Comparison of surgical outcomes of robot-assisted laparoscopic distal pancreatectomy versus laparoscopic and open resections: A systematic review and meta-analysis. Asian J Surg. 2019;42:32-45. [PMID: 30337121 DOI: 10.1016/j.asjsur.2018.08.011]

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.

[Robotic pancreatic surgery]

Robotic operations as a further development of conventional laparoscopic surgery have been introduced for nearly all interventions in visceral surgery during the last decade. They also currently have a high importance and acceptance in pancreatic surgery despite a relevant learning curve and high associated costs. Standard procedures, such as robotic distal pancreatectomy (RDP) and partial pancreatoduodenectomy (RPD) are most frequently performed, whereas extended resections, e.g., vascular reconstructions of the portal vein, are still limited to a small number of centers worldwide. Potential advantages of robotic pancreatic surgery compared to open surgery include, in particular, less blood loss and a faster postoperative recovery of the patients leading to a shorter hospital stay. Compared to conventional laparoscopic surgery, robotic approaches offer advantages with respect to better visualization and three-dimensional dexterity of the instruments; however, the currently published literature comprises only retrospective or prospective observational studies and randomized controlled results are not yet available but first study results in this respect are expected within the next 2-3 years.

Prince and princesses: The current status of robotic surgery in surgical oncology

Robotic surgery has experienced a dramatic increase in utilization across general surgery over the last two decades, including in surgical oncology. Although urologists and gynecologists were the first to show that this technology could be utilized in cancer surgery, the robot is now a powerful tool in the treatment of gastrointestinal, hepato-pancreatico-biliary, colorectal, endocrine, and soft tissue malignancies. While long-term outcomes are still pending, short-term outcomes have showed promise for this technologic advancement of cancer surgery.

A comparison of robotic versus laparoscopic distal pancreatectomy: a single surgeon's robotic experience in a high-volume center

BACKGROUND

Robotic surgery is the most recent advanced minimally invasive approach for distal pancreatectomy. However, its benefits over laparoscopic distal pancreatectomy (LDP) remain undetermined. Previous studies were limited by their small sample size or variations in surgeon skills. This study aimed to compare robotic distal pancreatectomy (RDP) performed by a single surgeon with LDP performed by skilled laparoscopic surgeons in a high-volume center.

METHODS

We retrospectively analyzed consecutive RDP performed by a single surgeon between December 2020 and November 2021 with LDP performed by experienced surgeons during the same period in a high-volume center. Patient characteristics and perioperative variables were compared.

RESULTS

The analysis included 55 RDP and 146 LDP procedures. The operative time in the RDP group was significantly shorter than the LDP group (171 vs. 222 min, P < 0.001), both in spleen-preserved (154 vs. 212 min, P < 0.001) and spleen-removed (192 vs. 230 min, P = 0.005) procedures. The RDP group made more frequent use of the stapler technique for pancreas transection (87.3 vs. 68.5%, P = 0.007), and its estimated blood loss was lower (79 vs. 155 mL, P < 0.001) than the LDP group. The postoperative hospital stay in the RDP group was significantly shorter than the LDP group (8 vs. 12 days, P < 0.001). The groups were similar in their complication distributions.

CONCLUSION

RDP is as safe and feasible a minimally invasive approach as LDP. The advanced manipulation and visualization capabilities of the robotic approach in distal pancreatectomy could help reduce operative time and blood loss, and is related to shorter postoperative hospital stay.

Use and outcome of minimally invasive pancreatic surgery in the European E-MIPS registry

BACKGROUND

The European registry for minimally invasive pancreatic surgery (E-MIPS) collects data on laparoscopic and robotic MIPS in low- and high-volume centers across Europe.

METHODS

Analysis of the first year (2019) of the E-MIPS registry, including minimally invasive distal pancreatectomy (MIDP) and minimally invasive pancreatoduodenectomy (MIPD). Primary outcome was 90-day mortality.

RESULTS

Overall, 959 patients from 54 centers in 15 countries were included, 558 patients underwent MIDP and 401 patients MIPD. Median volume of MIDP was 10 (7-20) and 9 (2-20) for MIPD. Median use of MIDP was 56.0% (IQR 39.0-77.3%) and median use of MIPD 27.7% (IQR 9.7-45.3%). MIDP was mostly performed laparoscopic (401/558, 71.9%) and MIPD mostly robotic (234/401, 58.3%). MIPD was performed in 50/54 (89.3%) centers, of which 15/50 (30.0%) performed ≥20 MIPD annually. This was 30/54 (55.6%) centers and 13/30 (43%) centers for MIPD respectively. Conversion rate was 10.9% for MIDP and 8.4% for MIPD. Overall 90 day mortality was 1.1% (n = 6) for MIDP and 3.7% (n = 15) for MIPD.

CONCLUSION

Within the E-MIPS registry, MIDP is performed in about half of all patients, mostly using laparoscopy. MIPD is performed in about a quarter of patients, slightly more often using the robotic approach. A minority of centers met the Miami guideline volume criteria for MIPD.

Comparative Efficacy of Robot-Assisted and Laparoscopic Distal Pancreatectomy: A Single-Center Comparative Study

Background

Laparoscopic distal pancreatectomy (LDP) has become a routine procedure in pancreatic surgery. Although robotic distal pancreatectomy (RDP) has not been popularized yet, it has shown new advantages in some aspects, and exploring its learning curve is of great significance for guiding clinical practice.

Methods

149 patients who received RDP and LDP in our surgical team were enrolled in this retrospective study. Patients were divided into two groups including LDP group and RDP group. The perioperative outcomes, histopathologic results, long-term postoperative complications, and economic cost were collected and compared between the two groups. The cumulative summation (CUSUM) analysis was used to explore the learning curve of RDP.

Results

The hospital stay, postoperative first exhaust time, and first feeding time in the RDP group were better than those in the LDP group (P < 0.05). The rate of spleen preservation in patients with benign and low-grade tumors in the RDP group was significantly higher than that of the LDP group (P=0.002), though the cost of operation and hospitalization was significantly higher (P < 0.001). The learning curve of RDP in our center declined significantly with completing 32 cases. The average operation time, the hospital stay, and the time of gastrointestinal recovery were shorter after the learning curve node than before.

Conclusion

RDP provides better postoperative recovery and is not difficult to replicate, but the high cost was still a major disadvantage of RDP.

Single-position robotic assisted laparoscopic anterograde bilateral inguinal lymphadenectomy versus laparoscopic inguinal lymphadenectomy for penile cancer: A retrospective controlled study

OBJECTIVES

The main purpose of this study was to compare the surgical strategy and clinical outcomes of single-position robotic assisted laparoscopic anterograde bilateral inguinal lymphadenectomy for penile cancer.

MATERIALS AND METHODS

21 patients were diagnosis with squamous cell carcinoma and identified from March 2010 to December 2020 in our department. Ten patients were received single-position robotic assisted laparoscopic anterograde bilateral inguinal lymphadenectomy (robot-assisted group), and eleven patients underwent laparoscopic inguinal lymphadenectomy (laparoscopic group). Preoperative physical examination and related auxiliary examinations all indicated bilateral inguinal lymph node enlargement, and there was no distant metastasis patient presented during the follow-up period.

RESULTS

There was no intraoperative conversion to open surgery. The operation time under robot-assisted group was 104 ± 13 min which was significantly shorter than laparoscopic group (136 ± 11 min, P < 0.01). The average number of lymph nodes was 22.2 ± 4.5 of both sides in robot-assisted group, which was statistically different compared with laparoscopic group (15.4 ± 3.1, p < 0.01). Moreover, there was significant difference of hospitalization cost between two groups (CNY 67429 ± 5586 vs 28582 ± 3774, P < 0.01). No differences in operation time, blood loss, and length of stay were recorded.

CONCLUSIONS

The single-position robotic assisted laparoscopic anterograde bilateral inguinal lymphadenectomy reveals with shorter operating time, and better surgical effect, Moreover, we prefer to no change the trocars layout and mechanical arm system during the operation.

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.

A comparison of robotic versus laparoscopic distal pancreatectomy: Propensity score matching analysis

BACKGROUND

The aim of this study was to assess the perioperative and pathologic outcomes of robotic distal pancreatectomy compared with a laparoscopic approach.

METHODS

A total of 121 robotic distal pancreatectomies and 992 laparoscopic distal pancreatectomies were retrospectively evaluated, comparing the demographic, perioperative and pathologic outcomes. After 1:2 propensity score matching (PSM) with 11 demographic variables, the factors were analysed again.

RESULTS

Following PSM, 104 robotic distal pancreatectomy patients were compared with 208 laparoscopic distal pancreatectomy patients. The operation time and proportion of spleen preservation were not different between the groups. The rates of open conversion were lower, whereas the hospital costs were higher in the robotic group. Other perioperative outcomes and pathologic factors did not differ between the groups.

CONCLUSIONS

Although robotic distal pancreatectomy is more expensive, this operation is feasible, with a higher probability of proceeding with the planned operation and with low open conversion rate.

Robotic versus laparoscopic distal pancreatectomy: multicentre analysis

BACKGROUND

The role of minimally invasive distal pancreatectomy is still unclear, and whether robotic distal pancreatectomy (RDP) offers benefits over laparoscopic distal pancreatectomy (LDP) is unknown because large multicentre studies are lacking. This study compared perioperative outcomes between RDP and LDP.

METHODS

A multicentre international propensity score-matched study included patients who underwent RDP or LDP for any indication in 21 European centres from six countries that performed at least 15 distal pancreatectomies annually (January 2011 to June 2019). Propensity score matching was based on preoperative characteristics in a 1 : 1 ratio. The primary outcome was the major morbidity rate (Clavien-Dindo grade IIIa or above).

RESULTS

A total of 1551 patients (407 RDP and 1144 LDP) were included in the study. Some 402 patients who had RDP were matched with 402 who underwent LDP. After matching, there was no difference between RDP and LDP groups in rates of major morbidity (14.2 versus 16.5 per cent respectively; P = 0.378), postoperative pancreatic fistula grade B/C (24.6 versus 26.5 per cent; P = 0.543) or 90-day mortality (0.5 versus 1.3 per cent; P = 0.268). RDP was associated with a longer duration of surgery than LDP (median 285 (i.q.r. 225-350) versus 240 (195-300) min respectively; P < 0.001), lower conversion rate (6.7 versus 15.2 per cent; P < 0.001), higher spleen preservation rate (81.4 versus 62.9 per cent; P = 0.001), longer hospital stay (median 8.5 (i.q.r. 7-12) versus 7 (6-10) days; P < 0.001) and lower readmission rate (11.0 versus 18.2 per cent; P = 0.004).

CONCLUSION

The major morbidity rate was comparable between RDP and LDP. RDP was associated with improved rates of conversion, spleen preservation and readmission, to the detriment of longer duration of surgery and hospital stay.

Clinical Outcomes of Robotic Surgery Compared to Conventional Surgical Approaches (Laparoscopic or Open): A Systematic Overview of Reviews

OBJECTIVE

Describe clinical outcomes (eg, postoperative complications, survival) after robotic surgery compared to open or laparoscopic surgery.

BACKGROUND

Robotic surgery utilization has increased over the years across a wide range of surgical procedures. However, evidence supporting improved clinical outcomes after robotic surgery is limited.

METHODS

We systematically searched MEDLINE, EMBASE, and the Cochrane Central Register of systematic reviews from inception to January 2019 for systematic reviews describing postoperative outcomes after robotic surgery. We qualitatively described patient outcomes of commonly performed robotic procedures: radical prostatectomy, hysterectomy, lobectomy, thymectomy, rectal resection, partial nephrectomy, distal gastrectomy, Roux-en-Y gastric bypass, hepatectomy, distal pancreatectomy, and cholecystectomy.

RESULTS

One hundred fifty-four systematic reviews included 336 studies and 18 randomized controlled trials reporting on patient outcomes after robotic compared to laparoscopic or open procedures. Data from the randomized controlled trials demonstrate that robotic-assisted radical prostatectomy offered fewer biochemical recurrence and improvement in quality of recovery and pain scores only up to 6 weeks postoperatively compared to open radical prostatectomy. When compared to laparoscopic prostatectomy, robotic surgery offered improved urinary and sexual functions. Robotic surgery for endometrial cancer had fewer conversion to open compared to laparoscopic. Otherwise, robotic surgery outcomes were similar to conventional surgical approaches for other procedures except for radical hysterectomy where minimally invasive approaches may result in patient harm compared to open approach.

CONCLUSION

Robotic surgery has been widely incorporated into practise despite limited supporting evidence. More rigorous research focused on patient-important benefits is needed before further expansion of robotic surgery.

Minimally invasive (laparoscopic and robot-assisted) versus open approach for central pancreatectomies: a single-center experience

BACKGROUND

There continues to be an interest in minimally invasive approaches to pancreatic surgery. At our institution, there has been a progressive change from an open to minimally invasive surgery (MIS) (laparoscopic, robotic, or laparoscopic-robotic) approach for central pancreatectomies (CP). The aim of this study was to evaluate surgical outcomes with open CP (O-CP) versus minimally invasive CP (MI-CP).

METHODS

A retrospective medical review of patients who underwent CP between 1993 and 2018 at Yonsei University Health System, Seoul, Korea was performed. Short-term perioperative outcomes were compared between O-CP and MI-CP.

RESULTS

Thirty-one CPs (11 open, 20 MIS) were identified during the study period. No difference was observed in admission days between O-CP and MI-CP (21.2 vs. 16.7 days, p = 0.340), although operating time was significantly increased in the MI-CP group (296.8 vs. 374.8 min, p = 0.036). Blood loss was significantly less in MI-CP vs. O-CP (807.1 vs. 214.0 mls, p = 0.001), with no difference in post-operative new-onset diabetes (9% vs. 5%). The overall post-operative pancreatic fistula rate was 25.8%, and no significant difference between O-CP and MI-CP or complication rates (45% vs. 40%) was observed.

CONCLUSION

Despite increased operative time, MI-CP is feasible and comparable to conventional O-CP with regard to surgical outcomes in well-selected patients.

[Evidence for robotics in oncological pancreatic surgery]

Robotic surgical procedures have been implemented and have become an important development in pancreatic surgery with an increasing acceptance worldwide. Nearly all types of pancreatic surgery have now been performed robotically and especially standardized resections, such as distal pancreatectomy (RDP) and partial pancreatoduodenectomy (RPD) have gained importance despite a potentially long learning curve and high associated procedural costs. The present review article summarizes the available literature and evidence on the respective procedures focused on their use for indications of malignancy.

Current state of minimally invasive pancreatic surgery

The growth in minimally invasive pancreatic surgery (MIPS) has been accompanied by a recent surge in evidence-based data available to analyze patient outcomes. A small complement of randomized control trials as well as a multitude of observational studies have demonstrated both consistent similarities and differences between MIPS and the open approach, although abundant questions remain. This review highlights the available literature and emphasizes key factors for evaluating laparoscopic and robotic pancreatic surgery.

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.

Comparison of 3 Minimally Invasive Methods Versus Open Distal Pancreatectomy: A Systematic Review and Network Meta-Analysis

Supplemental Digital Content is available in the text.

The efficacy and safety of open distal pancreatectomy (DP), laparoscopic DP, robot-assisted laparoscopic DP, and robotic DP have not been established. The authors aimed to comprehensively compare these 4 surgical methods using a network meta-analysis.

A single institution experience with robotic and laparoscopic distal pancreatectomies

Backgrounds/Aims

This study aims to describe our experience with minimally-invasive distal pancreatectomies, with emphasis on the comparison between robotic distal pancreatectomy (RDP) and laparoscopic distal pancreatectomy (LDP).

Methods

Retrospective review of 102 consecutive RDP and LDP from 2006 to 2019 was performed.

Results

There were 27 and 75 patients who underwent RDP and LDP, respectively. There were 12 (11.8%) open conversions and 16 (15.7%) patients had major (>grade 2) morbidities. Patients who underwent RDP had significantly higher rates of splenic preservation (44.4% vs. 13.3%, p=0.002), higher rates of splenic-vessel preservation (40.7% vs. 9.3%, p=0.001), higher median difficulty score (5 vs. 3, p=0.002) but longer operation time (385 vs. 245 minutes, p<0.001). The rate of open conversion tended to be lower with RDP (3.7% vs. 14.7%, p=0.175).

Conclusions

In our institution practice, both RDP and LDP were safe and effective. The use of RDP appeared to be complementary to LDP, allowing us to perform more difficult procedures with comparable postoperative outcomes.

Minimally invasive surgery for pancreatic cancer

Pancreatic cancer is the most lethal malignancy of the digestive organs. Although pancreatic resection is essential to radically cure this refractory disease, the multi-organ resection involved, as well as sequelae such as glucose tolerance insufficiency and severe complications impose a heavy burden on these patients. Since the late twentieth century, minimally invasive surgery has become more popular for the surgical management of digestive disease and pancreatic cancer. Minimally invasive pancreatic resection (MIPR), including pancreaticoduodenectomy and distal pancreatectomy, is now a treatment option for pancreatic cancer. Some evidence suggests that MIPR for pancreatic cancer provides comparable oncological outcomes to open surgery, with some advantages in perioperative outcomes. However, as this evidence is retrospective, prospective investigations, including randomized controlled trials, are necessary. Because neoadjuvant therapy for resectable or borderline-resectable pancreatic cancer and conversion surgery for initially unresectable pancreatic cancer has become more common, the feasibility of MIPR after neoadjuvant therapy or as conversion surgery requires further assessment. It is expected that progress in surgical techniques and devices, as well as the standardization of surgical procedures and widespread educational programs will improve the outcomes of MIPR.

Current Status of Laparoscopic and Robotic Pancreatic Surgery and Its Adoption in Singapore

Despite the potential clinical advantages offered by laparoscopic pancreatic surgery (LPS), the main obstacle to its widespread adoption is the technically demanding nature of the procedure and its steep learning curve. LPS and robotic pancreatic surgery (RPS) have been proven to result in superior short-term perioperative outcomes and equivalent long-term oncological outcomes compared to the conventional open approach, with the caveat that they are performed by expert surgeons who have been trained to perform such procedures. The primary challenge faced by most pancreatic surgeons is the steep learning curve associated with these complex procedures and the need to undergo surgical training, especially with regards to laparoscopic and robotic pancreaticoduodenectomy. Current evidence suggests that RPS may help to shorten the lengthy learning curve required for LPS. More robust evidence—in the form of large randomised controlled trials—is needed to determine whether LPS and RPS can be safely adopted universally. Ann Acad Med Singapore 2020;49:377–83 Key words: Laparoscopic pancreatectomy, Laparoscopic pancreaticoduodenectomy, Minimally invasive pancreatic surgery, Robotic pancreatectomy, Robotic pancreaticoduodenectomy

Up-to-date comparison of robotic-assisted versus open distal pancreatectomy: A PRISMA-compliant meta-analysis

BACKGROUND

Although robot-assisted distal pancreatectomy (RADP) has been successfully performed since 2003, its advantages over open distal pancreatectomy (ODP) are still uncertain. The objective of this meta-analysis is to compare the clinical and oncologic safety and efficacy of RADP vs ODP.

METHODS

Multiple databases (PubMed, Medline, EMBASE, Web of Science, and Cochrane Library) were searched to identify studies that compare the outcomes of RADP and ODP (up to February, 2020). Fixed and random effects models were applied according to different conditions.

RESULTS

A total of 7 studies from high-volume robotic surgery centers comprising 2264 patients were included finally. Compared with ODP, RADP was associated with lower estimated blood loss, lower blood transfusion rate, lower postoperative mortality rate, and shorter length of hospital stay. No significant difference was observed in operating time, the number of lymph nodes harvested, positive margin rate, spleen preservation rate, rate of severe morbidity, incidence of postoperative pancreatic fistula, and severe postoperative pancreatic fistula (grade B and C) between the 2 groups.

CONCLUSIONS

With regard to perioperative outcomes, RADP is a safe and feasible alternative to ODP in centers with expertise in robotic surgery. However, the evidence is limited and more randomized controlled trials are needed to further clearly define this role.

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.

Multidisciplinary consensus statement on the clinical management of patients with pancreatic cancer

Pancreatic cancer (PC) remains one of the most aggressive tumors with an increasing incidence rate and reduced survival. Although surgical resection is the only potentially curative treatment for PC, only 15–20% of patients are resectable at diagnosis. To select the most appropriate treatment and thus improve outcomes, the diagnostic and therapeutic strategy for each patient with PC should be discussed within a multidisciplinary expert team. Clinical decision-making should be evidence-based, considering the staging of the tumor, the performance status and preferences of the patient. The aim of this guideline is to provide practical and evidence-based recommendations for the management of PC.

Revisiting the potential advantage of robotic surgical system in spleen-preserving distal pancreatectomy over conventional laparoscopic approach

Background

This study aimed to compare success rate of spleen preservation between robotic and laparoscopic distal pancreatectomy (DP).

Methods

Between November 2007 and March 2018, forty-one patients underwent the conventional laparoscopic DP (Lap group) and the other 37 patients underwent robotic DP (Robot group). The perioperative clinicopathologic variables were compared.

Results

The robotic procedure was chosen by younger patients compared to conventional laparoscopic surgery (42.9±14.0 vs. 51.3±14.6 years, P=0.016). The mean operation time was longer (313 vs. 246 min, P=0.000), but the mean tumor size was smaller in Robot group (2.7±1.2 vs. 4.2±3.3 cm, P=0.018). The overall spleen-preserving rate was higher in the Robot group (91.9% vs. 68.3%, P=0.012). However, with accumulating laparoscopic experiences (after 16th case), the statistical differences in spleen preservation rate between the Robot and Lap groups had diminished (P=0.428).

Conclusions

The present results suggest a robot can be helpful to save the spleen during DP for benign and borderline malignancy. However, a surgeon highly experienced in the laparoscopic approach can also produce a high success rate of spleen preservation, similar to that shown with the robotic approach.

A retrospective comparison of robotic versus laparoscopic distal resection and enucleation for potentially benign pancreatic neoplasms

PURPOSE

The present study aimed to compare robotic-assisted versus laparoscopic distal pancreatic resection and enucleation for potentially benign pancreatic neoplasms.

METHODS

Patients were retrieved from a prospectively maintained database. Demographic data, tumor types, and the perioperative outcomes were retrospectively analyzed.

RESULTS

In a 10-year period, 75 patients (female, n = 44; male, n = 31; median age, 53 years [range, 9-84 years]) were identified. The majority of patients had pancreatic neuroendocrine neoplasms (n = 39, 52%) and cystic neoplasms (n = 23, 31%) with a median tumor size of 17 (3-60) mm. Nineteen (25.3%) patients underwent enucleation (robotic, n = 11; laparoscopic, n = 8) and 56 (74.7%) patients underwent distal pancreatic resection (robotic, n = 24; laparoscopic, n = 32), of those 48 (85%) underwent spleen-preserving procedures. Eight (10.7%) procedures had to be converted to open surgery. The rate of vessel preservation in distal pancreatectomy was significantly higher in robotic-assisted procedures (62.5% vs. 12.5%, p = 0.01). Twenty-six (34.6%) patients experienced postoperative complications (Clavien-Dindo grade > 3). Twenty (26.7%) patients developed a pancreatic fistula type B. There was no mortality. After a median follow-up period of 58 months (range 2-120 months), one patient (1.3%) developed local recurrence (glucagonoma) after enucleation, which was treated with a Whipple procedure.

CONCLUSION

The robotic approach is comparably safe, but increases the rate of splenic vessel preservation and reduces the risk of conversion to open surgery.

Meta-analysis of short-term outcomes comparing robot-assisted and laparoscopic distal pancreatectomy

Aim: To evaluate and compare the short-term outcomes of robotic surgery and laparoscopic approach in distal pancreatectomy (DP). Materials & methods: EMBASE, PubMed, the Cochrane Library, CNKI and Wan Fang database were retrieved from the inception of electronic databases to June 2019. All analyses were performed using Stata/SE 15.1 version (StataCorp). Results: Twenty-two papers were included, four of which were prospective studies and the rest were retrospective studies. There was significant difference in spleen preservation rate (odds ratio: 2.020; 95% CI: 1.085-3.758; p = 0.027), operation time (mean difference [MD]: 27.372; 95% CI: 8.236-47.210; p = 0.000), the length of hospital stay (MD: -0.911; 95% CI: -1.287 to -0.535; p = 0.000), conversion rate (rate difference: -0.090; 95% CI: -1.287 to -0.535; p = 0.000), operation cost (MD: 2816.564; 95% CI: 1782.028-3851.064; p = 0.000). However, no significant difference was detected in estimated blood loss, total complication, severe complication, lymph nodules harvest, blood transfusion rate, total pancreatic fistula, severe pancreatic fistula, R0 resection rate and mortality. Conclusion: Both robotic and laparoscopic DP are safe and feasible. Although robotic DP increases the operation cost, the spleen-preserving rate is much higher. Robotic surgery may be an alternative approach to DP.

Removal of pediatric stage IV neuroblastoma by robot-assisted laparoscopy: A case report and literature review

BACKGROUND

Neuroblastoma (NB) is the most common extracranial solid tumor in children, with an incidence of approximately 1/10000. Surgical resection is an effective treatment for children with NB. Robot-assisted laparoscopic surgery is a new method and is superior to conventional laparoscopic surgery, since it has been preliminarily applied in clinical practice with a significant curative effect. This paper discusses significance and feasibility of complete resection of stage IV NB using robot-assisted laparoscopic surgery, while comparing its safety and effectiveness with conventional laparoscopic surgery.

CASE SUMMARY

In June 2018, a girl with stage IV retroperitoneal NB, aged 3 years and 5 mo, was admitted. Her weight was 15 kg, and her height was 100 cm. Robot-assisted, five-port laparoscopic resection of NB was performed. Starting from the middle point between the navel and the anterior superior iliac spine to the left lower abdomen, the pneumoperitoneum and observation hole (10 mm) were established using the Hasson technique. Operation arm #1 was located between the left anterior axillary line, the navel, and the costal margin (8 mm); operation arm #2 was located at the intersection of the right anterior axillary line and Pfannenstiel line (8 mm); one auxiliary hole was located between arm #2 (on the Pfannenstiel line) and the observation hole (12 mm); and another auxiliary hole (5 mm) was located slightly below the left side of the xiphoid. Along the right line of Toldt and the hepatic flexure of the transverse colon, the colon was turned to the left and below with a hook electrode. Through Kocher's incision, the duodenum and the pancreatic head were turned to the left to expose the inferior vena cava and the abdominal aorta. The vein was separated along the right external iliac, and the inferior vena cava was then lifted to expose the right renal vein from the bottom to the top. The tumor was transected horizontally below the renal vein, and it was first cut into pieces and then resected. The right renal artery and the left renal vein were also exposed, and the retrohepatic inferior vena cava was isolated. The tumor was resected along the surface of the psoas muscle, the back of the inferior vena cava, and the right side of the abdominal aorta. Finally, the lymph node metas-tases in front of the abdominal aorta and left renal vein were completely removed. The specimens were loaded into a disposable specimen retrieval bag and removed from the enlarged auxiliary hole. T-tube drainage was placed and brought out through a hole in the right lower quadrant of the abdomen. The operative time was 389 min, the time of pneumoperitoneum was 360 min, the intraoperative blood loss was approximately 200 mL, and the postoperative recovery was smooth. There were no complications, such as lymphatic fistula, diarrhea, bleeding, and paralytic ileus. Two months after discharge, there were no other complications. The literature on the application of robot-assisted laparoscopic surgery in the treatment of NB in children was reviewed

CONCLUSION

The robot has the advantages of a three-dimensional view and flexible operation, and it can operate finely along blood vessels. The successful experience of this case confirmed that robot-assisted laparoscopic surgery can skeletonize the abdominal blood vessels in the tumor and cut the tumor into pieces, indicating that robot-assisted laparoscopic surgery is feasible.