Operative technique in robotic pancreaticoduodenectomy (RPD) at University of Illinois at Chicago (UIC): 17 steps standardized technique : Lessons learned since the first worldwide RPD performed in the year 2001

The optimal choice for patients underwent minimally invasive pancreaticoduodenectomy: a systematic review and meta-analysis including patient subgroups

The aim of this meta-analysis was to evaluate the efficacy and safety of robotic pancreaticoduodenectomy (RPD) in improving perioperative aspects and postoperative complications in patients.

METHODS

We searched PubMed, Embase, Web of Science, and the Cochrane Library database systems for studies that compared RPD with laparoscopic pancreaticoduodenectomy (LPD). Meta-analysis was performed for 24 relevant outcomes, including perioperative outcomes and postoperative complications. Subsequently, a subgroup analysis based on geographical regions was conducted to investigate the impact of regional differences on the perioperative outcomes of the RPD group and the LPD group.

RESULTS

This review found 19 studies with 12,731 individuals (3539 RPD and 9192 LPD). In comparison to LPD, RPD had lower rates of Conversion (OR = 0.58, P < 0.00001), Blood Transfusion (OR = 0.59, P = 0.02), Length of Stay (MD = - 0.54, P = 0.01), postoperative complications [Pneumonia (OR = 0.31, P < 0.0001), and Wound Disruption (OR = 0.26, P = 0.0007)], and more thorough lymph node harvesting (MD = 1.25, P = 0.001). Subgroup analysis showed that Blood Transfusion (I2 = 55%, P = 0.02), Conversion (I2 = 30%, P < 0.00001), Length of Stay (I2 = 71%, P = 0.01), and Lymph Node Harvested (I2 = 87%, P = 0.001) were statistically significant. Interestingly, compared to China, other countries had lower rates of Conversion and more lymph nodes harvested for RPD surgery.

CONCLUSION

The benefits of RPD surgery over LPD surgery in terms of therapy and an optimistic short-term prognosis are clearly supported by this study. Moreover, subgroup analysis based on regional differences revealed statistically significant results for Conversion, Length of Stay (days), Number of Lymph Nodes Harvested and the rate of Blood Transfusion, indicating significant variability across regions. This study provides a solid theoretical foundation and basis for the advancement of RPD in clinical practice.

Educational quality of Robotic Whipple videos on YouTube

BACKGROUND

Videos on Robotic pancreaticoduodenectomy (RPD) may be watched by surgeons learning RPD. This study sought to appraise the educational quality of RPD videos on YouTube.

METHODS

One-hundred videos showing RPD or 'Robotic Whipple' were assessed using validated scales (LAP-VEGaS & Consensus Statement Score (CSS)). The association between the scores and the video characteristics (e.g. order of appearance, provider type etc) was assessed. The minimum number of videos required to cumulatively cover the entire LAP-VEGaS and CSS was also noted.

RESULTS

The videos were of variable quality; median LAP-VEGaS = 0.67 (0.17-0.94), median CSS = 0.45 (0.29-0.53). There was no association between the educational quality of the videos and their order of appearance, view counts, provider type, length or country of origin. Videos lacked information such as patient consent (100%), potential pitfalls (97%) or surgeon credentials (84%). The first 29 videos cumulatively met all the criteria of CSS and LAP-VEGaS scores except for reporting consent.

CONCLUSION

YouTube videos on RPD are of variable quality, without any recognised predictors of quality, and miss important safety information. An impractical number of videos need to be watched to cumulatively fulfil educational criteria. There is a need for high-quality, peer-reviewed videos that adhere to educational principles.

International consensus guidelines on robotic pancreatic surgery in 2023

Background

With the rapid development of robotic surgery, especially for the abdominal surgery, robotic pancreatic surgery (RPS) has been applied increasingly around the world. However, evidence-based guidelines regarding its application, safety, and efficacy are still lacking. To harvest robust evidence and comprehensive clinical practice, this study aims to develop international guidelines on the use of RPS.

Methods

World Health Organization (WHO) Handbook for Guideline Development, GRADE Grid method, Delphi vote, and the AGREE-II instrument were used to establish the Guideline Steering Group, Guideline Development Group, and Guideline Secretary Group, formulate 19 clinical questions, develop the recommendations, and draft the guidelines. Three online meetings were held on 04/12/2020, 30/11/2021, and 25/01/2022 to vote on the recommendations and get advice and suggestions from all involved experts. All the experts focusing on minimally invasive surgery from America, Europe and Oceania made great contributions to this consensus guideline.

Results

After a systematic literature review 176 studies were included, 19 questions were addressed and 14 recommendations were developed through the expert assessment and comprehensive judgment of the quality and credibility of the evidence.

Conclusions

The international RPS guidelines can guide current practice for surgeons, patients, medical societies, hospital administrators, and related social communities. Further randomized trials are required to determine the added value of RPS as compared to open and laparoscopic surgery.

Robotic versus open pancreatoduodenectomy in patients with pancreatic duct adenocarcinoma after the learning curve: a propensity score-matched analysis

BACKGROUND

Studies have demonstrated that the learning curve plays an important role in robotic pancreatoduodenectomy (RPD). Although improved short-term outcomes of RPD after the learning curve have been reported compared to open pancreatoduodenectomy (OPD), there is a lack of long-term survival analyses.

METHODS

Patients who underwent curative intended RPD and OPD for pancreatic duct adenocarcinoma (PDAC) between January 2017 and June 2020 were retrospectively reviewed. A 1:2 propensity score matching (PSM) analysis was performed to balance the baseline characteristics between the RPD and OPD groups.

RESULTS

Of the 548 patients (108 RPD and 440 OPD), 103 RPD patients were matched with 206 OPD patients after PSM. There were 194 (62.8%) men and 115 (37.2%) women, with a median age of 64 (58-69) years. The median overall survival (OS) in the RPD group was 33.2 months compared with 25.7 months in the OPD group (p = 0.058, log-rank). The median disease-free survival (DFS) following RPD was longer than the OPD (18.5 vs. 14.0 months, p = 0.011, log-rank). The RPD group has a lower incidence of local recurrence compared the OPD group (36.9% vs. 51.2%, p = 0.071). Multivariate Cox analysis demonstrated that RPD was independently associated with improved OS (HR 0.70, 95% CI 0.52-0.94, p = 0.019) and DFS (HR 0.66, 95% CI 0.50-0.88, p = 0.005).

CONCLUSION

After the learning curve, RPD had improved oncologic outcomes in PDAC patients compared to OPD. Future prospective randomized clinical trials will be required to validate these findings.

[Anastomotic techniques in minimally invasive hepatobiliopancreatic surgery]

The established anastomotic techniques conventionally used in open surgery are increasingly being implemented in a minimally invasive approach and further developed. The aim of all innovations is to carry out a safe anastomosis with a feasible minimally invasive technique; however, there is currently no broad consensus about the role of laparoscopic and robotic surgery in performing pancreatic anastomotic techniques. Pancreatic fistulas determine the morbidity following a minimally invasive resection. The simultaneous minimally invasive resection and reconstruction of pancreatic processes and vascular structures is currently exclusively performed in specialized centers.

The influence of procedural volume on short-term outcomes for robotic pancreatoduodenectomy-a cohort study and a learning curve analysis

BACKGROUND

An increasing number of robotic pancreatoduodenectomies (RPD) are reported, however, questions remain on the number of procedures needed for gaining technical proficiency in RPD. Therefore, we aimed to assess the influence of procedure volume on short-term RPD outcomes and assess the learning curve effect.

METHODS

A retrospective review of consecutive RPD cases was undertaken. Non-adjusted 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, 60 patients had undergone an RPD at our institution. The median operative time was 360 min (IQR 302.25-442 min). CUSUM analysis of operative time identified 21 cases as proficiency threshold, indicated by curve inflexion. Median operative time was significantly shorter after the threshold of 21 cases (470 vs 320 min, p < 0.001). No significant difference was found between before- and after-threshold groups in major Clavien-Dindo complications (23.8 vs 25.6%, p = 0.876).

CONCLUSIONS

A decrease in operative time after 21 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. RPD can be safely performed by surgeons with prior laparoscopic surgery experience.

A duct-to-mucosa pancreaticojejunostomy for small main pancreatic duct and soft pancreas in minimally invasive pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is often associated with significant morbidity and mortality after the Whipple operation. Patient-related factors associated with POPF include soft pancreatic texture and a small main pancreatic duct (MPD). The traditional duct-to-mucosa anastomosis was modified to be easily performed. The aim of the study was to evaluate the simplified pancreaticojejunostomy (PJ) method in the prevention of POPF after minimally invasive pancreaticoduodenectomy (PD).

METHODS

Ninety-eight patients who underwent laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD) with a simplified PJ procedure containing only two duct-to-mucosa sutures and four penetrating-sutures to anastomose the pancreatic parenchyma and jejunal seromuscular layer in our center were retrospectively studied. Demographics and clinical short-term safety were assessed.

RESULTS

All LPD and RPD procedures were successfully performed. The median time of PJ was 17 min, and the median blood loss was 60 mL, with only one patient requiring transfusion. Four patients (4.1%) suffered from clinically relevant POPF (CR-POPF), including four grade B cases and no grade C cases. For patients with an MPD diameter of 3 mm or less, POPF was noted in two (4%) of the fifty patients, with all cases being grade B. Of the patients with a soft pancreas, only two (4.5%) patients suffered from grade B POPF. One patient (1.0%) experienced a 90-day mortality. Neither the main pancreatic diameter nor pancreatic texture had an impact on postoperative outcomes.

CONCLUSIONS

Our technique is a simple, safe and efficient alternative to prevent POPF after LPD and RPD. This method is suitable for almost all pancreatic conditions, including cases with a small main pancreatic duct and soft pancreas, and has the potential to become the preferred procedure in low-volume pancreatic surgery centers. Our modified duct-to-mucosa PJ, which contains only two duct-to-mucosa sutures and four penetrating-sutures to anastomose the pancreatic parenchyma and jejunal seromuscular layer, is ideal for small MPD and soft pancreas when performing minimally invasive PD and has a low rate of POPF. PJ pancreaticojejunostomy, MPD main pancreatic diameter, PD pancreaticoduodenectomy, POPF postoperative pancreatic fistula.

Perioperative and Oncological Outcomes of Robotic Versus Open Pancreaticoduodenectomy in Low-Risk Surgical Candidates: A Multicenter Propensity Score-Matched Study

OBJECTIVES

This study aimed to perform a multicenter comparison between robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD).

BACKGROUND

Previous comparisons of RPD versus OPD have only been carried out in small, single-center studies of variable quality.

METHODS

Consecutive patients who underwent RPD (n = 1032) or OPD (n = 1154) at 7 centers in China between July 2012 and July 2020 were included. A 1:1 propensity score matching (PSM) was performed.

RESULTS

After PSM, 982 patients in each group were enrolled. The RPD group had significantly lower estimated blood loss (EBL) (190.0 vs 260.0 mL; P < 0.001), and a shorter postoperative 1length of hospital stay (LOS) (12.0 (9.0-16.0) days vs 14.5 (11.0-19.0) days; P < 0.001) than the OPD group. There were no significant differences in operative time, major morbidity including clinically relevant postoperative pancreatic fistula (CR-POPF), bile leakage, delayed gastric emptying, postoperative pancreatectomy hemorrhage (PPH), reoperation, readmission or 90-day mortality rates. Multivariable analysis showed R0 resection, CR-POPF, PPH and reoperation to be independent risk factors for 90-day mortality. Subgroup analysis on patients with pancreatic ductal adenocarcinoma (PDAC) (n = 326 in each subgroup) showed RPD had advantages over OPD in EBL and postoperative LOS. There were no significant differences in median disease-free survival (15.2 vs 14.3 months, P = 0.94) or median overall survival (24.2 vs 24.1 months, P = 0.88) between the 2 subgroups.

CONCLUSIONS

RPD was comparable to OPD in feasibility and safety. For patients with PDAC, RPD resulted in similar oncologic and survival outcomes as OPD.

A chronicle of the pancreatoduodenectomy technique development - from the surgeon's hand to the robotic arm

BACKGROUND

Pancreatoduodenectomy (PD) remains one of the most challenging abdominal surgical procedures.

METHODS

A review of the literature regarding the history of PD, starting from the pioneers, Walter Kausch and Alan Whipple, through the great surgeons of the last century, up to the present day.

RESULTS

The greatest development of the PD technique took place at the end of the twentieth century. Over the last 40 years, there have been huge technological advances in medicine, which have resulted in the introduction of laparoscopic and robotic techniques for abdominal surgery. However, it turns out that PD is still performed as it used to be "by the surgeon's hand" via laparotomy rather than using the most modern robot or laparoscope and is currently recommended by experts for treatment of pancreatic head cancer (PHC). This is mainly caused by not many data comparing these three PD methods. Moreover, increasingly the results achieved by surgeons advanced in minimally invasive pancreatic resections are comparable to or even better than those achieved by the open method in reference centres. Robot-assisted PD appears to be gaining an advantage over laparoscopic technique in the efficacy of PHC treatment. The obstacles most inhibiting the use of surgical robotics are the high cost of the device and procedure, and the long learning curve. A bright future lies ahead for both methods, with the robotic technique in the forefront.

CONCLUSIONS

Despite significant advances in access and surgical technique, PD remains a challenging surgical procedure requiring a big surgeon's experience.

Morbidity and survival after laparoscopic versus open pancreatoduodenectomy: propensity score matched comparison

PURPOSE

Technical challenges and a perceived higher risk of complications hinder a wide adoption of minimally invasive pancreatoduodenectomy. We aim to further define the place of minimally invasive pancreatoduodenectomy by comparison with the traditional open approach.

METHODS

A comparison of the surgical outcomes and survival after laparoscopic (LPD) versus open pancreatoduodenectomy (OPD) was retrospectively performed from a prospectively kept database. To reduce the effect of bias and confounding, baseline characteristics of both groups were matched using propensity score matching (NCT05110573; Nov 8, 2021; retrospectively registered).

RESULTS

From a total of 67 LPD and 105 OPD patients, propensity score matching resulted in two balanced groups of 38 patients. In both groups, 87% of surgeries were performed for cancer. In the LPD group, conversion rate was 22.4%. Mean operative time was significantly longer after LPD versus OPD (320.1 ± 53.8 vs. 277.7 ± 63.8 min; p = .008). Hospital stay was significantly shorter after LPD versus OPD (median 13.5 vs. 17.0 days; p = .039). No significant differences were observed in blood loss, total complication rate (73.7% vs. 86.8%; p = .249), major complication rate (26.5% vs. 10.5%; p = .137), postoperative pancreatic fistula rate (13.2% vs. 7.9%; p = .711), 90-day mortality rate (5.3% vs. 0%; p = .493), R0 resection rate (85.4% vs. 85.8%), or number of lymph nodes (median 10.0 vs. 8.5; p = .273). In cancer patients, no significant differences were observed in overall survival (median 27.1 vs. 23.9 months; p = .693), disease-free survival, or recurrence rate.

CONCLUSION

LPD provided acceptable short-term and oncological outcomes. Compared to OPD, we noted a higher major complication rate, without compromising surgical safety or oncological outcomes.

Pancreatic head cancer - Current surgery techniques

Pancreatic head cancer is a highly fatal disease. For now, surgery offers the only potential long-term cure albeit with a high risk of complications. However, the progress of surgical technique during the past decade has resulted in 5-year survival approaching 30% after resection and adjuvant chemotherapy. This paper presents current data on the recommended extent of lymphadenectomy, the resection margin, on the definition of resectable and borderline resectable tumors and mesopancreas. Surgical techniques proposed to improve PD are presented: the artery first approach, the uncinate process first, the mesopancreas first approach, the triangle operation, periarterial divestment, and multiorgan resection.

Comparison of surgical outcomes among open, laparoscopic, and robotic pancreatoduodenectomy: a single-center retrospective study

BACKGROUND

There is no general consensus on the feasibility and safety of robotic pancreatoduodenectomy (RPD) and whether it increases surgical risks. The purpose of this study was to assess the safety, feasibility, and rationality of RPD by comparing perioperative data among open pancreatoduodenectomy (OPD), laparoscopic pancreatoduodenectomy (LPD), and RPD performed in our center in recent years.

METHODS

Clinical data of patients had undergone RPD (n = 32), LPD (n = 21), and OPD (n = 86) in The First Affiliated Hospital of Guangxi Medical University between January 2016 and June 2020 were retrospectively collected and analyzed.

RESULTS

RPD required more time for operation (537.2 min vs. 441.5 min, p < 0.001) than OPD did, but less time to remove abdominal drainage tube (12.5 d vs. 17.3 d, p = 0.001). The differences between the RPD group and LPD group were interesting, as the two groups had similar operation time (537.2 min vs. 592.9 min, p = 1.000) and blood loss (482.8 ml vs. 559.5 ml, p > 0.05), but the RPD group had a higher activity of daily living score on postoperative day 3 (35.8 vs. 25.7, p = 0.0017) and a lower rate of conversion to OPD (6.5% vs. 38.1%, p = 0.011). Regarding complications, such as the postoperative pancreatic fistula, abdominal hemorrhage, intra-abdominal infection, bile leakage, reoperation, and perioperative mortality, there were no significant differences among the three groups.

CONCLUSIONS

Not only is RPD feasible and reliable, it also offers significant advantages in that it improves postoperative recovery of skills needed for everyday life, has a low conversion rate to open surgery, and does not increase surgical risks.

Short-term and pathologic outcomes of robotic versus open pancreatoduodenectomy for periampullary and pancreatic head malignancy: an early experience

Open pancreatoduodenectomy (OPD) is associated with high perioperative morbidity. Adoption of robot-assisted pancreatoduodenectomy (RAPD) has been slow despite ergonomic advantages, improved visualization and dexterity. We aim to report our experience comparing operative and short-term outcomes following RAPD and OPD. We did retrospective analysis of prospectively maintained database, including all consecutive patients who underwent RAPD or OPD between January 2016 and August 2019. 48 patients were included, 21 in RAPD group and 27 in OPD group. RAPD was associated with longer mean operative time (440 vs. 414.1 min) but had significantly less mean intra-operative blood loss (256.9 vs. 404.5 ml), median length of ICU stay (1 vs. 3 days), overall length of stay (11 vs. 13 days) and lower rates of SSI (23.8% vs. 63%). Both groups showed equal incidence of POPF, comparable R0 resection rates (100% vs. 96.3%) and median number of lymph nodes harvested (14 vs. 18). Rate of open conversion was 28.6% (n = 6), most commonly for bleeding (66.6%) and mesenteric vessel involvement (33.3%). When compared to first ten RAPD cases, mean operative time (483.5 vs. 400.5 min) and rate of conversion (36.36% vs. 20%) was less in last eleven cases. RAPD is significantly better than OPD in terms of intra-operative blood loss, length of ICU stay, length of total stay and SSI. The longer operative time and conversion rate associated with RAPD progressively decreased as experience accumulated and the learning curve was crossed. Further randomized controlled trials are needed to investigate cost-effectiveness and long-term oncologic survival in RAPD patients.

Robotische Pankreaschirurgie – Lernkurve und Etablierung

Minimalinvasive Resektionstechniken zur Behandlung verschiedener Pathologien des Pankreas sind potenziell vorteilhaft für die behandelten Patienten in Bezug auf Rekonvaleszenzzeit und postoperative Morbidität, stellen jedoch eine besondere technische Herausforderung für den behandelnden Chirurgen dar. Der Einzug der robotischen Technik in die Viszeralchirurgie bietet eine prinzipielle Möglichkeit zur weitreichenden Verbreitung minimalinvasiver Verfahren in der Pankreaschirurgie.

Ziel dieser Arbeit war es, die Entwicklungsmöglichkeiten der robotischen Pankreaschirurgie in Deutschland zu überprüfen. Datengrundlage sind die Qualitätsberichte der Krankenhäuser der Jahre 2015–2019 kombiniert mit einer selektiven Literaturrecherche.

Die Anzahl der vorliegenden Qualitätsberichte reduzierte sich von 2015 bis 2019 von 1635 auf 1594. Im Median führten 96 Kliniken 11–20, 56 Kliniken 21–50 und 15 Kliniken mehr als 50 Pankreaskopfresektionen jährlich durch. Bei den Linksresektionen waren es 35 Kliniken mit 11–20, 14 Kliniken mit 21–50 und 2 Kliniken mit mehr als 50 Eingriffen. Unter Berücksichtigung aller Kliniken, die 5 oder mehr Linksresektionen pro Jahr durchführen, wurden an nur 29 Kliniken minimalinvasive Verfahren eingesetzt. Der Anteil an laparoskopischen Linksresektionen über 50% wurde an nur 7 Kliniken beschrieben.

Nach Datenlage in der Literatur divergieren die Lernkurven für die robotische Pankreaslinks- und Pankreaskopfresektion. Während die Lernkurve für die robotische Pankreaslinksresektion nach etwa 20 Eingriffen durchlaufen ist, hat die Lernkurve für die robotische Pankreaskopfresektion mehrere Plateaus, die etwa nach 30, 100 und 250 Eingriffen erreicht werden.

Aufgrund der dezentralen Struktur der Pankreaschirurgie in Deutschland scheint ein flächendeckendes Angebot robotischer Verfahren aktuell in weiter Ferne. Insbesondere die Etablierung der robotischen Pankreaskopfresektion wird zunächst Zentren mit entsprechend hoher Fallzahl vorbehalten bleiben.

Advanced Robotic Surgery: Liver, Pancreas, and Esophagus - The State of the Art?

Background

The trend in performing robotic-assisted operations in visceral surgery has been increasing in the last decade, also reaching the challenging field of hepatic, pancreatic, and esophageal surgery. Nevertheless, solid data about advantages and disadvantages of the robotic approach are still missing. The aim of this review is to analyze the benefit and impact of robotic surgery in the field of hepatic, pancreatic, and esophageal surgery, focusing on the comparison with the conventional laparoscopic or open approach.

Summary

The well-known advantages of laparoscopic surgery in comparison to the open approach are also valid for robotic surgery, with the addition of a 3D-view camera, wristed instrumentation, and an ergonomic console. On the other hand, the use of a robotic system leads to longer operating time and higher costs. Randomized controlled trials comparing the robotic approach with the laparoscopic one are still missing.

Key Message

Recent meta-analyses show promising results of the usage of robotic systems in advanced surgical procedures, like hepatic, pancreatic, and esophageal resections. Further randomized studies are needed to validate the postulated benefit.

The standardized technique and surgical video of robotic pancreaticoduodenectomy at the Chinese PLA General Hospital

The technical complexity of robotic pancreaticoduodenectomy (RPD) and lack of technical surgical standardization have slowed its widespread application. RPD is only routinely performed in a few highly specialized centers. This study describes in detail the standard steps and core techniques of an experienced robotic center in China. We took advantage of our single experience to provide a step-by-step technique and surgical video of our RPD standardized procedure. We divided RPD into 18 key steps. Demographics and perioperative outcomes of consecutive 20 patients who underwent the RPD standardized procedure were analyzed. For the 20 consecutive patients, the mean operative time was 253.6 min, and the median estimated blood loss was 210.0 mL. One patient required conversion to laparotomy due to the need for PV reconstruction. One patient had grade 3 complication. The median postoperative hospital stay was 11.0 days. No 90-day mortality was observed. By simplifying and optimizing the surgical techniques, the RPD procedure can be standardized and modeled to improve feasibility and repeatability.

State of the art of robotic pancreatoduodenectomy

Current evidence shows that robotic pancreatoduodenectomy (RPD) is feasible with a safety profile equivalent to either open pancreatoduodenectomy (OPD) or laparoscopic pancreatoduodenectomy (LPD). However, major intraoperative bleeding can occur and emergency conversion to OPD may be required. RPD reduces the risk of emergency conversion when compared to LPD. The learning curve of RPD ranges from 20 to 40 procedures, but proficiency is reached only after 250 operations. Once proficiency is achieved, the results of RPD may be superior to those of OPD. As for now, RPD is at least equivalent to OPD and LPD with respect to incidence and severity of POPF, incidence and severity of post-operative complications, and post-operative mortality. A minimal annual number of 20 procedures per center is recommended. In pancreatic cancer (versus OPD), RPD is associated with similar rates of R0 resections, but higher number of examined lymph nodes, lower blood loss, and lower need of blood transfusions. Multivariable analysis shows that RPD could improve patient survival. Data from selected centers show that vein resection and reconstruction is feasible during RPD, but at the price of high conversion rates and frequent use of small tangential resections. The true Achilles heel of RPD is higher operative costs that limit wider implementation of the procedure and accumulation of a large experience at most single centers. In conclusion, when proficiency is achieved, RPD may be superior to OPD with respect to CR-POPF and oncologic outcomes. Achievement of proficiency requires commitment, dedication, and truly high volumes.

Real robotic total mesopancreas excision (TMpE) assisted by hanging manoeuver (HM): Standardised technique

BACKGROUND

Pancreaticoduodenectomy (PD) is one of the most demanding interventions for digestive surgeons. R0 resection is a key point for the overall survival and disease-free survival. Total mesopancreas excision (TMpE) has been described by laparotomy but laparoscopy did not provide good results probably because of the technical difficulties of the approach. We propose a standardised total robotic approach.

METHODS

In this step-by-step technical description, we propose as example, a case of a 53-year-old man with a pancreatic head adenocarcinoma with doubts about the invasion of the mesopancreas surrounding superior mesenteric artery. The mesopancreas hanging manoeuver allows us to perform a TMpE.

RESULTS

The surgery performed was a robotic artery first pancreaticoduodenectomy with TMpE. The pathological result was pancreatic ductal adenocarcinoma pT2, N1 (1/23), M0, V0, L0, Pn0, R0.

CONCLUSIONS

Robotic approach is safe, effective and reproductible. Through a standardised technique, it may overcome some of the technical difficulties of laparoscopic PD.

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

INTRODUCTION

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.

PATIENTS AND METHODS

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.

RESULTS

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 395 min, 404 min, 510 min, respectively. Intraoperative blood loss for laparoscopic PD, hybrid PD, and robotic PD was 250 ml, 250 ml, and 413 ml, 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.

CONCLUSION

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 liver surgery: literature review and future perspectives

INTRODUCTION

Minimally invasive liver resections (MILR) have been gaining popularity over the last decades. MILR provides superior peri-operative outcome. Despite these advantages, the penetrance of MILR in the clinical setting has been limited, and it was slowed down, among other factors, also by the laparoscopic technological limitations.

EVIDENCE ACQUISITION

A literature review has been carried out (Pubmed, Embase and Scopus platforms) focusing on the role of robotic surgery in MILR.

EVIDENCE SYNTHESIS

The literature review results are presented and our additional remarks on the topic are discussed.

CONCLUSIONS

Robotic MILR has been helping to expand the penetrance of MIS in liver surgery by making possible increasingly more challenging procedures. Minor resections still represent most of the robotic liver surgery data currently available. Robotic liver surgery is safe and effective, and it shows perioperative outcomes comparable with laparoscopic and open surgery. The oncological efficacy, within the limitations of the current level of evidence (mostly retrospective studies and literature heterogeneity), seems to show promising result. High quality prospective randomized studies, the use of prospective registry data, and multi-institutional efforts are needed.

Association of Mentorship and a Formal Robotic Proficiency Skills Curriculum With Subsequent Generations' Learning Curve and Safety for Robotic Pancreaticoduodenectomy

Importance

Learning curves are unavoidable for practicing surgeons when adopting new technologies. However, patient outcomes are worse in the early stages of a learning curve vs after mastery. Therefore, it is critical to find a way to decrease these learning curves without compromising patient safety.

Objective

To evaluate the association of mentorship and a formal proficiency-based skills curriculum with the learning curves of 3 generations of surgeons and to determine the association with increased patient safety.

Design, Setting, and Participants

All consecutive robotic pancreaticoduodenectomies (RPDs) performed at the University of Pittsburgh Medical Center between 2008 and 2017 were included in this study. Surgeons were split into generations based on their access to mentorship and a proficiency-based skills curriculum. The generations are (1) no mentorship or curriculum, (2) mentorship but no curriculum, and (3) mentorship and curriculum. Univariable and multivariable analyses were used to create risk-adjusted learning curves by surgical generation and to analyze factors associated with operating room time, complications, and fellows completing the full resection. The participants include surgical oncology attending surgeons and fellows who participated in an RPD at University of Pittsburgh Medical Center between 2008 and 2017.

Main Outcomes and Measures

The primary outcome was operating room time (ORT). Secondary outcomes were postoperative pancreatic fistula and Clavien-Dindo classification higher than grade 2.

Results

We identified 514 RPDs completed between 2008 and 2017, of which 258 (50.2%) were completed by first-generation surgeons, 151 (29.3%) were completed by the second generation, and 82 (15.9%) were completed by the third generation. There was no statistically significant difference between groups with respect to age (66.3-67.3 years; P = .52) or female sex (n = 34 [41.5%] vs n = 121 [46.9%]; P = .60). There was a significant decrease in ORT (P < .001), from 450.8 minutes for the first-generation surgeons to 348.6 minutes for the third generation. Additionally, across generations, Clavien-Dindo classification higher than grade 2 (n = 74 [28.7%] vs n = 30 [9.9%] vs n = 12 [14.6%]; P = .01), conversion rates (n = 18 [7.0%] vs n = 7 [4.6%] vs n = 0; P = .006), and estimated blood loss (426 mL vs 288.6 mL vs 254.7 mL; P < .001) decreased significantly with subsequent generations. There were no significant differences in postoperative pancreatic fistula.

Conclusions and Relevance

In this study, ORT, conversion rates, and estimated blood loss decreased across generations without a concomitant rise in adverse patient outcomes. These findings suggest that a proficiency-based curriculum coupled with mentorship allows for the safe introduction of less experienced surgeons to RPD without compromising patient safety.

Evaluation of robotic versus open partial pancreatoduodenectomy-study protocol for a randomised controlled pilot trial (EUROPA, DRKS00020407)

Background

Partial pancreatoduodenectomy (PD) is the indicated surgical procedure for a wide range of benign and malignant diseases of the pancreatic head and distal bile duct and offers the only potential cure for pancreatic head cancer. The current gold standard, open PD (OPD) performed via laparotomy, is associated with morbidity in around 40% of cases, even at specialised centres. Robotic PD (RPD) might offer a viable alternative to OPD and has been shown to be feasible. Encouraging perioperative results have been reported for RPD in a number of small, non-randomised studies. However, since those studies showed a considerable risk of bias, a thorough comparison of RPD with OPD is warranted.

Methods

The EUROPA (EvalUation of RObotic partial PAncreatoduodenectomy) trial is designed as a randomised controlled unblinded exploratory surgical trial with two parallel study groups. A total of 80 patients scheduled for elective PD will be randomised after giving written informed consent. Patients with borderline or non-resectable carcinoma of the pancreatic head as defined by the National Comprehensive Cancer Network guidelines, distant metastases or an American Society of Anaesthesiologists (ASA) score > III will be excluded. The experimental intervention, RPD, will be compared with the control intervention, OPD. An intraoperative dropout of approximately eight patients per group is expected because they may receive another type of surgical procedure than planned. Overall, 64 patients need to be analysed. The primary endpoint of the trial is overall postoperative morbidity within 90 days after index operation, measured using the Comprehensive Complication Index (CCI). The secondary endpoints include the feasibility of recruitment and assessment of clinical, oncological and safety parameters and quality of life and cost-effectiveness.

Discussion

The EUROPA trial is the first randomised controlled trial comparing RPD with OPD. Differences in postoperative morbidity will be evaluated to design a future multicentre confirmatory efficacy trial.

Trial registration

German Clinical Trial Register DRKS00020407. Registered on 9 March 2020

Perioperative outcomes of robotic pancreaticoduodenectomy: a single surgeon's experience with 55 consecutive cases

Background

Robotic pancreaticoduodenectomy (RPD) has been increasingly performed for patients with periampullary tumours and tumours in the pancreatic head. This method offers several technical advantages compared to open and laparoscopic surgeries. However, the surgical results often vary depending on the experience of different pancreatic centres.

Methods

A retrospective study of our first 55 cases of RPD from August 2016 to April 2020 was conducted to evaluate the perioperative outcomes of RPD and to summarize the operative experiences in a single intuition. Benign and malignant tumours in the pancreatic head or periampullary tumours without obvious vascular and adjacent organ invasion were included in this study. Perioperative characteristics and postoperative complications of the enrolled patients were retrospectively collected.

Results

The first 17 cases were robot-assisted laparoscopic pancreaticoduodenectomy (RA-LPD) and the remaining 38 patients underwent total RPD. The RA-LPD group had a remarkably longer operative time than the total RPD group (415.3±89.2 vs. 362.4±75.6 min, P=0.047). The incidences of biliary leakage, chyle leakage, DGE, intra-abdominal infection and intra-abdominal haemorrhage were 3.6%, 0.0%, 5.5%, 9.1% and 5.5%, respectively. Two patients underwent relaparotomy due to severe intra-abdominal haemorrhage. The median length of hospital stay was 14 (11 to 19) days. There were no deaths during the perioperative period.

Conclusions

RPD is a technically feasible procedure for selected patients with periampullary tumours and tumours in the pancreatic head in experienced hands.

Overcoming the Arduous Transition for Robotic Hepatopancreatobiliary Cases: A Multi-Procedure Learning Curve Study Utilizing CUSUM Analysis

BACKGROUND/OBJECTIVE

Quick optimization and mastery of a new technique is an important part of procedural medicine, especially in the field of minimally invasive surgery. Complex surgeries such as robotic pancreaticoduodenectomies (RPD) and robotic distal pancreatectomies (RDP) have a steep learning curve; therefore, findings that can help expedite the burdensome learning process are extremely beneficial. This single-surgeon study aims to report the learning curves of RDP, RPD, and robotic Heller myotomy (RHM) and to review the results' implications for the current state of robotic hepatopancreaticobiliary (HPB) surgery.

STUDY DESIGN

This is a retrospective case series of a prospectively maintained database at a non-university tertiary care center. Total of 175 patients underwent either RDP, RPD, or RHM with the surgeon (DRJ) from January 2014 to January 2020.

RESULTS

Statistical significance of operating room time (ORT) was noted after 47 cases for RDP (p < 0.05), 51 cases for RPD (p < 0.0001), and 18 cases for RHM (p < 0.05). Mean ORT after the statistical mastery of the procedure for RDP, RPD, and RHM was 124, 232, 93 min, respectively. No statistical significance was noted for estimated blood loss or length of stay.

CONCLUSIONS

Robotic HPB procedures have significantly higher learning curves compared to non-HPB procedures, even for an experienced HPB surgeon with extensive laparoscopic experience. Our RPD curve, however, is quicker than the literature average. We suggest that this is because of the simultaneous implementation of HPB (RDP and RPD) and non-HPB robotic surgeries with a shorter learning curve-especially foregut procedures such as RHM-into an experienced surgeon's practice. This may accelerate the learning process without compromising patient safety and outcomes.

Combination of anterior superior mesenteric vein-first and right posterior superior mesenteric artery-first approaches for uncinate process dissection in minimally invasive pancreaticoduodenectomy

Background

Uncinate process dissection is a key step in minimally invasive pancreaticoduodenectomy (MIPD), including laparoscopic and robotic procedures, which increase the intraoperative blood loss and operative time and decrease the R0 resection rate if improperly handled. However, few studies have reported the operative skills in detail.

Methods

We performed uncinate process dissection using a combination of the anterior superior mesenteric vein (SMV)-first approach and the right posterior superior mesenteric artery (SMA)-first approach in MIPD for 138 patients with periampullary tumors between March 2017 and October 2019. The demographic and perioperative data of all the patients were collected to evaluate the efficacy of this method.

Results

All patients underwent an uneventful operation. An assistant incision was performed to separate extensive adhesion between the tumor and the SMV in 3 patients. The combined approach had a notably shorter operation time and resection time, less intraoperative blood loss and a shorter postoperative hospital stay than the traditional approach (P<0.05). There were no significant differences in conversion rate, numbers of harvested lymph node or postoperative complications, including postoperative pancreatic fistula, bile leakage, delayed gastric emptying, postoperative bleeding and reoperation between the two groups (P>0.05). There were no deaths during the perioperative period.

Conclusions

The combination of the anterior SMV-first approach and the right posterior SMA-first approach is a safe and feasible technique for uncinate process dissection in MIPD.

Transition from open and laparoscopic to robotic pancreaticoduodenectomy in a UK tertiary referral hepatobiliary and pancreatic centre - Early experience of robotic pancreaticoduodenectomy

BACKGROUND

Pancreaticoduodenectomy is performed using an open technique (OPD) as the gold standard. An increase in those performed laparoscopically (LPD) and robotically (RPD) are now reported. We compared the short-term outcomes of RPD cases with LPD and OPD.

METHODS

A retrospective review of a prospectively collected database was undertaken of our first consecutive RPD, our first LPD and consecutive OPD cases. Those requiring venous and/or arterial resection were excluded.

RESULTS

RPD (n = 25) had longer median operating times (461 (IQR 358-564) mins) than LPD (n = 41) (330 (IQR 262.5-397.5) mins) and OPD (n = 37) (330 (IQR 257-403) mins, p < 0.0001). Estimated blood loss and transfusion requirement was less after RPD and LPD compared to OPD (p = 0.012 and p < 0.0001 respectively). No RPD cases required conversion to open operation compared to 24.4% of LPD. Morbidity was comparable with a Clavien Dindo score ≥3 in 20.00%, 24.39% and 18.92% for RPD, LPD and OPD respectively (p = 0.83). Post-operative pancreatic fistula rates were seen in 16.00%, 29.27% and 21.62% of our RPD, LPD and OPD cohorts respectively (p = 0.81). 90-day mortality was seen in 0.97% of the total cohort. Length of hospital stay (LOS) was shorter for RPD compared to both LPD (p = 0.030) and OPD (p = 0.002).

CONCLUSION

RPD is safe to perform with comparable outcomes to LPD and OPD. Further evidence is provided that a randomised controlled trial for PD techniques is required.

Robotic hepaticojejunostomy: surgical technique and risk factor analysis for anastomotic leak and stenosis

BACKGROUND

A variety of techniques have been described for the construction of the HJ (hepaticojejunostomy). Due to its technical challenges, HJ is rarely performed in a pure laparoscopic setting. In stark contrast, the increasing availability of the robotic platform has sparked new interest in pursuing this procedure in a minimally invasive fashion. The aim of our study was to describe our surgical technique and to identify risk factors for anastomotic leak and stenosis following robotic surgery.

METHODS

We performed a retrospective analysis of a prospectively collected database, including all consecutive HJ carried out for different indications over a 10 year period.

RESULTS

One hundred fifty-two patients undergoing robotic HJ performed by the same surgeon were analyzed. Bile leak occurred in 2.6% of the patients. Stricture rate was 3.3%. The median follow up was 25.5 months. There was no mortality related to anastomotic complications. On univariate analysis, patient's age less than 65 years was the only risk factor for anastomotic stricture. On multivariate analysis, no predictor factors for leak or stenosis were identified.

CONCLUSION

HJs carried out in a robotic fashion allow highly satisfactory results. No independent risk factors for bile leak of stenosis were identified on multivariate analysis.

Applying the Delphi process for development of a hepatopancreaticobiliary robotic surgery training curriculum

BACKGROUND

Robotic hepatopancreaticobiliary (HPB) procedures are performed worldwide and establishing processes for safe adoption of this technology is essential for patient benefit. We report results of the Delphi process to define and optimize robotic training procedures for HPB surgeons.

METHODS

In 2019, a robotic HPB surgery panel with an interest in surgical training from the Americas and Europe was created and met. An e-consensus-finding exercise using the Delphi process was applied and consensus was defined as 80% agreement on each question. Iterations of anonymous voting continued over three rounds.

RESULTS

Members agreed on several points: there was need for a standardized robotic training curriculum for HPB surgery that considers experience of surgeons and based on a robotic hepatectomy includes a common approach for "basic robotic skills" training (e-learning module, including hardware description, patient selection, port placement, docking, troubleshooting, fundamentals of robotic surgery, team training and efficiency, and emergencies) and an "advanced technical skills curriculum" (e-learning, including patient selection information, cognitive skills, and recommended operative equipment lists). A modular approach to index procedures should be used with video demonstrations, port placement for index procedure, troubleshooting, and emergency scenario management information. Inexperienced surgeons should undergo training in basic robotic skills and console proficiency, transitioning to full procedure training of e-learning (video demonstration, simulation training, case observation, and final evaluation). Experienced surgeons should undergo basic training when using a new system (e-learning, dry lab, and operating room (OR) team training, virtual reality modules, and wet lab; case observations were unnecessary for basic training) and should complete the advanced index procedural robotic curriculum with assessment by wet lab, case observation, and OR team training.

CONCLUSIONS

Optimization and standardization of training and education of HPB surgeons in robotic procedures was agreed upon. Results are being incorporated into future curriculum for education in robotic surgery.

Ivor-Lewis oesophagectomy: A standardized operative technique in 11 steps

SYNOPSIS

Standardization of robotic oesophagectomy can benefit both patients and surgeons by decreasing complications, shortening the learning curve and improving surgical training.

BACKGROUND

Thoraco-abdominal oesophagectomy with lymphadenectomy is the cornerstone of curative therapy for oesophageal carcinoma. To reduce post-operative morbidity, minimally invasive technology has become increasingly established. Conventional thoraco-laparoscopic procedures, however, are limited by their technical feasibility. These limitations can be overcome using robot-assisted technology.

METHODS

Robotic Ivor-Lewis oesophageal resection has gradually been implemented in our clinic from 2013. We have performed over 250 robot-assisted minimally invasive oesophagectomies and more than 2000 robotic procedures overall. This experience allowed us to establish a standardized operative technique.

RESULTS

We identified 11 operative steps as key elements for oesophageal resection, which should help implementation of this technique and allow surgeons to approach this complex procedure with greater confidence.

CONCLUSION

Standardization is fundamental to the establishment of a new surgical technique and is a key element in the learning curve of Ivor-Lewis oesophageal resection. Standardization can lead to better reproducibility of results, and thus to improved quality.

Robotic resection for benign primary retroperitoneal tumors via the transperitoneal approach

BACKGROUND

Surgical resection is the primary treatment for benign primary retroperitoneal tumors. However, only a few studies have reported robotic resection for retroperitoneal tumors due to the low morbidity rate, and only a small fraction of retroperitoneal tumors are eligible for minimally invasive operations.

METHODS

A retrospective study enrolling 16 patients with benign primary retroperitoneal tumors between November 2016 and April 2020 was conducted to evaluate the efficacy of robotic resection for benign primary retroperitoneal tumors via the transperitoneal approach. Surgical skills were described in detail and operative experiences were summarized.

RESULTS

The operations were uneventfully performed without conversion in all the patients. The median operation time was 135 (120-180) min, and the median estimated blood loss was 25 (20-60) mL. The median duration of diet restoration was 2 (1-2) days and the median length of postoperative hospital stay was 6 (4-7) days. No serious intraoperative or postoperative complications occurred during the perioperative period.

CONCLUSIONS

Robotic resection via the transperitoneal approach is a feasible and safe procedure for highly selected patients with benign primary retroperitoneal tumors, with few postoperative complications and a rapid recovery.

International expert consensus on laparoscopic pancreaticoduodenectomy

IMPORTANCE

While laparoscopic pancreaticoduodenectomy (LPD) is being adopted with increasing enthusiasm worldwide, it is still challenging for both technical and anatomical reasons. Currently, there is no consensus on the technical standards for LPD.

OBJECTIVE

The aim of this consensus statement is to guide the continued safe progression and adoption of LPD.

EVIDENCE REVIEW

An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreaticoduodenectomy. Statements were produced upon reviewing the literature and assessed by the members of the expert panel. The literature search and its critical appraisal were limited to articles published in English during the period from 1994 to 2019. The Web of Science, Medline, and Cochrane Library and Clinical Trials databases were searched, The search strategy included, but was not limited to, the terms 'laparoscopic', 'pancreaticoduodenectomy, 'pancreatoduodenectomy', 'Whipple's operation', and 'minimally invasive surgery'. Reference lists from the included articles were manually checked for any additional studies, which were included when appropriate. Delphi method was used to establish expert consensus and the AGREE II-GRS Instrument was applied to assess the methodological quality and externally validate the final statements. The statements were further discussed during a one-day face-to-face meeting at the 1st Summit on Minimally Invasive Pancreatico-Biliary Surgery in Wuhan, China.

FINDINGS

Twenty-eight international experts from 8 countries constructed the expert panel. Sixteen statements were produced by the members of the expert panel. At least 80% of responders agreed with the majority (80%) of statements. Other than three randomized controlled trials published to date, most evidences were based on level 3 or 4 studies according to the AGREE II-GRS Instrument.

CONCLUSIONS AND RELEVANCE

The Wuhan international expert consensus meeting on LPD has produced a set of clinical practice statements for the safe development and progression of LPD. LPD is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. More robust randomized controlled trial and registry study are essential to proceed with the assessment of LPD.

Robotic Whipple for pancreatic ductal and ampullary adenocarcinoma: 10 years experience of a US single-center

BACKGROUND

There is currently ample consensus about the safety and feasibility of robotic pancreaticoduodenectomy (RPD). However, few studies are available on the long-term oncological outcomes of this procedure. We present a long-term survival analysis (up to 10 years) of our series of RPD carried out for ductal and ampullary adenocarcinoma.

METHODS

A retrospective analysis of a prospectively collected approved database was carried out including 39 patients who underwent RPD for pancreatic ductal and ampullary adenocarcinomas.

RESULTS

The 5-year overall survival for ductal and ampullary carcinoma was 41% with an estimated median and mean survival of 27 and 52 months. The ampullary group had significantly longer 5-year survival (68%) than the ductal group (30%).

CONCLUSION

Our data show, within the limitations of their retrospective nature, that robotic pancreaticoduodenectomy provides similar short- and long-term survival outcomes compared to open technique in the treatment of pancreatic ductal and ampullary adenocarcinoma.

Predictive factors for postoperative pancreatitis after pancreaticoduodenectomy: A single-center retrospective analysis of 1465 patients

BACKGROUND

Postoperative acute pancreatitis (POAP) after pancreaticoduodenectomy (PD) has been recently recognized as an independent complication that is associated with undesirable postoperative outcomes and often precedes other complications, yet predictive factors attributable to POAP after PD remain elusive.

METHODS

The data from 1465 consecutive patients who underwent laparotomy or minimally invasive robotic PD from March 2010 to December 2018 were retrospectively reviewed. POAP was defined as an elevation of the serum amylase levels above the institution's normal upper limit (100 U/L) on postoperative day (POD) 1. Univariate and multivariate analyses were performed to investigate the predictive factors for POAP after PD and the association between POAP and clinically relevant postoperative pancreatic fistulas (CR-POPFs).

RESULTS

Among the 1465 patients, 411 (28%) underwent minimally invasive robotic surgeries, and the overall POAP and CR-POPFs rates were 770 (53%) and 277 (19%), respectively. The female sex (OR 1.76), a normal bilirubin level (OR 1.55), the robotic surgery (OR 1.36), a main pancreatic duct (MPD) ≤3 mm (OR 5.69) and a high-risk nonadenocarcinoma pathology (cystic disease: OR 4.33; pNETs: OR 4.34; others: OR 2.74) were considered independent risk factors for POAP. A nondilated MPD was a predominant predictor for POAP, with 72.2% sensitivity and 71.8% specificity. POAP was also an independent predictive factor for CR-POPFs (OR 3.48).

CONCLUSION

A nondilated MPD, a high-risk pathology, the female sex, a normal bilirubin level and the robotic surgery were independent predictive factors for POAP after PD. Prevention and early treatment strategy changes can be made based on these preoperative predictive factors.

Educational step-by-step surgical video about operative technique in robotic pancreaticoduodenectomy (RPD) at University of Illinois at Chicago (UIC): 17 steps standardized technique-Lessons learned since the first worldwide RPD performed in the year 2001

Background

RPD (Robotic pancreatoduodenectomy) was first performed by P. C. Giulianotti in 2001 (Arch Surg 138(7):777–784, 2003). Since then, the complexity and lack of technique standardization has slowed down its widespread utilization. RPD has been increasingly adopted worldwide and in few centres is the preferred apporached approach by certain surgeons. Some large retrospective series are available and data seem to indicate that RPD is safe/feasible, and a valid alternative to the classic open Whipple. Our group has recently described a standardized 17 steps approach to RPD (Giulianotti et al. Surg Endosc 32(10): 4329–4336, 2018). Herin, we present an educational step-by-step surgical video with short technical/operative description to visually exemplify the RPD 17 steps technique.

Methods

The current project has been approved by our local Institutional Review Board (IRB). We edited a step-by-step video guidance of our RPD standardized technique. The data/video images were collected from a retrospective analysis of a prospectively collected database (IRB approved). The narration and the images describe hands-on operative “tips and tricks” to facilitate the learning/teaching/evaluation process.

Results

Each of the 17 surgical steps is visually represented and explained to help the in-depth understanding of the relevant surgical anatomy and the specific operative technique.

Conclusions

Educational videos descriptions like the one herein presented are a valid learning/teaching tool to implement standardized surgical approaches. Standardization is a crucial component of the learning curve. This approach can create more objective and reproducible data which might be more reliably assessed/compared across institutions and by different surgeons. Promising results are arising from several centers about RPD. However, RPD as gold standard-approach is still a matter of debate. Randomized-controlled studies (RCT) are required to better validate the precise role of RPD.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-07383-0) contains supplementary material, which is available to authorized users.

Predicting Selection Preference of Robotic Pancreaticoduodenectomy (RPD) in a Chinese Single Center Population: Development and Assessment of a New Predictive Nomogram

BACKGROUND Robotic pancreaticoduodenectomy (RPD) is a novel type of minimally invasive surgery to treat tumors located at the head of the pancreas. This study aimed to construct a novel prediction model for predicting selection preference for RPD in a Chinese single medical center population. MATERIAL AND METHODS The clinical data from 451 pancreatic ductal adenocarcinoma patients were collected and analyzed from January 2013 to December 2016. Twenty-three items affecting clinical strategies were optimized by LASSO (least absolute shrinkage and selection operator) regression analysis and then were incorporated in multivariable logistic regression analysis. C-index was used for evaluating the discriminative ability. Decision curve was applied to determine clinical application of this model and the calibration of this nomogram was evaluated by calibration plot. The model was internally validated through bootstrapping validation. RESULTS Clinicopathological factors included in the model were age, history of diabetes mellitus, history of hypertension, history of heart, brain and kidney disease, history of abdominal surgery, symptoms (jaundice, accidental discovery and weight loss), anemia, elevated carcinoembryonic antigen (CEA), smoking, alcohol intake, American Society of Anesthesiologists (ASA) scores, vascular invasion, overweight, preoperative lymph node metastasis and tumor size >3.5 cm. A C-index of 0.831 indicated good discrimination and calibration of this model. Interval validation generated an acceptable C-index of 0.787. When surgical approach was determined at the threshold of preference possibility less than 63%, decision curve analysis indicated that this model had good clinical application value in this range. CONCLUSIONS This new nomogram could be conveniently used to predict the selection preference of robotic surgery for patients with pancreatic head cancer.

Retrocolic versus antecolic gastrointestinal reconstruction in robotic pancreaticoduodenectomy

BACKGROUND

With the advancement of robotic pancreaticoduodenectomy (RPD), several reconstruction methods have been advocated to make RPD more effective and safer. In this study, we investigated the safety and effectiveness of RPD using a left retrocolic (L-port) technique and compared it with those of RPD using an antecolic technique.

METHODS

Between October 2015 and August 2016, we retrospectively reviewed consecutive cases of RPD before and after introducing the L-port technique for gastrointestinal reconstruction. The L-port technique was mainly performed for retrocolic gastrojejunal reconstruction and some cases of duodenojejunal reconstruction. The perioperative and postoperative outcomes were compared in the two groups.

RESULTS

Eighty-three cases of RPD were retrieved for statistical analysis. Compared with the antecolic group, the L-port group was significantly associated with a shorter operative time (median time [IQR] 345 [307-384] min vs. 390 [370-455] min, P < 0.001), reconstruction time (54 [48-59] min vs. 84 [75-98] min, P < 0.001) and lower incidence of delayed gastric emptying. There were no cases of re-operation due to internal herniation, colonic ischemia, or bowel volvulus in the L-port group during the 1-year follow-up period.

CONCLUSIONS

Our results demonstrated that the L-port technique of RPD is a safe and feasible technique for gastrointestinal reconstruction.

Modular step-up approach to robot-assisted transthoracic esophagectomy-experience of a German high volume center

Background

The use of robotic technology in general surgery is rapidly increasing in Europe. Aim of this study is to evaluate the introduction of new robotic technologies in a center of excellence for upper gastrointestinal surgery.

Methods

A standardized teaching protocol of a complete OR team was performed in simulation and animal models at the Center for the Future of Surgery (San Diego CA, USA) and IRCAD (Strasbourg, France) to receive certification as console surgeons. Starting 02/2017 the daVinci Xi and Stryker ICG laparoscopy systems were introduced at our academic center (certified center of excellence for surgery of the upper gastrointestinal tract, n>300 upper gastrointestinal cases/year). After simple training procedures based on our minimally invasive expertise were performed, difficulty was increased based on a modular step up approach to finally perform robotic assisted transthoracic Ivor Lewis esophagectomy.

Results

A total of 70 patients (9 females) fulfilled inclusion criteria to our study. Robotic assisted esophagectomy was divided into six modules. Level of difficulty was increased based on our modular step up approach without quality compromises. There were no intraoperative complications and no unplanned conversions to open surgery. Two surgeons were able to sequentially train and perform a completely robotic transthoracic esophagectomy using this modular approach without a substantial learning curve. A total of ten esophagectomies per surgeon were necessary to complete all modules in one case.

Conclusions

The standardized training protocol and the University of Cologne modular step up approach allowed safe introduction of the new technology used. All cases were performed safely without operation-associated complications.

International consensus statement on robotic pancreatic surgery

The robotic surgical system has been applied to various types of pancreatic surgery. However, controversies exist regarding a variety of factors including the safety, feasibility, efficacy, and cost-effectiveness of robotic surgery. This study aimed to evaluate the current status of robotic pancreatic surgery and put forth experts' consensus and recommendations to promote its development. Based on the WHO Handbook for Guideline Development, a Consensus Steering Group* and a Consensus Development Group were established to determine the topics, prepare evidence-based documents, and generate recommendations. The GRADE Grid method and Delphi vote were used to formulate the recommendations. A total of 19 topics were analyzed. The first 16 recommendations were generated by GRADE using an evidence-based method (EBM) and focused on the safety, feasibility, indication, techniques, certification of the robotic surgeon, and cost-effectiveness of robotic pancreatic surgery. The remaining three recommendations were based on literature review and expert panel opinion due to insufficient EBM results. Since the current amount of evidence was low/meager as evaluated by the GRADE method, further randomized controlled trials (RCTs) are needed in the future to validate these recommendations.

First Report of Gallbladder Volvulus Managed with a Robotic Approach

Gallbladder volvulus (GV) is an axial twisting of the gallbladder (GB). If not treated on time, this condition has a mortality up to 6%. It is usually diagnosed intraoperatively, because it can mimic a typical acute cholecystitis. An 81-year-old female patient presented with an acute onset of right upper quadrant pain accompanied with nausea. The patient was admitted to receive treatment for acute cholecystitis after the findings of ultrasound imaging. Robotic-assisted cholecystectomy was the approach chosen. GV was diagnosed after initial diagnostic laparoscopy. Cholecystectomy was performed uneventfully. Indocyanine green fluorescence was used to assess the biliary anatomy. The postoperatory course went uneventful. The patient was discharged home on postoperatory day 2.

Robot-assisted enucleation of gigantic liver hemangiomas: Case series of 3 patients

•

The key aspect of this technique is to selectively control the arterial inflow.

•

Mass enucleation represents the most challenging part of the procedure.

•

ICG allows identifying the surgical plane between the mass and normal parenchyma.

•

The robotic platform allows to replicate the enucleation performed in open surgery.

Introduction

Liver hemangiomas are benign liver lesions that require surgical excision when large and symptomatic. Often, these tumors are removed through large anatomical resections which sacrifice more liver parenchyma than needed. Tumor enucleation, which takes advantage of a digitoclasia-like technique along the plane between the tumor pseudo-capsule and liver parenchyma, poses challenges when performed laparoscopically. We propose a parenchymal sparing, minimally invasive, robotic-assisted technique to remove liver hemangiomas.

Presentation of cases

Three male patients with symptomatic hemangiomas were treated in our center between 2015 and 2018. The lesions were located in segment II, III and segment IV-V respectively. Robotic-assisted hemangioma enucleation was accomplished successfully in all three patients. The procedures were performed with a parenchyma-sparing intent and a formal segmentectomy was not required. There were no conversions to open surgery.

Discussion

The robotic platform provides a powerful tool in the enucleation of liver hemangiomas. The enhanced vision and the superior suturing ability allow to develop safely the plane between the tumor pseudo-capsule and the liver parenchyma, with outstanding selective control of all the vascular supply and drainage encountered during the dissection. Furthermore, precision of the hilar dissection allows selective lobar or sectorial arterial control which helps minimize intraoperative bleeding.

Conclusion

In our experience, robot-assisted enucleation of liver hemangiomas offers low morbidity, fast recovery, excellent cosmetic results, and it could become a therapeutic option when the location of the hemangioma allows this approach.

Robotic and laparoscopic surgery of the pancreas: an historical review

Surgery of the pancreas is a relatively new field, with operative series appearing only in the last 50 years. Surgery of the pancreas is technically challenging. The entire field of general surgery changed radically in 1987 with the introduction of the laparoscopic cholecystectomy. Minimally Invasive surgical techniques rapidly became utilized worldwide for gallbladder surgery and were then adapted to other abdominal operations. These techniques are used regularly for surgery of the pancreas including distal pancreatectomy and pancreatoduodenectomy. The progression from open surgery to laparoscopy to robotic surgery has occurred for many operations including adrenalectomy, thyroidectomy, colon resection, prostatectomy, gastrectomy and others. Data to show a benefit to the patient are scarce for robotic surgery, although both laparoscopic and robotic surgery of the pancreas have been shown not to be inferior with regard to major operative and oncologic outcomes. While there were serious concerns when laparoscopy was first used in patients with malignancies, robotic surgery has been used in many benign and malignant conditions with no obvious deterioration of outcomes. Robotic surgery for malignancies of the pancreas is well accepted and expanding to more centers. The importance of centers of excellence, surgeon experience supported by a codified mastery-based training program and international registries is widely accepted. Robotic pancreatic surgery is associated with slightly decreased blood loss and decreased length of stay compared to open surgery. Major oncologic outcomes appear to have been preserved, with some studies showing higher rates of R0 resection and tumor-free margins. Patients with lesions of the pancreas should find a surgeon they trust and do not need to be concerned with the operative approach used for their resection. The step-wise approach that has characterized the growth in robotic surgery of the pancreas, in contradistinction to the frenzy that accompanied the introduction of laparoscopic cholecystectomy, has allowed the identification of areas for improvement, many of which lie at the junction of engineering and medical practice. Refinements in robotic surgery depend on a partnership between engineers and clinicians.

Long term oncological outcome of laparoscopic techniques in pancreatic cancer

The laparoscopic technique in distal pancreatic resection (LDP) has been widely accepted, and outcome data support the hypothesis that survival is improved, partly due to improved postoperative safety and recovery, thus optimizing treatment with adjuvant chemotherapy. But laparoscopic pancreaticoduodenectomy (LPD or Whipple-procedures) has spread more slowly, due to the complexity of the procedure. Surgical safety has been a problem in hospitals with low patient volume, resulting in raised postoperative mortality, requiring careful monitoring of outcome during the surgical learning curve. Robotic assistance is expected to improve surgical safety, but data on long term oncological outcome of laparoscopic Whipple procedures with or without robotic assistance is scarce. Future research should still focus surgical safety, but most importantly long term outcome, recorded as recurrence at maximal follow up or - at best - overall long term survival (OS). Available data show median survival above 2.5 years, five year OS more than 30% after LDP even in series with suboptimal adjuvant chemotherapy. Also after LPD, long term survival is reported equal to or longer than open resection. However, surgical safety during the learning curve of LPD is a problem, which hopefully can be facilitated by robotic assistance. Patient reported outcome should also be an endpoint in future trials, including patients with pancreatic ductal adenocarcinoma.