Intraoperative hemorrhage control during robot-assisted pancreatoduodenectomy

Abstract

Introduction: Pancreatoduodenectomy is increasingly performed minimally invasively. The main advantage of robotic pancreatoduodenectomy (RPD), compared to laparoscopy, is control of intraoperative hemorrhage avoiding unnecessary conversion to laparotomy. Methods: Consecutive RPDs were collected in a prospectively maintained database. Video recordings were evaluated of RPDs with an intraoperative estimated blood loss (EBL) exceeding 1000cc. The recordings were evaluated for the timing, cause, source, and duration of the bleeding, as well as the method and outcome of bleeding control. Results: During a two-year period (2017-2018), the initial 64 RPD’s in a single center were performed. Baseline characteristics show a median age of 69 years, median BMI of 24.88 kg/m2, and pancreatic cancer diagnosis in 47%. All resections were completed robotically without conversion to laparotomy. Postoperative mortality was 1.6% and 13 patients (20%) had a grade B/C pancreatic fistula. The median EBL was 250cc (IQR:150-463). 5 patients had an EBL of more than 1000 ml. These patients all had a major venous bleeding from the portal vein, splenic vein, or superior mesenteric vein. Bleeding was initially controlled by closing the venous defect with a robotic grasper, because it could not be controlled by applying a gauze and pressure. Next, inflow and outflow were controlled with bulldogs and the defect was closed with interrupted sutures. Conclusion: Intraoperative hemorrhage control with RPD is safe and feasible even during the learning curve and avoids conversion to laparotomy.