Robotic Pancreaticoduodenectomy Research Articles

Robotic pancreatoduodenectomy for pancreatic cancer with aberrant vasculature: How to do it

Robotic pancreatoduodenectomy for pancreatic cancer with aberrant vasculature: How to do it

Current Trends of types of pancreatoduodenectomy focusing on the role of robot assisted pancreatoduodenectomy

Pancreatoduodenectomy (PD) is the most challenging abdominal surgery. In spite of the popularization of laparoscopic procedures for most GI surgery, laparoscopic PD is not so widely spread. Recently, robotic PD has gained popularity due to many merits. So we investigated current trends of types of PD and the clinical role of robotic surgery. Between 2015 and 2020, a total of 1,263 PD was performed. 929 patients underwent open PD, and 334 underwent robotic PD. Demographics and surgical outcomes were analyzed according to the time period, and propensity score-matched (PSM) analysis was performed to evaluate complications and oncologic outcomes. Patients undergoing robotic PD were younger (63.7 vs. 65.2 years, p = 0.035); however, no significant difference was observed in sex (p = 0.152) and BMI (p = 0.742). Robotic PD patients were more likely to have the benign disease (30.2%) than those who received open surgery (13.7%). Robot PD has gradually increased from 6.3% to 71.6%. Operation time was longer in the robot group (338.8 vs. 296.5 minutes, p < 0.001); however, estimated blood loss did not significantly differ (473.5 vs. 429.2 mL, p = 0.335). Overall complication (18.6% vs. 17.9%, p = 0.843) and CR-POPF rates (9.9% vs. 8.4%, p = 0.478) were similar. The hospital stay was shorter in robot PD (10.9 days) than open PD (15.3 days). After PSM analysis, no significant difference of morbidity and survival outcome in cancer patients was observed. The number of robot PD has markedly increased in a relatively short time showing comparable morbidity/mortality and oncologic outcome. Considering better recovery and cosmetic outcomes, robot PD has become one of standard surgical methods in pancreatic surgery.

Total robotic pancreatoduodenectomy with pancreatico-jejunostomy by modified Blumgart technique

Robotic pancreatoduodenectomy (RPD) has gained ground in recent past. Pancreaticojejunostomy with modified Blumgart technique is less often used with minimally invasive approach due to its technical complexity, however it is feasible with robotics due to its multi-arm platform, three-dimensional view and an extended range of motion. We describe our approach for total robotic pancreatoduodenectomy with pancreatojejunostomy by modified Blumgart technique in this video. Patient placed in reverse trendelenburg position with leg-split posture. Two port on each side of umbilicus 8 mm apart in mid-clavicular line and anterior axillary line with infra-umbilical port (12 mm) work as an assistant port. The dissection phase is performed in a standard manner with extended kocherisation, early division of antrum, caudal-cranial dissection of uncinate process. Pancreatico-jejunostomy: Transpancreatic horizontal mattress sutures are placed to secure the pancreatic parenchyma to the jejunum using 3-0 prolene. After a small enterotomy, a series of interrupted sutures with 5-0 PDS are used for duct to mucosa anastomosis. Finally, anterior layer of 3-0 prolene buttress sutures completes the anastomosis. Hepaticojejunostomy by Kelly's technique and gastrojejunostomy either stapled or hand sewn after extraction of specimen. Feeding jejunostomy was performed. Patient did well in the post-operative period and doing well after 1 year of follow up. Robotic pancreatoduodenectomy with pancreatojejunostomy using modified Blumgart technique is feasible with robotic arms.

Multi-center comparative study between totally laparoscopic and robotic pancreaticoduodenectomy: Propensity score and learning curve matching analysis

Minimally invasive surgery has been adopted in pancreaticoduodenectomy (PD) recently, though there have been few reports comparing totally robotic PD (TRPD) to totally laparoscopic PD (TLPD). Retrospective multi-center analysis was performed regarding TLPD and TRPD from the initial case of each three surgeons to June 2020. Perioperative outcomes were analyzed using propensity score matching (PSM). Additional PSM analysis was done after excluding cases before reaching learning curve maturity to minimize technical biases. A total of 362 cases were included (TLPD 282 and TRPD 80). Mean age was 61.7 ± 11.9 years, younger in TRPD (56.4 ± 9.9 vs. 63.2 ± 12.1, p < 0.001). Malignancy rate reported 72.5% in TRPD, and 85.5% in TLPD (p = 0.011). There was one case of mortality. Operative time was shorter in TRPD (409.1 ± 77.4 vs. 455.3 ± 75.1 min, p < 0.001). Postoperative hospital stay was also shorter in TRPD (11.7 ± 6.3 vs. 17.1 ± 11.7 days, p < 0.001). Conversion rate was 10.3% in TLPD, while no conversion in TRPD (p < 0.001). There were no significant differences in major complications (Clavien-Dindo ≥ III) or clinically-relevant postoperative pancreatic fistula (CR-POPF). R0 resection rate was 94.9% in TRPD, and 92.8% in TLPD. The number of retrieved lymph nodes showed higher in TRPD (17.1 ± 7.9 vs. 12.6 ± 8.7, p < 0.001). After PSM, operative time (411.6 ± 75.4 vs. 452.6 ± 76.8, p = 0.001) and hospital stay (11.9 ± 6.5 vs. 14.6 ± 7.8, p = 0.027) reported shorter in TRPD. Major complications and CR-POPF showed no significant differences. Likewise, after excluding immature cases, additional PSM analysis showed similar results for operative time, hospital stay and complications including CR-POPF. Both TRPD and TLPD are safe and feasible approaches showing comparative complications. TRPD showed shorter operative time and hospital stay, though there were no differences in major complications or CR-POPF.

Gastroenteropancreatic neuroendocrine tumor of the accessory papilla of the duodenum: a case report

BackgroundContrary to the increasing incidence of gastroenteropancreatic neuroendocrine tumors (GEP-NETs), GEP-NETs of the accessory papilla of the duodenum are extremely rare. Furthermore, there have been no recommendations regarding the treatment strategy for GEP-NETs of the accessory papilla of the duodenum. We present a case of GEP-NET of the accessory papilla of the duodenum successfully treated with robotic pancreatoduodenectomy.Case presentationA case of a 70-year-old complaining of no symptoms was diagnosed with GEP-NET of the accessory papilla of the duodenum. A 8-mm tumor was located at the submucosal layer with a biopsy demonstrating a neuroendocrine tumor grade 1. The patient underwent robotic pancreatoduodenectomy as curative resection for the tumor. The total operative time was 406 min with an estimated blood loss of 150 mL. The histological examination revealed a well-differentiated neuroendocrine tumor with low Ki-67 index (< 1%). In the posterior areas of the pancreas, the lymph node metastases were detected. The patient was followed up for 6 months with no recurrence postoperatively.ConclusionsConsidering the potential risks of the lymph node metastases, the standard treatment strategy for GEP-NETs of the accessory papilla of the duodenum should be radical resection with pancreatoduodenectomy. Minimally invasive approach can be the alternative to the conventional open surgery.

Robotic pancreatoduodenectomy for large solid pseudopapillary tumor of the pancreas using precise and systematic vascular control technique

Large tumors in the head of the pancreas pose technical challenges during resection in minimally invasive pancreatoduodenectomy (PD). The precise and systematic vascular control of the pancreaticoduodenal branches of the superior mesenteric artery and vein during robotic PD for a large solid pseudopapillary tumor of the pancreas is described in this video. A 16-year-old female presented with a lump in the abdomen, early satiety, and epigastric pain of 3 months duration. Contrast-enhanced computed tomography abdomen revealed 7.1 × 6.2 cm solid mass with cystic areas in the head of the pancreas. The tumor was compressing the portal vein with dilated pancreaticoduodenal veins. In the present technique, the anterosuperior pancreaticoduodenal vein is controlled first, followed by the superior pancreaticoduodenal artery (by ligating Gastroduodenal artery). This is followed by the control of inferior pancreaticoduodenal veins and arteries. The posterosuperior pancreaticoduodenal vein is ligated at the end to prevent vascular congestion of the uncinate region. The duration of surgery and intraoperative blood loss were 440 minutes and 200 mL, respectively. The patient had an uneventful postoperative course and discharged on the sixth postoperative day. Histopathological examination confirmed the diagnosis of the solid pseudopapillary tumor. At nine months follow-up, the patient remains asymptomatic with no recurrence. A stepwise precise vascular control described in this report could minimize intraoperative bleeding during robotic PD for large tumors in the head of the pancreas.

Impact of body mass index on the early experience of robotic pancreaticoduodenectomy

Obesity increases surgical morbidity and mortality in open pancreaticoduodenectomy (OPD). Its influence on robotic pancreaticoduodenectomy (RPD) remains uncertain. This study aimed to investigate the impact of body mass index (BMI) on the early experience of RPD. Between June 2015 and April 2020, 68 consecutive RPDs were performed at the National Cheng Kung University Hospital. The patients were categorized as normal-weight (BMI < 23 kg/m2), overweight (BMI = 23–27.5 kg/m2), and obese (BMI > 27.5 kg/m2) according to the definition of obesity in Asian people from the World Health Organization expert consultation. Preoperative characteristics, operative details, and postoperative outcomes were prospectively collected. The cumulative sum was used to assess the learning curves. The average age of the patients was 64.8 ± 11.7 years with an average BMI of 24.6 ± 3.7 kg/m2 (23 normal-weight, 29 overweight, and 16 obese patients). Eighteen patients were required to overcome the learning curve. The overall complication rate was 51.5%, and the major complication rate (Clavien grade ≥ III) was 19.1%. The normal-weight group showed the most favorable outcomes. The blood loss, major complication rate, peripancreatic fluid collection rate, and conversion rate were higher in the obese group than in the non-obese group. There were no differences in the operative time, clinically relevant postoperative pancreatic fistula, postoperative hemorrhage, delayed gastric emptying, bile leak, wound infection, reoperation, hospital stay, and readmission rate between the obese and non-obese groups. Multivariate analysis showed obesity as the only independent factor for major complications (OR: 5.983, CI: 1.394–25.682, p = 0.001), indicating that obesity should be considered as a surgical risk factor during the implementation of RPD.

Short-term and long term morbidity in robotic pancreatic surgery: a systematic review.

Pancreatic cancer is one of the most aggressive and lethal tumours in Western society. Pancreatic surgery can be considered a challenge for open and laparoscopic surgeons, even if the accuracy of gland dissection, due to the close relationship between pancreas, the portal vein, and mesenteric vessels, besides the reconstructive phase (in pancreaticoduodenectomy), lead to significant difficulties for laparoscopic technique. Minimally invasive pancreatic surgery changed utterly with the development of robotic surgery. However, this review aims to make more clarity on the influence of robotic surgery on long-term morbidity. A systematic literature search was performed in PubMed, Cochrane Library, and Scopus to identify and analyze studies published from November 2011 to September 2020 concerning robotic pancreatic surgery. The following terms were used to perform the search: "long term morbidity robotic pancreatic surgery". Eighteen articles included in the study were published between November 2011 and September 2020. The review included 2041 patients who underwent robotic pancreatic surgery, mainly for a malignant tumour. The two most common robotic surgical procedures adopted were the robotic distal pancreatectomy (RDP) and the robotic pancreaticoduodenectomy (RPD). In two studies, patients were divided into groups; on the one hand, those who underwent a robotic pancreaticoduodenectomy (RPD), on the other hand, those who underwent robotic distal pancreatectomy (RDP). The remaining items included surgical approach such as robotic middle pancreatectomy (RMP), robotic distal pancreatectomy and splenectomy, robotic-assisted laparoscopic pancreatic dissection (RALPD), robotic enucleation of pancreatic neuroendocrine tumours. Comparison between robotic surgery and open surgery lead to evidence of different advantages of the robotic approach. A multidisciplinary team and a surgical centre at high volume are essential for better postoperative morbidity and mortality.

Wrapping double-mattress anastomosis for pancreaticojejunostomy in minimally invasive pancreaticoduodenectomy can significantly reduce postoperative pancreatic fistula rate compared with conventional pancreaticojejunostomy in open surgery: An analysis of a propensity score-matched sample

BackgroundMinimally invasive pancreaticoduodenectomy (MIPD), including laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD), is technically demanding because of pancreaticojejunostomy (PJ). Postoperative pancreatic fistula (POPF) is the most serious complication of MIPD and open pancreaticoduodenectomy (OPD). Contrary to expectations, conventional PJ in MIPD did not improve POPF rate and length of hospital stay. High POPF rates are attributed to technical issues encountered during MIPD, which include motion restriction and insufficient water tightness. Therefore, we developed wrapping double-mattress anastomosis, the Kiguchi method, which is a novel PJ technique that can improve MIPD. Herein, we describe the Kiguchi method for PJ in MIPD and compare the outcomes between this technique and conventional PJ in OPD. MethodsThe current retrospective study included 83 patients in whom the complete obstruction of the main pancreatic duct by pancreatic tumors was absent on preoperative imaging. This research was performed from September 2016 to August 2020 at Fujita Health University Hospital. All patients were evaluated as having a soft pancreatic texture, which is the most important factor associated with POPF development. Briefly, 50 patients underwent OPD with conventional PJ (OPD group). Meanwhile, 33 patients, including 15 and 18 who had LPD and RPD, respectively, underwent MIPD using the Kiguchi method (MIPD group). After a 1:1 propensity score matching, 30 patients in the OPD group were matched to 30 patients in the MIPD group. ResultsThe patients’ preoperative data did not differ. The grade B/C POPF rate was significantly lower in the MIPD group than in the OPD group (6.7% vs 40.0%, p = 0.002). The MIPD group had a significantly shorter median length of hospital stay than the OPD group (24 vs 30 days, p = 0.004). ConclusionThe novel Kiguchi method in MIPD significantly reduced the POPF rate in patients without complete obstruction of the main pancreatic duct.

Mitigation of the Robotic Pancreaticoduodenectomy Learning Curve through comprehensive training

BackgroundThere is an associated lag in achieving competency for robotic pancreaticoduodenectomy (PD), resulting in a learning curve. We hypothesize that the reported learning curve can be mitigated through a comprehensive graduated training protocol. MethodsAll patients (n = 237) who underwent an open (n = 197, 83.1%) or robotic (n = 40, 16.9%) PD between 2015-2019 were identified at The Ohio State University. The learning curve for operative time and surgical failure (defined as conversion to open, blood transfusion, or Clavien-Dindo complication grade ≥3) was analyzed using a risk adjusted cumulative summation technique. ResultsAfter 10 cases, operative time plateaued to a mean of 468.3 ± 96.3 minutes for robotic PD versus a mean of 332.5 ± 103.9 minutes for open PD (P < 0.001). There was no further apparent learning curve over time relative to rates of operative time or surgical failure. After propensity score-matching, patients undergoing robotic PD had a similar incidence of major complications, grade B/C postoperative pancreatic fistula, and delayed gastric emptying versus patients undergoing open PD (all P > 0.05). ConclusionCompletion of a comprehensive procedure-specific robotic training protocol for PD mitigated the learning curve for this operative approach by shifting the curve into the training/simulation phase rather than the live operating phase. These data hold important implications for the future training and accreditation of surgeons embarking on robotic PD.

Learning curve of three European centers in laparoscopic, hybrid laparoscopic, and robotic pancreatoduodenectomy.

There are limited numbers of high-volume centers performing minimally invasive pancreatoduodenectomy (MIPD) routinely. Several approaches to MIPD have been described. Aim of this analysis was to show the learning curve of three different approaches to MIPD. Focus was on determining the number of cases necessary to obtain proficient level in MIPD. Retrospective study wherein outcomes of 300 consecutive patients at three centers-at each center the initial 100 consecutive patients undergoing MIPD for malignant and benign tumors of the head of the pancreas and perimpullary area, performed by three experienced surgeons were collected and analyzed. Overall, 300 patients after MIPD were included: the three different cohorts (laparoscopic n = 100, hybrid n = 100, robotic n = 100). CUSUM analysis of operating time in each center demonstrated that the plateau for laparoscopic PD was n = 61, for hybrid PDes was n = 32 and for robotic PD was n = 68. Median operative time for laparoscopic, hybrid, and robotic approaches was 395min, 404min, 510min, respectively. Intraoperative blood loss for laparoscopic PD, hybrid PD, and robotic PD was 250ml, 250ml, and 413ml, respectively. Delayed gastric emptying occurred 12% in laparoscopic cohort, 10% in hybrid, and 53% in robotic cohort. Major complications (Clavien-Dindo III/IV) rate for laparoscopic PD, hybrid PD, and robotic PD was 32%, 37%, and 22% with 5% death in each cohorts, respectively. This analysis of the learning curve of three European centers found a shorter learning curve with hybrid PD as compared to laparoscopic and robotic PD. In implementation of a MIPD program, a stepwise approach might be beneficial.

Robotic pancreaticoduodenectomy for pancreatic head cancer and periampullary lesions.

Pancreaticoduodenectomy, so‐called “Whipple operation,” is a time‐consuming and technically demanding complex operation. Traditionally, this procedure has been performed most usually by open approach, which results in a large and painful wound. With the introduction of laparoscopic and robotic surgery, minimally invasive surgery (MIS) has emerged as a worldwide trend to improve wound cosmesis and to minimize wound pain. Although MIS for pancreaticoduodenectomy has also been attempted at some centers, the role of MIS, either robotic or laparoscopic approach, has not been well‐established for complex pancreaticoduodenectomy. Given that laparoscopic pancreaticoduodenectomy has been limited by its technical complexity and the high level of advanced laparoscopic skills required for pancreatic reconstruction, a robotic surgical system is introduced to overcome several limitations related to the laparoscopic approach. Providing high‐quality three‐dimensional (3‐D) vision, high optical magnification, articulation of robotic instruments, greater precision with suture targeting, and elimination of surgeon tremor, robotic surgical systems innovatively perform more delicate and complex procedures involving extensive dissection and suturing techniques such as pancreaticoduodenectomy. Although associated with longer operative time, robotic pancreaticoduodenectomy (RPD) has been claimed to have the benefits of less delayed gastric emptying, less blood loss, shorter length of postoperative stay, and lower wound infection rate, as compared with the traditional open pancreaticoduodenectomy (OPD). Moreover, RPD seems to be not only technically feasible but also justified without compromising the survival outcomes for pancreatic head and ampullary adenocarcinomas. Therefore, RPD could be recommended not only to surgeons but also to patients in terms of surgical feasibility, surgical outcomes, and patient satisfaction.

Propensity score-matched comparison of the oncological feasibility and survival outcomes for pancreatic adenocarcinoma with robotic and open pancreatoduodenectomy.

This study is to clarify the feasibility of and justification for robotic pancreaticoduodenectomy (RPD) in patients with pancreatic adenocarcinoma. A 1-to-1 propensity score-matched comparison of RPD and open pancreaticoduodenectomy (OPD) was performed based on six covariates commonly used to predict the survival outcome for pancreatic adenocarcinoma. A total of 130 patients were enrolled, with 65 in each study group after propensity score matching. The median operating time was longer for RPD (8.3h vs. 7.0h, P = 0.002). However, RPD was associated with less blood loss, lower overall surgical complication rate, and lower incidence of delayed gastric emptying. The resection radicality was oncologically similar between these two groups, but the median lymph node yield was higher for RPD (18 vs. 16, P = 0.038). Before propensity score matching, the 5-year survival was better in RPD (27.0% vs. 17.6%, P = 0.006). After matching, there was still a trend towards improved overall survival in the RPD group; however, the difference in 5-year survival between RPD and OPD was not significant (24.5% vs. 19.7%, P = 0.088). RPD is not only technically feasible with no increase in surgical risk but also oncologically justifiable without compromising survival outcome. However, unlike randomized control trials, the limitations in this propensity score-matched analysis only accounted for 6 observed covariates commonly used to predict the survival outcome in patients with pancreatic adenocarcinoma, and confounders not included in this study could also affect our results.

Robotic Artery-First Approach During Pancreatoduodenectomy.

Surgical resection with adjuvant or neoadjuvant chemotherapy is the only curative modality for treatment of patients with pancreatic and periampullary tumors. With the increasing use of minimally invasive techniques, laparoscopic and robotic pancreatoduodenectomy (PD) has become more common, but laparoscopic artery-first techniques have been described in few studies. The aim of this study is to describe our robotic artery-first technique. Video clips were compiled from several robotic PDs to demonstrate the artery-first technique. This technique consists of early retroperitoneal dissection of the superior mesenteric artery from the pancreatic head. Overall, 73 patients underwent robotic PD at our center between March 2018 and August 2020. Of these, 24 patients underwent the robotic artery-first approach. Indication for its use included proximity of the tumor to the portal vein or SMV in six cases. In three cases, partial resection of the portomesenteric axis was necessary, and the artery-first approach allowed for safe venous resection and reconstruction. In three other cases, the tumor was in close contact with the vein, but it could be resected with free margins without venous resection. In the remaining 18 patients, the approach was systematically used regardless of tumor proximity to the portomesenteric axis. This robotic artery-first approach is feasible and safe for PD. The approach could facilitate robotic PD, and its systematical use could provide some important advantages during the resection phase. The videos could also help oncological surgeons to perform this complex yet important maneuver.

The current status and future directions of robotic pancreatectomy.

Robotic surgery has emerged as an alternative to laparoscopic surgery and it has also been applied to pancreatectomy. With the increase in the number of robotic pancreatectomies, several studies comparing robotic pancreatectomy and conventional open or laparoscopic pancreatectomy have been published. However, the use of robotic pancreatectomy remains controversial. In this review, we aimed to provide a comprehensive overview of the current status of robotic pancreatectomy. Various aspects of robotic pancreatectomy and conventional open or laparoscopic pancreatectomy are compared, including the benefits, limitations, oncological efficacy, learning curves, and costs. Both robotic pancreatoduodenectomy and distal pancreatectomy have favorable or comparable outcomes to conventional procedures, and robotic pancreatectomy has the potential to be an alternative to open or laparoscopic procedures. However, there are still several disadvantages to robotic platforms, such as prolonged operative duration and the high cost of the procedure. These disadvantages will be improved by developing instruments, overcoming the learning curve, and increasing the number of robotic pancreatectomies. In addition, robotic pancreatectomy is still in the introductory period in most centers and should only be used in accordance with strict indications.

Surgical training model and safe implementation of robotic pancreatoduodenectomy in Japan: a technical note

BackgroundGrowing evidence for the advantages of robotic pancreatoduodenectomy (RPD) has been demonstrated internationally. However, there has been no structured training program for RPD in Japan. Herein, we present the surgical training model of RPD and a standardized protocol for surgical technique.MethodsThe surgical training model and surgical technique were standardized in order to implement RPD safely, based on the Dutch training system collaborated with the University of Pittsburgh Medical Center.ResultsThe surgical training model included various trainings such as basic robotic training, simulation training, biotissue training, and a surgical video review. Furthermore, a standardized protocol on the surgical technique was established to understand the tips, tricks, and pitfalls of RPD.ConclusionsSafe implementation of RPD can be achieved through the completion of a structured training program and learning surgical technique. A nationwide structured training system should be developed to implement the program safely in Japan.

Robotic pancreaticoduodenectomy provides better histopathological outcomes as compared to its open counterpart: a meta-analysis

The aim of this meta-analysis was to evaluate whether robotic pancreaticoduodenectomy (PD) may provide better clinical and pathologic outcomes compared to its open counterpart. The Pubmed, EMBASE, and Cochrane Library were systematically searched. Overall postoperative morbidity and resection margin involvement rate were the primary endpoints. Secondary endpoints included operating time, estimated blood loss (EBL), incisional surgical site infection (SSI) rate, length of hospital stay (LOS), and number of lymph nodes harvested. Twenty-four studies totaling 12,579 patients (2,175 robotic PD and 10,404 open PD were included. Overall postoperative mortality did not significantly differ [OR (95%CI) = 0.86 (0.74, 1.01); p = 0.06]. Resection margin involvement rate was significantly lower in robotic PD [15.6% vs. 19.9%; OR (95%CI) = 0.64 (0.41, 1.00); p = 0.05; NNT = 23]. Operating time was significantly longer in robotic PD [MD (95%CI) = 75.17 (48.05, 102.28); p < 0.00001]. EBL was significantly decreased in robotic PD [MD (95%CI) = − 191.35 (− 238.12, − 144.59); p < 0.00001]. Number of lymph nodes harvested was significantly higher in robotic PD [MD (95%CI) = 2.88 (1.12, 4.65); p = 0.001]. This meta-analysis found that robotic PD provides better histopathological outcomes as compared to open PD at the cost of longer operating time. Furthermore, robotic PD did not have any detrimental impact on clinical outcomes, with lower wound infection rates.

Cost Analysis of Pancreaticoduodenectomy at a High-Volume Robotic Hepatopancreaticobiliary Surgery Program

The robotic approach to pancreaticoduodenectomy is thought by many to be associated with increased financial burden for hospitals. We undertook this study to analyze and compare the cost of "open" pancreaticoduodenectomy with that associated with the application of the robotic surgical system to pancreaticoduodenectomy in our hepatobiliary program. With IRB approval, all patients undergoing pancreaticoduodenectomy at our institution, from August 2012 to November 2019, were prospectively followed. Cost, including total, variable, fixed-direct, fixed-indirect, and profitability for robotic and "open" pancreaticoduodenectomy were analyzed and compared. Data are presented as median (mean±SD). There were 386 patients who underwent pancreaticoduodenectomy; 205 patients underwent robotic pancreaticoduodenectomy and 181 underwent "open" pancreaticoduodenectomy. Costs are presented as mean ± SD. Overall, the cost of care for robotic pancreaticoduodenectomy was $31,389 ($36,611 ± $20,545.40) vs $23,132 ($31,323 ± $28,885.50) for "open" pancreaticoduodenectomy (p= 0.04); total variable cost was $20,355 ($22,747 ±$11,127.60) vs $11,680 ($16,032 ± $14,817.20) (p= 0.01), total fixed direct cost was $1,999 ($2,330 ± $1,363.10) vs $2,073 ($2,983 ± $3,209.00) (p= 0.01), and total indirect cost was $7,217 ($9,354 ± $6,802.40) vs $6,802 ($9,505 ± $9,307.20) (p= 0.86), for robotic vs "open" pancreaticoduodenectomy, respectively. Since 2016, profitability was achieved in 29% of patients undergoing robotic pancreaticoduodenectomy. Robotic pancreaticoduodenectomy had lower estimated blood loss and shorter length of stay. Cost of care for robotic pancreaticoduodenectomy was greater across all categories, except for total indirect cost, than "open" pancreaticoduodenectomy. For our institution, profitability was accomplished in less than one-third of patients undergoing robotic pancreaticoduodenectomy. The role of the robotic platform for pancreaticoduodenectomy needs to be discussed among all stakeholders.

Robotic Pancreaticoduodenectomy for a Technically Challenging Pancreatic Head Cancer

BackgroundRobotic pancreaticoduodenectomy (RPD) is performed for resectable periampullary lesions with comparable outcomes to the open approach.1 Surgical therapy for borderline-resectable (BR) pancreatic tumors is technically challenging and poses a significant risk of bleeding and positive margins.2 As experience with RPD grows at high-volume centers, case selection can be carefully expanded to include complex vascular resections.3 We demonstrate a RPD performed for BR pancreatic adenocarcinoma with portal vein (PV) involvement and presence of anomalous hepatic arterial anatomy. MethodsA 75-year-old female presented with abdominal pain and obstructive jaundice. She was previously healthy and had a relatively normal body mass index (25.7 kg/m2). Endoscopic ultrasound and computed tomography imaging identified a pancreatic head mass measuring 2.3 cm with evidence of concomitant abutment of the PV (90–180 degree) and abutment of a replaced right hepatic artery (rRHA) originating from the superior mesenteric artery (SMA). Following four cycles of neoadjuvant gemcitabine/nab-paclitaxel, restaging imaging demonstrated partial radiographic response, represented by a lesser degree of PV abutment and resolution of rRHA abutment. RPD was performed with side-bite resection of the PV and preservation of rRHA. The video demonstrates the key steps followed in a robotic pancreaticoduodenectomy performed for a technically challenging pancreatic head cancer and highlights robotic control of bleeding from the PV and SMA obviating the need for conversion. Histopathology revealed a residual moderately differentiated ductal adenocarcinoma with 4-of-40 positive lymph nodes and negative surgical margins. The tumor was staged as ypT1cN2 (AJCC 8th edition). The patient had an uneventful postoperative course and was discharged on hospital day 8. ConclusionIn high-volume centers, the robotic approach can be safely used in selected cases of technically challenging BR pancreatic head cancers.

Minimally invasive pancreatic surgery—will robotic surgery be the future?

SummaryDue to the complexity of the procedures and the texture of the organ itself, pancreatic surgery remains a challenge in the field of visceral surgery. During the past decade, a minimally invasive approach to pancreatic surgery has gained distribution in clinical routine, extending from left-sided procedures to pancreatic head resections. While a laparoscopic approach has proven beneficial for many patients with left-sided pancreatic pathologies, the complex reconstruction in pancreas head resections remains worrisome with the laparoscopic approach. The robotic technique was established to overcome such technical constraints while preserving the advantages of the laparoscopic approach. Even though robotic systems are still in development, especially in pancreatoduodenectomy, the current literature demonstrates the feasibility of this approach and stable clinical and oncological outcomes compared to the open technique, albeit only under the condition of such operations being performed by specialist teams in a high-volume setting (&gt;20 robotic pancreaticoduodenectomies per year). The aim of this review is to analyze the current evidence regarding a minimally invasive approach to pancreatic surgery and to review the potential of a robotic approach. Presently, there is still a scarcity of sound evidence and long-term oncological data regarding the role of minimally invasive and robotic pancreatic surgery in the literature, especially in the setting of pancreaticoduodenectomy.