Robotic-assisted Pancreaticoduodenectomy Research Articles

Safety and learning curve analysis of robotic-assisted pancreaticoduodenectomy: experience of a single surgeon.

Although prior studies have discussed learning curves (LC) of robotic-assisted pancreaticoduodenectomy (RPD), a recognized definition is lacking. This study analyzed the clinical outcomes of 85 consecutive RPD cases performed by a single surgeon to evaluate the safety and learning curve of RPD using the da Vinci Xi robotic system. There were 51 male and 34 female patients, with a median age of 64 (20-87) years. The average preoperative body weight and BMI were 64.15 ± 11.43kg and 23.36 ± 3.33kg/m2, respectively. The clinical outcomes of each patient were analyzed using the textbook outcome(TO), and the learning curve of the RPD was evaluated by calculating the TO rate of patients using the cumulative sum analysis method (CUSUM).The operation time (OT) was 288.92 ± 44.41min, and the postoperative hospital stay was 10 (1-134) days. In total, 23.52% (20/85), 5.88% (5/85), 2.35% (2/85), and 5.9% (5/85) experienced grade IIIa, IIIb, IV, and V complications. A total of 46 patients achieved TO outcomes (TO group), while 39 did not (non-TO group). The smoking rate in the TO group was lower (P < 0.05) and the albumin level was higher (P < 0.05) than that in the non-TO group. The TO rate became positive after the 56th case, all patients were divided into a learning improvement group (56 cases) and a proficient group (29 cases). The total bilirubin level in the learning improvement group was lower (P < 0.05) and the bleeding volume was higher (P < 0.05).RPD is safe and effective for carefully selected patients. The learning curve was completed after 56 patients.

Management of Intra-Operative Hemorrhage and Safe Venous Resection in Robotic-Assisted Pancreaticoduodenectomy: Techniques to Avoid Open Conversion

Robotic-assisted pancreaticoduodenectomy (RPD) is increasingly utilized for operable periampullary malignancies with oncologic outcomes compared to the open approach. Indications can be carefully expanded to select borderline resectable tumors, but bleeding remains a significant threat. Moreover, the need for venous resection and reconstructions increases as more complex cases are selected to undergo RPD. Herein, we present a video compilation of our approach to safe venous resections during RPD, followed by several video examples of intraoperative hemorrhage highlighting various techniques and tips that the console and bedside surgeon can utilize to control bleeding. Conversion to an open procedure should not be seen as a failure but rather as a safe and sound intraoperative decision made in the patient’s best interest. Nonetheless, with experience and proper technique, many intraoperative hemorrhages and venous resections can be managed in a minimally invasive fashion.

Robotic pancreaticoduodenectomy for pancreatic cancer: a narrative review

Background and Objective: The indications and evidence base for robotic-assisted pancreaticoduodenectomy have grown exponentially over the last two decades and robotic-assisted resection is now considered a safe and oncologically-equivalent surgical option for patients with pancreaticobiliary cancers. In this narrative review, we outline the published literature regarding technical considerations and operative steps for robotic pancreaticoduodenectomy including techniques for safe vascular resection and reconstruction.

Technical tips to optimize the surgical view during robotic-assisted pancreaticoduodenectomy

Maintaining stability and completing the required trajectory are the most important motion control issues for a six-kinematic-degrees-of-freedom legged robot. Zero-moment point (ZMP) approaches have evolved into an indispensable tool for obtaining dynamic equilibrium in humanoid or bipod robots for walking and handling. It's point where momentary, applied, and reactive forces cancel out. Despite ZMP advancements, legged robots continue to struggle with a number of essential skills exhibited by primates, such as like the Atlas robot, which can walk but not jump, run, or sprint. In complex environments, it may be incapable of interception. Hence, in this study, the effect of center of mass (CoM) trajectory on biped robot stability has been explored to understand the secure walking behavior. The research investigates the predictive control technique of adjusting CoM trajectory to generate stable walking patterns, which pioneered the concept of altering the CoM in advance during human walking and reacting to changing path restrictions. This section explains how to fix continuous variation's ZMP tracking problem. This allows monitoring the necessary ZMP, expanding gait generation systems and their analysis. Predictive control can produce secure walking models by manipulating the COM and CoG pathline in bipod robots.

The Role of BMI on Postoperative Outcomes after Open vs Robotic-Assisted Pancreaticoduodenectomy

The Role of BMI on Postoperative Outcomes after Open vs Robotic-Assisted Pancreaticoduodenectomy

How Can We Optimize Surgical View During Robotic-Assisted Pancreaticoduodenectomy? Feasibility of Multiple Scope Transition Method.

Inoue, Yosuke MD, PhD; Sato, Takafumi MD, PhD; Kato, Tomotaka MD, FACS, PhD; Oba, Atsushi MD, PhD; Ono, Yoshihiro MD, PhD; Ito, Hiromichi MD, FACS; Makuuchi, Rie MD; Takahashi, Yu MD, PhD Author Information

Robotic versus open pancreaticoduodenectomy with vascular resection for pancreatic ductal adenocarcinoma: surgical and oncological outcomes from pilot experience.

Venous resection and reconstruction (VR) is a feasible surgical technique to achieve optimal outcomes in selected patients with pancreatic ductal adenocarcinoma (PDAC) who undergo open pancreaticoduodenectomy (OPD). However, data regarding patient outcomes in patients who undergo VR in robotic-assisted pancreaticoduodenectomy (RPD) are scarce. All patients with a diagnosis of PDAC who underwent upfront open or robotic pancreatoduodenectomy with VR in a high-volume institution for pancreatic surgery between 2011 and 2019 were retrospectively reviewed. Perioperative and long-term outcomes were compared between the RPD and OPD cohorts. A total of 84 patients were included in the final analysis, 14 patients underwent RPD with VR and 70 who had OPD with VR. Reconstructed venous patency, postoperative 30-day morbidity, and 90-day mortality were comparable; however, lymph node resection rates were lower in the RPC cohort (p = 0.029). No difference was identified in 3-year survival rates between the two groups (34.0% versus 25.7% respectively, p = 0.667). RPD with VR is a feasible approach for patients with PDAC and venous invasion. Further studies are needed to assess long-term outcomes compared to the open approach.

Transitioning from Open to Minimally Invasive Pancreaticoduodenectomy. the Learning Curve Factor in an Academic Center

Background: Pancreatic surgery has been known to have substantial morbidity and mortality rates. Minimally invasive surgery has shown to decrease morbidity and recovery time, which in the context of cancer, will eventually translate into a larger number of patients who will be ready to get adjuvant treatment. We compared three periods of time when we transitioned from an open, hybrid-laparoscopic, and robotic assisted pancreaticoduodenectomy.

P-P37 Robot assisted pancreaticojejunostomy may be associated with lower risk of post-operative pancreatic fistula in high-risk cases: Initial experience

Abstract Background Robot assisted pancreaticoduodenectomy has increased in popularity over recent years. There is evidence from high volume centers which suggests that it is associated with lower risk of post-operative pancreatic fistula than open surgery. The aims of this study were to evaluate our initial experience after robotic assisted pancreaticoduodenectomy and compare if a low volume center can produce similar positive outcomes. Methods The initial 12 patients who were listed for a robot assisted pancreaticoduodenectomy were included in the study in a consecutive manner. A standardised method of anastomosis was used in all surgeries, this being a duct-to-mucosa two-layer modified Blumgart pancreato-jejunostomy. Data was collected prospectively and stored in an encrypted database. Surgical outcomes were then analysed. Results The study included first 12 consecutive patients who underwent robotic pancreaticoduodenectomy between August 2019 and January 2020. None of the patients had clinically relevant postoperative pancreatic fistula despite 75% of the patients falling into moderate to high-risk group for fistula development. Median operative time and length of stay was 547 minutes and 8 days respectively with three Clavien Dindo grade III complications and three Clavien-Dindo grade II complications. Conclusions Robotic assisted pancreaticoduodenectomy maybe associated with lower risk of post-operative pancreatic fistula in high-risk cases.

"How I dissect the uncinate process of the superior mesenteric vessels" a robotic assisted approach in pancreaticoduodenectomy

Presenter: Nicole M Nevarez MD | University of Texas Southwestern Medical Center Methods: In this submitted video we detail the four steps utilized in dissecting the uncinate process off the superior mesenteric vessels during a robotic assisted pancreaticoduodenectomy. The four steps we commonly utilize during this segment of the procedure include in order:1.Dissection of superior mesenteric vein from uncinate process2.Cranial dissection of uncinate process for landing zone3.Dissection of 1st jejunal branch of superior mesenteric vein4.Dissection of uncinate process off superior mesenteric artery-caudal to cranial approach

Robotic-assisted pancreaticoduodenectomy with vascular resection. Description of the surgical technique and analysis of early outcomes

BackgroundDespite the potential benefits, the adoption of the minimally invasive surgery for the treatment of borderline resectable pancreatic cancer is still in the initial phase. We investigated the safety and feasibility of the robotic pancreaticoduodenectomy with venous resection/reconstruction (RPD SMV/PV). MethodsSince March 2013 to October 2019, a total of 73 RPD and 10 RPD SMV/PV were performed. The two groups were case-matched according to the preoperative characteristics. ResultsMean operative times and estimated blood loss were less in the RPD group in comparison to that in the RPD with SMV-PV group (525 vs 642 min, p = 0.003 and 290 vs 620 ml, p = 0.002, respectively). The mean length of hospital stay was similar in the RPD group in comparison to that in the RPD with SMV-PV group (10 days vs 13 days, p = 0.313). The two groups had similar overall postoperative morbidity rate (57.5% vs 60%, p = 0.686), although the severe complication rate was lower in the RPD group (11% vs 40%, p = 0.004). ConclusionsRPD with SMV-PV is associated with increased operative time, estimated blood loss, higher major complication rate compared with RPD.

Readmission and Resource Use After Robotic-Assisted versus Open Pancreaticoduodenectomy: 2010-2017

Unplanned rehospitalization is considered an adverse quality of care indicator. Minimally invasive operations carry the potential to reduce resource use while enhancing recovery. Robotic-assisted pancreaticoduodenectomy (RAPD) has been used to improve outcomes of its morbid open counterpart. We sought to identify factors associated with readmission between RAPD and open pancreaticoduodenectomy (OPD). We used the 2010-17 National Readmissions Database to identify adults who underwent RAPD or OPD. The primary outcome was 30-day readmission. Secondary outcomes included readmission diagnosis: index, readmission, and total (index+readmission) length of stay, costs, and mortality. Of an estimated 84,036 patients undergoing pancreaticoduodenectomy, 96.9% survived index hospitalization. Frequency of both RAPD and OPD increased during the study period with similar mortality (2.5% versus 3.2%, P=0.46). Compared with OPD, RAPD was not an independent predictor of 30-day readmission (adjusted odds ratio (AOR): 1.0, P=0.98). Disposition with home health care (AOR: 1.1, P<0.001) or to a skilled nursing facility (AOR: 1.5, P<0.001) was significantly associated with increased 30-day readmission. Readmission after pancreaticoduodenectomy is common, regardless of surgical approach. Although RAPD saves in-patient days on index admission, readmission rates and length of stay are similar between the two modalities. Neither RAPD nor OPD is a risk factor for readmission, highlighting the complexity of pancreaticoduodenectomy, with complications that may result from factors independent of the operative approach.

National Trends in Robotic Pancreas Surgery

BackgroundRobotic pancreatic surgery is expanding throughout centers across the country. We investigated national trends in the use and outcomes for robotic-assisted pancreaticoduodenectomy (RPD) and distal pancreatectomy (RDP) for primary pancreatic tumors. MethodsThe National Cancer Database was queried for RPD and RDP performed during three time periods: 2010–2012, 2013–2014, and 2015–2016. These time periods were compared for patient and center factors as well as surgical outcomes. ResultsThe use of robotic surgery increased during the study period. Most centers performed a low volume of robotic surgery (RPD, 82% of centers averaged < 1 case/year; RDP, 87% averaged < 1 case/year). From the first to last time period, the proportion of cases performed at academic centers decreased (RPD, 83% to 56%; RDP, 77% to 58%, p < 0.001) while patient characteristics remained largely unchanged. For RPD, improvements in mortality (6.7 to 1.8%, p = 0.013) and lymphadenectomy (18 to 21 nodes, p = 0.035) were observed, with no changes in conversion to open surgery, negative margin resections, or readmissions. For RDP, length of stay decreased (7 to 6 days, p = 0.048), but there were no changes in other outcomes. Compared with academic centers, non-academic centers had equivalent rates of conversion to open surgery, negative margins, and 90-day mortality. On multivariate analysis, there was no difference in survival between academic and non-academic centers. DiscussionRobotic pancreas surgery is expanding to a greater variety of centers nationwide with preservation of key surgical outcomes. These findings support the continued rigorous training and proliferation of qualified robotic pancreas surgeons going forward.

Tangential Venous Resections during Robotic-Assisted Pancreaticoduodenectomy: the Results of a Case Series (with Video)

IntroductionDespite the potential advantages in terms of microdissection and microsuturing capabilites, the robotic approach for borderline resectable pancreatic cancer is scarcely reported. MethodsWe report our technique for a robotic-assisted pancreaticoduodenectomy with tangential Portal/ Superior Mesenteric Vein resection/reconstruction (RPD PV/SMV).We also compared the surgical outcomes of eight consecutive patients undergoing RPD PV/SMV with that of sixty patients who underwent robotic-assisted pancreaticoduodenectomy (RPD) in the same period of time. ResultsA total of eight consecutive patients underwent RPD PV/SMV. We observed an increased estimated blood loss (550 vs 280 mL, p = 0.003) and operative time (438 vs 350 min, p = 0.002) in the RPD PV/SMV group of patients compared with RPD group, whereas the complication rate (28% vs 31%, p = 0.726) was similar. No venous-congestion related complications were observed in the postoperative course. The median length of hospital stay was similar in the RPD group in comparison to that in the RPD PV/SMV group (10 vs 13 range 6-19 days, p = 0.313). ConclusionRPD PV/SMV is a challenging operation. It is associated with higher operative time and increased estimated blood loss in comparison to standard RPD.

Operations on the pancreas using robotic complex

Background: Aim: to create a conception of adequate usage of robotic complex in pancreatic surgery. Methods: A retrospective study of robotic-assisted (RA) operations in 84 patients was held. Ductal adenocarcinomas were in 20 cases (23.8%), NETs in 33 (39.3%), cystic tumors in 15 (17.9%), SPPNs in 9 (10.7%), nesidioblastosis in 2 (2.4%), metastasis of neuphrocellar carcinoma in pancreas in 1 (1.2%), benign tumors in 5 (5.9%) patients. Distal pancreatectomy was carried in 44 participants, tumor enucleation in 15, pancreaticoduodenectomy (PD) in 17, central resection in 6. Total duodenumpancreatectomy was made in 2 cases. Results: Duration of RA PD varied within 305 to 670 minutes and took 407 min. median time. Conversion was in 2 cases. Blood loss volume (blw) was 225 ml. Median length os stay (Los) was 15.5. Lymph nodes harvest was 18.5 correlate with the quantity of removed along the traditional PD. Duration of the distal pancreatectomy was 210 min, blw was 100 ml. Postoperative period in 18 patients was accompanied by pancreatic fistulas. Median enucleation and central resection time was 140 and 238 min. Conclusion: Indications to the RA surgery are: malignant pancreatic tumors Т1-T2, benign and low malignant tumors 4-5 cm without invasion into vessels. RA operations provide precise remove of the lymphatic nodes and anastomosis formation. Postoperative period passes more comfortable for the patients due to the minimal tissue trauma. It doesn’t prevent specific postoperative complications.

Operations on the pancreas using robotic complex

Background: Aim: to create a conception of adequate usage of robotic complex in pancreatic surgery. Methods: A retrospective study of robotic-assisted (RA) operations in 84 patients was held. Ductal adenocarcinomas were in 20 cases (23.8%), NETs in 33 (39.3%), cystic tumors in 15 (17.9%), SPPNs in 9 (10.7%), nesidioblastosis in 2 (2.4%), metastasis of neuphrocellar carcinoma in pancreas in 1 (1.2%), benign tumors in 5 (5.9%) patients. Distal pancreatectomy was carried in 44 participants, tumor enucleation in 15, pancreaticoduodenectomy (PD) in 17, central resection in 6. Total duodenumpancreatectomy was made in 2 cases. Results: Duration of RA PD varied within 305 to 670 minutes and took 407 min. median time. Conversion was in 2 cases. Blood loss volume (blw) was 225 ml. Median length os stay (Los) was 15.5. Lymph nodes harvest was 18.5 correlate with the quantity of removed along the traditional PD. Duration of the distal pancreatectomy was 210 min, blw was 100 ml. Postoperative period in 18 patients was accompanied by pancreatic fistulas. Median enucleation and central resection time was 140 and 238 min. Conclusion: Indications to the RA surgery are: malignant pancreatic tumors Т1-T2, benign and low malignant tumors 4-5 cm without invasion into vessels. RA operations provide precise remove of the lymphatic nodes and anastomosis formation. Postoperative period passes more comfortable for the patients due to the minimal tissue trauma. It doesn’t prevent specific postoperative complications.

The robotic-assisted pancreaticoduodenectomy with vascular reconstruction: our personal experience

Introduction: Firstly described in 2003, the widespread of robotic pancreaticoduodenectomy (PD) is still slow. The complexity of the procedure, the higher cost of this technology and the lack of a specific training confined this procedure to high-selected centres. We investigated the perioperative outcomes of our first 50 robotic PD including our initial experience with resection and reconstruction of superior mesenteric/portal vein (PD-SMV/PV) in order to evaluate the safety and feasibility of this approach. Methods: We performed a retrospective analysis from January 2012 to April 2017 of our prospectively maintained database on robotic pancreatic surgery. Results: A total of 50 patients during the time period evaluated underwent to robotic PD. We performed 45 robotic PD and 5 robotic PD-SMV/PV. The overall operative time was 425 min (290–550), with a reduction over the course of learning curve, while the median blood loss was 170 ml (30–700). We observed a low conversion rate 5/50 (10%) and an acceptable overall postoperative morbidity rate of 12/50 (24%). The pancreatic fistula rate was 8/50 (16 %), but only 3 (6%) clinically significant. We achieved a R0 resection rate in 46/50 (92%) of patients with a mean lymph nodes retrieved of 20.5 (17–25). The reoperation rate for all series was low 6/50 (12%) as well as the 90-day mortality rate 3/50 (6%). Conclusions: Despite our initial learning curve, the robotic approach seems to be safe and effective giving some potential advantages in terms of estimated blood loss and conversion rate, preserving a good oncologic adequacy.

Internal Hernia Following Robotic Assisted Pancreaticoduodenectomy.

BackgroundRobotic assisted pancreaticoduodenectomy (RPD) is reported to be safe and feasible. Internal hernia (IH) after RPD is a serious but rarely reported complication.Material/MethodsWe retrospectively reviewed data of 231 patients who underwent RPD from October 2010 to December 2016. The incidence, symptoms, time of presentation, and outcome were investigated.ResultsFive patients (2.6%) were diagnosed with IH. Significant correlation (P<0.001) between IH and transverse mesocolon defect was confirmed. In patients without defect closure, the incidence of IH was 62.5%, while patients who received defect closure experienced no IH. The median time between initial surgery and occurrence of IH was 76 days. The main symptoms were abdominal pain, nausea, and vomiting. All patients received abdominal computed tomography (CT) and were suspected to have IH according to imaging and symptoms. All patients underwent reoperation (2 laparoscopic and 3 open surgery). The median length of hospital stay was 13 days. No patient experienced a relapse after treatment.ConclusionsAbdominal pain, nausea, and vomiting were common symptoms in our study patients who underwent RPD. IH should be suspected if there is a positive finding on CT. Timely reoperation is necessary because IH may cause intestinal ischemia. Meticulous closure of the mesenteric defect is vital to avoid IH.

Robotic-Assisted Pancreatic Resections.

Robotic assistance enhances surgical dexterity and could facilitate wider adoption of laparoscopy for pancreatic resections (PR). 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). 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%). RAPR, including RAPD, are safely feasible in selected patients. The results of RAPD in pancreatic cancer are encouraging but deserve further investigation.

Early experience with robotic pancreatic surgery in a Canadian institution.

Pancreatic resections have traditionally been associated with substantial morbidity and mortality. The robotic platform is believed to improve technical aspects of the procedure while offering minimally invasive benefits. We sought to determine the safety and feasibility of the first robotic pancreaticoduodenectomies performed at our institution. We retrospectively reviewed data on all patients who underwent robotic-assisted pancreaticoduodenectomy (RAPD) between July 2010 and June 2014 and compared them to outcomes of patients undergoing hybrid laparoscopic pancreaticoduodenectomies (HLAPD) during the same time period. Fifteen patients were scheduled for RAPD; 2 were converted to an open approach and 1 to a mini-laparotomy during the laparoscopic portion of the procedure. Patients who had RAPD (n = 12) had a median duration of surgery of 596.6 (range 509-799) minutes, estimated blood loss of 275 (range 50-1000) mL and median length of stay of 7.5 (range 5-57) days. Mean total opioid use up to postoperative day 7 was 142.599 ± 68.2 versus 176.9 ± 112.7 mg equivalents of intravenous morphine for RAPD and HLAPD, respectively. There was no significant difference between RAPD and HLAPD in any parameters, highlighting the safety and feasibility of a step-wise minimally invasive learning platform. Most patients in the RAPD group had malignant pathology (88.2%). Oncologic outcomes were maintained with no significant difference in ability to resect lymph nodes or achieve negative margins. There were 4 (28.5%) Clavien I-II complications and 3 (29.4%) Clavien III- IV complications, 2 of which required readmission. There were no reported deaths at 90 days. Complication, pancreatic leak and mortality rates did not differ significantly from our laparoscopic experience. Outcomes of RAPD and HLAPD were comparable at our centre, even during the early stages of our learning curve. These results also highlight the safety, feasibility and patient benefits of a step-wise transition from open to hybrid to fully robotic pancreaticoduodenectomies in a high-volume academic centre.