRODUCTION

Pancreatic ductal adenocarcinoma (PDAC) is a devastating disease, and multimodal treatment including high-quality surgery can improve survival outcomes. Pancreaticoduodenectomy (PD) has evolved with minimally invasive approaches including the implementation of robotic PD (RPD). In this special report, we review the literature whilst evaluating the 'true benefits' of RPD compared to open approach for the treatment of PDAC.

AREAS COVERED

We have performed a mini-review of studies assessing PD approaches and compared intraoperative characteristics, perioperative outcomes, post-operative complications and oncological outcomes.

EXPERT OPINION

RPD was associated with similar or longer operative times, and reduced intra-operative blood loss. Perioperative pain scores were significantly lower with shorter lengths of stay with the robotic approach. With regards to post-operative complications, post-operative pancreatic fistula rates were similar, with lower rates of clinically relevant fistulas after RPD. Oncological outcomes were comparable or superior in terms of margin status, lymph node harvest, time to chemotherapy and survival between RPD and OPD. In conclusion, RPD allows safe implementation of minimally invasive PD. The current literature shows that RPD is either equivalent, or superior in certain aspects to OPD. Once more centers gain sufficient experience, RPD is likely to demonstrate clear superiority over alternative approaches.

Defining the learning curve for robotic pancreaticoduodenectomy for a single surgeon following experience with laparoscopic pancreaticoduodenectomy

Robotic pancreaticoduodenectomy (RPD) has a learning curve of approximately 30-250 cases to reach proficiency. The learning curve for laparoscopic pancreaticoduodenectomy (LPD) at Duke University was previously defined as 50 cases. This study describes the RPD learning curve for a single surgeon following experience with LPD. LPD and RPD were retrospectively analyzed. Continuous pathologic and perioperative metrics were compared and learning curve were defined with respect to operative time using CUSUM analysis. Seventeen LPD and 69 RPD were analyzed LPD had an inverted learning curve possibly accounting for proficiency attained during the surgeon's fellowship and acquisition of new skills coinciding with more complex patient selection. The learning curve for RPD had three phases: accelerated early experience (cases 1-10), skill consolidation (cases 11-40), and improvement (cases 41-69), marked by reduction in operative time. Compared to LPD, RPD had shorter operative time (379 vs 479 min, p < 0.005), less EBL (250 vs 500, p < 0.02), and similar R0 resection. RPD also had improved LOS (7 vs 10 days, p < 0.007), and lower rates of surgical site infection (10% vs 47%, p < 0.002), DGE (19% vs 47%, p < 0.03), and readmission (13% vs 41%, p < 0.02). Experience in LPD may shorten the learning curve for RPD. The gap in surgical quality and perioperative outcomes between LPD and RPD will likely widen as exposure to robotics in General Surgery, Hepatopancreaticobiliary, and Surgical Oncology training programs increase.

Trends in access to minimally invasive pancreaticoduodenectomy for pancreatic cancers

BACKGROUND

Minimally invasive pancreaticoduodenectomy (MIPD), including robotic (RPD) and laparoscopy (LPD), is becoming more frequently employed in the management of pancreatic ductal adenocarcinoma (PDAC), though the majority of operations are still performed via open approach (OPD). Access to technologic advances often neglect the underserved. Whether disparities in access to MIPD exist, remain unclear.

METHODS

The National Cancer Database (NCDB) was queried (2010-2020) for patients who underwent pancreatoduodenectomy for PDAC. Cochran-Armitage tests assessed for trends over time. Social determinants of health (SDH) were compared between approaches. Multinomial logistic models identified predictors of MIPD.

RESULTS

Of 16,468 patients, 80.03 % underwent OPD and 19.97 % underwent MIPD (22.60 % robotic; 77.40 % laparoscopic). Black race negatively predicted LPD (vs white (OR 0.822; 95 % CI 0.701-0.964)). Predictors of RPD included Medicare/other government insurance (vs uninsured or Medicaid (OR 1.660; 95 % CI 1.123-2.454)) and private insurance (vs uninsured or Medicaid (OR 1.597; 95 % CI 1.090-2.340)). Early (2010-2014) vs late (2015-2020) diagnosis, stratified by race, demonstrated an increase in Non-White patients undergoing OPD (13.15 % vs 14.63 %; p = 0.016), but not LPD (11.41 % vs 13.57 %;p = 0.125) or RPD (14.15 % vs 15.23 %; p = 0.774).

CONCLUSION

SDH predict surgical approach more than clinical stage, facility type, or comorbidity status. Disparities in race and insurance coverage are different between surgical approaches.

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.

The weight of BMI in impacting postoperative and oncologic outcomes in pancreaticoduodenectomy is attenuated by a robotic approach

This study was undertaken to observe the effect of body mass index (BMI) on perioperative outcomes and survival when comparing robotic vs 'open' pancreaticoduodenectomy. With IRB approval, we prospectively followed 505 consecutive patients who underwent either robotic or 'open' pancreaticoduodenectomy from 2012 to 2021. For illustrative purposes, patients were separated based on the Center for Disease Control and Prevention BMI table but regression analysis was utilized to identify significant relationships involving BMI. Data are presented as median (mean ± SD). Significance was determined at p ≤ 0.05. 205 and 300 patients underwent 'open' and robotic pancreaticoduodenectomy, respectively. Neither sex nor age correlated with BMI in patients undergoing 'open' nor robotic operation. Operative duration correlated with increasing BMI in each operational approach, which was statistically significant for those receiving the 'open' operation (p = 0.02). There were statistically significantly fewer lymph nodes harvested with rising BMI in patients that had an 'open' operation (p = 0.01), but no such difference was found in patients undergoing the robotic approach. Length of stay (LOS) and in-hospital mortality were statistically significantly associated with rising BMI when an 'open' operation was undertaken (p = 0.02 and p = 0.0002, respectively) but not when the robotic platform was utilized. Patients with higher BMI had significantly longer operative duration, smaller lymph node harvest, greater LOS, and increased in-hospital mortality rate when undergoing 'open' pancreaticoduodenectomy, but not robotic pancreaticoduodenectomy. Thus, the robotic platform may attenuate the increased technical and oncologic difficulties associated with a greater BMI in patients undergoing pancreaticoduodenectomy.

Reappraisal of surgical and survival outcomes of 500 consecutive cases of robotic pancreaticoduodenectomy

BACKGROUND

The role of the robotic approach for pancreaticoduodenectomy has not been well established with robust data. This study aimed to reappraise feasibility and justification of robotic pancreaticoduodenectomy (RPD) over time.

METHODS

A total of 500 patients undergoing RPD were enrolled and divided into early (first 250 patients) and late (last 250 patients) groups for a comparative study.

RESULTS

The conversion rate was 8.8% overall and was significantly lower in the late group (5.6% vs. 12.0%; p = .012). The overall median intraoperative blood loss was 130 mL. Radicality of resection was similar between early and late groups. The overall surgical mortality after RPD was 1.3%. The overall surgical morbidity and major complication was 44.1% and 13.2%, respectively, and similar between early and late groups. Chyle leakage was the most common complication after RPD (25.0%), followed by postoperative pancreatic fistula (POPF). The POPF rate was 8.6% overall, with 5.9% in the early group and 11.0% in the late group, p = .051. The overall delayed gastric emptying rate was 3.5%. The late group had better survival outcomes than those of the early group after RPD for ampullary adenocarcinoma (p = .027) but not for pancreatic head adenocarcinoma.

CONCLUSIONS

Reappraisal of this study has confirmed that RPD is not only technically feasible without increasing surgical risks but also oncologically justified without compromising survival outcomes for both pancreatic head and other periampullary cancers over time. Moreover, RPD is associated with the benefits of low surgical mortality, blood loss, and delayed gastric emptying.

Current progress in robotic hepatobiliary and pancreatic surgery at a high-volume center

There has been steady growth in the adoption of robotic HPB procedures world-wide over the past 20 years, but most of this increase has occurred only recently. Not surprisingly, the vast majority of robotics has been in the United States, with very few, select centers of adoption in Italy, South Korea, and Brazil, to name a few. We began our robotic HPB program in 2008, well before almost all other centers in the world, with the most notable exception of Giullianotti and colleagues. Our program began gradually, with smaller cases carefully selected to optimize the strengths of the original robotic platform and included complex biliary and pancreatic resections. We performed the first reported series of choledochojejunostomy for benign biliary strictures and first series of completion cholecystectomies. We began performing robotic distal pancreatectomies and longitudinal pancreaticojejunostomies, reporting our early experience for each of these procedures. Over time we progressed to robotic pancreaticoduodenectomies. Initially, these were performed with planned conversions until we were able to optimize efficiency. Now we have performed over 200 robotic whipples, reaching a 100% robotic completion rate by 2020. Finally, we have added robotic major hepatectomies, including resections for hilar cholangiocarcinoma to our repertoire. Since the program began, we have performed over 1600 robotic HPB cases. Outcomes from our program have shown superior lymph node harvest, lower DGE rates, shorter hospitalizations, and fewer rehab admissions with similar overall complications to open and laparoscopic procedures, signifying that over time a robotic HPB program is not only feasible but advantageous as well.

Surgical Risks and Survival Outcomes in Robotic Pancreaticoduodenectomy for the Aged Over 80: A Retrospective Cohort Study

Aim

Whether to execute pancreaticoduodenectomy or not for older people could pose a dilemma. This study clarifies the safety and justification of robotic pancreaticoduodenectomy (RPD) for older individuals over 80.

Methods

A total of 500 patients undergoing RPD were divided into group O (≥ 80 y/o) and group Y (< 80 y/o) for comparison.

Results

There were 62 (12.4%) patients in group O. Surgical mortality was 1.6% for overall patients and higher in group O, 6.5% vs 0.9%; p = 0.001. The surgical complication was comparable between groups O and Y. Delayed gastric emptying and bile leakage were higher in group O, 9.7% vs 2.5%; p = 0.004, and 6.5% vs 0.9%; p = 0.001, respectively. Length of stay was also longer in group O, with a median of 26 vs 19 days; p = 0.001. Survival outcome after RPD was poorer in group O for overall periampullary adenocarcinomas, with a 5-year survival of 48.1% vs 51.2%; p = 0.025 and also for the subgroup of pancreatic head adenocarcinoma, with a 3-year survival of 27.4% vs 42.5%; p = 0.030.

Conclusion

RPD is safe and justified for the selected octogenarians and even nonagenarians, whoever is fit for a major operation. Nevertheless, pancreatic head cancer and higher mortality risk for the aged over 80 with advanced ASA score ≥ 3 should be informed as part of counselling in offering RPD.

Ligamentum teres hepatis wrapping of the gastroduodenal artery stump for protection in total laparoscopic pancreaticoduodenectomy: a single-center experience

OBJECTIVE

Hemorrhage from the stump of the gastroduodenal artery (GDA) is a significant postoperative risk with pancreaticoduodenectomy (PD). Studies have shown that wrapping the GDA stump using the omentum or the falciform ligament can help prevent bleeding. We aimed to determine whether wrapping the GDA stump with the ligamentum teres hepatis (LTH) would reduce postoperative PD hemorrhage.

METHODS

We retrospectively reviewed data for 148 patients who underwent laparoscopic pancreatoduodenectomy (LPD) at our hospital from November 2015 to September 2021. We compared perioperative data from 63 LPD patients without wrapping of the GDA (unwrapped group) and 85 whose GDA stumps were wrapped (wrapped group).

RESULTS

There were no significant differences in the groups' baseline characteristics. The postoperative GDA stump bleeding incidence was significantly lower in the wrapped group than that in the unwrapped group (7.9% vs. 0, respectively). There was also no significant difference in the incidence of other complications (intra-abdominal infection, postoperative pancreatic fistula (POPF), biliary fistula, and gastrointestinal bleeding).

CONCLUSION

Using the LTH to wrap the GDA stump during LPD can reduce bleeding from the GDA stump but not the incidence of other complications.

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.

Feasibility of simultaneous development of laparoscopic and robotic pancreaticoduodenectomy

Laparoscopic (LPD) and robotic pancreaticoduodenectomy (RPD) are both challenging procedures. The feasibility and safety of simultaneously developing LPD and RPD remain unreported. We retrospectively reviewed the data of patients undergoing LPD or RPD between 2014 and 2021. A total of 114 patients underwent minimally invasive pancreaticoduodenectomy (MIPD): 39 LPDs and 75 RPDs. The learning process of LPD and RPD were similar. The cutoff points of the learning curve were LPD, 13th patient (the 27th patient of MIPD), and RPD, 18th patient (the 31st patient of MIPD) according the cumulative sum analysis of operative time. A decrease in the operative time was associated with the case sequence (p < 0.001) but not with the surgical approach (p = 0.36). The overall surgical outcomes were comparable between both the LPD and RPD groups. When evaluating the learning curve impact on MIPD, LPD had higher major complication (≧ Clavien-Dindo grade III), bile leak and wound infection rates in the pre-learning curve phase than those in the after-learning curve phase, while RPD had similar surgical outcomes between two phases. Simultaneous development of LPD and RPD is feasible and safe for experienced surgeons, with similar learning process and comparable surgical outcomes.

Robotic pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: Analysis of surgical outcomes and long-term prognosis in a high-volume center

BACKGROUND

Robotic pancreaticoduodenectomy (RPD) has been reported to be safe and feasible for patients with pancreatic ductal adenocarcinoma (PDAC) of the pancreatic head. This study aimed to analyze the surgical outcomes and risk factors for poor long-term prognosis of these patients.

METHODS

Data from patients who underwent RPD for PDAC of pancreatic head were retrospectively analyzed. Multivariate Cox regression analysis was used to seek the independent prognostic factors for overall survival (OS), and an online nomogram calculator was developed based on the independent prognostic factors.

RESULTS

Of the 273 patients who met the inclusion criteria, the median operative time was 280.0 minutes, the estimated blood loss was 100.0 mL, the median OS was 23.6 months, and the median recurrence-free survival (RFS) was 14.4 months. Multivariate analysis showed that preoperative carbohydrate antigen 19-9 (CA19-9) [hazard ratio (HR) = 2.607, 95% confidence interval (CI): 1.560-4.354, P < 0.001], lymph node metastasis (HR = 1.429, 95% CI: 1.005-2.034, P = 0.047), tumor moderately (HR = 3.190, 95% CI: 1.813-5.614, P < 0.001) or poorly differentiated (HR = 5.114, 95% CI: 2.839-9.212, P < 0.001), and Clavien-Dindo grade ≥ III (HR = 1.657, 95% CI: 1.079-2.546, P = 0.021) were independent prognostic factors for OS. The concordance index (C-index) of the nomogram constructed based on the above four independent prognostic factors was 0.685 (95% CI: 0.640-0.729), which was significantly higher than that of the AJCC staging (8th edition): 0.541 (95% CI: 0.493-0.589) (P < 0.001).

CONCLUSIONS

This large-scale study indicated that RPD was feasible for PDAC of pancreatic head. Preoperative CA19-9, lymph node metastasis, tumor poorly differentiated, and Clavien-Dindo grade ≥ III were independent prognostic factors for OS. The online nomogram calculator could predict the OS of these patients in a simple and convenient manner.

Discrepancies in survival after conversion to open in minimally invasive pancreatoduodenectomy

BACKGROUND

The extent by which conversion to open (CTO) during minimally invasive procedures for pancreatic cancer impact survival outcomes is not fully understood.

METHODS

The 2010-2017 National Cancer Database identified 12,424 non-metastatic patients who underwent pancreatoduodenectomy for ductal adenocarcinoma. Patients were stratified into three cohorts: open (OPD), completed MIPD (cMIPD), and CTO. Subgroups were dichotomized by hospital MIPD volume.

RESULTS

Across the study period, 80.6% of patients underwent OPD, 19.4% MIPD, and 24% were CTO. Median overall survival was worse after CTO (21.8 months) than for OPD (23.6 months) or cMIPD (25.2 months) (p < 0.001). Although this effect persisted for <10 MIPD/year, CTO did comparably to OPD at hospitals performing ≥10MIPD/year (CTO = 26.8 months, OPD = 27.9 months; p = 0.128). Ninety-day mortality after CTO was worse at ≤ 10 MIPD/year hospitals (9.3% vs. 2.6%).

CONCLUSIONS

Short and long-term survival is impacted by CTO after MIPD, especially at lower surgical volumes, stressing careful adoption while ascending the learning curve.

Robotic versus open pancreaticoduodenectomy in elderly patients: a propensity score-matched analysis

BACKGROUND

Pancreaticoduodenectomy (PD) is complex procedure with high morbidity in the elderly. This retrospective study aimed to compare post-operative outcomes in patients ≥75 years of age who underwent robot-assisted (RA)PD and open PD.

METHODS

We analyzed 2502 patients ≥75 years of age who underwent PD from 2015 to 2018 in the National Surgical Quality Improvement Program (NSQIP) database. RAPD and open PD patients were propensity score matched 1:5 to assess the 30-day outcomes of interest: postoperative complications, length of stay, discharge destination, and readmissions.

RESULTS

Of 725 matched patients, 110 underwent RAPD, 615 OPD, and 12 were converted to an open operation. Post-operative outcomes were largely similar between cohorts. RAPD was associated a shorter length of stay (median 8 days, interquartile range [IQR] 6 to 11) than OPD (median 8 days, IQR 7 to 13) (p = 0.003). However, RAPD was associated with more readmissions (28.1% vs. 17.7%; p = 0.02).

CONCLUSIONS

RAPD in patients ≥75 years of age appears to be safe and has a similar complication profile to open PD. Randomized or well-designed prospective matched studies are needed to confirm these findings.

Figures do matter: A literature review of 4587 robotic pancreatic resections and their implications on training

BACKGROUND

The use of robotic assistance in minimally invasive pancreatic resection is quickly growing.

METHODS

We present a systematic review of the literature regarding all types of robotic pancreatic resection (RPR). Our aim is to show for which procedures there is enough experience to permit safe training and provide an estimation of how many centers could serve as teaching institutions.

RESULTS

Sixty-four studies reporting on 4587 RPRs were analyzed. A total of 2598 pancreatoduodenectomies (PD) were reported by 28 centers from Europe (6/28; 21.4%), the Americas (11/28; 39.3%), and Asia (11/28; 39.3%). Six studies reported >100 robot PD (1694/2598; 65.2%). A total of 1618 distal pancreatectomies (DP) were reported by 29 centers from Europe (10/29; 34.5%), the Americas (10/29; 34.5%), and Asia (9/29; 31%). Five studies reported >100 robotic DP (748/1618; 46.2%). A total of 154 central pancreatectomies were reported by six centers from Europe (1/6; 16.7%), the Americas (2/6; 33.3%), and Asia (3/6; 50%). Only 49 total pancreatectomies were reported. Finally, 168 enucleations were reported in seven studies (with a mean of 15.4 cases per study). A single center reported on 60 enucleations (35.7%). Results of each type of robotic procedure are also presented.

CONCLUSIONS

Experience with RPR is still quite limited. Despite high case volume not being sufficient to warrant optimal training opportunities, it is certainly a key component of every successful training program and is a major criterion for fellowship accreditation. From this review, it appears that only PD and DP can currently be taught at few institutions worldwide.

Meta-analysis of robotic versus open pancreaticoduodenectomy in all patients and pancreatic cancer patients

Purposes

To compare perioperative outcomes of robotic pancreaticoduodenectomy (RPD) to open pancreaticoduodenectomy (OPD) using evidence from cohort studies.

Methods

Outcomes of interest include operative time, blood loss, R0 resection rate, lymph nodes harvested, overall complication rate, pancreatic fistula rate, delayed gastric emptying rate and 90-day mortality.

Results

6 prospective studies and 15 retrospective studies were included. Five of these studies were limited to patients with pancreatic cancer. Operative time was significantly longer in RPD (WMD: 64.60 min; 95% CI: 26.89 to 102.21; p = 0.001). Estimated blood loss was lower in RPD (WMD: −185.44 ml; 95% CI: −239.66 to −131.21; p < 0.001). Overall complication rates (OR: 0.66; 95% CI: 0.44 to 0.97; p < 0.001) and pancreatic fistula rate (OR: 0.67; 95% CI: 0.55 to 0.82; p < 0.001) were both lower in RPD. Length of hospital stay was longer in OPD (WMD: −1.90; 95% CI: −2.47 to −1.33). 90-day mortality was lower in RPD [odds ratio (OR): 0.77; 95% CI: 0.45 to 0.95; p = 0.025].

Conclusion

At current level of evidence, RPD is a safer alternative than OPD with regard to post-operative outcomes and blood loss. However, in terms of oncological outcomes RPD show no advantage over OPD, and the cost of RPD was higher. In general, RPD is now considered a reliable technology, but high-quality randomized controlled trial (RCT) studies are still needed to support this conclusion.

A comparative study of robotics and laparoscopic in minimally invasive pancreatoduodenectomy: A single-center experience

Objective

To retrospectively compare the short-term benefits of robotic surgery and laparoscopic in the perioperative period of minimally invasive pancreatoduodenectomy (MIPD).

Methods

This retrospective analysis evaluated patients who underwent laparoscopic pancreatoduodenectomy (LPD) or robotic pancreatoduodenectomy (RPD) from March 2018 to January 2022 in the First Affiliated Hospital of Zhengzhou University (Zhengzhou, China). Perioperative data, including operating time, complications, morbidity and mortality, estimated blood loss (EBL), and postoperative length of stay, were analysed.

Result

A total of 190 cases of MIPD were included, of which 114 were LPD and 76 were RPD. There was no significant difference between the two groups in gender, age, previous history of upper abdominal operation, jaundice (>150 µmol/L), or diabetes (P > 0.05). The conversion rate to laparotomy was similar in the LPD and RPD groups (5.3% vs. 6.6%, P = 0.969). A total of 179 cases of minimally invasive pancreatoduodenectomy were successfully performed, including 108 cases of LPD and 71 cases of RPD. There were significant differences between the laparoscopic and robotic groups in operation time [mean, 5.97 h vs. 5.42 h, P < 0.05] and postoperative length of stay [mean, 15.3 vs. 14.6 day, P < 0.05]. No significant difference was observed between the two groups in terms of EBL, intraoperative transfusion, complication rate, mortality rate, or reoperation rate (P > 0.05). There were no significant differences in pathological type, number of lymph nodes harvested, or positive lymph node rate (P > 0.05).

Conclusion

RPD had an advantage compared to LPD in reduced operation time and postoperative length of stay, technical feasibility, and safety.

Robotic parenchymal-sparing pancreatectomy and pancreas-sparing duodenectomy avoid pancreaticoduodenectomy for benign and low-grade malignant tumours

BACKGROUND

Parenchymal-sparing pancreatectomy (PSP) or pancreas-sparing duodenectomy (PSD) is an alternative method for patients with benign or low-grade malignant tumours at the pancreatic head or duodenum. It avoids traumatic pancreaticoduodenectomy (PD) with pancreatic function preservation and improves quality of life. However, few studies have reported on robotic PSP (RPSP) or robotic PSD (RPSD).

METHODS

A retrospective analysis of 17 patients with benign and low-grade malignant pancreatic head and duodenal tumours who underwent RPSP or RPSD from January 2018 to February 2022 was conducted. The demographic, perioperative, and postoperative data of all patients were collected and analysed.

RESULTS

The operations were successful for all seventeen patients without conversion, including 10 cases of RPSP and 7 cases of RPSD. For RPSP, eight patients underwent pancreatic enucleation, and two patients underwent uncinate process resection. For RPSD, five patients underwent local duodenectomy, and two patients underwent segmental duodenectomy, with five simultaneous jejunostomies and two distal gastrectomies. The median OT and EBL were 135 min and 50 mL for RPSP and 220 min and 100 mL for RPSD, respectively. The median LOS was 8 days for RPSP and 19 days for RPSD. The main postoperative complications for RPSP included POPF (grade B, 6 cases), DGE (grade B, 1 case), PPH (1 case), and intra-abdominal infection (1 case). The main postoperative complications for RPSD included DGE (grade B, 1 case, grade C, 3 cases), postoperative haemorrhage (1 case), intra-abdominal infection (1 case), and duodenal fistula (1 case). One patient underwent interventional drain placement after RPSP because of POPF.

CONCLUSION

RPSP or RPSD is feasible for highly selected patients with benign and low-grade malignant pancreatic head and duodenal tumours, avoiding potential pancreaticoduodenectomy.

Robot-assisted pancreatoduodenectomy with the da Vinci Xi: can the costs of advanced technology be offset by clinical advantages? A case-matched cost analysis versus open approach

BACKGROUND

Robot-assisted pancreatoduodenectomy (RPD) has shown some advantages over open pancreatoduodenectomy (OPD) but few studies have reported a cost analysis between the two techniques. We conducted a structured cost-analysis comparing pancreatoduodenectomy performed with the use of the da Vinci Xi, and the traditional open approach, and considering healthcare direct costs associated with the intervention and the short-term post-operative course.

MATERIALS AND METHODS

Twenty RPD and 194 OPD performed between January 2011 and December 2020 by the same operator at our high-volume multidisciplinary center for robot-assisted surgery and for pancreatic surgery, were retrospectively analyzed. Two comparable groups of 20 patients (Xi-RPD-group) and 40 patients (OPD-group) were obtained matching 1:2 the RPD-group with the OPD-group. Perioperative data and overall costs, including overall variable costs (OVCs) and fixed costs, were compared.

RESULTS

No difference was reported in mean operative time: 428 min for Xi-RPD-group versus 404 min for OPD, p = 0.212. The median overall length of hospital stay was significantly lower in the Xi-RPD-group: 10 days versus 16 days, p = 0.001. In the Xi-RPD-group, consumable costs were significantly higher (€6149.2 versus €1267.4, p < 0.001), while hospital stay costs were significantly lower: €5231.6 versus €8180 (p = 0.001). No significant differences were found in terms of OVCs: €13,483.4 in Xi-RPD-group versus €11,879.8 in OPD-group (p = 0.076).

CONCLUSIONS

Robot-assisted surgery is more expensive because of higher acquisition and maintenance costs. However, although RPD is associated to higher material costs, the advantages of the robotic system associated to lower hospital stay costs and the absence of difference in terms of personnel costs thanks to the similar operative time with respect to OPD, make the OVCs of the two techniques no longer different. Hence, the higher costs of advanced technology can be partially compensated by clinical advantages, particularly within a high-volume multidisciplinary center for both robot-assisted and pancreatic surgery. These preliminary data need confirmation by further studies.

Robotic Harvest of the Deep Inferior Epigastric Perforator Flap for Breast Reconstruction: A Case Series

BACKGROUND

Robotic surgery is emerging as a viable tool in reconstructive surgery. Harvesting of the deep inferior epigastric perforator flap is typically performed through an anterior approach, which involves a long fascial incision. A robotic approach allows the deep inferior epigastric pedicle to be harvested from the posterior surface. This approach reduces the length of the fascial incision and should decrease the abdominal morbidity associated with large fascial dissections.

METHODS

A case series study of 21 patients who underwent a robotic deep inferior epigastric perforator or during a 12-month period for breast reconstruction was performed. Patient demographics, surgical characteristics, and complications were assessed.

RESULTS

Mean patient age was 54.6 ± 7.6 years, and mean body mass index was 30.4 ± 3.9 kg/m2. Mean fascial incision and pedicle length were 3.6 ± 1.6 cm and 13.3 ± 1 cm, respectively. None of the patients required conversion to open harvest. Mean length of hospital stay was 3.8 ± 0.9 days. Surgical site occurrences were identified in five patients (31.3 percent). One patient had delayed wound healing at the donor site. None of the patients developed hernia or bulge. The mean benefit (B = C - A), defined as length of fascial incision spared and measured as the difference between pedicle length and intramuscular course, was 9.83 ± 2.28 cm. The precision of computed tomography angiography in identifying the intraoperative fascial incision was 86 percent.

CONCLUSION

The robotic deep inferior epigastric perforator flap is a safe and reliable technique that decreases the length of fascial incision and short-term complications associated with the open approach.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Quality of Life Associated with Open vs Minimally Invasive Pancreaticoduodenectomy: A Prospective Pilot Study

BACKGROUND

This prospective study was designed to compare quality of life (QoL) among patients who underwent open (O-PD) vs minimally invasive pancreaticoduodenectomy (MI-PD), using a combination of validated qualitative and quantitative methodologies.

STUDY DESIGN

From 2017 to 2019, patients scheduled for pancreaticoduodenectomy (PD) were enrolled and presented with Functional Assessment of Cancer Therapy-Hepatobiliary surveys preoperatively, before discharge, at first postoperative visit and approximately 3 to 4 months after operation ("3 months"). Longitudinal plots of median QoL scores were used to illustrate change in each score over time. In a subset of patients, content analysis of semistructured interviews at postoperative time points (1.5 to 6 months after operation) was conducted.

RESULTS

Among 56 patients who underwent PD, 33 had an O-PD (58.9%). Physical and functional scores decreased in the postoperative period but returned to baseline by 3 months. No significant differences were found in any domains of QoL at baseline and in the postoperative period between patients who underwent O-PD and MI-PD. Qualitative findings were concordant with quantitative data (n = 14). Patients with O-PD and MI-PD reported similar experiences with complications, pain, and wound healing in the postoperative period. Approximately half the patients in both groups reported "returning to normal" in the 6-month postoperative period. A total of 4 patients reported significant long-term issues with physical and functional well-being.

CONCLUSIONS

Using a novel combination of qualitative and quantitative analyses in patients undergoing PD, we found no association between operative approach and QoL in patients who underwent O-PD vs MI-PD. Given the increasing use of minimally invasive techniques for PD and the steep learning curve associated with these techniques, continued assessment of patient benefit is critical.

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

International expert consensus on precision anatomy for minimally invasive pancreatoduodenectomy: PAM-HBP surgery project

BACKGROUND

The anatomical structure around the pancreatic head is very complex and it is important to understand its precise anatomy and corresponding anatomical approach to safely perform minimally invasive pancreatoduodenectomy (MIPD). This consensus statement aimed to develop recommendations for elucidating the anatomy and surgical approaches to MIPD.

METHODS

Studies identified via a comprehensive literature search were classified using the Scottish Intercollegiate Guidelines Network method. Delphi voting was conducted after experts had drafted recommendations, with a goal of obtaining >75% consensus. Experts discussed the revised recommendations with the validation committee and an international audience of 384 attendees. Finalized recommendations were made after a second round of online Delphi voting.

RESULTS

Three clinical questions were addressed, providing six recommendations. All recommendations reached at least a consensus of 75%. Preoperatively evaluating the presence of anatomical variations and superior mesenteric artery (SMA) and superior mesenteric vein (SMV) branching patterns was recommended. Moreover, it was recommended to fully understand the anatomical approach to SMA and intraoperatively confirm the SMA course based on each anatomical landmark before initiating dissection.

CONCLUSIONS

MIPD experts suggest that surgical trainees perform resection based on precise anatomical landmarks for safe and reliable MIPD.

Robot-assisted pancreatic surgery-optimized operating procedures: set-up, port placement, surgical steps

Even in most complex surgical settings, recent advances in minimal-invasive technologies have made the application of robotic-assisted devices more viable. Due to ever increasing experience and expertise, many large international centers now offer robotic-assisted pancreatic surgery as a preferred alternative. In general however, pancreatic operations are still associated with high morbidity and mortality, while robotic-assisted techniques still require significant learning curves. As a prospective post-marketing trial, we have established optimized operating procedures at our clinic. This manuscript intends to publicize our standardized methodology, including pre-operative preparation, surgical set-up as well as the surgeons’ step-by-step actions when using pancreatic-assisted robotic surgery. This manuscript is based on our institutional experience as a high-volume pancreas operating center. We introduce novel concepts that should standardize, facilitate and economize the surgical steps in all types of robotic-assisted pancreatic surgery. The “One Fits All” principle enables single port placement irrespective of the pancreatic procedure, while the “Reversed 6-to-6 Approach” offers an optimized manual for pancreatic surgeons using the robotic console. Novel and standardized surgical concepts could guide new centers to establish a robust, efficient and safe robotic-assisted pancreatic surgery program.

Technical progress in robotic pancreatoduodenectomy: TRIANGLE and periadventitial dissection for retropancreatic nerve plexus resection

PURPOSE

The resection of retropancreatic nerve plexuses for pancreatic head cancer became standard of care during open pancreatoduodenectomy to minimize local recurrences. Since more surgical centers are progressing on the learning curve, robotically-assisted pancreatoduodenectomy is now increasingly performed with decreasing anatomic exclusion criteria. To achieve comparable and favorable oncologic outcomes, advanced surgical techniques should be transferred and implemented when performing robotic resections.

METHODS

The nomenclature and anatomic principles of retropancreatic nerve plexuses and three different levels of dissections are utilized based on established definitions.

RESULTS

The en bloc dissection in the "TRIANGLE" area (triangular-shaped retropancreatic space enclosed by the common hepatic artery, superior mesenteric artery, and superior mesenteric vein/portal vein) and the periadventitial dissection of arteries for non-tunica media-invading tumors were executed robotically. Both can be utilized to achieve a radical dorsal and medial margin. Video recordings are provided to illustrate varying TRIANGLE dissections.

CONCLUSION

To accomplish oncologic non-inferiority, established principles from open pancreatic resections can be incorporated precisely and safely, overcoming the lack of haptic feedback while exploiting the technological advantages of the robotically-assisted platform.