Robotic hepatobiliary and pancreatic surgery: lessons learned and predictors for conversion

Implementation of robotic and laparoscopic hepatopancreatobiliary surgery in low- and middle-income settings: a systematic review and meta-analysis

BACKGROUND

Despite numerous barriers, the application of minimally invasive surgery (MIS) for hepatopancreatobiliary (HPB) conditions has been increasing globally. This study aims to review the current status of HPB MIS in LMICs.

METHODS

Relevant databases were searched, identifying 3452 publications, 38 of which met the inclusion criteria. Meta-analysis of outcomes was carried out using "R" statistical software.

RESULTS

This study reviewed reports of application of MIS for HPB conditions in LMICs, analyzing a total of 3272 procedures. India (66.87 %) and Egypt (20.11 %) contributed majorly to the procedures reviewed. Others were from Indonesia (8.68 %), Colombia (3.06 %), Pakistan (0.67 %), Sri Lanka (0.34 %), Trinidad and Tobago (0.18 %), and Nigeria (0.09 %). India was the only LMIC with robotic HPB MIS. The majority of the procedures were biliary (74.88 %). Basic procedures accounted for 55.63 %, while 44.37 % were advanced. The overall conversion rate and prevalence of morbidity were 8 % [95 % CI: 5; 13], and 15 % [95 % CI: 9; 22], respectively. Robotics was associated with higher conversion (14 % vs 6 %, p < 0.01) but lower morbidity (10 % vs 16 %, p = 0.91), compared to laparoscopic surgery. There were 5 cases of mortality from laparoscopy.

CONCLUSION

The outcomes in this systematic review, compared to findings in other settings indicate successful implementation of HPB MIS in LMICs.

Perspectives on robotic HPB training in the UK: a survey analysis

BACKGROUND

We Published a step-up approach for robotic training in hepato-pancreato-biliary (HPB) surgery has been previously. The approach was mostly based on personal experience and communications between experts and needed appraisal and validation by the HPB surgical community. At the Great Britain and Ireland HPB Association (GBIHPBA) robotic HPB meeting held in Coventry, UK in October 2022, the authors sought consensus from the live audience, with an open forum for answering key questions. The aim of this exercise was to appraise the step-up approach, and in turn, lay the foundation for a more substantial UK robotic HPB surgical curriculum.

METHODS

The study was conducted using VEVOX online polling platform at the October 2022 GBIHPBA robotic HPB meeting in Coventry, UK. The questionnaire was designed based on a literature search and was externally validated. The data were collated and analysed to assess patterns of response.

RESULTS

A median (IQR) of 104 (96-117) responses were generated for each question. 93 consultants and 61 trainees were present Over 90% were in favour of a standardised training pathway. 93.6% were in favour of the proposed step-up approach, with a significant number (67.3%; p < 0.001) considering three levels of case complexity.

CONCLUSION

The survey shows a favourable outlook on adopting step-up training in robotic HPB surgery. Ongoing monitoring of progress, clinical outcomes, and collaboration among surgeons and units will bolster this evidence, potentially leading to an official UK robotic HPB curriculum.

Expanding the utility of robotics for pancreaticoduodenectomy: a 10-year review and comparison to international benchmarks in pancreatic surgery

BACKGROUND

Robotic pancreaticoduodenectomy (RPD) is an emerging alternative to open pancreaticoduodenectomy (OPD). Although RPD offers various theoretical advantages, it is used in less than 10% of all pancreaticoduodenectomies. The aim of this study was to report our 10-year experience and compare RPD outcomes with international benchmarks for OPD.

METHODS

A retrospective review of a prospectively maintained institutional database was performed of consecutive patients who underwent RPD between January 2011 and December 2021. Patients were categorized into low-risk and high-risk groups according to the selection criteria set by the benchmark study. Their outcomes were compared to the international benchmark cut off values. Outcomes were then evaluated over time to identify improvements in practice and establish a learning curve.

RESULTS

Of 201 RPDs, 36 were low-risk and 165 high-risk patients. Compared to the OPD benchmarks, outcomes of low-risk patients were within the cutoff values. High-risk patients were outside the cutoff for blood transfusions (26% vs. ≤ 23%), overall complications (78% vs. ≤ 73%), grade I-II complications (68% vs. ≤ 62%), and readmissions (22% vs ≤ 21%). Oncologic outcomes for high-risk patients were within benchmark cutoffs. Cases at the end of the learning curve included more pancreatic cancer (42% from 17%) and fewer low-risk patients (10% from 24%) than those at the beginning. After 41 RPD there was a decline in conversion rates and operative time. Between 95 and 143 cases operative time, transfusion rates, and LOS declined significantly. Complications did not differ over time.

CONCLUSION

RPD yields results comparable to the established benchmarks in OPD in both low- and high-risk patients. Along the learning curve, RPD evolved with the inclusion of more high-risk cases while outcomes remained within benchmarks. Addition of a robotic HPB surgery fellowship did not compromise outcomes. These results suggest that RPD may be an option for high-risk patients at specialized centers.

Safe implementation of a minimally invasive hepatopancreatobiliary program, a narrative review and institutional experience

Laparoscopic and robotic-assisted approaches to hepatopancreatobiliary (HPB) operations have expanded worldwide. As surgeons and medical centers contemplate initiating and expanding minimally invasive surgical (MIS) programs for complex HPB surgical operations, there are many factors to consider. This review highlights the key components of developing an MIS HPB program and shares our recent institutional experience with the adoption and expansion of an MIS approach to pancreaticoduodenectomy.

Current progress in robotic hepatobiliary and pancreatic surgery at a high-volume center

There has been steady growth in the adoption of robotic HPB procedures world-wide over the past 20 years, but most of this increase has occurred only recently. Not surprisingly, the vast majority of robotics has been in the United States, with very few, select centers of adoption in Italy, South Korea, and Brazil, to name a few. We began our robotic HPB program in 2008, well before almost all other centers in the world, with the most notable exception of Giullianotti and colleagues. Our program began gradually, with smaller cases carefully selected to optimize the strengths of the original robotic platform and included complex biliary and pancreatic resections. We performed the first reported series of choledochojejunostomy for benign biliary strictures and first series of completion cholecystectomies. We began performing robotic distal pancreatectomies and longitudinal pancreaticojejunostomies, reporting our early experience for each of these procedures. Over time we progressed to robotic pancreaticoduodenectomies. Initially, these were performed with planned conversions until we were able to optimize efficiency. Now we have performed over 200 robotic whipples, reaching a 100% robotic completion rate by 2020. Finally, we have added robotic major hepatectomies, including resections for hilar cholangiocarcinoma to our repertoire. Since the program began, we have performed over 1600 robotic HPB cases. Outcomes from our program have shown superior lymph node harvest, lower DGE rates, shorter hospitalizations, and fewer rehab admissions with similar overall complications to open and laparoscopic procedures, signifying that over time a robotic HPB program is not only feasible but advantageous as well.

Risk factors and outcomes of conversion in minimally invasive distal pancreatectomy: a systematic review

Purpose

The reported conversion rates for minimally invasive distal pancreatectomy (MIDP) range widely from 2 to 38%. The identification of risk factors for conversion may help surgeons during preoperative planning and patient counseling. Moreover, the impact of conversion on outcomes of MIDP is unknown.

Methods

A systematic review was conducted as part of the 2019 Miami International Evidence-Based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR). The PubMed, Cochrane, and Embase databases were searched for studies concerning conversion to open surgery in MIDP.

Results

Of the 828 studies screened, eight met the eligibility criteria, resulting in a combined dataset including 2592 patients after MIDP. The overall conversion rate was 17.1% (range 13.0–32.7%) with heterogeneity between studies associated with the definition of conversion adopted. Only one study divided conversion into elective and emergency conversion. The main indications for conversion were vascular involvement (23.7%), concern for oncological radicality (21.9%), and bleeding (18.9%). The reported risk factors for conversion included a malignancy as an indication for surgery, the proximity of the tumor to vascular structures in preoperative imaging, higher BMI or visceral fat, and multi-organ resection or extended resection. Contrasting results were seen in terms of blood loss and length of stay in comparing converted MIDP and completed MIDP patients.

Conclusion

The identified risk factors for conversion from this study can be used for patient selection and counseling. Surgeon experience should be considered when contemplating MIDP for a complex patient. Future studies should divide conversion into elective and emergency conversion.

Adoption of Robotic Liver, Pancreatic and Biliary Surgery in Singapore: A Single Institution Experience with Its First 100 Consecutive Cases

Introduction: Presently, robotic hepatopancreatobiliary surgery (RHPBS) is increasingly adopted worldwide. This study reports our experience with the first 100 consecutive cases of RHPBS in Singapore. Methods: Retrospective review of a single-institution prospective database of the first 100 consecutive RHPBS performed over 6 years from February 2013 to February 2019. Eighty-six cases were performed by a single surgeon. Results: The 100 consecutive cases included 24 isolated liver resections, 48 pancreatic surgeries (including 2 bile duct resections) and 28 biliary surgeries (including 8 with concomitant liver resections). They included 10 major hepatectomies, 15 pancreaticoduodenectomies, 6 radical resections for gallbladder carcinoma and 8 hepaticojejunostomies. The median operation time was 383 minutes, with interquartile range (IQR) of 258 minutes and there were 2 open conversions. The median blood loss was 200ml (IQR 350ml) and 15 patients required intra-operative blood transfusion. There were no post-operative 90-day nor in-hospital mortalities but 5 patients experienced major (> grade 3a) morbidities. The median post-operative stay was 6 days (IQR 5 days) and there were 12 post-operative 30-day readmissions. Comparison between the first 50 and the subsequent 50 patients demonstrated a significant reduction in blood loss, significantly lower proportion of malignant indications, and a decreasing frequency in liver resections performed. Conclusion: Our experience with the first 100 consecutive cases of RHPBS confirms its feasibility and safety when performed by experienced laparoscopic hepatopancreatobiliary surgeons. It can be performed for even highly complicated major hepatopancreatobiliary surgery with a low open conversion rate. Keywords: Biliary surgery, hepaticojejunostomy, liver resection, pancreas, pancreaticoduodenectomy

A retrospective comparison of robotic versus laparoscopic distal resection and enucleation for potentially benign pancreatic neoplasms

PURPOSE

The present study aimed to compare robotic-assisted versus laparoscopic distal pancreatic resection and enucleation for potentially benign pancreatic neoplasms.

METHODS

Patients were retrieved from a prospectively maintained database. Demographic data, tumor types, and the perioperative outcomes were retrospectively analyzed.

RESULTS

In a 10-year period, 75 patients (female, n = 44; male, n = 31; median age, 53 years [range, 9-84 years]) were identified. The majority of patients had pancreatic neuroendocrine neoplasms (n = 39, 52%) and cystic neoplasms (n = 23, 31%) with a median tumor size of 17 (3-60) mm. Nineteen (25.3%) patients underwent enucleation (robotic, n = 11; laparoscopic, n = 8) and 56 (74.7%) patients underwent distal pancreatic resection (robotic, n = 24; laparoscopic, n = 32), of those 48 (85%) underwent spleen-preserving procedures. Eight (10.7%) procedures had to be converted to open surgery. The rate of vessel preservation in distal pancreatectomy was significantly higher in robotic-assisted procedures (62.5% vs. 12.5%, p = 0.01). Twenty-six (34.6%) patients experienced postoperative complications (Clavien-Dindo grade > 3). Twenty (26.7%) patients developed a pancreatic fistula type B. There was no mortality. After a median follow-up period of 58 months (range 2-120 months), one patient (1.3%) developed local recurrence (glucagonoma) after enucleation, which was treated with a Whipple procedure.

CONCLUSION

The robotic approach is comparably safe, but increases the rate of splenic vessel preservation and reduces the risk of conversion to open surgery.

The Impact of Corporate Payments on Robotic Surgery Research: A Systematic Review

OBJECTIVE

To quantify the influence of financial conflict of interest (COI) payments on the reporting of clinical results for robotic surgery.

DATA SOURCES AND STUDY SELECTION

A systematic search (Ovid MEDLINE databases) was conducted (May 2017) to identify randomized controlled trials (RCTs) and observational studies comparing the efficacy of the da Vinci robot on clinical outcomes. Financial COI data for authors (per study) were determined using open payments database.

MAIN OUTCOMES AND MEASURES

Primary outcomes assessed were receipt of financial COI payments and overall conclusion reported between robotic versus comparative approach. Quality/risk of bias was assessed using Newcastle-Ottawa Scale (NOS)/Cochrane risk of bias tool. Disclosure discrepancies were also analyzed.

DATA EXTRACTION AND SYNTHESIS

Study characteristics, surgical subspecialty, methodological assessment, reporting of disclosure statements, and study findings dual abstracted. The association of the amount of financial support received as a predictor of reporting positive findings associated robotic surgery was assessed at various cut-offs of dollar amount received by receiver operating curve (ROC).

RESULTS

Thirty-three studies were included, 9 RCTs and 24 observational studies. There was a median, 111 patients (range 10 to 6420) across studies. A little more than half (17/33) had a conclusion statement reporting positive results in support of robotic surgery, with 48% (16/33) reporting results not in favor [equivocal: 12/33 (36%), negative: 4/33 (12%)]. Nearly all (91%) studies had authors who received financial COI payments, with a median of $3364.46 per study (range $9 to $1,775,378.03). ROC curve demonstrated that studies receiving greater than $9557.31 (cutpoint) were more likely to report positive robotic surgery results (sensitivity: 0.65, specificity: 0.81, area under the curve: 0.73). Studies with financial COI payment greater than this amount were more likely to report beneficial outcomes with robotic surgery [(78.57% vs 31.58%, P = 0.013) with an odds ratio of 2.07 (confidence interval: 0.47-3.67; P = 0.011)]. Overall, studies were high quality/low risk of bias [median NOS: 8 (range 5 to 9)]; Cochrane risk: "low risk" (9/9, 100%)].

CONCLUSION AND RELEVANCE

Financial COI sponsorship appears to be associated with a higher likelihood of studies reporting a benefit of robotic surgery. Our findings suggest a dollar amount where financial payments influence reported clinical results, a concept that challenges the current guidelines, which do not account for the amount of COI funding received.

Robotic-assisted versus laparoscopic left pancreatectomy at a high-volume, minimally invasive center

INTRODUCTION

While minimally invasive left pancreatectomy has become more widespread and generally accepted over the last decade, opinions on modality of minimally invasive approach (robotic or laparoscopic) remain mixed with few institutions performing a significant portion of both operative approaches simultaneously.

METHODS

247 minimally invasive left pancreatectomies were retrospectively identified in a prospectively maintained institutional REDCap™ database, 135 laparoscopic left pancreatectomy (LLP) and 108 robotic-assisted left pancreatectomy (RLP). Demographics, intraoperative variables, postoperative outcomes, and OR costs were compared between LLP and RLP with an additional subgroup analysis for procedures performed specifically for pancreatic adenocarcinoma (35 LLP and 23 RLP) focusing on pathologic outcomes and 2-year actuarial survival.

RESULTS

There were no significant differences in preoperative demographics or indications between LLP and RLP with 34% performed for chronic pancreatitis and 23% performed for pancreatic adenocarcinoma. While laparoscopic cases were faster (p < 0.001) robotic cases had a higher rate of splenic preservation (p < 0.001). Median length of stay was 5 days for RLP and LLP, and rate of clinically significant grade B/C pancreatic fistula was approximately 20% for both groups. Conversion rates to laparotomy were 4.3% and 1.8% for LLP and RLP approaches respectively. RLP had a higher rate of readmission (p = 0.035). Pathologic outcomes and 2-year actuarial survival were similar between LLP and RLP. LLP on average saved $206.67 in OR costs over RLP.

CONCLUSIONS

This study demonstrates that at a high-volume center with significant minimally invasive experience, both LLP and RLP can be equally effective when used at the discretion of the operating surgeon. We view the laparoscopic and robotic platforms as tools for the modern surgeon, and at our institution, given the technical success of both operative approaches, we will continue to encourage our surgeons to approach a difficult operation with their tool of choice.

Assessing the impact of conversion on outcomes of minimally invasive distal pancreatectomy and pancreatoduodenectomy

BACKGROUND

Our aim was to compare outcomes of patients who undergo conversion to open during minimally invasive distal pancreatectomy (MI-DP) and pancreatoduodenectomy (MI-PD) to those completed in minimally invasive fashion, and to compare outcomes of minimally invasive completions and conversions to planned open pancreatectomy.

METHODS

Propensity scoring was used to compare outcomes of completed and converted cases from a national cohort, and multivariate regression analysis (MVA) was used to compare minimally invasive completions and conversions to planned open pancreatectomy.

RESULTS

MI-DP was performed in 43.0%. Conversions (20.2%) had increased morbidity (32.3 vs 42.0%), serious morbidity (11.1 vs 21.2%), and organ space infection (6.2 vs 14.2%). Outcomes of MI-DP conversions were comparable to open. MI-PD was performed in 6.1%. Conversions (25.2%) had increased organ space infection (10.9 vs 26.6%), blood transfusions (17.2 vs 42.2%), and clinically relevant pancreatic fistula (11.5 vs 28.1%). On MVA, conversion of MI-PD was associated with increased mortality (OR 2.84, 95% CI 1.09-7.42), post-operative percutaneous drain placement (OR 2.36, 95% CI 1.32-4.20), and blood transfusions (OR 1.85, 95% CI 1.07-3.21).

CONCLUSION

Converted cases have increased morbidity compared to completions, and for patients undergoing PD, conversions may be associated with inferior outcomes compared to planned open cases.

Early experience with robot-assisted laparoscopic hepatobiliary and pancreatic surgery in Singapore: single-institution experience with 20 consecutive patients

INTRODUCTION

Experience with robot-assisted laparoscopic (RAL) hepatobiliary and pancreatic (HPB) surgery remains limited worldwide. In this study, we report our early experience with RAL HPB surgery in Singapore.

METHODS

A retrospective review of the first 20 consecutive patients who underwent RAL HPB surgery at a single institution over a 34-month period from February 2013 to November 2015 was conducted. The 20 cases were performed by three principal surgeons, of which 17 (85.0%) were performed by a single surgeon.

RESULTS

The median age of patients was 56 (range 22-75) years and median tumour size was 4.0 (range 1.2-7.5) cm. The surgeries performed included left-sided pancreatectomies (n = 10), hepatectomies (n = 7), triple bypass with bile duct exploration for obstructing pancreatic head cancer with choledocholithiasis (n = 1), cholecystectomy for Mirizzi's syndrome (n = 1) and gastric resection for gastrointestinal stromal tumour (n = 1). The median operation time was 445 (range 80-825) minutes and median blood loss was 350 (range 0-1,200) mL. There was only 1 (5%) open conversion. There were 2 (10.0%) major morbidities (> Grade II on the Clavien-Dindo classification) and no 30-day/in-hospital mortalities. There was no reoperation for postoperative complications. The median postoperative stay was 5.5 (range 3-22) days.

CONCLUSION

Our initial experience confirms the feasibility and safety of RAL HPB surgery.

Robotic pancreaticoduodenectomy and distal pancreatectomy: State of the art

Over recent years, minimally invasive pancreatic resections have increasingly been reported in the literature. Even though pancreatic surgery is still considered a challenge for surgeons due to its technical difficulties and high morbidity, the development and spread of robotic surgery has highlighted a new interest, which has induced a rapid spread of robotic approaches for pancreatic resections. This study presents a systematic review of the literature regarding robotic pancreaticoduodenectomy and distal pancreatectomy in order to assess the safety and feasibility of robotic pancreatic resection.

First experience with robotic spleen-saving, vessel-preserving distal pancreatectomy in Singapore: a report of three consecutive cases

INTRODUCTION

The use of laparoscopic distal pancreatectomy (LDP) has increased worldwide due to the reported advantages associated with this minimally invasive procedure. However, widespread adoption is hindered by its technical complexity. Robotic distal pancreatectomy (RDP) was introduced to overcome this limitation, but worldwide experience with RDP is still lacking. There is presently evidence that RDP is associated with decreased conversion rate and increased splenic preservation as compared to LDP.

METHODS

We conducted a prospective study on our initial experience with robotic spleen-saving, vessel-preserving distal pancreatectomy (SSVP-DP) between July 2013 and April 2014.

RESULTS

Three consecutive patients underwent attempted robotic SSVP-DP. The indications were a 2.1-cm indeterminate cystic neoplasm, 4.5-cm solid pseudopapillary neoplasm and 1.2-cm pancreatic neuroendocrine tumour. For all three patients, the procedure was completed without conversion, and the spleen, with its main vessels, was successfully conserved. The median total operation time, blood loss and postoperative stay were 350 (range 300-540) minutes, 200 (range 50-300) mL and 7 (range 6-14) days, respectively. Two patients had minor Clavien-Dindo Grade I complications (one Grade A pancreatic fistula and one postoperative ileus). One patient had a Clavien-Dindo Grade IIIa complication (Grade B pancreatic fistula requiring percutaneous drainage). All patients were well at the time of reporting after at least six months of follow-up.

CONCLUSION

Our preliminary experience with robotic SSVP-DP confirmed the feasibility of the procedure.

Comparison of Risk Factors for Unplanned Conversion from Laparoscopic and Robotic to Open Colorectal Surgery Using the Michigan Surgical Quality Collaborative (MSQC) Database

Robotic colorectal surgery has been shown to have lower rates of unplanned conversion to open surgery when compared to laparoscopic surgery. Risk factors associated with conversion from robotic to open colectomy and comparisons of the risk factors between robotic and laparoscopic approaches have not been previously reported. Patients who underwent elective laparoscopic and robotic colorectal surgeries between July 1, 2012 and April 28, 2015, were identified in the Michigan Surgical Quality Collaborative registry. Candidate covariates were identified, and hierarchical logistic regression models were used to identify risk factors for conversion. There were 4796 cases that met study inclusion criteria. Conversion was required in 18.2 % of laparoscopic and 7.7 % of robotic cases (p < 0.0001). Risk factors for conversion in the laparoscopic group included the following: moderate/severe adhesions, obesity, colorectal cancer, hypertension, rectal operations, urgent priority, and tobacco use. Risk factors for conversion in the robotic group included the following: severe adhesions, bleeding disorder, presence of cancer, cirrhosis, and use of statins. Higher surgeon volume was protective in both groups. Conversion rates are lower for robotic than for laparoscopic colorectal surgery with fewer predictors of conversion. Recognition of factors predicting conversion may allow surgeons to choose an operative approach that optimizes the benefits of the available technologies.

Consensus Conference on North American Training in Hepatopancreaticobiliary Surgery: A Review of the Conference and Presentation of Consensus Statements

The findings and recommendations of the North American consensus conference on training in hepatopancreaticobiliary (HPB) surgery held in October 2014 are presented. The conference was hosted by the Society for Surgical Oncology (SSO), the Americas Hepato-Pancreatico-Biliary Association (AHPBA), and the American Society of Transplant Surgeons (ASTS). The current state of training in HPB surgery in North America was defined through three pathways-HPB, surgical oncology, and solid organ transplant fellowships. Consensus regarding programmatic requirements included establishment of minimum case volumes and inclusion of quality metrics. Formative assessment, using milestones as a framework and inclusive of both operative and nonoperative skills, must be present. Specific core HPB cases should be defined and used for evaluation of operative skills. The conference concluded with a focus on the optimal means to perform summative assessment to evaluate the individual fellow completing a fellowship in HPB surgery. Presentations from the hospital perspective and the American Board of Surgery led to consensus that summative assessment was desired by the public and the hospital systems and should occur in a uniform but possibly modular manner for all HPB fellowship pathways. A task force composed of representatives of the SSO, AHPBA, and ASTS are charged with implementation of the consensus statements emanating from this consensus conference.

Factors associated with intraoperative conversion during robotic sacrocolpopexy

OBJECTIVE

To evaluate for potential predictors of intraoperative conversion from robotic sacrocolpopexy (RSC) to open abdominal sacrocolpopexy.

PATIENTS AND METHODS

We identified 83 consecutive patients from 2002-2012 with symptomatic high-grade post-hysterectomy vaginal vault prolapse that underwent RSC. Multiple clinical variables including patient age, comorbidities (body-mass index [BMI], hypertension, diabetes mellitus, tobacco use), prior intra-abdominal surgery and year of surgery were evaluated for potential association with conversion.

RESULTS

Overall, 14/83 cases (17%) required conversion to an open sacrocolpopexy. Patients requiring conversion were found to have a significantly higher BMI compared to those who did not (median 30.2 kg/m(2) versus 25.8 kg/m(2); p=0.003). Other medical and surgical factors evaluated were similar between the cohorts. When stratified by increasing BMI, conversion remained associated with an increased BMI. That is, conversion occurred in 3.8% (1/26) of patients with BMI ≤ 25 kg/m(2), 14.7% (5/34) with BMI 25-29.9 kg/m(2) and 34.7% (8/23) with BMI ≥ 30 kg/m(2) (p=0.004). When evaluated as a continuous variable, BMI was also associated with a significantly increased risk of conversion to an open procedure (OR 1.18, p=0.004).

CONCLUSIONS

Higher BMI was the only clinical factor associated with a significantly increased risk of intra-operative conversion during robotic sacrocolpopexy. Recognition of this may aid in pre-operative counseling and surgical patient selection.

Robotic pancreaticoduodenectomy for pancreatic adenocarcinoma: role in 2014 and beyond

Minimally invasive surgery (MIS) for pancreatic adenocarcinoma has found new avenues for performing pancreaticoduodenectomy (PD) procedures, a historically technically challenging operation. Multiple studies have found laparoscopic PD to be safe, with equivalent oncologic outcomes as compared to open PD. In addition, several series have described potential benefits to minimally invasive PD including fewer postoperative complications, shorter hospital length of stay, and decreased postoperative pain. Yet, despite these promising initial results, laparoscopic PDs have not become widely adopted by the surgical community. In fact, the vast majority of pancreatic resections performed in the United States are still performed in an open fashion, and there are only a handful of surgeons who actually perform purely laparoscopic PDs. On the other hand, robotic assisted surgery offers many technical advantages over laparoscopic surgery including high-definition, 3-D optics, enhanced suturing ability, and more degrees of freedom of movement by means of fully-wristed instruments. Similar to laparoscopic PD, there are now several case series that have demonstrated the feasibility and safety of robotic PD with seemingly equivalent short-term oncologic outcomes as compared to open technique. In addition, having the surgeon seated for the procedure with padded arm-rests, there is an ergonomic advantage of robotics over both open and laparoscopic approaches, where one has to stand up for prolonged periods of time. Future technologic innovations will likely focus on enhanced robotic capabilities to improve ease of use in the operating room. Last but not least, robotic assisted surgery training will continue to be a part of surgical education curriculum ensuring the increased use of this technology by future generations of surgeons.

Robotic spleen preserving distal pancreatectomy: how I do it (with video)

Laparoscopic hepatobiliary surgery, although technically demanding, gains popularity due to the patient benefits of a mini-invasive approach. Laparoscopic distal pancreatectomy is a technically feasible and reproducible operation that doesn't require complex digestive reconstruction. It requires advanced laparoscopic skill for vascular dissection and control. Due to the absence of trials proving its oncological results it is mainly indicated for benign or borderline tumours of the pancreatic body and tail. Since for these tumours there is no indication for a lymph node dissection, there are benefits for the patient if the spleen is preserved. There is some evidence that robotic assistance facilitates the procedure and makes it accessible to surgeons diminishing the necessity of advanced laparoscopic skills. In this technical multimedia article, we present our method for a robotic mini-invasive spleen preserving distal pancreatectomy with preservation of the splenic vessels. The technique is presented in a stepwise approach with an accompanying video. We believe that the use of the Da Vinci robotic platform facilitates this demanding procedure.

Robotic distal pancreatectomy with or without preservation of spleen: a technical note

Background

Distal pancreatectomy (DP) is a surgical procedure performed to remove the pancreatic tail jointly with a variable part of the pancreatic body and including a spleen resection in the case of conventional distal pancreatectomy or not in the spleen-preserving distal pancreatectomy.

Methods

In this article, we describe a standardized operative technique for fully robotic distal pancreatectomy.

Results

In the last decade, the use of robotic systems has become increasingly common as an approach for benign and malignant pancreatic disease treatment. Robotic Distal Pancreatectomy (RDP) is an emerging technology for which sufficient data to draw definitive conclusions in surgical oncology are still not available because the follow-up period after surgery is too short (less than 2 years).

Conclusions

RDP is an emerging technology for which sufficient data to draw definitive conclusions of value in surgical oncology are still not available, however this techniques is safe and reproducible by surgeons that possess adequate skills.

The second "time-out": a surgical safety checklist for lengthy robotic surgeries

Robotic surgeries of long duration are associated with both increased risks to patients as well as distinct challenges for care providers. We propose a surgical checklist, to be completed during a second "time-out", aimed at reducing peri-operative complications and addressing obstacles presented by lengthy robotic surgeries. A review of the literature was performed to identify the most common complications of robotic surgeries with extended operative times. A surgical checklist was developed with the goal of addressing these issues and maximizing patient safety. Extended operative times during robotic surgery increase patient risk for position-related complications and other adverse events. These cases also raise concerns for surgical, anesthesia, and nursing staff which are less common in shorter, non-robotic operations. Key elements of the checklist were designed to coordinate operative staff in verifying patient safety while addressing the unique concerns within each specialty. As robotic surgery is increasingly utilized, operations with long surgical times may become more common due to increased case complexity and surgeons overcoming the learning curve. A standardized surgical checklist, conducted three to four hours after the start of surgery, may enhance perioperative patient safety and quality of care.