Robotic Pancreatic Surgery Research Articles

Interpretation of the 2023 version of the international consensus guidelines for robotic pancreatic surgery

With the continuous advancement of robot-assisted surgical system and the continuous accumulation of clinical experience of surgeons, robot-assisted surgical systems are becoming more and more widely used in the field of pancreatic surgery. Several studies have suggested that robot-assisted pancreatic surgery has significant advantages over traditional pancreatic surgery. The "International consensus guidelines on robotic pancreatic surgery in 2023" provides more standardized guidance on the applicability and safety of robotic-assisted pancreatic surgery, and discusses in detail the indications, safety, learning curve, and related issues of robot-assisted pancreaticoduodenectomy, distal pancreatectomy,and mid pancreatectomy. In addition, the application value of robot-assisted surgical systems in special patients was discussed, as well as the new technology of robot-assisted pancreaticointestinal anastomosis and the new concept of pancreatic duct repair surgery. This article interprets the guidelines based on the recommendations of the guidelines and the practical experience of the authors' team in the field of robotic-assisted pancreatic surgery.

Current Status and Prospects of Robotic Pancreatic Surgery

Introduction Over the past two decades, the application of robotic surgery (RS) in pancreatic surgery has steadily increased. RS offers advantages such as reduced blood loss, less postoperative pain, and shorter hospital stays. However, there is still no consensus on its safety, efficacy, and learning curve in pancreatic diseases. This study aims to summarize the current state of RS in pancreatic surgery and to forecast its prospects. Method A literature search was conducted in PubMed using keywords including “robotic surgery”, “pancreatic surgery”, “minimally invasive surgery”, “open surgery” and “laparoscopic surgery”. Studies on robotic surgery in pancreatic surgery were collected, including research comparing robotic surgery with open or laparoscopic surgery. Results RS has been applied to various pancreatic surgeries, demonstrating good safety and feasibility. Compared to open or laparoscopic surgery, robotic pancreatic surgery (RPS) shows favorable short-term outcomes such as reduced blood loss, shorter hospital stays, and lower conversion rates, especially in surgeries with narrow operative spaces or complex anatomical structures. No significant differences were reported in postoperative complications or short-term mortality rates. RPS achieves comparable R0 resection rates, lymph node harvest numbers, and long-term outcomes. However, RPS also presents limitations, including a long learning curve, high surgical costs, a lack of dedicated instruments, and the absence of natural tactile feedback. Conclusion Robotic pancreatic surgery demonstrates favorable short-term and long-term outcomes, showing promising potential for application. Further multi-center randomized controlled trials are needed to determine its safety and efficacy conclusively.

Robotic surgery reduces the consumption of medical consumables: cost analysis of robotic pancreatic surgery from a tertiary hospital in China.

Robotic surgery has been increasingly adopted in various surgical fields, but the cost-effectiveness of this technology remains controversial due to its high cost and limited improvements in clinical outcomes. This study aims to explore the health economic implications of robotic pancreatic surgery, to investigate its impact on hospitalization costs and consumption of various medical resources. Data of patients who underwent pancreatic surgery at our institution were collected and divided into robotic and traditional groups. Statistical analyses of hospitalization costs, length of stay, costs across different service categories, and subgroup cost analyses based on age, BMI class, and procedure received were performed using t tests and linear regression. Although the total hospitalization cost for the robotic group was significantly higher than that for the traditional group, there was a notable reduction in the cost of medical consumables. The reduction was more prominentamong elderly patients, obese patients, and those undergoing pancreaticoduodenectomy, which could be attributed to the technological advantages of the robotic surgery platform that largely facilitate blood control, tissue protection, and suturing. The study concluded that despite higher overall costs, robotic pancreatic surgery offers significant savings in medical consumables, particularly benefiting certain patient subgroups. The findings provide valuable insights into the economic viability of robotic surgery, supporting its adoption from a health economics perspective.

Robotická pankreatická chirurgie v České republice – první zkušenosti

Robotic surgery is experiencing considerable development across surgical disciplines worldwide. The increasing number of robotic centres, as well as the expansion of the spectrum of robotically assisted minimally invasive procedures contribute to the increase in the number of performed procedures. Compared to laparoscopy or open surgery, robotic surgery offers several advantages, while maintaining adequate safety and oncological radicality of the operations. Pancreatic surgery is currently a hot topic in robotic surgery worldwide. Czech Republic is also following this trend. Robotic surgery is gradually being introduced to established pancreatic centres. The Department of Surgery of the 2nd Faculty of Medicine of Charles University and the Central Military Hospital in Prague ranks among the pioneers of this industry. In this communication, we present a summary of our first experiences with robotic pancreatic surgery. Keywords robotic pancreatic surgery, miniinvazivní chirurgie, robotic surgery, robotic pancreatoduodenectomy, robotic distal pancreatectomy

Robotic Vascular Resection in Pancreatic Ductal Adenocarcinoma: A Systematic Review.

(1) Background: This study comprehensively compared robotic pancreatic surgery with vascular resection (RPS-VR) to other surgical procedures in the treatment of pancreatic ductal adenocarcinoma (PDAC). (2) Methods: A systematic review of relevant literature was conducted to assess a range of crucial surgical and oncological outcomes. (3) Results: Findings indicate that robotic surgery with vascular resections (VRs) significantly prolongs the duration of surgery compared to other surgical procedures, and they notably demonstrate an equal hospital stay. While some studies reported a lower conversion rate and a higher rate of blood loss and blood transfusion in the RPS-VR group, others found no significant disparity. Furthermore, RPS-VR consistently correlated with comparable recurrence rates, free margins R0, postoperative mortality, and complication rates. Concerning the last one, certain reviews reported a higher rate of major complications. Overall survival and disease-free survival remained comparable between the RPS-VR and other surgical techniques in treating PDAC. (4) Conclusions: The analysis emphasizes how RPS-VR is a resembling approach in terms of surgical outcomes and aligns with existing literature findings in this field.

International consensus guidelines on robotic pancreatic surgery in 2023.

With the rapid development of robotic surgery, especially for the abdominal surgery, robotic pancreatic surgery (RPS) has been applied increasingly around the world. However, evidence-based guidelines regarding its application, safety, and efficacy are still lacking. To harvest robust evidence and comprehensive clinical practice, this study aims to develop international guidelines on the use of RPS. World Health Organization (WHO) Handbook for Guideline Development, GRADE Grid method, Delphi vote, and the AGREE-II instrument were used to establish the Guideline Steering Group, Guideline Development Group, and Guideline Secretary Group, formulate 19 clinical questions, develop the recommendations, and draft the guidelines. Three online meetings were held on 04/12/2020, 30/11/2021, and 25/01/2022 to vote on the recommendations and get advice and suggestions from all involved experts. All the experts focusing on minimally invasive surgery from America, Europe and Oceania made great contributions to this consensus guideline. After a systematic literature review 176 studies were included, 19 questions were addressed and 14 recommendations were developed through the expert assessment and comprehensive judgment of the quality and credibility of the evidence. The international RPS guidelines can guide current practice for surgeons, patients, medical societies, hospital administrators, and related social communities. Further randomized trials are required to determine the added value of RPS as compared to open and laparoscopic surgery.

Robotic pancreatic surgery at a western Indian center: start up experience

Robotic pancreatic surgery at a western Indian center: start up experience

Robotic pancreatic surgery in pediatric patients: is it safe and feasible – a case of robotic distal pancreatectomy in a fourteen years old patient with solid pseudopapillary neoplasm

Robotic pancreatic surgery in pediatric patients: is it safe and feasible – a case of robotic distal pancreatectomy in a fourteen years old patient with solid pseudopapillary neoplasm

Robotic Pancreatic Surgery: Current Status and Techniques

Robotic Pancreatic Surgery: Current Status and Techniques

Robotická chirurgie slinivky břišní v pankreatochirurgickém high-volume centru – první zkušenosti

Summary: Introduction: Robotic pancreatic surgery is still not widely used in the Czech Republic. On a global scale, it is gradually being systematically implemented, especially in high-volume centers. The study presents the first experiences with robotic pancreatic surgery in a pancreatic surgery high-volume center in the Czech Republic. Methods: Comparative analysis of the first ten patients operated on robotically for pancreatic pathology with a comparable group operated open (smaller procedures: left pancreatectomy with/without splenectomy, enucleation, central resection) evaluates age, length of hospitalization, ICU stay, blood loss and operative time using non-parametric Mann--Whitney U-test, and complications and rehospitalization using descriptive statistics. The results: The compared sets consist of 10 patients, 5 women, with a robotic procedure (5× enucleation, 4× distal pancreatectomy and central resection – median age 65.3 [46–76] years) and 10 patients, 5 women, with comparable open procedures (5× enucleation, 4× distal resection and central resection – median age 65.5 [52–78]years. Hospitalization length 4.5 days vs. 9 days (P = 0.0003) and operation time 275 min vs. 142 min (P = 0.004) were statistically different in the robotic vs open group. ICU stay and blood loss were lower in the robotic group, but not statistically significant, age was comparable. Complications according to the Clavien-Dindo classification in the open group: 3× type II, 1× type IIIa, 1× type IIIb, in the robotic group 1× type II and 1× type IIIa. Rehospitalization in the open group was 2×, in the robotic group 1x, always for late postoperative complications. Conclusion: Robotic surgery of the pancreas is currently in its infancy in the Czech Republic. The experience so far with the first ten patients operated on using the DaVinci Xi robotic system has yielded promising results in form of shorter hospitalization, but at cost of longer operating time. Key words: pancreatectomy – enucleation – pancreas – robotics – minimal invasiveness – hospital stay – enhanced postsurgical recovery

The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS).

To develop and update evidence-based and consensus-based guidelines on laparoscopic and robotic pancreatic surgery. Minimally invasive pancreatic surgery (MIPS), including laparoscopic and robotic surgery, is complex and technically demanding. Minimizing the risk for patients requires stringent, evidence-based guidelines. Since the International Miami Guidelines on MIPS in 2019, new developments and key publications have been reported, necessitating an update. Evidence-based guidelines on 22 topics in 8 domains were proposed: terminology, indications, patients, procedures, surgical techniques and instrumentation, assessment tools, implementation and training, and artificial intelligence. The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS, September 2022) used the Scottish Intercollegiate Guidelines Network (SIGN) methodology to assess the evidence and develop guideline recommendations, the Delphi method to establish consensus on the recommendations among the Expert Committee, and the AGREE II-GRS tool for guideline quality assessment and external validation by a Validation Committee. Overall, 27 European experts, 6 international experts, 22 international Validation Committee members, 11 Jury Committee members, 18 Research Committee members, and 121 registered attendees of the 2-day meeting were involved in the development and validation of the guidelines. In total, 98 recommendations were developed, including 33 on laparoscopic, 34 on robotic, and 31 on general MIPS, covering 22 topics in 8 domains. Out of 98 recommendations, 97 reached at least 80% consensus among the experts and congress attendees, and all recommendations were externally validated by the Validation Committee. The EGUMIPS evidence-based guidelines on laparoscopic and robotic MIPS can be applied in current clinical practice to provide guidance to patients, surgeons, policy-makers, and medical societies.

Role of the Pfannenstiel Incision in Robotic Hepato-Pancreato-Biliary Surgery

Studies remain limited on the role of the Pfannenstiel incision in minimally invasive hepato-pancreato-biliary (HPB) surgery, especially robotic surgery. The role of various extraction sites in robotic HPB surgery should be understood. Herein, we describe the surgical techniques, outcomes, advantages, and disadvantages of the Pfannenstiel incision in robotic pancreatic surgery. Seventy patients underwent robotic pancreatectomy at our institution between September 2020 and October 2022. The Pfannenstiel incision was used for specimen retrieval in 55 patients. Advantages of the Pfannenstiel incision include less pain, cosmetic benefits, and a lower incidence of complications. Moreover, the specimen could be removed using the robotic system docked. However, all complex reconstructions should be performed intra-abdominally during robotic pancreatoduodenectomies. The incidence of mortality and postoperative pancreatic fistula (grade B) was 0% and 9.1%, respectively. During the median follow-up (11.2 months) after surgery, complications at the Pfannenstiel incision site included surgical site infection (n = 1, 1.8%) and incisional hernia (n = 1, 1.8%). The Pfannenstiel incision can be a useful option for specimen retrieval in minimally invasive HPB surgery, according to the surgeon's preferences and the patient's condition.

Robotic pancreatic and liver surgery is being done more frequently: Are we getting better or bolder?

Background: Robotic surgery has been increasingly adopted in liver and pancreatic surgeries. A paucity of data exists concerning utilization, pace of uptake, peri-operative outcomes, and evolution of these outcomes as robotic procedures become commonplace.

Implementation of Robotic Pancreatic Surgery Program in our Center – Is Copy Paste from Established High-volume Robotic Surgery Center Feasible?

Implementation of Robotic Pancreatic Surgery Program in our Center – Is Copy Paste from Established High-volume Robotic Surgery Center Feasible?

Implementing Robotic Pancreatic Surgery in Belgium, Initial 2-year Experience in a High-volume Center

Implementing Robotic Pancreatic Surgery in Belgium, Initial 2-year Experience in a High-volume Center

Robotic Pancreatoduodenectomy - how I do it: tips, tricks and pitfalls to standardize the technique to reduce postoperative morbidity and mortality

benefits of minimally invasive surgery and equivalent oncological outcomes compared with conventional open PD (OPD). When LPD and RPD are compared, RPD offers better precision with 3D vision and advanced instrumentation. Although the learning curve for RPD is long with a longer operating time compared with OPD, this can be reduced to a duration similar to that for OPD through standardization of techniques and case numbers.Perioperative outcomes such as length of stay, blood loss, and transfusion requirement are significantly improved compared to OPD and fewer cases require conversion to open than LPD. In this article, we describe our approach to RPD through standardizing PD techniques along with tips and tricks for the benefit of surgeons interested in learning robotic pancreatic surgery.

Establishing an open and robotic pancreatic surgery program in a level 1 trauma center community teaching hospital and comparing its outcomes to high-volume academic center outcomes: a retrospective review

BackgroundThe debate of whether to centralize hepato-pancreato-biliary surgery has been ongoing. The principal objective was to compare outcomes of a community pancreatic surgical program with those of high-volume academic centers.MethodsThe current pancreatic surgical study occurred in an environment where (1) a certified abdominal transplant surgeon performed all surgeries; (2) complementary quality enhancement programs had been developed; (3) the hospital’s trauma center had been verified; and (4) the hospital’s surgical training had been accredited. Pancreatic surgical outcomes at high-volume academic centers were obtained through PubMed literature searches. Articles were selected if they described diverse surgical procedures. Two-tailed Fisher exact and mid-P tests were used to perform 2 × 2 contingency analyses.ResultsThe study patients consisted of 64 consecutive pancreatic surgical patients. The study patients had a similar pancreaticoduodenectomy proportion (59.4%) when compared to literature patients (66.8%; P = 0.227). The study patients also had a similar distal pancreatectomy proportion (25.0%) when compared to literature patients (31.9%; P = 0.276). The study patients had a significantly higher American Society of Anesthesiologists physical status ≥ 3 proportion (100%) than literature patients (28.1%; P < 0.001). The 90-day study mortality proportion (0%) was similar to the literature proportion (2.3%; P = 0.397). The study postoperative pancreatic fistula proportion was lower (3.2%), when compared to the literature proportion (18.4%; P < 0.001; risk ratio = 5.8). The study patients had a lower reoperation proportion (3.1%) than the literature proportion (8.7%; mid-P = 0.051; risk ratio = 2.8). The study patients had a lower surgical site infection proportion (3.1%) than those in the literature (21.1%; P < 0.001; risk ratio = 6.8). The study patients had equivalent delayed gastric emptying (15.6%) when compared to literature patients (10.6%; P = 0.216). The study patients had decreased Clavien–Dindo grades III–IV complications (10.9%) compared to the literature patients (21.8%; mid-P = 0.018). Lastly, the study patients had a similar readmission proportion (20.3%) compared to literature patients (18.4%; P = 0.732).ConclusionDespite pancreatic surgical patients having greater preoperative medical comorbidities, the current community study outcomes were comparable to or better than high-volume academic center results.

Single-port (SP) robotic pancreatic surgery using the da Vinci SP system: A retrospective study on prospectively collected data in a consecutive patient cohort

BackgroundSingle-port (SP) robotic systems have the advantages of multi-jointed wristed instruments and a fully wristed three-dimensional high-definition camera. SP robotic pancreatic surgery (SPRPS) is rarely reported because of its complexity and technical challenges. This study aimed to evaluate the feasibility of SPRPS using the new da Vinci SP system. MethodsThe demographics and short-term outcomes of a consecutive series of patients who underwent SP robotic pancreatic enucleation, distal pancreatectomy, and pancreaticoduodenectomy between December 24, 2021, and February 23, 2022, were analyzed. ResultsTwenty-three patients (eight men and 15 women; mean age, 39.7 years) were included in the study; 11 underwent SP robotic pancreatic enucleation, 11 underwent SP robotic distal pancreatectomy, and one underwent SP robotic pancreaticoduodenectomy. The mean operative time was 156.5 min, and the median estimated blood loss was 40.0 (interquartile range, 20.0–50.0) mL. No patient required conversion to laparotomy or blood transfusions. One patient in each of the three groups had grade B postoperative pancreatic fistula (POPF) and abdominal infection; they all recovered after conservative treatment. No patient had postoperative complications of grade C POPF, pancreatectomy hemorrhage, or major complications (Clavien grade ≥3). The mean length of postoperative length of hospital stay was 4.0 days. Pathological examination showed that all tumors were benign, and the mean largest tumor diameter was 2.8 cm. ConclusionsSPRPS using the da Vinci SP system is safe and feasible in selected patients. Further research and more surgical experience are needed to determine the indications for SPRPS.

Robotic Pancreatic Surgery - Learning Curve and Implementation

Minimally invasive resection techniques for the treatment of various pathologies of the pancreas are potentially advantageous for the treated patients in terms of restitution time and postoperative morbidity, but are a technical challenge for the responsible surgeon. The introduction of robotic assistance in visceral surgery offers a possibility for further distribution of minimally invasive procedures in pancreatic surgery.The aim of this study was to examine the possibilities for developing robotic pancreatic surgery in Germany. The data are based on the quality reports of the hospitals for the years 2015-2019 combined with a selective literature search.The number of quality reports available decreased from 1635 to 1594 between 2015 and 2019. A median of 96 clinics performed 11-20, 56 clinics 21-50 and 15 clinics more than 50 pancreaticoduodenectomies. For distal resections, there were 35 clinics with 11-20, 14 clinics with 21-50 and two clinics with more than 50 procedures. In relation to all clinics with at least five distal resections per year, minimally invasive procedures were performed at only 29 clinics; a ratio to laparoscopic left resections of over 50% was reported in only seven clinics.According to the literature, the learning curves for robotic pancreatic distal resection and pancreaticoduodenectomy diverge. While the learning curve for robotic distal resection is completed after around 20 procedures, the learning curve for robotic pancreaticoduodenectomy has several plateaus, which are reached after around 30, 100 and 250 procedures.Due to the decentralised structure of pancreatic surgery in Germany, a nationwide introduction of robotic pancreatic surgery is unlikely. The routine use of robotic pancreaticoduodenectomy will probably be restricted to high volume centres in the foreseeable future.

Learning Curves in Open, Laparoscopic, and Robotic Pancreatic Surgery: A Systematic Review and Proposal of a Standardization.

To depict and analyze learning curves for open, laparoscopic, and robotic pancreatoduodenectomy (PD) and distal pancreatectomy (DP). Formal training is recommended for safe introduction of pancreatic surgery but definitions of learning curves vary and have not been standardized. A systematic search on PubMed, Web of Science, and CENTRAL databases identified studies on learning curves in pancreatic surgery. Primary outcome was the number needed to reach the learning curve as defined by the included studies. Secondary outcomes included endpoints defining learning curves, methods of analysis (statistical/arbitrary), and classification of learning phases. Out of 1115 articles, 66 studies with 14,206 patients were included. Thirty-five studies (53%) based the learning curve analysis on statistical calculations. Most often used parameters to define learning curves were operative time (n = 51), blood loss (n = 17), and complications (n = 10). The number of procedures to surpass a first phase of learning curve was 30 (20-50) for open PD, 39 (11-60) for laparoscopic PD, 25 (8-100) for robotic PD (P = 0.521), 16 (3-17) for laparoscopic DP, and 15 (5-37) for robotic DP (P = 0.914). In a three-phase model, intraoperative parameters improved earlier (first to second phase: operating time -15%, blood loss -29%) whereas postoperative parameters improved later (second to third phase: complications -46%, postoperative pancreatic fistula -48%). Studies with higher sample sizes showed higher numbers of procedures needed to overcome the learning curve (rho = 0.64, P < 0.001). This study summarizes learning curves for open-, laparoscopic-, and robotic pancreatic surgery with different definitions, analysis methods, and confounding factors. A standardized reporting of learning curves and definition of phases (competency, proficiency, mastery) is desirable and proposed.