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

Implementation of a robotic hepato-pancreato-biliary surgery program: a swedish referral center's experience

Robotic-assisted surgery has been recognized for enhancing the feasibility of minimally invasive procedures, particularly in high-complexity fields like hepato-pancreato-biliary (HPB) surgery. This study aims to describe the implementation and development of a robotic HPB surgery program at a Swedish referral center, during a structured transition from mostly open surgery, as well as evaluating perioperative outcomes. A retrospective observational study at Karolinska University Hospital (September 2020-July 2024) included patients undergoing robotic HPB resections. Data on demographics, procedure types, intraoperative metrics, and outcomes were collected. Program implementation followed a stepwise approach. A total of 495 robotic resections were performed by three generations of surgeons, including 235 liver, 208 pancreatic, and 52 biliary resections. The overall conversion rate to open surgery was 7.7%. Major complications were observed in 10.9% of cases, with a mortality rate of 0.8%. Exposure and training improved outcomes over time, indicating the value of a structured implementation approach and a stepwise introduction of new surgeons into the robotic program. The transition to robotic HPB surgery requires a well-organized approach that includes thorough training and close collaboration within a multidisciplinary team. The program focused on helping junior surgeons develop their skills, starting with simpler procedures to reduce risks and ensure patient safety. After 8 semesters, minimally invasive HPB surgeries have increased from 15 to 41%. Results show that the program is safe and effective, highlighting the importance of institutional support, teamwork, and strategic planning in building a successful and lasting robotic surgery program.

Robotic Versus Open Distal Pancreatectomy: A Propensity Score Matching Analysis

BACKGROUND

Minimally invasive distal pancreatectomy offers recognised benefits over open surgery. Robotic surgery, with its shorter learning curve and technical advancements, presents a promising alternative to laparoscopy in managing pancreatic diseases.

METHODS

This study enrolled consecutive patients undergoing distal pancreatectomy between January 2013 and May 2022. After propensity score matching, perioperative and medium-term outcomes were compared between robotic and open procedures.

RESULTS

Among 79 patients analysed, 50 were eligible after matching. Both groups showed similar demographics, with 11% experiencing grade III-IV complications, and one patient died within 90 days after surgery. Robotic surgery exhibited longer operating times but allowed for earlier refeeding, drain removal, canalisation, and shorter hospital stays compared with open surgery. Spleen preservation rates, postoperative pancreatic fistula occurrences and survival were comparable between the groups.

CONCLUSIONS

Overall, robotic and open distal pancreatectomy demonstrated similar outcomes, with robotic surgery offering advantages in certain postoperative parameters despite longer operation times.

Clinical effectiveness of robotic versus laparoscopic and open surgery: an overview of systematic reviews

OBJECTIVE

To undertake a review of systematic reviews on the clinical outcomes of robotic-assisted surgery across a mix of intracavity procedures, using evidence mapping to inform the decision makers on the best utilisation of robotic-assisted surgery.

ELIGIBILITY CRITERIA

We included systematic reviews with randomised controlled trials and non-randomised controlled trials describing any clinical outcomes.

DATA SOURCES

Ovid Medline, Embase and Cochrane Library from 2017 to 2023.

DATA EXTRACTION AND SYNTHESIS

We first presented the number of systematic reviews distributed in different specialties. We then mapped the body of evidence across selected procedures and synthesised major findings of clinical outcomes. We used a measurement tool to assess systematic reviews to evaluate the quality of systematic reviews. The overlap of primary studies was managed by the corrected covered area method.

RESULTS

Our search identified 165 systematic reviews published addressing clinical evidence of robotic-assisted surgery. We found that for all outcomes except operative time, the evidence was largely positive or neutral for robotic-assisted surgery versus both open and laparoscopic alternatives. Evidence was more positive versus open. The evidence for the operative time was mostly negative. We found that most systematic reviews were of low quality due to a failure to deal with the inherent bias in observational evidence.

CONCLUSION

Robotic surgery has a strong clinical effectiveness evidence base to support the expanded use of robotic-assisted surgery in six common intracavity procedures, which may provide an opportunity to increase the proportion of minimally invasive surgeries. Given the high incremental cost of robotic-assisted surgery and longer operative time, future economic studies are required to determine the optimal use of robotic-assisted surgery capacity.

Efficacy of pancreaticojejunostomy of the pancreatic stump during distal or central pancreatectomy

BACKGROUND

A stapler is usually used for transection and closure of the pancreas in distal pancreatectomy (DP) or central pancreatectomy (CP). When the pancreas is transected to the right of the portal vein, it is difficult to use a stapler and clinically relevant postoperative pancreatic fistula (CR-POPF) frequently occurs. We report on the efficacy of pancreaticojejunostomy (PJ) of the pancreatic stump for patients in whom stapler use is difficult.

METHODS

Patients who underwent DP or CP were enrolled in this study. The pancreas was usually transected by a stapler, and ultrasonic coagulating shears (UCS) were used depending on the tumor situation. When using UCS, hand-sewn closure or PJ was performed for the pancreatic stump. The relationship between clinicopathological factors and the methods of pancreatic transection and closure were investigated.

RESULTS

In total, 164 patients underwent DP or CP, and the pancreas was transected with a stapler in 150 patients and UCS in 14 patients. The rate of CR-POPF was higher and the postoperative hospital stay was longer in the UCS group than in the stapler group. PJ of the pancreatic stump, which was performed for 7 patients, did not worsen intraoperative factors. CR-POPF was not seen in these 7 patients, which was significantly less than that with hand-sewn closure.

CONCLUSIONS

PJ of the pancreatic stump during DP or CP reduces CR-POPF compared with hand-sewn closure and may be useful especially when the pancreas is transected to the right of the portal vein.

Short- and long-term outcomes of robotic versus open radical antegrade modular pancreatosplenectomy: a retrospective propensity score-matched cohort study

BACKGROUND

Robotic distal pancreatectomy has increasingly been accepted as it has overcome some of the limitations of open distal pancreatectomy, whilst the outcomes following robotic radical antegrade modular pancreatosplenectomy (RAMPS) in patients with pancreatic ductal adenocarcinoma (PDAC) are still uncertain. This study aimed to evaluate the short and long-term outcomes of robotic RAMPS and open RAMPS for PDAC.

METHODS

The patients who underwent robotic RAMPS and open RAMPS for PDAC at our clinical centre between January 2017 and December 2021 were reviewed. After a propensity score matching (PSM) at a 1:1 ratio, the perioperative and pathological outcomes in the both groups were reviewed. Univariable and multivariable Cox regression analyses were used to identify independent prognosis factors for overall survival (OS) and recurrence-free survival (RFS) of these patients.

RESULTS

318 cases were recorded in robotic and open groups. The robotic group showed advantages in operative time [205.00 (166.00, 240.00) min vs 235 (184.75, 270.00) min, P = 0.002], estimated blood loss [100 (50, 100) ml vs 300 (100, 400) ml, P < 0.001], delayed gastric emptying [0 vs 5.03%, P = 0.007] and postoperative hospital stay [7.00 (5.00, 10.00) days vs 11.00 (8.00, 14.00) days, P < 0.001]. There were no significant differences in rate of severe postoperative complications between the robotic group and the open group. Multivariable analysis showed that carbohydrate antigen 19-9, estimated blood loss, N stage, tumour differentiation, chemotherapy and vascular invasion were independent risk factors for OS and RFS of these patients.

CONCLUSIONS

Robotic RAMPS was safe and had some advantages over open RAMPS for PDAC. There were no significantly differences in oncological outcomes and long-term survival rates between the robotic and open groups. Robotic RAMPS expanded the indications for minimally invasive surgeries for PDAC to a certain extent.

Short-Term Outcomes of Conventional Laparoscopic versus Robot-Assisted Distal Pancreatectomy for Malignancy: Evidence from US National Inpatient Sample, 2005-2018

BACKGROUND

The primary treatment for pancreatic cancer is surgical resection, and laparoscopic resection offers benefits over open surgery. This study aimed to compare the short-term outcomes of robot-assisted vs. conventional laparoscopic distal pancreatectomy.

METHODS

Data of adults ≥ 20 years old with pancreatic cancer who underwent conventional laparoscopic or robot-assisted laparoscopic distal pancreatectomy were extracted from the United States (US) Nationwide Inpatient Sample (NIS) 2005-2018 database. Comorbidities and complications were identified through the International Classification of Diseases (ICD) codes. Short-term outcomes were compared using logistic regression and included length of hospital stay (LOS), perioperative complications, in-hospital mortality, unfavorable discharge, and total hospital costs.

RESULTS

A total of 886 patients were included; 27% received robot-assisted, and 73% received conventional laparoscopic surgery. The mean age of all patients was 65.3 years, and 52% were females. Multivariable analysis revealed that robot-assisted surgery was associated with a significantly reduced risk of perioperative complications (adjusted odds ratio (aOR) = 0.61, 95% confidence interval (CI): 0.45-0.83) compared to conventional laparoscopic surgery. Specifically, robot-assisted surgery was associated with a significantly decreased risk of VTE (aOR = 0.35, 95% CI: 0.14-0.83) and postoperative blood transfusion (aOR = 0.37, 95% CI: 0.23-0.61). Robot-assisted surgery was associated with a significantly shorter LOS (0.76 days shorter, 95% CI: -1.43--0.09) but greater total hospital costs (18,284 USD greater, 95% CI: 4369.03-32,200.70) than conventional laparoscopic surgery.

CONCLUSIONS

Despite the higher costs, robot-assisted distal pancreatectomy is associated with decreased risk of complications and shorter hospital stays than conventional laparoscopic distal pancreatectomy.

International consensus guidelines on robotic pancreatic surgery in 2023

Background

With the rapid development of robotic surgery, especially for the abdominal surgery, robotic pancreatic surgery (RPS) has been applied increasingly around the world. However, evidence-based guidelines regarding its application, safety, and efficacy are still lacking. To harvest robust evidence and comprehensive clinical practice, this study aims to develop international guidelines on the use of RPS.

Methods

World Health Organization (WHO) Handbook for Guideline Development, GRADE Grid method, Delphi vote, and the AGREE-II instrument were used to establish the Guideline Steering Group, Guideline Development Group, and Guideline Secretary Group, formulate 19 clinical questions, develop the recommendations, and draft the guidelines. Three online meetings were held on 04/12/2020, 30/11/2021, and 25/01/2022 to vote on the recommendations and get advice and suggestions from all involved experts. All the experts focusing on minimally invasive surgery from America, Europe and Oceania made great contributions to this consensus guideline.

Results

After a systematic literature review 176 studies were included, 19 questions were addressed and 14 recommendations were developed through the expert assessment and comprehensive judgment of the quality and credibility of the evidence.

Conclusions

The international RPS guidelines can guide current practice for surgeons, patients, medical societies, hospital administrators, and related social communities. Further randomized trials are required to determine the added value of RPS as compared to open and laparoscopic surgery.

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.

Transition from open to robotic distal pancreatectomy in a low volume pancreatic surgery country: a single Australian centre experience

BACKGROUND

Advances in technology and techniques have allowed for robotic distal pancreatectomies to be readily performed in patients at high volume centres. This study describes the experience of a single surgeon during the learning curve and transition from open to robotic distal pancreatectomy in Australia, a traditionally low volume pancreatic surgery country.

METHODS

All patients undergoing distal pancreatectomy at an Australian-based tertiary referral centre between 2010 and 2021 were reviewed retrospectively. Demographic, clinicopathologic and survival data were analysed to compare perioperative and oncological outcomes between patients who underwent open, laparoscopic and robotic distal pancreatectomies.

RESULTS

A total of 178 distal pancreatectomies were identified for analysis during the study period. Ninety-one open distal pancreatectomies (ODP), 48 laparoscopic distal pancreatectomies (LDP), and 39 robotic distal pancreatectomies (RDP) were performed. Robotic distal pancreatectomy was non-inferior with respect to perioperative outcomes and yielded statistically non-significant advantages over LDP and ODP.

CONCLUSION

RDP is feasible and can be performed safely in well-selected patients during the learning phase at large pancreatic centres in a traditionally low-volume country like Australia. Referral to large pancreatic centres where access to the robotic platform and surgeon experience is not a barrier, and where a robust multidisciplinary team meeting can take place, remains pivotal in the introduction and transition toward the robotic approach for management of patients with pancreatic body or tail lesions.

Impact of the transection plan on postoperative pancreatic fistulas occurring after robot-assisted distal pancreatectomy for nonmalignant pancreatic neoplasms

OBJECTIVES

Postoperative pancreatic fistula (POPF) is the main complication of distal pancreatectomy (DP) and affects the prognosis of patients. The impact of several clinical factors mentioned in recent studies on POPF remains controversial. This study aimed to investigate the impact of a remnant pancreas and other perioperative factors on POPFs occurring after robot-assisted distal pancreatectomy (RDP) for nonmalignant pancreatic neoplasms.

METHODS

A total of 197 patients who received robot-assisted distal pancreatectomy (RDP) for nonmalignant pancreatic neoplasms at the Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine from January 2018 to December 2020 were included in this retrospective study. According to the intraoperative transection plan, patients were divided into an RDP body group and an RDP tail group. Clinical and pathological features and perioperative factors affecting POPF were analyzed and compared between the two groups.

RESULTS

The results showed that a transection plan involving the tail of the pancreas (OR = 2.133, 95% CI 1.109-4.103, p = 0.023) and spleen preservation (OR = 2.588, 95% CI 1.435-4.665, p = 0.001) independently increased the incidence of POPF in patients with nonmalignant pancreatic neoplasms treated by RDP. A transection plan involving the tail of the pancreas was also an independent risk factor (OR = 3.464, 95% CI 1.270-9.450, p = 0.015) for grade B/C POPF. Length of remnant pancreas > 6.23 cm was an independent risk factor for POPF (OR = 3.116, 95% CI 1.364-7.121, p = 0.007). Length of remnant pancreas > 9.82 cm was an independent risk factor for grade B/C POPF (OR = 3.340, 95% CI 1.386-8.051, p = 0.007).

CONCLUSION

This retrospective study suggests that a transection plan involving the tail of the pancreas is an independent risk factor for POPF in patients with nonmalignant neoplasms treated by RDP. We also propose that the postoperative length of the remnant pancreas evaluated by computed tomography scans can be used to identify patients with a high risk of POPF in order to optimize the individualized strategy.

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.

Review of minimally invasive pancreas surgery and opinion on its incorporation into low volume and resource poor centres

Pancreatic surgery has been one of the last areas for the application of minimally invasive surgery (MIS) because there are many factors that make laparoscopic pancreas resections difficult. The concept of service centralization has also limited expertise to a small cadre of high-volume centres in resource rich countries. However, this is not the environment that many surgeons in developing countries work in. These patients often do not have the opportunity to travel to high volume centres for care. Therefore, we sought to review the existing data on MIS for the pancreas and to discuss. In this paper, we review the evolution of MIS on the pancreas and discuss the incorporation of this service into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating all studies published on laparoscopic and robotic surgery of the pancreas. The data in the Caribbean is examined and we discuss tips for incorporating this operation into resource poor hospital practice. Low pancreatic case volume in the Caribbean, and financial barriers to MIS in general, laparoscopic distal pancreatectomy, enucleation and cystogastrostomy are feasible operations to integrate in to a resource-limited healthcare environment. This is because they can be performed with minimal to no consumables and require an intermediate MIS skillset to complement an open pancreatic surgeon’s peri-operative experience.

The current status and future directions of robotic pancreatectomy

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

Perioperative and oncologic outcomes of open, laparoscopic, and robotic distal pancreatectomy for pancreatic adenocarcinoma

The utilization of minimally invasive distal pancreatectomy (MIDP) is increasing, yet debate remains regarding its oncologic safety in the setting of pancreatic adenocarcinoma (PDAC). Herein we present our institutional experience with robotic (RDP), laparoscopic (LDP), and open distal pancreatectomy (ODP) in the setting of PDAC.Retrospective review of a prospectively collected single institutional database of patients undergoing consecutive ODP, LDP, and RDP for left-sided PDAC between January 2008 and December 2019 at the University of Pittsburgh Medical Center (UPMC) was done. Perioperative and postoperative outcomes were compared using non-parametric testing and Fischer exact or chi-squared testing. Kaplan-Meier survival curves for disease-free survival and overall survival were compared by Log-Rank sum test. Backward Cox-proportional hazard regression analysis was used to determine if the operative approach was an independent predictor of recurrence and overall survival.Over 12 years, 146 consecutive distal pancreatectomies for PDAC were performed, of which 28.1% ODP, 60.3% RDP, and 11.6% LDP. There were no statistical differences in patients' baseline characteristics, including gender, comorbidities, prior abdominal surgeries, and AJCC^8th stage (p > 0.05). Postoperatively, there was no difference in the frequency of major complications (p = 0.414), CR-POPF (p = 0.563), or DGE (p = 0.179). The median overall survival was 28.4 months for ODP, 34.6 months for RDP, and 32.5 months for LDP (Log Rank p = 0.914). On multivariate Cox proportional hazard analysis, the surgical approach was not associated with overall survival. This comparative analysis suggests a non-inferiority of RDP platforms, compared to LDP and classic ODP. The merits of MIS pancreatic surgery in the setting of PDAC should be evaluated in future prospective studies with care to analyze RDP outcomes separately from LDP.