Early experience of a robotic foregut surgery program at a cancer center: video of shared steps in robotic pancreatoduodenectomy and gastrectomy

Abstract

Presenter: Naruhiko Ikoma MD | The University of Texas MD Anderson Cancer Center Background: Over the past few decades, robotic surgery techniques required to resect periampullary malignancies have evolved remarkably. However, the safety and generalizability of robotic pancreatoduodenectomy remain unknown. New robotic pancreatic surgery programs must be implemented thoughtfully to ensure safety, and every effort should be made to accelerate the rate at which the necessary skills can be acquired in this context. At our cancer center, gastrectomies and pancreatectomies are performed in a combined foregut MIS program; this effectively increases the composite case volume and shortens the learning curve for any individual surgeon. Methods: In this video, we demonstrate the shared steps in pancreatoduodenectomy and gastrectomy and explain how the skills gained through robotic gastrectomy can be used during robotic pancreatoduodenectomy. The following steps in pancreatoduodenectomy and gastrectomy are similar, and focusing on them will therefore help shorten the learning curve: 1. entering the lesser sac and exposing the bare area of the mesocolon, 2. dissecting lymph nodes along the hepatic artery, and 3. suturing anastomoses. After gaining the skills associated with gastrectomy and distal pancreatectomy, the surgeon can focus on the critical steps specific to pancreatoduodenectomy, such as superior mesenteric artery dissection and pancreaticojejunostomy anastomosis. Results: During the initial 2-year period of our robotic foregut surgery program, we performed 120 pancreatic and gastric operations, including 22 pancreatoduodenectomies (excluding 1 aborted and 1 converted case) and 37 gastrectomies. Our first robotic pancreatoduodenectomy was performed following successful completion of 45 other robotic foregut operations. Of those 22 patients who underwent robotic pancreatoduodenectomy, 11 (50%) had pancreatic ductal adenocarcinoma, 7 (32%) had intraductal papillary mucinous neoplasms, 2 (9%) had periampullary cancer, 1 (5%) had pancreatic neuroendocrine tumor, and 1 (5%) had solid pseudopapillary neoplasm. The median hospital stay was 4 days (range, 3-17 days), and the readmission rate was 14% (3/22). The rate of grade B/C pancreatic fistula was 9% (2/22) and there was no 90-day mortality. The mean operative time was 520 min, and the operative time appears to be improving over time. Conclusion: In conclusion, the presented video showing the shared steps in robotic pancreatoduodenectomy and gastrectomy demonstrates the potential for a combined robotic surgery program to increase composite case volumes and to shorten the learning curve. At our cancer center, implementation of this approach has been helpful in accelerating development of our new robotic pancreatectomy program, especially in honing the skills necessary to perform robotic pancreatoduodenectomy.