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Robotic total pancreatectomy with splenectomy: technique and outcomes

Authors:
Ioannis T Konstantinidis at Texas Tech University Health Sciences Center El Paso
Ioannis T Konstantinidis
  • Texas Tech University Health Sciences Center El Paso
Zeljka Jutric
Zeljka Jutric
Zeljka Jutric
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Oliver S. Eng
Oliver S. Eng
Oliver S. Eng
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Susanne Warner at City of Hope National Medical Center
Susanne Warner
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Abstract

Background: Robotic total pancreatectomy (TP) represents a minimally invasive approach to a major intra-abdominal operation. Its utility, technique, and outcomes are evolving. Methods: In this video, we describe a systematic approach to a robotic total pancreatectomy performed for multifocal intraductal papillary mucinous neoplasm (IPMN). Additionally, we reviewed the National Cancer Database (NCDB) to examine the outcomes of robotic TP compared to laparoscopic and open TP between 2010 and 2014. Results: The patient is a 61-year-old female who was diagnosed with multifocal IPMN. A total of 6 robotic ports were placed and the da Vinci Xi robotic system was used with the patient supine. The approach entailed as follows: (1) Diagnostic laparoscopy; (2) Entry into the lesser sac; (3) Division of the short gastric vessels; (4) Exposure and dissection of the inferior pancreas border; (5) Dissection and transection of the splenic artery; (6) Mobilization of the pancreas tail/spleen; (7) Exposure of the splenic vein-superior mesenteric vein confluence; (8) Kocher maneuver; (9) Release of the ligament of Treitz and transection of the proximal jejunum; (10) Transection of the distal stomach; (11) Portal lymphadenectomy; (12) Dissection and transection of the gastroduodenal artery; (13) Superior mesenteric vein exposure/dissection of the uncinate process; (14) Hepaticojejunostomy; (15) Cholecystectomy; and (16) Gastrojejunostomy. NCDB database review of 73 patients who underwent robotic TP revealed similar rates of margin negative resections and retrieved lymph nodes between robotic, laparoscopic, and open TP, whereas robotic and laparoscopic TP were associated with shorter in-hospital stay and reduced mortality at 30 and 90 days compared to open TP. Overall median survival of pancreatic adenocarcinoma patients who underwent TP was similar between robotic, laparoscopic, and open approaches. Conclusion: Robotic total pancreatectomy with splenectomy offers a minimally invasive approach to a major abdominal operation and is feasible in a stepwise, reproducible technique. It is associated with improved postoperative outcomes and equivalent oncologic outcomes compared to open TP.
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Surgical Endoscopy (2018) 32:3691–3696
https://doi.org/10.1007/s00464-017-6003-1
VIDEO
Robotic total pancreatectomy withsplenectomy: technique
andoutcomes
IoannisT.Konstantinidis1· ZeljkaJutric1· OliverS.Eng1· SusanneG.Warner1· LalehG.Melstrom1· YumanFong1·
ByrneLee1· GagandeepSingh1
Received: 1 May 2017 / Accepted: 2 December 2017 / Published online: 22 December 2017
© Springer Science+Business Media, LLC, part of Springer Nature 2017
Abstract
Background Robotic total pancreatectomy (TP) represents a minimally invasive approach to a major intra-abdominal opera-
tion. Its utility, technique, and outcomes are evolving.
Methods In this video, we describe a systematic approach to a robotic total pancreatectomy performed for multifocal intra-
ductal papillary mucinous neoplasm (IPMN). Additionally, we reviewed the National Cancer Database (NCDB) to examine
the outcomes of robotic TP compared to laparoscopic and open TP between 2010 and 2014.
Results The patient is a 61-year-old female who was diagnosed with multifocal IPMN. A total of 6 robotic ports were
placed and the da Vinci Xi robotic system was used with the patient supine. The approach entailed as follows: (1) Diagnos-
tic laparoscopy; (2) Entry into the lesser sac; (3) Division of the short gastric vessels; (4) Exposure and dissection of the
inferior pancreas border; (5) Dissection and transection of the splenic artery; (6) Mobilization of the pancreas tail/spleen;
(7) Exposure of the splenic vein-superior mesenteric vein confluence; (8) Kocher maneuver; (9) Release of the ligament of
Treitz and transection of the proximal jejunum; (10) Transection of the distal stomach; (11) Portal lymphadenectomy; (12)
Dissection and transection of the gastroduodenal artery; (13) Superior mesenteric vein exposure/dissection of the uncinate
process; (14) Hepaticojejunostomy; (15) Cholecystectomy; and (16) Gastrojejunostomy. NCDB database review of 73
patients who underwent robotic TP revealed similar rates of margin negative resections and retrieved lymph nodes between
robotic, laparoscopic, and open TP, whereas robotic and laparoscopic TP were associated with shorter in-hospital stay and
reduced mortality at 30 and 90days compared to open TP. Overall median survival of pancreatic adenocarcinoma patients
who underwent TP was similar between robotic, laparoscopic, and open approaches.
Conclusion Robotic total pancreatectomy with splenectomy offers a minimally invasive approach to a major abdominal
operation and is feasible in a stepwise, reproducible technique. It is associated with improved postoperative outcomes and
equivalent oncologic outcomes compared to open TP.
Keywords Robotic total pancreatectomy· National cancer database· Postoperative outcomes
Total pancreatectomy (TP) is indicated for the treat-
ment of pancreatic cancer when most of the pancreas is
involved, for multifocal pathologies involving the entire
gland, such as intraductal papillary mucinous neoplasm
(IPMN), or uncommonly in refractory chronic pancrea-
titis. Its benefits have to be weighed carefully against its
significant morbidity, which is the highest among pan-
createctomies [1–4].
Robotic-assisted pancreatic surgery is increasingly
being utilized. Most reports come from a few experi-
enced centers [5–7]. The operative technique is evolv-
ing and the short- and long-term outcomes are unknown.
Herein, we describe our technique with a robotic-assisted
total pancreatectomy for multifocal branch duct IPMN
involving the entire pancreas. Additionally, we reviewed
the National Cancer Database (NCDB) to examine the
nationwide utilization and outcomes of robotic total
and Other Interventional Te
chniques
Electronic supplementary material The online version of this
article (https://doi.org/10.1007/s00464-017-6003-1) contains
supplementary material, which is available to authorized users.
* Gagandeep Singh
gsingh@coh.org
1 Department ofSurgery, City ofHope National Medical
Center, Medical Office Bldg., 1500 East Duarte Road,
Duarte, CA91010, USA
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... Post-operatively, many studies report equivalent to significantly reduced length of stay after robotic TP [58,62,63]. Most studies have noted no differences in morbidity, biliary leak rates, and post-operative mortality with robotic TP compared to open surgery [58,60,62]. ...
... TP is indicated in malignancies where the extent or recurrence of disease necessitates the removal of the entire pancreas. Multiple studies, including a national cancer database analysis, showed no differences in lymph node yield and margin negativity rate between robotic, laparoscopic, and open platforms [62,63]. Recent studies have shed light on the potential advantages of robotic TP, suggesting delayed disease recurrence and enhanced overall survival rates in patients when compared to those who undergo the traditional open surgical approach. ...
... Recent studies have shed light on the potential advantages of robotic TP, suggesting delayed disease recurrence and enhanced overall survival rates in patients when compared to those who undergo the traditional open surgical approach. However, a national cancer database analysis failed to corroborate these results [60,63,64]. At a minimum, the outcomes of TP using the robotic approach have been equivalent in quality to those achieved with the open surgical method. ...
Robotic Surgeries in Benign and Malignant Pancreatic Disease
Article
Full-text available
  • Apr 2024
Purpose of review Pancreatic resection stands as one of the most challenging abdominal surgeries, primarily indicated for pancreatic malignancies such as pancreatic ductal adenocarcinoma (PDAC), pre-malignant conditions like intraductal papillary mucinous neoplasm (IPMN), and benign pathologies that manifest with significant symptoms, including intractable pain, often concomitant with endocrine or exocrine dysfunction. The inherent complexity and morbidity associated with pancreatic resection, exacerbated by the high risk of pancreatic anastomosis complications, including pancreatic leaks of amylase-rich fluid, is further amplified by the pancreas’s retroperitoneal location near vital anatomical structures. This underscores the imperative need for a thorough assessment of emerging surgical approaches, with particular attention to the application of robotic technology. This review appraises the impact of robotic-assisted surgery on the operative and oncological outcomes of patients afflicted with benign and malignant, pancreatic and peri-pancreatic, diseases. Recent findings Robotic surgery has exhibited a correlation with enhanced post-operative outcomes such as reduced morbidity and mortality following pancreatic resections. Furthermore, it has demonstrated a positive association with improved oncological resection and outcomes in patients diagnosed with pancreatic and peri-pancreatic cancer. Summary Minimally invasive surgery has substantially refined the landscape of pancreatic resections, offering diminished post-operative pain and reduced hospital stay. Robotic surgery, distinguished by its superior visualization and meticulous tissue handling capabilities, enables precise dissection and seamless anastomosis in the complex realm of pancreatic surgery. Consequently, this has translated into ameliorated morbidity and mortality in this patient cohort, emphasizing the critical role of surgeon proficiency and case volume. Minimally invasive resection in the context of malignancy has demonstrated favorable oncological outcomes. This is potentially attributed to improved oncological resection (increased negative margins and lymph node yield) expedited post-operative recovery, facilitating prompt initiation of adjuvant therapy and attenuating surgical stress-induced tumorigenesis. Nonetheless, future randomized controlled trials are indispensable to comprehensively elucidate the impact of robotic resection on the host immune response and long-term outcomes following pancreatic resections, encompassing both benign and malignant etiologies. Such investigations hold the promise of advancing our understanding and optimizing the role of robotic surgery in the context of pancreatic diseases.
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... MITP included robot-assisted TP, laparoscopicassisted TP and Laparoscopic TP. • Open total pancreatectomy is defined as open TP. pancreatectomy (MITP) and open total pancreatectomy (OTP) in terms of short and long-term outcomes and QOL [11][12][13][14][15][16][17][18][19][20] . Nevertheless, there are a few small retrospective studies with relevant data [13,21,22] . ...
... Another four studies were also excluded because of no recruitment of patients [17,38] , duplicate data presentation [39] , and data reported for children [14] . Finally, seven studies [12,13,16,[18][19][20]40 ] with 4275 patients were analyzed. Detailed information on the screening process was illustrated in the PRISMA flow diagram (Fig. 1). ...
... No randomized controlled studies were found. Four studies were retrospective [16,18,19,40] . Three studies were prospective observational studies [12,13,20] . ...
Minimally invasive versus open total pancreatectomy: a systematic review and meta-analysis
Article
Full-text available
  • Jul 2023
  • Int J Surg
Objective: The aim of this study was to perform a systematic review and meta-analysis on the safety and effectiveness regarding outcomes of minimally invasive total pancreatectomy (MITP) versus open total pancreatectomy (OTP). Background: Total pancreatectomy is a complicated operation in abdominal surgery. The flexibility of minimally invasive surgery offers a new surgical approach to this technology. At present, there is little research on MITP, and its advantages over OTP remain uncertain. Methods: A systematic literature review and meta-analysis was conducted basing on comparative studies between MITP and OTP from January 1943 to November 2022. Intraoperative outcomes and postoperative outcomes were assessed. Pooled odds ratios (ORs) and mean differences with a 95% CI were calculated using fixed-effect or random-effect models under heterogeneity. Results: Seven studies with a total of 4275 patients were included. The major morbidity in the MITP group was significant lower (OR 0.50, 95% CI: 0.30-0.84, P=0.008, I²= 0%) than OTP group. At the same time, comparing with OTP, the MITP group had lower estimated blood loss (MD -362.50, 95% CI -641.34 to -83.66, P=0.01, I²=96%) and lower intraoperative transfusion rate (OR 0.36, 95% CI 0.16-0.84, P=0.02, I²=0%). There were no significant differences between the MITP and OTP groups for other outcomes. Conclusions: The results suggested that MITP was associated with lower major morbidity, estimated blood loss, and intraoperative transfusion rate comparing with OTP. However, the further evidence with a better design is required.
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... Overall, a literature search identified 108 articles, as depicted in Figure 1. Finally, eight case series regarding RTP were included (5)(6)(7)(8)(9)(10)(11)(12). The characteristics of the included articles are summarized in Table I. ...
Robotic Total Pancreatectomy: A Narrative Review
Article
  • Jul 2021
Background/aim: Studies on robotic total pancreatectomy (RTP) have been limited regardless of the increasing evidence on robotic pancreatoduodenectomy. The aim of this study was to review the current status of RTP in terms of surgical techniques and outcomes. Materials and methods: A literature search using PubMed was conducted to investigate surgical techniques and outcomes of RTP. Results: A total of eight case series with 56 patients were included. The indications for RTP consisted of benign or pre-malignant tumors in 43 patients and malignant tumors in 13 patients. Surgical techniques included the "dividing technique" and "en-bloc technique". Regarding surgical outcomes, the rate of conversion to open total pancreatectomy was 3.6% and the incidence of major complications was 10.7%. Conclusion: Although evidence for RTP is still lacking, RTP is feasible for selected patients when performed in specialized centers. Further studies are essential to investigate the effectiveness of RTP compared to open total pancreatectomy.
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... There has recently been increasing evidence regarding robotic pancreatic surgery. 1 However, several literatures have been reported regarding the robotic total pancreatectomy (RTP). 2,3 Conventional technique consisted of starting with distal panc r e a t e c t o m y ( D P ) p a r t f i r s t , f o l l o w e d w i t h pancreatoduodenectomy (PD) part and reconstructions. Others have recommended transecting the neck of the pancreas and performing a separate DP and PD. ...
Robotic Total Pancreatectomy: A Novel Pancreatic Head-First Approach (with Video)
Article
  • Feb 2021
Background The development of the Da Vinci robotic platform has drastically altered the paradigm of minimal invasive pancreatic surgery. However, the evidence of robotic total pancreatectomy (RTP) is still limited. Here we report an alternative approach of RTP, starting with pancreatoduodenectomy (the pancreatic head-first approach).Methods The patient was a 55-year-old female with a diagnosis of diffuse PNET in the head, body, and tail of the pancreas. The da Vinci Xi robotic system was used for RTP. Our technique of RTP consists of three steps: (1) pancreatoduodenectomy, (2) (en bloc) distal pancreatectomy, and (3) reconstructions.ResultsThe operative time was 490 min with an estimated blood loss of 100 ml. The postoperative course was uneventful, and the patient was discharged on postoperative day 10.ConclusionsRTP is a technically challenging procedure; however, the pancreatic head-first approach of RTP has several advantages.
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... Robotic total pancreatectomy remains an uncommon procedure. The National Cancer Database captured 3876 cases performed between 2010 and 2014 [25]. Only 73 (1.9%) cases were approached robotically. ...
Update on Robotic Pancreatic Surgery
Article
Full-text available
  • Jul 2020
Purpose of Review This review serves as an update on the status of robotic pancreatic surgery. It will focus on major changes in the adoption, safety, patient selection, and procedural refinements in robotic pancreatic surgery over the past 5 years. Recent Findings While the findings of this review support the notion that adoption of robotic pancreatic surgery is growing, it is still challenged by the long learning curve. A curriculum has been constructed and disseminated to address this issue. Furthermore, multiple international meetings have been organized to set helpful recommendations and guidelines. Summary Robotic pancreatic surgery is a growing platform that is expected to expand with further advancements in technology and increased adoption of the new generation of Hepato-Pancreato-Biliary Surgeons.
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... For noninvasive IPMN located in the pancreatic body, several investigators have reported better long-term outcomes after central pancreatectomy than after distal pancreatectomy [55][56][57]. Furthermore, recent reports have shown that laparoscopic or robotic pancreatectomy for IPMN is feasible and minimally invasive [58][59][60]. Establishing an appropriate operative procedure for noninvasive IPMN from the viewpoint not only of short-term outcomes, including postoperative complications, but also of long-term outcomes, including preserving function of the remnant pancreas, is critical. ...
Surgical strategy for intraductal papillary mucinous neoplasms of the pancreas
Article
Full-text available
  • Dec 2019
  • SURG TODAY
The current treatment strategy for intraductal papillary mucinous neoplasms (IPMNs), based on the international consensus guideline, has been accepted widely. However, reported outcomes after surgical resection for IPMN show that once the tumor progresses to invasive intraductal papillary mucinous carcinoma (IPMC), recurrence is not uncommon. The surgical treatment for IPMN is invasive and sometimes followed by complications. Therefore, the best timing for resection might be at the point when high-grade dysplasia (HGD) is evident. According to previous reports, main duct type IPMN has a high malignant potential and its surgical resection is universally accepted, whereas, the incidence of HGD/invasive IPMC in branch duct and mixed type IPMNs is thought to be lower. In addition to mural nodules and a dilated main pancreatic duct, cytology and measurement of the carcinoembryonic antigen level in the pancreatic juice might be useful to differentiate HGD/invasive IPMC from low-grade dysplasia. The nomogram proposed recently to predict the risk of HGD/invasive IPMC in IPMN patients might help surgeons decide on the best treatment strategy, depending on the patient's age and general condition. Second resection for high-risk lesions in the remnant pancreas might improve the survival of IPMN patients.
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... Robotic total pancreatectomy has also been reported. In a video case report of a patient with an intrapancreatic medullary neoplasm, Konstantinidis and colleagues present a succinct 16 step procedure for the conduct of a robotic total pancreatectomy [54]. In a review of data from the National Cancer Data Base, they evaluated the results of robotic total pancreatectomy in 73 patients and found similar rates of negative resection margins and number of lymph nodes resected compared with laparoscopic and open total pancreatectomy. ...
Robotic and laparoscopic surgery of the pancreas: an historical review
Article
Full-text available
  • Jan 2019
Abstract Surgery of the pancreas is a relatively new field, with operative series appearing only in the last 50 years. Surgery of the pancreas is technically challenging. The entire field of general surgery changed radically in 1987 with the introduction of the laparoscopic cholecystectomy. Minimally Invasive surgical techniques rapidly became utilized worldwide for gallbladder surgery and were then adapted to other abdominal operations. These techniques are used regularly for surgery of the pancreas including distal pancreatectomy and pancreatoduodenectomy. The progression from open surgery to laparoscopy to robotic surgery has occurred for many operations including adrenalectomy, thyroidectomy, colon resection, prostatectomy, gastrectomy and others. Data to show a benefit to the patient are scarce for robotic surgery, although both laparoscopic and robotic surgery of the pancreas have been shown not to be inferior with regard to major operative and oncologic outcomes. While there were serious concerns when laparoscopy was first used in patients with malignancies, robotic surgery has been used in many benign and malignant conditions with no obvious deterioration of outcomes. Robotic surgery for malignancies of the pancreas is well accepted and expanding to more centers. The importance of centers of excellence, surgeon experience supported by a codified mastery-based training program and international registries is widely accepted. Robotic pancreatic surgery is associated with slightly decreased blood loss and decreased length of stay compared to open surgery. Major oncologic outcomes appear to have been preserved, with some studies showing higher rates of R0 resection and tumor-free margins. Patients with lesions of the pancreas should find a surgeon they trust and do not need to be concerned with the operative approach used for their resection. The step-wise approach that has characterized the growth in robotic surgery of the pancreas, in contradistinction to the frenzy that accompanied the introduction of laparoscopic cholecystectomy, has allowed the identification of areas for improvement, many of which lie at the junction of engineering and medical practice. Refinements in robotic surgery depend on a partnership between engineers and clinicians.
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Minimally invasive surgery versus open surgery for total pancreatectomy: a bibliometric review and meta-analysis
Article
  • Feb 2023
  • HPB
Background: Minimally invasive total pancreatectomy (MITP) is considered safe and feasible with limited evidence on this procedure. The aim of this study was to systematically analyze the current literature on MITP compared to open TP (OTP). Method: Randomized controlled trials and prospective non-randomized comparative studies were sought systematically in MEDLINE, Web of Science and CENTRAL from their inception until December 2021. Outcome measures included operative time, length of hospital stay (LOH), spleen-preservation rate, estimated blood loss (EBL), need for transfusion, venous resection rate, delayed gastric emptying (DGE), biliary leakage, postpancreatectomy hemorrhage (PPH), reoperation rate, overall 30-day morbidity (Clavien-Dindo > IIIa), 90-day mortality, 90-day readmission, examined lymph nodes (ELN). Pooled results are presented as odds ratios (OR) or mean difference (MD) with 95% confidence interval (CI). Results: 7 observational studies with a total of 4212 patients were included. MITP had a decreased EBL and transfusion rate, lower 30-day morbidity and 90-day mortality with a longer LOH compared to OTP. There were no significant differences regarding operative time, spleen preservation rate, DGE, biliary leakage, venous resection rate, PPH, reoperation, 90-day readmission and ELN. Discussion: Based on the available studies, MITP is safe and feasible compared to OTP in highly experienced hands from high-volume centers. Further high-quality studies are needed to verify the conclusion.
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Retrospective study of the functional and oncological outcomes of conformal sphincter preservation operation in the treatment of very low rectal cancer
Article
Full-text available
  • May 2020
Background Conformal sphincter preservation operation (CSPO) is a new surgical procedure for very low rectal cancers (within 4–5 cm from the anal verge). CSPO preserves more of the dentate line and distal rectal wall and also avoids injuring nerves in the intersphincteric space, resulting in satisfactory anal function after resection. The aim of this study was to analyze the short-term surgical results and long-term oncological and functional outcomes of CSPO.Methods Consecutive patients with very low rectal cancer, who had CSPO between January 2011 and October 2018 at Changhai Hospital, Shanghai were included. Patient demographics, clinicopathological features, oncological outcomes and anal function were analyzed.ResultsA total of 102 patients (67 men) with a mean age of 56.9 ± 10.8 years were included. The median distance of the tumor from the anal verge was 3 (IQR, 3–4) cm. Thirty-five patients received neoadjuvant chemoradiation (nCRT). The median distal resection margin (DRM) was 0.5 (IQR, 0.3–0.8) cm. One patient had a positive DRM. All circumferential margins were negative. There was no perioperative mortality. The postoperative complication rate was 19.6%. The median duration of follow-up was 28 (IQR, 12–45.5) months. The local recurrence rate was 2% and distant metastasis rate was 10.8%. The 3-year overall survival and disease-free survival rates were 100% and 83.9%, respectively. The mean Wexner incontinence and low anterior resection syndrome scores 12 months after ileostomy reversal were 5.9 ± 4.3, and 29.2 ± 6.9, respectively.Conclusions For patients with very low rectal cancers, fecal continence can be preserved with CSPO without compromising oncological results.
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Minimally invasive distal pancreatectomy: greatest benefit for the frail
Article
Full-text available
  • Dec 2017
  • SURG ENDOSC
Objective: The benefits of minimally invasive distal pancreatectomy (MIDP) over open surgery continue to be investigated. Frailty is a known predictor of postoperative outcome. We hypothesized that the benefit of minimally invasive distal pancreatectomy is the greatest for the frailest of patients. Methods: Data from the pancreas-targeted National Surgical Quality Improvement Program (NSQIP) database for 2014 were reviewed. A modified frailty index (mFI) with 11 preoperative variables previously validated for use in NSQIP was used to determine the correlation between frailty and postoperative outcomes, including Clavien grade IV complications. Patients were classified into non-frail (mFI = 0) or frail (mIF > 0), in which they were subclassified into mildly frail (mFI 1 or 2) or severely frail (mFI = 3). Results: A total of 1,038 distal pancreatectomies (DP) were included in the analysis, of which 387 were minimally invasive (MIDP: laparoscopic: 285, robotic: 102), 558 open DP (ODP), and 93 MIDP converted to open (MIDPcODP: laparoscopic: 80, robotic: 13). More than 90% of patients had an mFI of 0 or 1 (mFI 0 = 473 (45.6%), 1 = 466 (44.9%), 2 = 94 (9.1%), and 3 = 5 (0.5%), respectively). Overall, 4.6% of patients experienced Clavien grade IV complications and 1.1% a mortality. Non-frail patients experienced a similar rate of grade IV Clavien complications with MIDP vs. ODP vs. MIDPcOP (2.3 vs. 2.3 vs. 4.9%; p = 0.6), whereas frail patients (mFI > 0) had a lower rate of complications with MIDP (2.4 vs. 8.3 vs. 11.5; p = 0.007). Worsening frailty correlated with an increase in complications (non-frail: 2.5%; mildly frail: 6.3%; severely frail: 20%; p = 0.005). Conclusion: MIDP is associated with a lower risk of Clavien grade IV complications compared to ODP for frail patients, especially for benign disease. Thus, minimally invasive approach may mitigate risk in frail patients.
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The surgical outcomes of robot-assisted laparoscopic pancreaticoduodenectomy versus laparoscopic pancreaticoduodenectomy for periampullary neoplasms: a comparative study of a single center
Article
Full-text available
  • Jun 2017
  • SURG ENDOSC
Background Pancreaticoduodenectomy (PD) is a difficult and complex operation. The introduction of robotics has opened up new angles in pancreatic surgery. This study aims to assess the surgical outcomes of robot-assisted laparoscopic pancreaticoduodenectomy relative to its laparoscopic counterpart. MethodsA retrospective study was designed to compare the surgical outcomes of 27 robot-assisted laparoscopic pancreaticoduodenectomy (RPD) and 25 laparoscopic pancreaticoduodenectomy (LPD). Perioperative data, including operating time, complication, morbidity and mortality, estimated blood loss, and postoperative length of stay, were analyzed. ResultsThe robotic group exhibited significantly shorter operative time (mean 387 vs. 442 min), shorter hospital stay (mean 17 vs. 24 days), and less blood loss (mean 219 vs. 334 ml) than those in the LPD group. No statistical difference was observed between the two groups in terms of complication rate, mortality rate, R0 resection rate, and number of harvested lymph node. ConclusionsRPD is more efficient and secure process than LPD among properly selected patients. RPD is therefore a feasible alternative to the laparoscopic procedure. Further studies are needed to evaluate the cost effectiveness of the robotic approach for PD.
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Robotic pancreatoduodenectomy with vascular resection
Article
Full-text available
  • Dec 2016
  • LANGENBECK ARCH SURG
Purpose: This study aims to define the current status of robotic pancreatoduodenectomy (RPD) with resection and reconstruction of the superior mesenteric/portal vein (RPD-SMV/PV). Methods: Our experience on RPD, including RPD-SMV/PV, is presented along with a description of the surgical technique and a systematic review of the literature on RPD-SMV/PV. Results: We have performed 116 RPD and 14 RPD-SMV/PV. Seven additional cases of RPD-SMV/PV were identified in the literature. In our experience, RPD and RPD-SMV/PV were similar in all baseline variables, but lower mean body mass and higher prevalence of pancreatic cancer in RPD-SMV/PV. Regarding the type of vein resection, there were one type 2 (7.1 %), five type 3 (35.7 %) and eight type 4 (57.2 %) resections. As compared to RPD, RPD-SMV/PV required longer operative time, had higher median estimated blood loss, and blood transfusions were required more frequently. Incidence and severity of post-operative complications were not increased in RPD-SMV/PV, but post-pancreatectomy hemorrhage occurred more frequently after this procedure. In pancreatic cancer, RPD-SMV/PV was associated with a higher mean number of examined lymph nodes (60.0 ± 13.9 vs 44.6 ± 11.0; p = 0.02) and with the same rate of microscopic margin positivity (25.0 % vs 26.1 %). Mean length or resected vein was 23.1 ± 8.08 mm. Actual tumour infiltration was discovered in ten patients (71.4 %), reaching the adventitia in four patients (40.0 %), the media in two patients (20.0 %), and the intima in four patients (40.0 %). Literature review identified seven additional cases, all reported to have successful outcome. Conclusions: RPD-SMV/PV is feasible in carefully selected patients. The generalization of these results remains to be demonstrated.
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Laparoscopic robot-assisted versus open total pancreatectomy: a case-matched study
Article
Full-text available
  • Aug 2014
Background: The enhanced dexterity offered by robotic assistance could be excessive for distal pancreatectomy but not enough to improve the outcome of laparoscopic pancreaticoduodenectomy. Total pancreatectomy retains the challenges of uncinate process dissection and digestive reconstruction, but avoids the risk of pancreatic fistula, and could be a suitable operation to highlight the advantages of robotic assistance in pancreatic resections. Methods: Eleven laparoscopic robot-assisted total pancreatectomies (LRATP) were compared to 11 case-matched open total pancreatectomies. All operations were performed by one surgeon during the same period of time. Robotic assistance was employed in half of the patients, based on robot availability at the time of surgery. Variables examined included age, sex, American Society of Anesthesiologists score, body mass index, estimated blood loss, need for blood transfusions, operative time, tumor type, tumor size, number of examined lymph nodes, margin status, post-operative complications, 90-day or in-hospital mortality, length of hospital stay, and readmission rate. Results: No LRATP was converted to conventional laparoscopy, hand-assisted laparoscopy or open surgery despite two patients (18.1 %) required vein resection and reconstruction. LRATP was associated with longer mean operative time (600 vs. 469 min; p = 0.014) but decreased mean blood loss (220 vs. 705; p = 0.004) than open surgery. Post-operative complications occurred in similar percentages after LRATP and open surgery. Complications occurring in most patients (5/7) after LRATP were of mild severity (Clavien-Dindo grade I and II). One patient required repeat laparoscopic surgery after LRATP, to drain a fluid collection not amenable to percutaneous catheter drainage. One further patient from the open group required repeat surgery because of bleeding. No patient had margin positive resection, and the mean number of examined lymph nodes was 45 after LRATP and 36 after open surgery. Conclusions: LRATP is feasible in selected patients, but further experience is needed to draw final conclusions.
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*A Multi-institutional Comparison of Perioperative Outcomes of Robotic and Open Pancreaticoduodenectomy
Article
  • Jul 2016
Objectives: Limited data exist comparing robotic and open approaches to pancreaticoduodenectomy (PD). We performed a multicenter comparison of perioperative outcomes of robotic PD (RPD) and open PD (OPD). Methods: Perioperative data for patients who underwent postlearning curve PD at 8 centers (8/2011-1/2015) were assessed. Univariate analyses of clinicopathologic and treatment factors were performed, and multivariable models were constructed to determine associations of operative approach (RPD or OPD) with perioperative outcomes. Results: Of the 1028 patients, 211 (20.5%) underwent RPD (4.7% conversions) and 817 (79.5%) underwent OPD. As compared with OPD, RPD patients had higher body mass index, rates of prior abdominal surgery, and softer pancreatic remnants, whereas OPD patients had a higher percentage of pancreatic ductal adenocarcinoma cases, and greater proportion of nondilated (<3 mm) pancreatic ducts. On multivariable analysis, as compared with OPD, RPD was associated with longer operative times [mean difference = 75.4 minutes, 95% confidence interval (CI) 17.5-133.3, P = 0.01], reduced blood loss (mean difference = -181 mL, 95% CI -355-(-7.7), P = 0.04) and reductions in major complications (odds ratio = 0.64, 95% CI 0.47-0.85, P = 0.003). No associations were demonstrated between operative approach and 90-day mortality, clinically relevant postoperative pancreatic fistula and wound infection, length of stay, or 90-day readmission. In the subset of 522 (51%) pancreatic ductal adenocarcinomas, operative approach was not a significant independent predictor of margin status or suboptimal lymphadenectomy (<12 lymph nodes harvested). Conclusions: Postlearning curve RPD can be performed with similar perioperative outcomes achieved with OPD. Further studies of cost, quality of life, and long-term oncologic outcomes are needed.
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Robotic-Assisted Pancreatic Resections
Article
  • May 2016
Background Robotic assistance enhances surgical dexterity and could facilitate wider adoption of laparoscopy for pancreatic resections (PR). Methods Data were prospectively entered into a database and analyzed retrospectively to assess feasibility and safety of robotic-assisted PR (RAPR). Additionally, robotic-assisted pancreaticoduodenectomy (RAPD) was compared to a contemporary group of open pancreaticoduodenectomies (OPD). Results Between October 2008 and October 2014, 200 consecutive patients underwent RAPR. Three procedures were converted to open surgery (1.5 %), despite 14 patients required associated vascular procedures. RAPD was performed in 83 patients (41.5 %), distal pancreatectomy in 83 (41.5 %), total pancreatectomy in 17 (8.5 %), tumor enucleation in 12 (6 %), and central pancreatectomy in 5 (2.5 %). Thirty-day and 90-day mortality rates were 0.5 and 1 %, respectively. Both deaths occurred after RAPD with vein resection. Complications occurred in 63.0 % of the patients (≥Clavien-Dindo grade IIIb in 4 %). Median comprehensive complication index was 20.9 (0-26.2). Incidence of grade B/C pancreatic fistula was 28.0 %. Reoperation was required in 14 patients (7.0 %). The risk of reoperation decreased after post-operative day 20 (OR 0.072) (p = 0.0015). When compared to OPD, RAPD was associated with longer mean operative time (527.2 ± 166.1 vs. 425.3 ± 92.7; <0.0001) but had an equivalent safety profile. The median number of examined lymph nodes (37; 28.8–45.3 vs. 36; 28–52.8) and the rate of margin positivity in patients diagnosed with pancreatic cancer were also similar (12.5 vs. 45.5 %). Conclusions RAPR, including RAPD, are safely feasible in selected patients. The results of RAPD in pancreatic cancer are encouraging but deserve further investigation.
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The learning curve for robotic distal pancreatectomy: An analysis of outcomes of the first 100 consecutive cases at a high-volume pancreatic centre
Article
  • Apr 2015
  • HPB
Robotic distal pancreatectomy (RDP) is performed increasingly, but knowledge of the number of cases required to attain procedural proficiency is lacking. The aim of this study was to identify the learning curve associated with RDP at a high-volume pancreatic centre. Metrics of perioperative safety and efficiency for all consecutive RDPs were evaluated. Outcomes were followed to 90 days. Cumulative sum (CUSUM) analysis was used to identify inflexion points corresponding to the learning curve. Between 2008 and 2013, 100 patients underwent RDP. There was no 90-day mortality. In two patients (2.0%), surgery was converted to laparotomy. Thirty procedures were performed for pancreatic adenocarcinoma. Precipitous operative time reductions from an initial operative time of 331 min were observed after the first 20 and 40 cases to 266 min and 210 min, respectively (P < 0.0001). The likelihood of readmission was significantly lower after the first 40 cases (P = 0.04), and non-significant reductions were observed in incidences of major (Clavien-Dindo Grade II or higher) morbidity and Grade B and C leaks, and length of stay. In this experience, RDP outcomes were optimized after 40 cases. Familiarity with the platform and dedicated training are likely to contribute to significantly shorter learning curves in future adopters. © 2015 International Hepato-Pancreato-Biliary Association.
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Assessment of Quality Outcomes for Robotic Pancreaticoduodenectomy: Identification of the Learning Curve
Article
  • Mar 2015
Quality assessment is an important instrument to ensure optimal surgical outcomes, particularly during the adoption of new surgical technology. The use of the robotic platform for complex pancreatic resections, such as the pancreaticoduodenectomy, requires close monitoring of outcomes during its implementation phase to ensure patient safety is maintained and the learning curve identified. To report the results of a quality analysis and learning curve during the implementation of robotic pancreaticoduodenectomy (RPD). A retrospective review of a prospectively maintained database of 200 consecutive patients who underwent RPD in a large academic center from October 3, 2008, through March 1, 2014, was evaluated for important metrics of quality. Patients were analyzed in groups of 20 to minimize demographic differences and optimize the ability to detect statistically meaningful changes in performance. Robotic pancreaticoduodenectomy. Optimization of perioperative outcome parameters. No statistical differences in mortality rates or major morbidity were noted during the study. Statistical improvements in estimated blood loss and conversions to open surgery occurred after 20 cases (600 mL vs 250 mL [P = .002] and 35.0% vs 3.3% [P < .001], respectively), incidence of pancreatic fistula after 40 cases (27.5% vs 14.4%; P = .04), and operative time after 80 cases (581 minutes vs 417 minutes [P < .001]). Complication rates, lengths of stay, and readmission rates showed continuous improvement that did not reach statistical significance. Outcomes for the last 120 cases (representing optimized metrics beyond the learning curve) included a mean operative time of 417 minutes, median estimated blood loss of 250 mL, a conversion rate of 3.3%, 90-day mortality of 3.3%, a clinically significant (grade B/C) pancreatic fistula rate of 6.9%, and a median length of stay of 9 days. Continuous assessment of quality metrics allows for safe implementation of RPD. We identified several inflexion points corresponding to optimization of performance metrics for RPD that can be used as benchmarks for surgeons who are adopting this technology.
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Robotic Total Pancreatectomy with or without Autologous Islet Cell Transplantation: Replication of an Open Technique through a Minimal Access Approach
Article
  • Jul 2014
Background: Total pancreatectomy (TP) is a morbid but sometimes necessary operation. Robotic TP is not often reported but may harbor some advantages compared to the open approach. This manuscript details a single institution's outcomes and technique of robotic TP. An accompanying video demonstrates a robotic TP with auto islet cell transplantation (IAT) in which (1) the arterial blood supply and venous drainage are kept intact until the last step of the TP to minimize warm ischemia time and (2) extirpation of the entire pancreas is performed without dividing the pancreatic neck to maximize islet recovery. Methods: This study is a retrospective review of a prospective database of perioperative outcomes of all consecutive robotic TPs at a single institution. This included a single robotic TP with IAT performed on a twenty-year-old patient with chronic pancreatitis. Results: Between 2010 and January 2014, ten robotic TPs were performed (7 males, mean age 58 years), one of which included an IAT. Median body mass index was 28. Indications were intraductal papillary mucinous neoplasms (6), pancreatic adenocarcinoma (1), and chronic pancreatitis (3). The median operative time was 560 min with a median estimated blood loss of 650 ml. One case was converted to laparotomy. Ninety days mortality and Clavien III-IV complication rate were 0 and 20 %, respectively. The average length of stay was 10 ± 3 days, with only 1 readmission within 90 days. The single TP and IAT were completed successfully without conversion, and were achieved without division of the pancreatic neck thereby maintaining vascular inflow to an entire specimen up until extraction. Conclusion: This represents the largest series of robotic TP, demonstrating its safety and feasibility. Additionally, TP and IAT using the technique described above can be recapitulated using the robotic approach.
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