Robotic Central Pancreatectomy Research Articles

Robotic central pancreatectomy: a surgical technique.

Robotic central pancreatectomy has not been widely performed because of its rare indications, technical difficulties, and concern about the high complication rate. We reviewed six robotic central pancreatectomy cases between May 2016 and June 2021 at a single institution. This multimedia article aims to introduce our technique of robotic central pancreatectomy with perioperative and follow-up outcomes. All patients experienced biochemical leakage of postoperative pancreatic fistula, except in one with a grade B pancreatic fistula, which resulted in a pseudocyst formation and was successfully managed by endoscopic internal drainage. All patients achieved completely negative resection margins. There was no new-onset diabetes mellitus or recurrence during the median follow-up period of 13.5 months (range, 10-74 months). With an acceptable complication rate and the preservation of pancreatic function, robotic central pancreatectomy could be a good surgical option for patients with benign and borderline malignant tumors of the pancreatic neck or proximal body.

Comparison of robotic and open central pancreatectomy.

Central pancreatectomy (CP) is an ideal parenchyma-sparing procedure. The experience of r robotic central pancreatectomy (RCP) is very limited. Patients undergoing CP were included. Comparisons were made between RCP and open central pancreatectomy (OCP) groups. The most common lesion in patients undergoing CP was serous cystadenoma (35.5%). The median operation time was 4.2h for RCP versus 5.5h for OCP. The median blood loss was significantly lower in RCP, 20 c.c. versus 170 c.c., p=0.001. Postoperative pancreatic fistula occurred in 19.4% of all patients, with 22.1% in RCP and 15.4% in OCP. There was no significant difference regarding other surgical complications between the RCP and OCP groups. Only one patient in the OCP group developed de novo diabetes mellitus (DM), and no steatorrhoea/diarrhoea occurred after either RCP or OCP. RCP is feasible and safe without compromising surgical outcomes and pancreatic functions.

Early experience with robotic central pancreatectomy with patient-reported outcomes and comparison with open central pancreatectomy.

Robotic central pancreatectomy (CP) has emerged in recent years as a noninferior approach to open CP and may offer improved patient-reported outcomes and reduction in incisional hernias. All patients who underwent open and robotic CP between (2013 and 2022) were selected, and perioperative outcomes were analyzed. Patients who underwent robotic CP were interviewed over the phone to assess patient-reported postoperative outcomes. A total of 18 CP operations (56%-open vs. 44%-robotic) were identified. The overall median age was 67 years (interquartile range: 60-72), and 50% (n = 9) of patients were female. Median length of surgery was statistically longer for robotic CP(411 vs. 138 min,p = 0.002); all other intraoperative variables were similar. Postoperatively, a similar number of patients in the open and robotic cohorts developed clinically significant postoperative pancreatic fistulas (37.5% vs. 30%,p = 1) and major complications (37.5% vs. 20%,p = 0.60), respectively. No patients in the robotic cohort developed an incisional hernia, compared to 40% (n = 4) in open (p = 0.08). All patients returned to a baseline level of activity and reported a high quality of life. With the exception of longer operative times, robotic CP is a noninferior, definitive resection technique for select lesions of the middle pancreas. Additionally, the robotic approach may result in a reduction in incisional hernia development.

Robotic-assisted central pancreatectomy: A minimally invasive approach for benign and low-grade lesions

BackgroundCentrally located pancreatic lesions are often treated with extended pancreaticoduodenectomy or distal pancreatectomy resulting in loss of healthy parenchyma and a high risk of diabetes and exocrine insufficiency. Robotic central pancreatectomy (RCP) is a parenchyma sparring alternative that has been shown safe and feasible [1,2]. MethodsIn this article, we describe our operative technique and the perioperative outcomes of a series of RCP for low-grade or benign pancreatic tumors. ResultsSix patients (5 female and 1 man) with a median age of 51.5 (44–68) years underwent a RCP for 2 serous cystadenomas, 2 mucinous cystic tumors, 1 neuroendocrine tumor, and 1 autoimmune pancreatitis. There were no conversions, intraoperative complications, or perioperative transfusions. Median operative time and was 240 (230–291) minutes and median blood loss was 100 (100–400) ml. The median hospital stay was 8 (5–27) days. There were no mortalities, reoperations, or readmissions. One patient developed a grade B pancreatic fistula which was successfully managed conservatively. All resections had free margins and the median tumor size was 2.5 (1.5–3.5) cm. After a mean follow-up of 46 months, no patients presented new-onset diabetes or exocrine insufficiency. ConclusionsRCP represents the least invasive option for both the patient and the pancreatic parenchyma. With a standardized technique, RCP results in low postoperative morbidity and excellent long-term pancreatic function. Although our results are excellent, POPF still represents the main complication of central pancreatectomy with an incidence ranging from 0 to 80% depending on multiple factors such as the surgeon, technique, and pancreatic texture.

The robotic central pancreatectomy: surgical technique, and literature review

The robotic central pancreatectomy: surgical technique, and literature review

A comparative study of end-to-end pancreatic anastomosis versus pancreaticojejunostomy after robotic central pancreatectomy.

Robotic central pancreatectomy has been applied for 20years with the advantage of minimally invasive surgery. The general pancreatic reconstruction approaches include pancreaticojejunostomy and pancreaticogastrostomy. Recently, our group reported a few preliminary cases of application of end-to-end pancreatic anastomosis in robotic central pancreatectomy. This novel approach has not been compared with the conventional approach on a large scale. The objective of this study is to compare end-to-end pancreatic anastomosis with pancreaticojejunostomy after robotic central pancreatectomy based on the perioperative and long-term outcomes. Clinical data consist of demographics, clinicopathologic characteristics, perioperative and long-term outcomes of patients who underwent robotic central pancreatectomy from March 2015 to December 2019 were collected and analyzed. Seventy-four patients received a robotic central pancreatectomy with either end-to-end pancreatic anastomosis (n = 52) or pancreaticojejunostomy (n = 22). End-to-end pancreatic anastomosis was associated with shorter operative time and reduced blood loss. Despite a higher incidence of clinically relevant postoperative pancreatic fistula (69.2% vs. 36.4%, p = 0.009), the newer anastomotic technique was also associated with earlier removal of nasogastric tube and resumption of oral intake. Long-term results, in terms of either endocrine or exocrine function, were not affected by the anastomotic technique. We have shown the feasibility of robotic central pancreatectomy with end-to-end pancreatic anastomosis. Despite streamlined technique, the newer anastomosis appears to improve early post-operative results while preserving endocrine and exocrine functions in the long-term period. Evaluation of the true potential of robotic central pancreatectomy with end-to-end pancreatic anastomosis requires a prospective and randomized study enrolling a large number of patients.

Robotic central pancreatectomy for neuroendocrine tumor (NET) in a patient with a Roux-en-Y Gastric Bypass (RYGB)

Purpose: We present the case of a 45 years old patient with a diagnosis of a single resectable 12mm histologically proved G1 NET of the pancreatic isthmus. Method: In her past medical hystory we notice a laparoscopic gastric by-pass was performed for morbid obesity. Pre-operative work-up included pancreatic MRI, thoracic CT-scan and blood exams. Chromogranine A was within limits. After multidisciplinary discussion either resection or surveillance were conceived considering size and grading, the patient preferred surgical resection in order to avoid life-long surveillance and because of the fear of having a pancreatic lesion potentially evolving. A robotic minimally invasive approach was then considered, the surgical strategy focused on the distal pancreatic stump anastomosis. Results: Intraoperative ultrasound confirmed the absence of other pancreatic lesions. A pancreatico-gastric anastomosis was performed on the excluded stomach, tutored by an Escat drain exteriorized according to Voelker. Post-operative course was uneventful, the patient was discharged on postoperative day 9 (POD9),Pathological findings: grade 1 well-differentiated neuroendocrine tumor, Ki-67 index <1%, R0 (complete resection) Escat drain clamped on POD 14 and withdrawn 1 month after the operation. Conclusion: robotic central pancreatectomy allowed a very precise dissection with the possibility of an ergonomic pancreatico-gastric anastomosis.

Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

Purpose: Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign of low-grade malignant tumor in the body of the pancreas. The aim of central pancreatectomy is to prevent postoperative life-long endocrine and exocrine insufficiency. Due to the high rate of postoperative pancreatic fistula after central pancreatectomy, many surgeons do not routinely use central pancreatectomy in patients who would be eligible. This is the first description of a standardized approach to robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy reconstruction in an adolescent. Method: We demonstrate a video of the technical approach of a robotic assisted central pancreatectomy with Roux-en-Y pancreaticojejunostomy in an adolescent. The surgery was performed using the da Vinci Xi system. Results: The case involves a 16-year-old boy with an incidental finding in the body of the pancreas. The operation time was 248 min with 20 ml blood loss. The postoperative course was uneventful. No clinically relevant pancreatic fistula or other postoperative complications occurred. Pathology assessment revealed a radically resected solid pseudo papillary tumor. Conclusion: Robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy seems feasible and can be safely applied in selected patients in experienced centers.

Robotic central pancreatectomy with pancreaticogastrostomy for solid pseudopapillary tumor

Aims: Central pancreatectomy is a viable option for the removal of benign and low-grade malignant tumor located at the body and neck of the pancreas which are not suitable for enucleation. This video describes the technique of robotic centra pancreatectomy with pancreaticogastrostomy. Methods: A 24-year-old woman with no previous medical history was incidentally diagnosed with a solid tumor of the body of the pancreas. MRI demonstrated a 2-centimeter mass with upstream duct dilatation and EUS-guided FNA confirmed the suspicion of solid pseudopapillary tumor (SPT). Results: Four robotic trocars were placed along the transumbilical line (two on the left, one supraumbilical and one on the right flank, spaced at least 8 cm from each other). Two additional assistant laparoscopic trocars were placed caudal to the previous ones. Robotic central pancreatectomy was performed with a stapler section of the cephalad pancreatic margin. After wide mobilization of the distal pancreatic stump and a running, single-layered pancreaticogastrostomy was performed. The postoperative course was uneventful although a biochemical leak was detected. The patient was discharge on day 11 and surgical drains were removed on day 7 and 19. Pathology confirms the diagnosis of SPT with negative margin and no lymph nodes involved (N0/11). Conclusions: In the setting of a high-volume center, central pancreatectomy is associated with good short-term surgical morbidity and it can be achieved with minimally invasive approach. Pancreaticogastrostomy is a valid reconstruction option and avoids an additional anastomosis.

Robotic central pancreatectomy for a well-differentiated neuroendocrine tumor

In this video, we show a robotic central pancreatectomy for a well-differentiated neuroendocrine tumor. This is the case of a 50-year-old patient admitted to the emergency department for acute pancreatitis. CT-scan and MRI demonstrate the presence of a hypervascularized lesion of approximately 15mm in diameter in the pancreatic isthmus. Octreoscan does not evidence any intense uptake. The colon and the omentum are detached and the stomach is suspended laparoscopically. The robot is docked using a lateral approach. A retropancreatic passage is achieved on the mesenteric-portal axis. An intraoperative ultrasonography is performed to visualize the tumor and delimitate the resection margins. After the dissection, the anastomosis is performed between the distal part of the pancreatic remnant and the posterior gastric wall. The postoperative period was characterised by a grade B pancreatic fistula. Pathologist report confirmed the presence of a well-differentiated neuroendocrine tumor. The patient was discharged on postoperative day 22.

ASO Author Reflections: Formalization of Robotic Central Pancreatectomy Focusing on the Reconstruction of Pancreatic Digestive Continuity

ASO Author Reflections: Formalization of Robotic Central Pancreatectomy Focusing on the Reconstruction of Pancreatic Digestive Continuity

Robotic Central Pancreatectomy for Well-Differentiated Neuroendocrine Tumor: Parenchymal-Sparing Procedure.

The frequency of pancreatic neuroendocrine tumors (pNETs), representative of benign and borderline malignant pancreatic tumors, has been increasing. For pNETs, pancreas-preserving pancreatectomy can be an appropriate option. Conversely, some articles have recently shown that robotic central pancreatectomy (RCP) is feasible and safe. We demonstrated our standardized technique of RCP. In our technique, pancreaticoenteric reconstruction is performed via a pancreaticogastrostomy to manage the distal pancreatic remnant. We also evaluated our initial experience with four consecutive RCPs for well-differentiated pNETs, retrospectively. In our evaluation, two men and two women had a median age of 45years (range 36-64). Median tumor size was 2.1cm (range 1-5), and median operative time was 315min (range 268-630). No transfusion was given perioperatively. Median hospital stay was 17days (range 13-22). Grade A postoperative pancreatic fistula was identified in two patients, while grade B was identified in the other two patients. One of the patients was managed using an additional percutaneous drainage. No operative mortality was observed. Pathological findings confirmed R0 resection for all well-differentiated pNETs (pT1: two patients; pT2: two patients). Central pancreatectomy can be carefully selected as a relevant surgical option for well-differentiated pNETs circumscribed in the pancreatic isthmus and body. Our robotic procedure might overcome the complexity of central pancreatectomy, a parenchymal-preserving procedure, with adequate oncological outcomes.

An end-to-end pancreatic anastomosis in robotic central pancreatectomy

BackgroundSuturing the proximal pancreatic stump and performing pancreaticoenterostomy for the distal pancreatic stump following central pancreatectomy is a conventional procedure. This reconstruction after resection of the pathological pancreatic lesion brings changes in anatomy and physiology. In this study, an innovative one-stage robotic end-to-end pancreatic anastomosis was reported to replace the conventional pancreaticoenterostomy following central pancreatectomy.Materials and methodsThe clinical data of 11 consecutive patients who underwent robotic central pancreatectomy with end-to-end pancreatic anastomosis between August 2017 and December 2017 were analyzed retrospectively.ResultsAll operations were completed successfully without any conversion to open surgery. Nine patients had benign tumors, one had a mass-forming chronic pancreatitis, and one had an isolated pancreatic metastasis from a renal cancer. The mean gap left after central pancreatectomy was 4.3 ± 1.0 cm. The median operative time was 121 (range, 105 to 199) min. The median blood loss was 50 (range, 20 to 100) ml. Seven (63.6%) patients developed complications which included Clavien–Dindo Grade I complications in five patients, a Grade II complication in one patient, and a Grade IIIa complication in one patient. Seven patients developed a Grade B postoperative pancreatic fistula, and two patients a biochemical leak. There was no Grade C or worse pancreatic fistula. Magnetic resonance cholangiopancreatography at postoperative 6 months showed no stricture in any of the main pancreatic ducts. Three patients had an asymptomatic and small pancreatic pseudocyst.ConclusionRobotic central pancreatectomy with end-to-end pancreatic anastomosis was safe and feasible. It restores the normal anatomy of the pancreas. With its good short-and long-term outcomes, it could be an alternative reconstructive method to pancreaticoenterostomy following central pancreatectomy.

Application of End-to-end Anastomosis in Robotic Central Pancreatectomy

Application of End-to-end Anastomosis in Robotic Central Pancreatectomy

A single-team experience with robotic pancreatic surgery in 1010 cases

To assess the safety and advantages of robotic pancreatic surgery (RPS) based on the single-team experience with 1010 cases. The clinical data of 1010 cases of RPS performed by a single team from November, 2011 to September, 2017 in our hospital were collected prospectively and analyzed. In most of cases the surgeries were performed using the third-generation da Vinci robotic surgical system. The 1010 cases receiving RPS included 417 cases of robotic pancreatoduodenectomy (RPD), 428 cases of robotic distal pancreatectomy, 60 cases of robotic central pancreatectomy, 53 cases of robotic pancreatic tumor enucleation, 3 cases of Appleby procedure, and 49 cases of other operations (including 4 cases of innovative robotic retroperitoneal laparoscopic surgery, 4 cases of robotic pancreatic tumor enucleation combined with main pancreatic duct bridging repair, 1 case of single incision robotic pancreatic tumor enucleation, and 2 cases of robotic central pancreatectomy combined with end-to-end anastomosis reconstruction). The median operative time was 210 min (30-720 min) with a median intraoperative blood loss of 80 mL (10-2000 mL), a conversion rate of 4.06% (41/1010), a blood transfusion rate of 6.7% (68/1010), a mean post-operative stay of 10.87∓6.70 days, a complication rate (beyond grade III according to Clavien-Dindo scoring system) of 8.0% (81/1010), and a pancreatic fistula rate (beyond) grade B of 9.21% (93/1010). The mortality rate of the patients was 0.69% (7/1010) in 30 days and 1.31% (12//934) in 90 days. The application of RPS in total pancreatectomy increased steadily from the rate of 10.44% in 2012 to 72.06% in 2017. This represents to our knowledge the world largest series of robotic pancreatic resections. RPS is expected to gradually replace open procedure and laparoscopic procedure to become the primary choice of approach for pancreatectomy. After the learning curve, RPS procedure including distal pancreatectomy, robotic Appleby procedure and other operations can be safely performed, and the experiences from other centers can be beneficial to reduce severe complications in the early stage of learning.

Robotic central pancreatectomy and pancreatogastrostomy: surgical technique and review of literature

Improved imaging techniques, coupled with more frequent cross-sectional imaging, have led to a recent rise in the detection of low-grade pancreatic lesions, including intraductal papillary mucinous neoplasms (IPMN), mucinous cystic neoplasms (MCN), pancreatic neuroendocrine tumors (PNET) and solid pseudopapillary tumors (SPEN). Consequently, in addition to more routine procedures to treat resectable pancreatic lesions such as the pancreaticoduodenectomy (PD) and distal pancreatectomy (DP), the use of central pancreatectomy (CP) to resect low-grade, mid-pancreatic tumors has increased. The aim of a CP is the removal of disease while maintaining optimal preservation of the surrounding pancreatic parenchyma. It has been demonstrated that open CP is safe and efficacious, but literature on robotic CP is limited. The aim of this manuscript was to describe the technique of robotic CP and review the current literature. PubMed, Embase and Google Scholar were reviewed to identify literature on robotic CP. Twelve articles reporting 116 patients were identified and data were collected. The overall morbidity and mortality was 64.7%, and 0.0% respectively. Reoperation was required in 1.7% patients, and 56.9%, and 0.9% developed postoperative pancreatic fistula (POPF) and diabetes mellitus (DM) respectively. No postoperative exocrine insufficiency. These outcomes were comparable to those reported for open and laparoscopic CP. Robotic CP is a safe procedure when performed by trained surgeons at high-volume centers.

Robotic central pancreatectomy operative video

Robotic central pancreatectomy operative video

Central pancreatectomy - a suitable candidate for robotic surgery

Background: In the last few decades central pancreatectomy is increasedly adopted in treatment of benign pancreatic lesions situated in the body of the pancreas, especially in young patients. With recent advances in technology, patients with these lesions could benefit from the advantages of the robotic approach. Case presentation: We present the case of a 30-years old woman investigated for epigastric pain. CT showed a 3 cm cystic tumor located in the proximal part of the pancreas body. Robotic central pancreatectomy with pancreatogastrostomy was performed. Results: Operative time was 220 minutes with minimal blood loss. The postoperative course was marked by a basal left pneumonia on postoperative day 3 treated conservatively. The patient was discharged home on postoperative day 8. Pathology showed a 30 mm well differentiated neuroendocrine tumor with free resection margins. Conclusions: Robotic systems offer several advantages compared to laparoscopy: increased and stabile tridimensional view of the operative field and articulated instruments. Robotic central pancreatectomy seems to be a suitable candidate for robotic surgery requiring delicate vascular dissection and a safe reconstruction. Although there are only few cases published in the literature so far, robotics could lead to an increased adoption of minimally invasive techniques in difficult pancreatic procedures, especially in those requiring reconstructions.

Robotic central pancreatectomy with pancreaticogastrostomy (transgastric approach) in a solid pseudopapillary tumor of the pancreas.

Function preserving minimal invasive pancreatectomy is thought to be ideal approach for benign and borderline malignant tumors of the pancreas because these tumors can be expected for longterm survival. Pancreatic tumor in the neck of the pancreas is a challenging issue. Pancreaticoduodenectomy and distal pancreatectomy with/without splenectomy are the usual modes of surgery for them. Central pancreatectomy is a rare surgical procedure, even in open surgery. With the development of laparoscopic experiences, a few cases of laparoscopic central pancreatectomy have begun to be reported, but they are believed to be still demanding tremendous laparoscopic skills and experiences. However, advancements in technology have encouraged surgeons to overcome the limitations of conventional laparoscopic surgery. Herein, we report a case of robot-assisted central pancreatectomy with pancreaticogastrostomy (transgastric approach). Wrist-like movements of effector instruments and stable 3-D visualization provided by the robot surgical system are believed to enhance the precise and safe laparoscopic performance. More experiences need to be accumulated in order to evaluate the real value of robot pancreatic surgery.

Robotic central pancreatectomy with stented pancreaticogastrostomy: operative details

Central pancreatectomy (CP) is increasingly being used to treat selected lesions of the central pancreatic segment. A step-by-step technique for robotic CP is described and a literature review provided for this minimally invasive approach. A 55-year-old woman was referred to the authors' center for the treatment of a single 4 cm lesion located at the proximal part of the pancreatic body. The da Vinci Robotic surgical system® with a five trocar technique was used. The pancreatic neck was transected using an endoscopic stapler. The pancreatic body was progressively dissected from the splenic vessels right to left and sectioned with an appropriate oncologic margin. A pancreaticogastrostomy protected by a transanastomotic external stent was constructed to the distal pancreatic stump. Surgery lasted 450 min (8 min docking time) with minimal blood loss. Pathology showed a 28 mm well-differentiated neuroendocrine pancreatic tumor with tumor-free resection margins. The patient was discharged home on postoperative day 15 in good condition. Robotic surgery can be safely used for complex pancreatic resection requiring pancreaticoenteric reconstruction. The experience reported so far is still limited but the results are encouraging; robotics shows the potential to bridge the gap between minimally invasive surgery and advanced pancreatic surgery.