Robotic pancreatoduodenectomy at an experienced institution is not associated with an increased risk of post-pancreatic hemorrhage

Abstract

Objective: Post-Pancreatic hemorrhage (PPH) is the Achilles heel of pancreatoduodenectomy and reported to occur in 5–6% of patients. Early reports of minimally invasive pancreatoduodenectomy have shown increased incidence of PPH. Our objective is to determine whether PPH incidence is elevated in a mature series of robotic pancreatoduodenectomy (RPD) or if video review can identify technical factors which may contribute to PPH. Methods: A retrospective review of RPDs between 10/2008–3/2016 was performed. PPH was classified by ISGPS criteria. Technical factors from video analysis were reviewed for variables including: anomalous arterial anatomy, trauma to vessels, method of GDA ligation, length of GDA stump, use of clip on arteries, and creation of falciform flap. Clinical and technical variables were analyzed using multivariate analysis (MVA). Results: 400 patients underwent RPD with a PPH=16(4%), 167 (42%) RPD had videos to review. MVA of clinical variables showed females, EBL>500 ml, long OR time, and neoadjuvant therapy were predictors of PPH (p=0.042, R2=0.148). Falciform flaps were routinely performed after RPD#181 and were performed with less frequency in the PPH group (37.5% vs 75%, p=0.033). On MVA of clinical and technical variables, suture ligation of GDA and long OR times were predictive of PPH (p=0.06, R2=0.19). A negative relationship (Figure) was found between frequency of PPH and time (Ï=−0.533, p<0.05). Routine use of falciform flaps dropped the PPH rate (Early-200 RPD=6% vs Late-200 RPD=2%, p<0.05). Conclusion: PPH for RPD in a mature series is on par with historical open control, however, improves with experience and use of a falciform flap.