Robotic Pancreaticoduodenectomy Research Articles

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.

Author response to: Risk of conversion to open surgery during robotic and laparoscopic pancreatoduodenectomy and effect on outcomes: international propensity score-matched comparison study.

Author response to: Risk of conversion to open surgery during robotic and laparoscopic pancreatoduodenectomy and effect on outcomes: international propensity score-matched comparison study.

Survival and Robotic Approach for Pancreaticoduodenectomy: A Propensity Score-Match Study.

Robotic surgery is a burgeoning minimally invasive approach to pancreaticoduodenectomy. This study was undertaken to compare survival after robotic vs "open" pancreaticoduodenectomy for ductal adenocarcinoma using propensity score-matched patients. With institutional review board approval, we prospectively followed 521 patients who underwent robotic (n = 311) or open (n = 210) pancreaticoduodenectomy. Patients who underwent robotic (n = 75) or open (n = 75) pancreaticoduodenectomy were propensity score-matched by age, sex, and American Joint Committee on Cancer stage. Neoadjuvant therapy was rarely administered, and adjuvant therapy was stressed (FOLFIRINOX for patients <70 years of age and gemcitabine + nab-paclitaxel for patients >70 years of age). Data are presented as median (mean ± SD). Operative duration was longer and estimated blood loss and length of stay were less with robotic pancreaticoduodenectomy (421 [409 ± 94.0] vs 267 [254 ± 81.2] minutes; 307 [(150 ± 605.3] vs 444 [255 ± 353.1] mL; 7 [5 ± 5.1] vs 11 [8 ± 9.5] days; p < 0.00001 for all). There were no differences in complications (Clavien-Dindo class ≥III, p = 0.30), in-hospital mortality (p = 0.61), or 30-day readmission rates (p = 0.19). Median survival after robotic vs open pancreaticoduodenectomy was 37 vs 24 months (p = 0.08). For propensity score-matched patients, operative duration for robotic pancreaticoduodenectomy was longer (442 [438 ± 117.7] vs 261 [249 ± 67.1] minutes) and estimated blood loss was less (269 [200 ± 296.1] vs 468 [300 ± 394.9] mL), as was length of stay (7 [5 ± 5.1] vs 10 [7 ± 8.6] days; p < 0.00001 for all). There were no differences in complication rates (Clavien-Dindo class ≥ III, p = 0.31) or in-hospital mortality (p = 0.40); 30-day readmissions were fewer after robotic pancreaticoduodenectomy (7% vs 20%, p = 0.03). Median survival for the robotic vs the open approach was 41 vs 17 months (p = 0.02). Patients that underwent robotic pancreaticoduodenectomy had longer operations, less estimated blood loss, shorter length of stay, and fewer 30-day readmissions; they lived much longer than patients who underwent open pancreaticoduodenectomy. We believe that robotic pancreaticoduodenectomy provides salutary and survival benefits for reasons yet unknown.

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.

Reduced-port robotic pancreaticoduodenectomy versus open pancreaticoduodenectomy: a single-surgeon experience.

Multiple-port robotic pancreaticoduodenectomy (RPD) has been increasingly used as an alternative to open pancreaticoduodenectomy (OPD) in pancreatic cancer. However, the comparative safety and efficacy of reduced-port RPD versus OPD are unknown. This was a prospective cohort study comprising adult patients who underwent reduced-port RPD (single-port or single-site plus one port) or OPD for malignant tumors of the pancreas and periampullary region from July 2015 to October 2020 at a single center. We collected data on the patient demographics, perioperative results, oncologic outcomes, and one-year survival. Forty-five patients underwent reduced-port RPD, and 13 underwent OPD. There were no significant differences in the age, sex, body mass index, ASA score, tumor location, or occurrences of postoperative complications between the two groups. Compared with OPD, reduced-port RPD was associated with less blood loss (300ml [95% confidence interval {CI} 155-700] vs. 650ml [95% CI 300-850], p value = 0.11) but a longer operative time (325min [95% CI 290-370] vs. 215min [95% CI 180-270], p value < 0.001). Compared with patients who underwent OPD, patients who underwent reduced-port RPD had a higher 1-year survival rate (68% [95% CI 49-81] vs. 22% [95% CI 3-51], log-rank, p value = 0.007). Reduced-port RPD can be safely performed in experienced surgeons and is associated with better perioperative and oncologic outcomes than OPD.

Mesopancreas Level 3 Dissection in Robotic Pancreaticoduodenectomy

Introduction: There is no study regarding mesopancreas dissections using the robotic approach in pancreaticoduodenectomy in the literature. This study is to evaluate the feasibility and justification of mesopancreas level 3 dissection in robotic pancreaticoduodenectomy (RPD). Method: Surgical outcomes after RPD and open pancreaticoduodenectomy (OPD) were evaluated and compared. Results: There were 289 RPD and 162 OPD patients. Postoperative diarrhea occurred in 34.5% by mesopancreas level 3 dissection, higher than those for level 2 and 1. Blood loss in the RPD group was higher by mesopancreas level 3 dissection, with a median of 263 ml. The rate of R0 resection with margin >1 mm by mesopancreas level 3 dissection was 93.8%, higher than 72.2% by level 2 dissection. Lymph node yield by mesopancreas level 3 dissection in RPD was higher, with a median of 21, vs. 18 by level 2 and 14 by level 1. Compared with mesopancreas level 1 and 2 dissections in RPD groups, level 3 dissection did not increase in surgical mortality, postoperative complications including postoperative pancreatic fistula, delayed gastric emptying (DGE), postpancreatectomy hemorrhage, chyle leakage, bile leakage, and wound infection. Compared with OPD, mesopancreas level 3 dissection in RPD was associated with less blood loss, no DGE, and lower chyle leakage. Conclusion: Mesopancreas level 3 dissection in RPD is not only justified with increasing oncological radicality but also feasible without compromising the surgical risks. Therefore, RPD can be recommended as a safe alternative to OPD for mesopancreas level 3 dissection.

Defining the Operative Time Threshold for Safety in Patients Undergoing Robotic Pancreaticoduodenectomy

Introduction: Robotic pancreaticoduodenectomy (RPD) is a safe and efficacious operation in appropriately selected patients. However, the increased complexity of a robotic approach results in longer operative times. It is unknown at what operative time the risks of a longer RPD exceed those of a shorter open pancreaticoduodenectomy (OPD). Method: The NSQIP database was queried for patients who underwent RPD and OPD between 2014-2019. Emergent operations and vascular resections were excluded. The benchmark OPD control was defined as the fastest tertile with regards to operative time. Multivariable and sensitivity analysis were employed to identify the operative time threshold (OTT). Results: 6,270 patients were included in the study with 939 (15.0%) undergoing RPD and 5,331 (85.0%) as a benchmark OPD control. Incidence of major morbidity or mortality was similar in the RPD and OPD cohorts (32.8% vs. 35.1%, p=0.17). The median operative time for RPD was longer than OPD (6.7 vs. 4.1 hours, p<0.01). Stepwise logistic regression analysis identified operative time as the only variable associated with increased complications in RPD patients (OR: 1.20, 95% CI: 1.12-1.29, p<0.01). The OTT – the time above which RP patients experience greater than the 35.1% OP benchmark complication rate - was identified as 7.7 hours (FIGURE 1). Furthermore, on subgroup analysis of RPD patients, the slowest tertile had more complications than the middle and fastest tertiles (41.5% vs. 32.2% vs. 24.5%, p<0.01). Conclusion: RPD is associated with similar or improved outcomes when the operative time threshold of 7.7 hours is met when compared to OPD.

Defining the Learning Curve for Robotic Pancreaticoduodenectomy at a Single Center with an Established Laparoscopic Pancreaticoduodenectomy Program

Introduction: Robotic pancreaticoduodenectomy (RPD) has a learning curve (LC) of approximately 30-250 cases to reach proficiency. The LC for laparoscopic pancreaticoduodenectomy (LPD) at Duke University was previously defined as 50 cases. This study compares the LC for LPD and subsequently RPD at a single institution. Methods: LPD and RPD were retrospectively analyzed. Continuous pathologic and perioperative metrics were compared and LCs were defined with respect to operative time using CUSUM analysis. Results: Thirty-nine LPD and 69 RPD were analyzed. Introduction of LPD was completed first as a hybrid technique (excluded), followed by total LPD. LPD had a bimodal or inverted LC possibly accounting for proficiency attained from hybrid LPD and introduction of additional surgeons later in the experience. The LC for RPD had three phases: accelerated early experience (cases 1-10), skill consolidation (cases 11-40), and improvement (cases 41-69), marked by reduction in operative time. Compared to LPD, RPD had shorter operative time (379 vs 406 minutes, p<0.03), improved LN harvest (15 vs 19, p<0.02), and similar estimated blood loss and R0 resection. RPD also had improved LOS (7 vs 9 days, p<0.002), and lower rates of surgical site infection (10% vs 38%, p<0.001), abscess (7% vs 23%, p<0.04), and readmission (13% vs 33%, p<0.03). Conclusion: Experience in LPD may shorten the learning curve for RPD. The gap in surgical quality and perioperative outcomes between RPD will likely widen as exposure to robotics in General Surgery, Hepatopancreaticobiliary, and Surgical Oncology training programs increase.

A Matched Cohort Study Comparing Perioperative Outcomes in Robotic Versus Open Pancreaticoduodenectomy

Introduction: Robotic pancreaticoduodenectomy (RPD) may offer technical, quality of life, or cost advantages over open pancreaticoduodenectomy (OPD). Methods: OPD and RPD performed from 2015-2020 were retrospectively matched 2:1 by age, sex, BMI and pathology. To account for matching, continuous variables were compared using generalized estimating-equations, and categorical variables using the Cochran-Mantel-Haenzel test. Subset analysis was conducted for pancreatic adenocarcinoma. Results: A matched cohort of 94 OPD and 47 RPD showed comparable demographics and pathology. Oncologic quality outcomes such as negative surgical margins, lymph nodes sampled, and operative time were equivalent (Table). RPD was associated with decreased estimated blood loss (EBL) (median 250mL vs 350mL, p=0.03), surgical site infections (9% vs 23%, p=0.04), abscess (6% vs 20%, p=0.04) and median length of stay (LOS) (6 days vs 8 days, p=0.05) for RPD compared to OPD. Readmission favored RPD (11% vs 27%, p=0.06), however, it did not reach significance in this limited cohort. There was no difference between the two groups with respect to pancreatic fistula, delayed gastric emptying, or hemorrhage. In subgroup analysis of pancreatic adenocarcinoma, LOS remained lower for RPD (6 vs 7.5, days, p=0.05), while oncologic quality measures were preserved. Conclusion: RPD is associated with lower EBL, postoperative infection, and LOS compared to OPD, with comparable oncologic quality. RPD is feasible and safe and should be considered in appropriately selected patients to minimize blood loss and postoperative complications. Given the improvement to perioperative complications and LOS, the potential for RPD to improve costs of care delivery should be investigated.

Impact of Robotic Pancreaticoduodenectomy on Long-term Survival of Pancreatic Ductal Adenocarcinoma Patients

Introduction: The overall survival (OS) rate for pancreatic ductal adenocarcinoma (PDAC) patients is low. Comparison of perioperative outcomes have shown clinical advantages of the robotic pancreaticoduodenectomy (RPD) over open pancreaticoduodenectomy (OPD). The long-term survival outcomes of PDAC patients undergoing OPD vs. RPD have not been compared. Methods: The study was a single-center retrospective analysis of consecutive PDAC patients who underwent pancreaticoduodenectomies by single surgeon. Clinical outcomes, tumor characteristics, neoadjuvant and adjuvant therapies and OS were studied between OPD and RPD. Predictive factors that impacts OS were analyzed. Results: A total of 100 (36 OPD vs 64 RPD) patients were treated from 2013 to 2020. In the RPD group, patients had significantly shorter length of stay (mean, 7.02 vs. 10.72 days; P<.0001), longer operative time (mean, 364.22 vs. 202.64 min; P<.0001) and more patients started adjuvant therapy within 6 weeks (49.06% vs 16%; P=0.0061) compared to OPD. The OS for OPD was 20.4 and RPD was 20.3 months (P=0.6745). Overall percentage of patients that survived after 12, 36 and 60 months was 68%, 29% and 20%. A multivariate analysis showed tumor size and discharge to home were associated with improved survival. Conclusion: The OS between RPD and OPD was not statistically different. The factors that appear to impact OS irrespective of the procedure approach are tumor size, 90-day readmissions, adjuvant therapy and discharge disposition. RPD patients did start chemo sooner and had a tendency to complete chemo more often than OPD but these factors did not impact the OS.

Robotic Pancreatoduodenectomy: Trends in Technique and Training Challenges

Introduction: The current the learning curve for robotic pancreatoduodenectomy (RPD) is described to be 20-40 cases. This study aims to characterize trends in RPD over time, associated patient outcomes and opportunities for advanced trainees. Methods: Using the ACS-NSQIP database from 2014-2019, PD cases were studied, and operative approach (open-OPN, laparoscopic-LAP, robotic-ROB) was characterized. Postoperative outcomes were described by year and operative technique. Results: During the study period, a total of 24,268 PDs were identified, 71% of which were for malignant disease. The ROB approach increased from 2.8% to 7.5% while the LAP approach decreased from 4.2% to 3.6%. Unplanned conversion increased over time for LAP (27.7 to 40.4%, p=0.003) but was unchanged for ROB cases (14.8% to 14.7%, p=0.257). Morbidity increased in OPN PD (35.5% to 36.8%, p=0.041) and decreased in ROB PD (38.7% to 30.3%, p=0.010). Mean LOS was lower in ROB than LAP and OPN (9.51 vs. 10.90, p<0.00001). In 2019, only 360 RPDs were performed in NSQIP, which accounts for approximately 70% of the PDs. Given a total of 100 AHPBA, SSO, ASTS fellows, only 5 RPDs are available per trainee per year which is far below the learning curve. Conclusion: Over a six-year period, a significant increase was observed in the use of RPD without a concomitant increase in conversion rates. RPD was associated with decreased morbidity and length of stay. Despite a shift towards more RPDs, the number of cases being performed in North America is not adequate for all fellows to achieve the learning curve before graduation.

International Outcomes and Learning Curves for Robotic Pancreatoduodenectomy

Introduction: Robotic pancreatoduodenectomy (RPD) is increasingly being implemented worldwide with good results reported from individual expert centers. However, data from large international series on clinical outcomes of RPD and learning curves are lacking. Methods: An international retrospective cohort study including consecutive patients after RPD until 31 December 2019, providing the first overview of international outcomes. Cumulative sum (CUSUM) analysis was performed to determine the inflection points for the feasibility and proficiency learning curves. Outcomes were compared in groups based on these inflection points. Results: Overall, 2186 patients after RPD were included from 18 centers in 8 countries. The median operative time was 360 minutes [IQR 285-460], conversion rate 3.9% (n=85), and median blood loss 200 mL [100-380]. The rate of major morbidity was 17.7% (n=386), POPF grade B/C rate 14.3% (n=311) and 30-day or in-hospital mortality 1.7% (n=38). Median hospital stay was 16 days [IQR 12-24] and the R0 resection rate in pancreatic cancer 79.9% (700/876 patients). The first inflection point for feasibility learning curve was after 30 procedures and for the proficiency learning curve after 90 procedures. Although these cut-offs did impact major morbidity (24.7%, 23.4%, and 12.3%, p<0.001) they did not impact in-hospital mortality (2.1%, 2%, and 1.5%, p=0.67). The Miami guideline annual volume advice of >20 RPDs was met by 13/18 (72%) centers. Conclusions: This first international study on RPD reported good outcomes in experienced centers and provides a reference point for the feasibility and proficiency learning curves which could be used in future randomized trials.

The Influence of Procedural Volume on Short-Term Outcomes for Robotic Pancreaticoduodenectomy

Introduction: An increasing number of robotic pancreaticoduodenectomies (RPD) are reported, with benefits in reduced complications and shortened postoperative stay. However, questions remain on the number of procedures needed for gaining technical proficiency in RPD and the impact of procedure volume on outcomes. Therefore, we aimed to assess the influence of procedure volume on short-term RPD morbidity and operative variables. Methods: A retrospective review of consecutive RPD cases performed by a single surgeon was undertaken. Cumulative sum (CUSUM) analysis was performed to identify the procedure volume threshold, following which before-threshold and after-threshold outcomes were compared. Results: Since May 2017, 57 patients underwent an RPD at our institution. The median operative time was 360 min (IQR 300 – 445 min). The overall morbidity (Clavien-Dindo grade ≥3) in the cohort was 27.1%. The postoperative pancreatic fistula rate was 8.3% (all grade A), while the re-operation rate was 6.3%. CUSUM analysis has identified 20 cases as proficiency threshold, indicated by curve inflexion (Figure 1). Median operative time was significantly shorter after the threshold of 20 cases (470 min vs 320 min, p<0.001). However, no significant difference between before- and after-threshold groups in median Clavien-Dindo complication grade (0.5 vs 1.5, p=0.675) was found. Conclusion: A decrease in operative time after 20 RPD cases suggests a threshold of technical proficiency potentially associated with an initial adjustment to new instrumentation, port placement and standardisation of operative step sequence. Nonetheless, no clinically meaningful decrease in short-term morbidity was found during the initial learning phase, suggesting its safety.

Assessing the Outcomes of Robotic Pancreatoduodenectomy According to the Benchmark Cutoffs for the Open Approach: International Multicenter Study

Introduction: Several studies from high-volume centers have reported on the safety and feasibility of robotic pancreatoduodenectomy (RPD). Since no randomized trials have compared RPD versus open pancreatoduodenectomy (OPD) it is unclear how outcomes after these two approaches compare. Recently, outcome benchmarks for OPD were established to allow for unbiased outcome comparisons. Methods: An international multicenter retrospective cohort study, including consecutive patients after RPD in high-volume centers (first case – 31 December 2019) was conducted. Outcomes of the benchmark cases (low-risk patients) and patients with ASA≥3 were compared to the OPD benchmark cutoffs, reported by Sánchez-Velázquez et al. Lastly, clinical outcomes were stratified based on learning curve phases and annual volume. Results: Overall, 2186 patients from 18 centers in 8 countries were included, the percentage of benchmark cases was 53.5% (n=1169). Median annual volume of RPD per center was 24. Operative outcomes of the RPD-benchmark cases were compared to the OPD-benchmark cutoffs: operative time (5.5 vs ≤7.5 hours), POPF grade B/C rate (13.6% vs ≤19%), Clavien-Dindo ≥3 rate (14.4% vs ≤30%), in-hospital or 30-day mortality (1.1% vs ≤1.6%) and R1 rate for PDAC (12.4% vs ≤39%). As expected, patients with ASA≥3 had worse outcomes (7.1 hours, 16.7%, 22.4%, 3.5%, and 32%, respectively). Conclusions: Outcomes of RPD in this international cohort meet the established OPD-benchmark cutoffs. Moreover, 11 out of 14 available OPD-benchmark cutoffs are also met in patients with ASA≥3. These findings suggest that RPD can be performed safely in both low-risk and high-risk patients in high-volume centers.

Robotic Pancreaticoduodenectomy, the First Experience in Thailand at Siriraj Hospital

Introduction: Robotic pancreaticoduodenectomy (RPD) is one of advanced procedures that required high volume of cases to overcome the learning curve. However, case numbers slowly increased due to its high-cost procedure. This study aimed to evaluate our early learning experience in RPD. Methods: Retrospective data of patients who had undergone RPD at Siriraj Hospital between 2014 and 2020 were reviewed. The operations were performed with daVinci Si in earlier cases and substituted by Xi model in later cases. Most of the cases (82.5%) were performed by a single surgeon. We compared the outcomes of the early experience group (group A) and the last 10-case experience group (group B). Results: Thirty-three cases were performed mandatory by a single surgeon. Male:Female ratio was 17:16 with an average BMI of 24.15 kg/m2. The periampullary mass located at ampulla, head, distal bile duct, and duodenum in 18 (54.5%), 9 (27.3%), 5 (15.2%), 2 (6.0%) cases, respectively. An average tumor size was 2.6 cm and 24 cases (72.7%) were pathologically reported as malignancy. The perioperative outcome comparison between group A and group B showed the operative time was 628.0 vs. 598.2 minutes, usage of blood transfusion was 43.5% vs. 30.0%, conversion rate was 27.8% vs. 0%, post-operative pancreatic fistula grade B/C rate was 47.8% vs. 30.0%. Trends of unfavorable outcomes decreased after a set of experiences. Unfortunately, statistical significance was not reached due to small case numbers. Conclusion: Robotic pancreaticoduodenectomy is the most complicated procedure. Surgical outcomes tended to be improved after passing more experience.

Pancreaticoduodenectomy for Benign and Pre-Malignant Pancreatic and Ampullary Disease: Is Robotic Surgery the Better Approach?

Background: The robotic platform is increasingly being utilized in pancreatic surgery, yet its overall putative advantages remain to be adjudicated. We hypothesized that the benefits of robotic pancreatic surgery are maximized in benign and premalignant disease, in the setting of friable tissue and small duct. Methods: Retrospective analysis of a single institution pancreatic database of all consecutive patients who underwent pancreaticoduodenectomy (PD) for benign or premalignant conditions between 2010 to 2020. Peri-operative outcomes and long-term complications (> 90 days post-PD) were compared between robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD). Results: Two hundred and four (n=204) patients met our inclusion criteria, of which 68 were OPD and 136 RPD. Baseline characteristics were similar between the two groups (Table 1). RPD cohort had more classic Whipple procedure (84.6% vs. 55.9%, p<0.001), shorter operative time (387.80±114.11 vs. 453.79±159.18 minutes, p<0.001), and lesser lymph node yield (21 vs. 20, p=0.011). Post-operatively, RPD cohort had a significantly shorter length of stay (LOS) (7 vs. 10 days, p=0.004), fewer grade B pancreatic fistulas (8.8% vs. 32.3%, p=0.001) and lower 90-day mortality (0.7% vs. 5.9%, p=0.025). Rates of long-term complications were comparable between the two groups, with th exception for a higher small bowel obstruction requiring surgical intervention in the open group (3.1% vs. 0%, p=0.039). Conclusion: This analysis suggest that RPD has lower 90-day mortality, shorter LOS and lower rates of selected complications compared to OPD and suggest a potential role in the treatment of benign and premalignant pancreatic conditions in select populations.

Video Grading of the Pancreatico-Jejunostomy in Robotic Pancreatoduodenectomy to Determine the Learning Curve and the Risk of Postoperative Pancreatic Fistula

Introduction: Video grading may be used to assess the surgical learning curve and could predict complications. Predicting the risk of postoperative pancreatic fistula (POPF) could guide treatment, quality control, or be used for benchmarking however a cut-off variable regarding surgical expertise is lacking. We graded the pancreatico-jejunostomy of robotic pancreatoduodenectomy (RPD) to assess learning curve and the risk of POPF. Methods: We included patients who underwent RPD for all indications from a recently completed multicenter training program in RPD (LAELAPS-3). Technical performance was graded by two blinded graders using the Objective Structured Assessment of Technical Skills (OSATS) score, ranging from 12-60. Cumulative sum (CUSUM) analysis was used to assess a learning curve inflection point. Logistic regression was used to determine the cut-off OSATS score to predict the increased chance of POPF grade B/C. Results: Videos of 153 patients from four centers were assessed. POPF B/C occurred in 35 patients (22.9%). Based on uaFRS criteria, 72 (47.1%) patients had intermediate or high-risk anastomoses. Median OSATS was 48 [interquartile range 41–52]. CUSUM analysis of OSATS found an inflection point after 33 procedures. An OSATS score below 49 was associated with a higher risk of POPF, OR 2.27 (1.04–4.99, p=0.041). Conclusion: This multicenter study demonstrates that video grading of the pancreatico-jejunostomy can determine both the learning curve and the risk of POPF after RPD.

Robotic pancreaticoduodenectomy in a patient with situs inversus totalis and variant celiacomesenteric trunk

Situs inversus totalis (SIT) is a rare congenital anomaly characterized by right–left reversal of visceral organs and dextrocardia; the use of robotic pancreaticoduodenectomy (RPD) may be challenging in these patients. A male patient presented with jaundice; imaging studies revealed a bile duct tumor and SIT with variant celiacomesenteric trunk and multiple vascular anomalies. RPD was carried out cautiously and successfully. The trocar port design mirrored that of a normal patient. Pathological examination revealed extrahepatic bile duct adenocarcinoma, classified as pT3N1M0, stage IIB. The patient recovered uneventfully. Although difficult, RPD is technically feasible in an SIT patient with cholangiocarcinoma.

Open and Robotic Pancreaticoduodenectomies Exhibit Comparable True Hospital Costs in Year-Adjusted Matched Cohort

Introduction. Robotic pancreaticoduodenectomy (RPD) is associated with higher total hospital costs than open pancreaticoduodenectomy (OPD). This study investigates the cost differences between OPDs and RPDs at a single institution using internal true hospital cost data.