Robotic versus open pancreaticoduodenectomy: a meta-analysis of short-term outcomes

Comparing the outcomes of robotic vs. open partial nephrectomy in obese patients: a meta-analysis and systematic review

This meta-analysis examines and compares the perioperative results (such as complications, recovery, and other surgical outcomes) in obese patients who undergo either robotic-assisted partial nephrectomy (RPN) or open partial nephrectomy (OPN). Essentially, the study is looking at how these two types of surgeries perform in obese patients, specifically focusing on outcomes related to the surgery process itself. We conducted a comprehensive search of major databases, including PubMed, Cochrane Library, and Web of Science, focusing on English studies, up to November 2024. Review articles, research protocols without published data, conference abstracts, and irrelevant studies were excluded. We performed data analysis using the Cochran-Mantel-Haenszel method and random-effects models, followed by mean differences, inverse variance, and 95% confidence intervals (CIs). The results were presented as odds ratios (ORs) and 95% CIs, and data with p values less than 0.05 were identified. This meta-analysis included three cohort studies with a total of 604 patients. Compared to OPN, RPN was associated with significantly shorter hospital stays (WMD  - 2.27, 95% CI  - 3.67 to  - 0.87; p = 0.002), lower overall complication rates (OR 0.50, 95% CI 0.34-0.73; p = 0.0004), and reduced estimated blood loss (WMD  - 125.12, 95% CI  - 198.02 to  - 52.22; p = 0.0008). No significant differences were found between the two groups in transfusion rates, major complications, renal ischemia times, or operative times. RPN offers a safe and feasible option for obese patients compared to OPN, with advantages such as shorter hospital stays, reduced blood loss, and fewer overall complications.

Robotic versus open pancreatoduodenectomy for periampullary neoplasm: a propensity matched analysis of peri-operative and oncologic outcomes

INTRODUCTION

Though open pancreatoduodenectomy (OPD) is the gold standard, robotic pancreatoduodenectomy (RPD) is on the rise due to its technical ease with robotic armamentarium and claim to decrease morbidity in the perioperative period. This study compares the perioperative and oncologic outcomes of RPD performed for periampullary neoplasms (PANs) with OPD.

METHOD

This is a retrospective study conducted from January 2018 to December 2023 for all the patients who underwent either OPD or RPD for PANs. Demographic, peri-operative outcomes and oncological parameters [disease-free survival (DFS) and overall survival (OS)] were analysed and compared. The two groups were matched using 1:1 propensity score matching (PSM) to reduce the risk of confounding.

RESULTS

A hundred patients were analysed (30 in RPD and 70 in OPD), and both groups were similar in demographic characteristics. Post-operative morbidity in terms of clinically relevant pancreatic fistula, post-pancreatectomy haemorrhage, delayed gastric emptying and overall Clavien-Dindo ≥ Grade 3 complications were similar in both groups. Surgical site infection (SSI) was significantly higher in the OPD group compared to RPD (31.4% vs. 6.7, p = 0.008); however, the median postoperative hospital stay was similar in both groups. After PSM (26 patients in each group), the RPD group had significantly more operative time (480 min vs. 360 min, p = 0.007) less blood loss (250 ml vs. 400 ml, p = 0.004), and similar SSI [2(7.7%) vs. 6(23.1%), p = 0.178). The R0 resection rate, lymph nodal yield, lymph nodal positivity, DFS and OS were similar in both groups.

CONCLUSION

The robotic approach for PD is technically safe and feasible with equivalent resection quality and oncological outcomes compared to the open approach. RPD has equivalent postoperative morbidity, DFS and OS.

Postoperative complications and surgical outcomes of robotic versus laparoscopic pancreaticoduodenectomy: a meta-analysis of propensity-score-matched studies

BACKGROUND

Robotic pancreaticoduodenectomy (RPD) is used more commonly, but high-level evidence is still scarce. This meta-analysis aimed to compare the short-term outcomes between RPD and laparoscopic pancreaticoduodenectomy (LPD) using data collected from propensity score-matched (PSM) studies.

MATERIALS AND METHODS

We searched PubMed, Cochrane Library, Embase, and Web of Science databases for PSM studies comparing RPD and LPD. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals were calculated.

RESULTS

Ten PSM studies were included, encompassing 8106 patients (RPD group: 3695 patients; LPD group: 4411 patients). Compared with LPD, RPD was associated with a lower conversion rate (RR, 0.56) and blood transfusion rate (RR, 0.49), as well as a higher number of harvested lymph nodes (MD, 2.15). There were no significant differences observed in 30-day readmission (RR, 1.02), 90-day mortality (RR, 1.01), overall morbidity (RR, 0.94), major complications (RR, 1.06), operative time (MD, -8.00 min), blood loss (MD, -19.37 mL), reoperation (RR, 0.95), bile leak (RR, 0.93), chylous leak (RR, 1.40), postoperative pancreatic fistula (RR, 1.06), delayed gastric emptying (RR, 0.92), wound infection (RR, 1.12), length of stay (MD, -0.32 days), and R0 resection (RR, 0.98) between the groups.

CONCLUSIONS

Although LPD and RPD had similar surgical outcomes, RPD had the perioperative advantage over LPD in decreasing conversion rates and blood transfusion rates and increasing the number of lymph nodes harvested. Further randomized controlled trials evaluating the potential advantages of RPD over LPD are warranted.

Transperitoneal vs retroperitoneal robotic partial nephrectomy: a meta-analysis and systematic review of propensity-matched studies

The main aim of this meta-analysis is to assess and compare the impact of two different surgical approaches, transperitoneal and retroperitoneal, on perioperative outcomes in robotic partial nephrectomy. A systematic search of MEDLINE, PubMed, Google Scholar, and the Cochrane Database was conducted to identify relevant studies published between January 2000 and January 2025. Included were nine non-randomized controlled trials with a total of 2420 patients with matching propensity scores. Among these patients, 1321 had robotic TPPN and 1099 had robotic RPPN, the abbreviation for robotic partial nephrectomy. Shorter operating times, shorter hospital stays, less estimated intraoperative blood loss, and fewer total postoperative problems were related to RPPN compared to TPPN. There were no notable disparities between the two groups when comparing the duration of renal ischemia, the fall in postoperative glomerular filtration rate (GFR), the occurrence of serious postoperative sequelae, or the necessity for blood transfusions. Compared to TPPN, RPPN demonstrates certain advantages in perioperative metrics such as surgical time, hospital stay, and overall complication rates. However, further high-quality studies are needed to confirm these findings.

Comparing Operative Outcomes and Resection Quality in Robotic vs Open Pancreaticoduodenectomy: A Meta-analysis of 54,000 Patients

BACKGROUND

High morbidity and mortality make pancreaticoduodenectomy (PD) one of the most complicated surgical procedures. This meta-analysis aimed to compare the outcomes of robotic pancreaticoduodenectomy (RPD) versus open pancreaticoduodenectomy (OPD).

METHOD

A comprehensive literature search of PubMed, Cochrane Central, and Google Scholar was conducted from inception to November 2024. Studies comparing RPD and OPD in adults aged ≥ 18 years were included. Data for the outcomes of interest were extracted.

RESULTS

Forty-one studies with a total of 54,287 patients were pooled. RPD is significantly superior to OPD in terms of overall postoperative complications (RR = 0.91, 95% CI: [0.86-0.97]; p = 0.001), wound infections (RR = 0.63, 95% CI: [0.49-0.81], p = 0.0004), estimated blood loss (WMD = -171.99 ml, 95% CI: [ -217.76 to -126.22], p < 0.01) and hospitalization duration (WMD = -1.33 days, 95% CI: [ -1.84 to -0.82], p < 0.01) with a longer operating time (WMD = 73.22 min, 95% CI: [56.20 to 90.23], p < 0.01).

CONCLUSION

In conclusion, RPD shows a lower risk of wound infections and overall postoperative morbidity compared to OPD. It has lower estimated blood loss, shorter hospitalization duration, and a longer operating time. The two approaches were comparable in terms of resection quality. More high-quality RCTs are required to draw definite conclusions.

Comparison of short-term outcomes of robotic versus open pancreaticoduodenectomy: a meta-analysis of randomized controlled trials and propensity-score-matched studies

BACKGROUND

Robotic pancreaticoduodenectomy (RPD) is used more commonly, but this surge is mostly based on observational data. This meta-analysis aimed to compare the short-term outcomes between RPD and open pancreaticoduodenectomy (OPD) using data collected from randomized controlled trials (RCTs) and propensity-score-matched (PSM) studies.

METHODS

We searched PubMed, Cochrane Library, Embase, and Web of Science databases for RCTs and PSM studies comparing RPD and OPD. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated.

RESULTS

Twenty-four studies, encompassing two RCTs and 22 PSM studies, were included, with a total of 9393 patients (RPD group: 3919 patients; OPD group: 5474 patients). Although RPD was associated with a longer operative time (MD, 61.61 min), patients may benefit from reduced blood loss (MD, -154.05 ml), shorter length of stay (MD, -1.60 days), lower blood transfusion rate (RR, 0.85), and wound infection rate (RR, 0.61). There were no significant differences observed in 30-day readmission (RR, 0.99), 90-day mortality (RR, 0.97), overall morbidity (RR, 0.88), major complications (RR, 1.01), reoperation (RR, 1.08), bile leak (RR, 1.01), chylous leak (RR, 0.98), postoperative pancreatic fistula (RR, 0.97), post-pancreatectomy hemorrhage (RR, 1.15), delayed gastric emptying (RR, 0.88), number of harvested lymph nodes (MD, -0.12), and R0 resection (RR, 1.01) between the groups.

CONCLUSIONS

Although some short-term outcomes were similar between RPD and OPD, RPD exhibited reduced intraoperative blood loss, shorter hospital stays, lower wound infection, and blood transfusion rates. In the future, RPD may become a safe and effective alternative to OPD.

Robotic versus laparoscopic pancreaticoduodenectomy for pancreatic and periampullary tumors: a meta-analysis

Objective

The value of robotic pancreaticoduodenectomy (RPD) compared with laparoscopic pancreaticoduodenectomy (LPD) for pancreatic and periampullary tumors is controversial. This study aims to assess the available literature and compare the short outcomes of RPD and LPD.

Methods

The PubMed, Cochrane Library, Embase, and Web of Science databases were searched to identify available research published up to 24 July, 2024. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated.

Results

Seventeen studies with a total of 9417 patients (RPD group: 3334 patients; LPD group: 6083 patients) were included in this meta-analysis. The RPD group had lower overall morbidity (RR, 0.79), conversion (RR, 0.29) and blood transfusion rates (RR, 0.61), shorter length of stay (MD, -0.72 days), and higher number of harvested lymph nodes (MD, 0.62) than the LPD group. There were no significant differences in 90-day mortality (RR, 0.89), major complications (RR, 0.87), operative time (MD, -3.74 mins), blood loss (MD, -24.14 mL), reoperation (RR, 0.94), bile leak (RR, 0.62), postoperative pancreatic hemorrhage (RR, 0.96), postoperative pancreatic fistula (RR, 0.74), delayed gastric emptying (RR, 1.24), and R0 resection (RR, 1.00) between the groups.

Conclusions

Compared with LPD, RPD for pancreatic and periampullary tumors could be safe and effective, and it has superior surgical outcomes. Further randomized controlled trials to verify the potential advantages of RPD over LPD are necessary.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=581133, identifier CRD42024581133.

Task division by multiple console surgeons is beneficial for safe robotic pancreaticoduodenectomy implementation and education

BACKGROUND

The optimal approach for the safe implementation and education of robotic pancreaticoduodenectomy (RPD) remains unclear. Prolonged operation time may cause surgeon fatigue and result in perioperative complications. To solve this issue, our department adopted task division by the console surgeon turnover between resection and reconstruction in 2022.

METHODS

This study retrospectively investigated consecutive patients who underwent RPD from November 2009 (initial introduction of RPD) to December 2023. The analysis excluded patients who underwent concomitant resection of other organs. The cases performed by a single console surgeon (single approach) were compared with those performed by two or more console surgeons (multiple approach).

RESULTS

This study analyzed 85 consecutive RPD cases, including 51 with the single approach and 34 with the multiple approach. The operation time was significantly shorter (832 vs. 618 min, p < 0.001), and the postoperative major complication was less frequent (45% vs. 12%, p = 0.003) in the multiple approach group, although less experienced surgeons performed the multiple approach (number of RPD experiences: 19 cases vs. 5 cases, p < 0.001). The console surgeon turnover between the resection and reconstruction resulted in a safe pancreatojejunostomy performed by the less experienced surgeon (number of pancreatic reconstruction experiences: 6.5 vs. 14 cases, p = 0.010). Surgeons who started RPD with a multiple approach observed a reduction in surgical time and a lower incidence of complications earlier than those who started with a single approach.

CONCLUSION

Task division during the early introduction phase of RPD using the multiple approach demonstrated potential contributions to improved surgical outcomes and enhanced educational benefits.

Perioperative and oncologic outcomes of robot-assisted versus open surgery for pancreatic ductal adenocarcinoma: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to compare perioperative and oncologic outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) treated with robotic-assisted surgery versus open laparotomy. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Randomized controlled trials (RCTs) and cohort studies up to June 15, 2024, were identified using PubMed, EMBASE, and Google Scholar. Additionally, reference lists of included studies, relevant review articles, and clinical guidelines were manually searched. The primary outcomes evaluated were length of stay, 90-day mortality, postoperative pancreatic fistula (POPF), and Post-pancreatectomy haemorrhage (PPH). Secondary outcomes included estimated blood loss, reoperation rate, lymph node yield, and operative time. The final analysis included 10 retrospective cohort studies involving 23,272 patients (2,179 robotic-assisted and 21,093 open surgery). There were no significant differences between the two procedures in terms of postoperative pancreatic fistula, Post-pancreatectomy haemorrhage, lymph node yield, and operative time. However, patients undergoing robotic-assisted surgery had shorter lengths of stay, lower 90-day mortality, and less estimated blood loss compared to those undergoing open surgery. The reoperation rate was higher for the robotic-assisted group. Robotic-assisted surgery for pancreatic ductal adenocarcinoma is safe and feasible. Compared to open surgery, it offers better perioperative and short-term oncologic outcomes, but with a higher risk of reoperation.

Robotic pancreaticoduodenectomy in patients with overweight or obesity: a meta-analysis protocol

INTRODUCTION

The prevalence of overweight or obesity among patients undergoing pancreaticoduodenectomy is on the rise. The utilisation of robotic assistance has the potential to enhance the feasibility of performing minimally invasive pancreaticoduodenectomy in this particular group of patients who are at a higher risk. The objective of this meta-analysis is to assess the safety and effectiveness of robotic pancreaticoduodenectomy in individuals with overweight or obesity.

METHODS AND ANALYSIS

This investigation will systematically search for randomised controlled trials (RCTs) and non-randomised comparative studies that compare robotic pancreaticoduodenectomy with open or laparoscopic pancreaticoduodenectomy in patients with overweight or obesity, using PubMed, Embase and the Cochrane Library databases. The methodological quality of studies will be evaluated using the Cochrane risk of bias tool for RCTs and the Newcastle-Ottawa Scale for observational studies. RevMan software (V.5.4.1) will be used for statistical analysis. The OR and weighted mean differences will be calculated separately for dichotomous and continuous data. The selection of a fixed-effects or random-effects model will depend on the level of heterogeneity observed among the included studies.

ETHICS AND DISSEMINATION

This study will be conducted based on data in the published literature from publicly available databases. Therefore, ethics approval is not applicable. The results will be disseminated in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023462321.

A comparative analysis of robotic versus open pancreaticoduodenectomy in octogenarians

Old age is a predictor of increased morbidity following pancreatic operations. This study was undertaken to compare the peri-operative variables between robotic and 'open' pancreaticoduodenectomy, in octogenarians (≥ 80 years of age). Since 2012, with IRB approval, we retrospectively followed 69 patients, who underwent robotic (n = 42) and 'open' (n = 27) pancreaticoduodenectomy. Statistical analysis was performed using chi-square test and Student's t test. Data are presented as median(mean ± SD), and significance accepted with 95% probability. Patients who underwent the robotic approach had a greater Charlson Comorbidity Index [6 (6 ± 1.6) vs 5 (5 ± 1.0), (p = 0.01)] and previous abdominal operations [n = 24 (57%) vs n = 9 (33%), (p = 0.04)]. The robotic approach led to longer operative time [426 (434 ± 95.8) vs 240 (254 ± 71.1) minutes, (p < 0.0001)], decreased blood loss [200 (291 ± 289.2) vs 426 (434 ± 95.8) mL (p = 0.008)], and decreased intraoperative blood transfusions (p < 0.05). Patients who underwent robotic pancreaticoduodenectomy had comparable and at times superior outcomes, consistent with the literature regarding robotic and 'open' pancreaticoduodenectomy. This study indicates that robotic pancreaticoduodenectomy continues to offer same benefits for patients of advanced age and demonstrates age should not be a preclusion to robotic operations.

Minimally invasive pancreaticoduodenectomy: A favorable approach for frail patients with pancreatic cancer

BACKGROUND

Within the past decade, minimally invasive pancreaticoduodenectomy has been increasingly adopted in high-volume cancer centers. Amid broader trends of a growing older population, the numbers of frail patients with cancer are expected to increase. In this study, we compared the postoperative outcomes of open pancreaticoduodenectomy and minimally invasive pancreaticoduodenectomy in frail patients with pancreatic ductal adenocarcinoma.

METHODS

Using the pancreatectomy-targeted American College of Surgeons-National Surgical Quality Improvement Program database (2014-2021), we identified pancreaticoduodenectomy cases for pancreatic ductal adenocarcinoma. Patients with a modified frailty index ≥2 were considered frail. We performed 2:1 (open pancreaticoduodenectomy to minimally invasive pancreaticoduodenectomy) optimal pair propensity score matching for both patient- and disease-specific characteristics. We evaluated baseline covariate balance for homogeneity and assessed 30-day postoperative outcomes: complications, discharge destination, major morbidity, and mortality.

RESULTS

We identified 3,143 frail patients who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. Of those, 275 (9%) underwent minimally invasive pancreaticoduodenectomy. Minimally invasive pancreaticoduodenectomy was associated with a lower rate of any complications compared with open pancreaticoduodenectomy (43% vs 54%; P < .001), major morbidity (29% vs 35%; P = .042), and nonhome discharge (12% vs 17%; P = .022). When comparing the 2 minimally invasive pancreaticoduodenectomy approaches, robotic surgery was associated with fewer complications compared with laparoscopy (39% vs 51%; P = .040) and a lower mortality rate (1% vs 4%; P = .041) CONCLUSION: In frail patients with pancreatic cancer, minimally invasive pancreaticoduodenectomy was associated with better postoperative outcomes than open pancreaticoduodenectomy. This study builds on growing literature reporting that, when properly implemented, minimally invasive pancreaticoduodenectomy is associated with more favorable postoperative outcomes. Given the particularly high risk of complication in frail patients, implementing a preoperative frailty assessment can provide valuable insights to inform patient counseling.

Short-term Outcomes of Robotic Versus Open Pancreatoduodenectomy: Propensity Score-matched Analysis

OBJECTIVE

The goal of the current study was to investigate the perioperative outcomes of robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD) in a high-volume center.

BACKGROUND

Despite RPDs prospective advantages over OPD, current evidence comparing the 2 has been limited and has prompted further investigation. The aim of this study was to compare both approaches while including the learning curve phase for RPD.

METHODS

A 1:1 propensity score-matched analysis of a prospective database of RPD with OPD (2017-2022) at a high-volume center was performed. The main outcomes were overall- and pancreas-specific complications.

RESULTS

Of 375 patients who underwent PD (OPD n=276; RPD n=99), 180 were included in propensity score-matched analysis (90 per group). RPD was associated with less blood loss [500 (300-800) vs 750 (400-1000) mL; P =0.006] and more patients without a complication (50% vs 19%; P <0.001). Operative time was longer [453 (408-529) vs 306 (247-362) min; P <0.001]; in patients with ductal adenocarcinoma, fewer lymph nodes were harvested [24 (18-27) vs 33 (27-39); P <0.001] with RPD versus OPD. There were no significant differences for major complications (38% vs 47%; P =0.291), reoperation rate (14% vs 10%; P =0.495), postoperative pancreatic fistula (21% vs 23%; P =0.858), and patients with the textbook outcome (62% vs 55%; P =0.452).

CONCLUSIONS

Including the learning phase, RPD can be safely implemented in high-volume settings and shows potential for improved perioperative outcomes versus OPD. Pancreas-specific morbidity was unaffected by the robotic approach. Randomized trials with specifically trained pancreatic surgeons and expanded indications for the robotic approach are needed.

Defining the operative time threshold for safety in patients undergoing robotic pancreaticoduodenectomy

BACKGROUND

Robotic pancreaticoduodenectomy (RPD) is a safe and efficacious procedure in appropriately selected patients, though frequently with increased operative times compared to open pancreaticoduodenectomy (OPD).

METHODS

From 2014 to 2019, patients who underwent elective, low-risk, RPDs and OPDs in the NSQIP database were isolated. The operative time threshold (OTT) for safety in RPD patients was estimated by identifying the operative time at which complication rates for RPD patients exceeded the complication rate of the benchmark OPD control.

RESULTS

Of 6270 patients identified, 939 (15%) underwent RPD and 5331 (85%) underwent OPD. The incidence of major morbidity or mortality for the OPD cohort was 35.1%. The OTT was identified as 7.7 h. Patients whose RPDs were above the OTT experienced a higher incidence of major morbidity (42.5% vs. 35.0%, p < 0.01) and 30-day mortality (2.7% vs. 1.2%, p = 0.03) than the OPD cohort. Preoperative obstructive jaundice (OR: 1.47, [95% CI: 1.08-2.01]) and pancreatic duct size <3 mm (OR: 2.44, [95% CI: 1.47-4.06]) and 3-6 mm (OR: 2.15, [95% CI: 1.31-3.52]) were risk factors for prolonged RPDs on multivariable regression.

CONCLUSION

The operative time threshold for safety, identified at 7.7 h, should be used to improve patient selection for RPDs and as a competency-based quality benchmark.

The weight of BMI in impacting postoperative and oncologic outcomes in pancreaticoduodenectomy is attenuated by a robotic approach

This study was undertaken to observe the effect of body mass index (BMI) on perioperative outcomes and survival when comparing robotic vs 'open' pancreaticoduodenectomy. With IRB approval, we prospectively followed 505 consecutive patients who underwent either robotic or 'open' pancreaticoduodenectomy from 2012 to 2021. For illustrative purposes, patients were separated based on the Center for Disease Control and Prevention BMI table but regression analysis was utilized to identify significant relationships involving BMI. Data are presented as median (mean ± SD). Significance was determined at p ≤ 0.05. 205 and 300 patients underwent 'open' and robotic pancreaticoduodenectomy, respectively. Neither sex nor age correlated with BMI in patients undergoing 'open' nor robotic operation. Operative duration correlated with increasing BMI in each operational approach, which was statistically significant for those receiving the 'open' operation (p = 0.02). There were statistically significantly fewer lymph nodes harvested with rising BMI in patients that had an 'open' operation (p = 0.01), but no such difference was found in patients undergoing the robotic approach. Length of stay (LOS) and in-hospital mortality were statistically significantly associated with rising BMI when an 'open' operation was undertaken (p = 0.02 and p = 0.0002, respectively) but not when the robotic platform was utilized. Patients with higher BMI had significantly longer operative duration, smaller lymph node harvest, greater LOS, and increased in-hospital mortality rate when undergoing 'open' pancreaticoduodenectomy, but not robotic pancreaticoduodenectomy. Thus, the robotic platform may attenuate the increased technical and oncologic difficulties associated with a greater BMI in patients undergoing pancreaticoduodenectomy.

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

OBJECTIVE

To develop and update evidence-based and consensus-based guidelines on laparoscopic and robotic pancreatic surgery.

SUMMARY BACKGROUND DATA

Minimally invasive pancreatic surgery (MIPS), including laparoscopic and robotic surgery, is complex and technically demanding. Minimizing the risk for patients requires stringent, evidence-based guidelines. Since the International Miami Guidelines on MIPS in 2019, new developments and key publications have been reported, necessitating an update.

METHODS

Evidence-based guidelines on 22 topics in 8 domains were proposed: terminology, indications, patients, procedures, surgical techniques and instrumentation, assessment tools, implementation and training, and artificial intelligence. The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS, September 2022) used the Scottish Intercollegiate Guidelines Network (SIGN) methodology to assess the evidence and develop guideline recommendations, the Delphi method to establish consensus on the recommendations among the Expert Committee, and the AGREE II-GRS tool for guideline quality assessment and external validation by a Validation Committee.

RESULTS

Overall, 27 European experts, 6 international experts, 22 international Validation Committee members, 11 Jury Committee members, 18 Research Committee members, and 121 registered attendees of the 2-day meeting were involved in the development and validation of the guidelines. In total, 98 recommendations were developed, including 33 on laparoscopic, 34 on robotic, and 31 on general MIPS, covering 22 topics in 8 domains. Out of 98 recommendations, 97 reached at least 80% consensus among the experts and congress attendees, and all recommendations were externally validated by the Validation Committee.

CONCLUSIONS

The EGUMIPS evidence-based guidelines on laparoscopic and robotic MIPS can be applied in current clinical practice to provide guidance to patients, surgeons, policy-makers, and medical societies.

Prince and princesses: The current status of robotic surgery in surgical oncology

Robotic surgery has experienced a dramatic increase in utilization across general surgery over the last two decades, including in surgical oncology. Although urologists and gynecologists were the first to show that this technology could be utilized in cancer surgery, the robot is now a powerful tool in the treatment of gastrointestinal, hepato-pancreatico-biliary, colorectal, endocrine, and soft tissue malignancies. While long-term outcomes are still pending, short-term outcomes have showed promise for this technologic advancement of cancer surgery.

Epidemiology of healthcare-associated infections and outcomes among open and robotic pancreatoduodenectomy: A retrospective study from 2013 to 2022

BACKGROUND AND AIM

Healthcare-associated infections (HAIs) after pancreaticoduodenectomy (PD) are one of the common postoperative complications. This study aims to investigate the epidemiology of postoperative HAIs in patients with open pancreaticoduodenectomy (OPD) and robotic pancreaticoduodenectomy (RPD).

METHODS

This retrospective cohort study described the trend of HAIs in patients undergoing PD from January 2013 to December 2022 at a tertiary hospital. Patients were divided into OPD and RPD, and the HAIs and outcomes were compared.

RESULTS

Among 2632 patients who underwent PD, 230 (8.7%, 95% confidence interval [CI] 7.7-9.9%) were diagnosed with HAIs, with a decreasing trend from 2013 to 2022 (P < 0.001 for trend). The incidence of postoperative HAIs was significantly higher in patients with OPD than RPD (9.6% vs 5.8%; P = 0.003). The incidence of HAIs for patients with OPD showed a decreasing trend (P = 0.001 for trend), and the trend for RPD was not significant (P = 0.554 for trend). Logistic regression showed that RPD was significantly associated with postoperative HAIs after adjusting for covariates (adjusted odds ratio = 0.654; 95% CI 0.443-0.965; P = 0.032), especially in the subgroup of patients without preoperative biliary drainage (adjusted odds ratio = 0.486; 95% CI 0.292-0.809; P = 0.006). Regarding clinical outcomes, RPD has a shorter length of stay and a more expensive charge than OPD (all P < 0.05).

CONCLUSION

Postoperative HAIs in patients with PD showed a decreasing trend in recent years, especially in OPD. RPD was significantly associated with reduced postoperative HAIs and length of stay, although the charge is more expensive. Attention should be paid to postoperative HAIs in OPD, and it is imperative to continue reducing the costs of RPD.

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.

Autologous blood transfusion reduces the requirement for perioperative allogenic blood transfusion in patients undergoing major hepatopancreatobiliary surgery: a retrospective cohort study

INTRODUCTION

Major hepatopancreatobiliary surgery is associated with a risk of major blood loss. The authors aimed to assess whether autologous transfusion of blood salvaged intraoperatively reduces the requirement for postoperative allogenic transfusion in this patient cohort.

MATERIALS AND METHODS

In this single centre study, information from a prospective database of 501 patients undergoing major hepatopancreatobiliary resection (2015-2022) was analysed. Patients who received cell salvage ( n =264) were compared with those who did not ( n =237). Nonautologous (allogenic) transfusion was assessed from the time of surgery to 5 days postsurgery, and blood loss tolerance was calculated using the Lemmens-Bernstein-Brodosky formula. Multivariate analysis was used to identify factors associated with allogenic blood transfusion avoidance.

RESULTS

32% of the lost blood volume was replaced through autologous transfusion in patients receiving cell salvage. Although the cell salvage group experienced significantly higher intraoperative blood loss compared with the noncell salvage group (1360 ml vs. 971 ml, P =0.0005), they received significantly less allogenic red blood cell units (1.5 vs. 0.92 units/patient, P =0.03). Correction of blood loss tolerance in patients who underwent cell salvage was independently associated with avoidance of allogenic transfusion (Odds ratio 0.05 (0.006-0.38) P =0.005). In a subgroup analysis, cell salvage use was associated with a significant reduction in 30-day mortality in patients undergoing major hepatectomy (6 vs. 1%, P =0.04).

CONCLUSION

Cell salvage use was associated with a reduction in allogenic blood transfusion and a reduction in 30-day mortality in patients undergoing major hepatectomy. Prospective trials are warranted to understand whether the use of cell salvage should be routinely utilised for major hepatectomy.

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.

Robotic pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: Analysis of surgical outcomes and long-term prognosis in a high-volume center

BACKGROUND

Robotic pancreaticoduodenectomy (RPD) has been reported to be safe and feasible for patients with pancreatic ductal adenocarcinoma (PDAC) of the pancreatic head. This study aimed to analyze the surgical outcomes and risk factors for poor long-term prognosis of these patients.

METHODS

Data from patients who underwent RPD for PDAC of pancreatic head were retrospectively analyzed. Multivariate Cox regression analysis was used to seek the independent prognostic factors for overall survival (OS), and an online nomogram calculator was developed based on the independent prognostic factors.

RESULTS

Of the 273 patients who met the inclusion criteria, the median operative time was 280.0 minutes, the estimated blood loss was 100.0 mL, the median OS was 23.6 months, and the median recurrence-free survival (RFS) was 14.4 months. Multivariate analysis showed that preoperative carbohydrate antigen 19-9 (CA19-9) [hazard ratio (HR) = 2.607, 95% confidence interval (CI): 1.560-4.354, P < 0.001], lymph node metastasis (HR = 1.429, 95% CI: 1.005-2.034, P = 0.047), tumor moderately (HR = 3.190, 95% CI: 1.813-5.614, P < 0.001) or poorly differentiated (HR = 5.114, 95% CI: 2.839-9.212, P < 0.001), and Clavien-Dindo grade ≥ III (HR = 1.657, 95% CI: 1.079-2.546, P = 0.021) were independent prognostic factors for OS. The concordance index (C-index) of the nomogram constructed based on the above four independent prognostic factors was 0.685 (95% CI: 0.640-0.729), which was significantly higher than that of the AJCC staging (8th edition): 0.541 (95% CI: 0.493-0.589) (P < 0.001).

CONCLUSIONS

This large-scale study indicated that RPD was feasible for PDAC of pancreatic head. Preoperative CA19-9, lymph node metastasis, tumor poorly differentiated, and Clavien-Dindo grade ≥ III were independent prognostic factors for OS. The online nomogram calculator could predict the OS of these patients in a simple and convenient manner.

New perspectives on robotic pancreaticoduodenectomy: An analysis of the National Cancer Database

BACKGROUND

Pancreatic ductal adenocarcinoma is a common malignancy. Despite all advancements, the prognosis remains, poor with an overall 5-year survival of only 10.8%. Recently, a robotic platform has become an attractive tool for treating pancreatic cancer (PC). While recent studies indicated improved lymph node (LN) harvest during robotic pancreaticoduodenectomy (PD), data on long-term outcomes are insufficient.

AIM

To evaluate absolute LN harvest during PD. Secondary outcomes included evaluating the association between LN harvest and short- and long-term oncological outcomes for three different surgical approaches.

METHODS

We conducted an analysis of the National Cancer Database, including patients diagnosed with PC who underwent open, laparoscopic, or robotic PD in 2010-2018. One-way analysis of variance was used to compare continuous variables, chi-square test - for categorical. Overall survival was defined as the time between surgery and death. Median survival time was estimated with the Kaplan-Meier method, and groups were compared with the Wilcoxon test. A Cox proportional hazards model was used to assess the association of covariates with survival after controlling for patient characteristics and procedure type.

RESULTS

17169 patients were included, 8859 (52%) males; mean age 65; 14509 (85%) white. 13816 (80.5%) patients had an open PD, 2677 (15.6%) and 676 (3.9%) - laparoscopic and robotic PD respectively. Mean comorbidity index (Charlson-Deyo Score) 0.50. On average, 18.84 LNs were harvested. Mean LN harvest during open, laparoscopic and robotic PD was 18.59, 19.65 and 20.70 respectively (P < 0.001). On average 2.49 LNs were positive for cancer and did not differ by the procedure type (P = 0.26). Vascular invasion was noted in 42.6% of LNs and did differ by the approach: 42.1% for open, 44.0% for laparoscopic and 47.2% for robotic PD (P = 0.015). Median survival for open PD was 26.1 mo, laparoscopic - 27.2 mo, robotic - 29.1 mo (P = 0.064). Survival was associated with higher LN harvest, while higher number of positive LNs was associated with higher mortality.

CONCLUSION

Our study suggests that robotic PD is associated with increased intraoperative LN harvest and has comparable short-term oncological outcomes and survival compared to open and laparoscopic approaches.

Meta-analysis of robotic versus open pancreaticoduodenectomy in all patients and pancreatic cancer patients

Purposes

To compare perioperative outcomes of robotic pancreaticoduodenectomy (RPD) to open pancreaticoduodenectomy (OPD) using evidence from cohort studies.

Methods

Outcomes of interest include operative time, blood loss, R0 resection rate, lymph nodes harvested, overall complication rate, pancreatic fistula rate, delayed gastric emptying rate and 90-day mortality.

Results

6 prospective studies and 15 retrospective studies were included. Five of these studies were limited to patients with pancreatic cancer. Operative time was significantly longer in RPD (WMD: 64.60 min; 95% CI: 26.89 to 102.21; p = 0.001). Estimated blood loss was lower in RPD (WMD: −185.44 ml; 95% CI: −239.66 to −131.21; p < 0.001). Overall complication rates (OR: 0.66; 95% CI: 0.44 to 0.97; p < 0.001) and pancreatic fistula rate (OR: 0.67; 95% CI: 0.55 to 0.82; p < 0.001) were both lower in RPD. Length of hospital stay was longer in OPD (WMD: −1.90; 95% CI: −2.47 to −1.33). 90-day mortality was lower in RPD [odds ratio (OR): 0.77; 95% CI: 0.45 to 0.95; p = 0.025].

Conclusion

At current level of evidence, RPD is a safer alternative than OPD with regard to post-operative outcomes and blood loss. However, in terms of oncological outcomes RPD show no advantage over OPD, and the cost of RPD was higher. In general, RPD is now considered a reliable technology, but high-quality randomized controlled trial (RCT) studies are still needed to support this conclusion.

Minimally Invasive Pancreatoduodenectomy: Contemporary Practice, Evidence, and Knowledge Gaps

Minimally invasive pancreatoduodenectomy has gained popularity throughout the last decade. For laparoscopic pancreatoduodenectomy, some high-level evidence exists, but with conflicting results. There are currently no published randomized controlled trials comparing robotic and open pancreatoduodenectomy. Comparative long-term data for patients with pancreatic ductal adenocarcinoma is lacking to date. Based on the existing evidence, current observed benefits of minimally invasive pancreatoduodenectomy over open pancreatoduodenectomy seem scarce, but retrospective data indicate the safety of these procedures in selected patients. As familiarity with the robotic platform increases, studies have shown an expansion in indications, also including patients with vascular involvement and even indicating favorable results in patients with obesity and high-risk morphometric features. Several ongoing randomized controlled trials aim to investigate potential differences in short- and long-term outcomes between minimally invasive and open pancreatoduodenectomy. Their results are much awaited.

Robot-assisted pancreatoduodenectomy with the da Vinci Xi: can the costs of advanced technology be offset by clinical advantages? A case-matched cost analysis versus open approach

BACKGROUND

Robot-assisted pancreatoduodenectomy (RPD) has shown some advantages over open pancreatoduodenectomy (OPD) but few studies have reported a cost analysis between the two techniques. We conducted a structured cost-analysis comparing pancreatoduodenectomy performed with the use of the da Vinci Xi, and the traditional open approach, and considering healthcare direct costs associated with the intervention and the short-term post-operative course.

MATERIALS AND METHODS

Twenty RPD and 194 OPD performed between January 2011 and December 2020 by the same operator at our high-volume multidisciplinary center for robot-assisted surgery and for pancreatic surgery, were retrospectively analyzed. Two comparable groups of 20 patients (Xi-RPD-group) and 40 patients (OPD-group) were obtained matching 1:2 the RPD-group with the OPD-group. Perioperative data and overall costs, including overall variable costs (OVCs) and fixed costs, were compared.

RESULTS

No difference was reported in mean operative time: 428 min for Xi-RPD-group versus 404 min for OPD, p = 0.212. The median overall length of hospital stay was significantly lower in the Xi-RPD-group: 10 days versus 16 days, p = 0.001. In the Xi-RPD-group, consumable costs were significantly higher (€6149.2 versus €1267.4, p < 0.001), while hospital stay costs were significantly lower: €5231.6 versus €8180 (p = 0.001). No significant differences were found in terms of OVCs: €13,483.4 in Xi-RPD-group versus €11,879.8 in OPD-group (p = 0.076).

CONCLUSIONS

Robot-assisted surgery is more expensive because of higher acquisition and maintenance costs. However, although RPD is associated to higher material costs, the advantages of the robotic system associated to lower hospital stay costs and the absence of difference in terms of personnel costs thanks to the similar operative time with respect to OPD, make the OVCs of the two techniques no longer different. Hence, the higher costs of advanced technology can be partially compensated by clinical advantages, particularly within a high-volume multidisciplinary center for both robot-assisted and pancreatic surgery. These preliminary data need confirmation by further studies.

Robotic Versus Laparoscopic Pancreaticoduodenectomy: An Up-To-Date System Review and Meta-Analysis

Background

Although minimally invasive pancreaticoduodenectomy has gained worldwide interest, there are limited comparative studies between two minimally invasive pancreaticoduodenectomy techniques. This meta-analysis aimed to compare the safety and efficacy of robotic and laparoscopic pancreaticoduodenectomy (LPD), especially the difference in the perioperative and short-term oncological outcomes.

Methods

PubMed, China National Knowledge Infrastructure (CNKI), Wanfang Data, Web of Science, and EMBASE were searched based on a defined search strategy to identify eligible studies before July 2021. Data on operative times, blood loss, overall morbidity, major complications, vascular resection, blood transfusion, postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), conversion rate, reoperation, length of hospital stay (LOS), and lymph node dissection were subjected to meta-analysis.

Results

Overall, the final analysis included 9 retrospective studies comprising 3,732 patients; 1,149 (30.79%) underwent robotic pancreaticoduodenectomy (RPD), and 2,583 (69.21%) underwent LPD. The present meta-analysis revealed nonsignificant differences in operative times, overall morbidity, major complications, blood transfusion, POPF, DGE, reoperation, and LOS. Alternatively, compared with LPD, RPD was associated with less blood loss (p = 0.002), less conversion rate (p < 0.00001), less vascular resection (p = 0.0006), and more retrieved lymph nodes (p = 0.01).

Conclusion

RPD is at least equivalent to LPD with respect to the incidence of complication, incidence and severity of DGE, and reoperation and length of hospital stay. Compared with LPD, RPD seems to be associated with less blood loss, lower conversion rate, less vascular resection, and more retrieved lymph nodes.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier CRD2021274057

The impact of robotics in liver surgery: A worldwide systematic review and short-term outcomes meta-analysis on 2,728 cases

BACKGROUND

The dissemination of robotic liver surgery is slow-paced and must face the obstacle of demonstrating advantages over open and laparoscopic (LLS) approaches. Our objective was to show the current position of robotic liver surgery (RLS) worldwide and to identify if improved short-term outcomes are observed, including secondary meta-analyses for type of resection, etiology, and cost analysis.

METHODS

A PRISMA-based systematic review was performed to identify manuscripts comparing RLS vs open or LLS approaches. Quality analysis was performed using the Newcatle-Ottawa score. Statistical analysis was performed after heterogeneity test and fixed- or random-effect models were chosen accordingly.

RESULTS

After removing duplications, 2728 RLS cases were identified from the final set of 150 manuscripts. More than 75% of the cases have been performed on malignancies. Meta-analysis from the 38 comparative reports showed that RLS may offer improved short-term outcomes compared to open procedures in most of the variables screened. Compared to LLS, some advantages may be observed in favour of RLS for major resections in terms of operative time, hospital stay and rate of complications. Cost analyses showed an increased cost per procedure of around US$5000.

CONCLUSIONS

The advantages of RLS still need to be demonstrated although early results are promising. Advantages vs open approach are demonstrated. Compared to laparoscopic surgery, minor perioperative advantages may be observed for major resections although cost analyses are still unfavorable to the robotic approach.

Robotic pancreaticoduodenectomy for pancreatic head cancer and periampullary lesions

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

Robotic pancreaticoduodenectomy: Where do we stand?

Pancreaticoduodenectomy (PD) is a complex operation accompanied by significant morbidity rates. Due to this complexity, the transition to minimally invasive PD has lagged behind other abdominal surgical operations. The safety, feasibility, favorable post-operative outcomes of robotic PD have been suggested by multiple studies. Compared to open surgery and other minimally invasive techniques such as laparoscopy, robotic PD offers satisfactory outcomes, with a non-inferior risk of adverse events. Trends of robotic PD have been on rise with centers substantially increasing the number the operation performed. Although promising, findings on robotic PD need to be corroborated in prospective trials.

Robotic pancreas surgery: an overview of history and update on technique, outcomes, and financials

The use robotics in surgery is gaining momentum. This approach holds substantial promise in pancreas surgery. Robotic surgery for pancreatic lesions and malignancies has become well accepted and is expanding to more and more center annually. The number of centers using robotics in pancreatic surgery is rapidly increasing. The most studied robotic pancreas surgeries are pancreaticoduodenectomy and distal pancreatectomy. Most studies are in their early phases, but they report that robotic pancreas surgery is safe feasible. Robotic pancreas surgery offers several advantages over open and laparoscopic techniques. Data regarding costs of robotics versus conventional techniques is still lacking. Robotic pancreas surgery is still in its early stages. It holds promise to become the new surgical standard for pancreatic resections in the future, however, more research is still needed to establish its safety, cost effectiveness and efficacy in providing the best outcomes.

Safety and efficacy of robot-assisted versus open pancreaticoduodenectomy: a meta-analysis of multiple worldwide centers

The objective of the study is to compare the safety and efficacy of robot-assisted pancreaticoduodenectomy (PD) with open PD. The PubMed, EMBASE and Cochrane Library databases were searched for the literature available from their respective inception dates up to May 2020 to find studies comparing robot-assisted pancreaticoduodenectomy (RPD) with open pancreaticoduodenectomy (OPD). The RevMan 5.3 statistical software was used for analysis to evaluate surgical outcome and oncology safety. The combination ratio (RR) and weighted mean difference (WMD) and their 95% confidence intervals (CIs) were calculated using fixed-effect or random effect models. 18 cohort studies from 16 medical centers were eligible with a total of 5795 patients including 1420 RPD group patients and 4375 OPD group patients. The RPD group fared better than the OPD group in terms of estimated blood loss (EBL) (WMD = - 175.65, 95% CI (- 251.85, - 99.44), P < 0.00001), wound infection rate (RR = 0.60, 95% CI (0.44, 0.81), P = 0.001), reoperation rate (RR = 0.61, 95% CI (0.41, 0.91), P = 0.02), hospital day (WMD = - 2.95, 95% CI (- 5.33, - 0.56), P = 0.02), intraoperative blood transfusion (RR = 0.56, 95% CI (0.42, 0.76), P = 0.0001), overall complications (RR = 0.78, 95% CI (0.64, 0.95), P = 0.01), and clinical postoperative pancreatic fistula (POPF) (RR = 0.54, 95% CI (0.41, 0.70), P < 0.0001). In terms of lymph node clearance (WMD = 0.48, 95% CI (- 2.05, 3.02), P = 0.71), R0 rate (RR = 1.05, 95% CI (1.00, 1.11), P = 0.05), postoperative pancreatic fistula (RR = 1, 95% CI (0.85, 1.19), P = 0.97), bile leakage (RR = 0.99, 95% CI (0.54, 1.83), P = 0.98), delayed gastric emptying (DGE) (RR = 0.79, 95% CI (0.60, 1.03), P = 0.08), 90-day mortality (RR = 0.82, 95% CI (0.62, 1.10), P = 0.19), and severe complications (RR = 0.98, 95% CI (0.71, 1.36), P = 0.91), and there were no significant differences between the two groups. Robotic surgery was inferior to open surgery in terms of operational time (WMD = 80.85, 95% CI (16.09, 145.61), P = 0.01). RPD is not inferior to OPD, and it is even more advantageous for EBL, wound infection rate, reoperation rate, hospital stay, intraoperative transfusion, overall complications and clinical POPF. However, these findings need to be further verified by high-quality randomized controlled trials.

Short-term outcomes after minimally invasive versus open pancreaticoduodenectomy in elderly patients: a propensity score-matched analysis

BACKGROUND

To date, the evidence on the safety and benefits of minimally invasive pancreatoduodenectomy (MIPD) in elderly patients is still controversy. This study aim to compare the risk and benefit between MIPD and open pancreatoduodenectomy (OPD) in elderly patients.

METHODS

From 2016 to 2020, we retrospective enrolled 26 patients underwent MIPD and other 119 patients underwent OPD. We firstly compared the baseline characteristics, 90-day mortality and short-term surgical outcomes of MIPD and OPD. Propensity score matching was applied for old age patient (≥ 65-year-old vs. < 65-year-old) for detail safety and feasibility analysis.

RESULTS

Patients received MIPD is significantly older, had poor performance status, less lymph node harvest, longer operation time, less postoperative hospital stay (POHS) and earlier drain removal. After 1:2 propensity score matching analysis, elderly patients in MIPD group had significantly poor performance status (P = 0.042) compared to OPD group. Patients receiving MIPD had significantly shorter POHS (18 vs. 25 days, P = 0.028), earlier drain removal (16 vs. 21 days, P = 0.012) and smaller delay gastric empty rate (5.9 vs. 32.4% P = 0.036). There was no 90-day mortality (0% vs. 11.8%, P = 0.186) and pulmonary complications (0% vs. 17.6%, P = 0.075) in MIPD group, and the major complication rate is comparable to OPD group (17.6% vs. 29.4%, P = 0.290).

CONCLUSION

For elderly patients, MIPD is a feasible and safe option even in patients with inferior preoperative performance status. MIPD might also provide potential advantage for elderly patients in minimizing pulmonary complication and overall mortality over OPD.

Effects of deep neuromuscular block with low-pressure pneumoperitoneum on respiratory mechanics and biotrauma in a steep Trendelenburg position

We hypothesized that deep neuromuscular blockade (NMB) with low-pressure pneumoperitoneum (PP) would improve respiratory mechanics and reduce biotrauma compared to moderate NMB with high-pressure PP in a steep Trendelenburg position. Seventy-four women undergoing robotic gynecologic surgery were randomly assigned to two equal groups. Moderate NMB group was maintained with a train of four count of 1–2 and PP at 12 mmHg. Deep NMB group was maintained with a post-tetanic count of 1–2 and PP at 8 mmHg. Inflammatory cytokines were measured at baseline, at the end of PP, and 24 h after surgery. Interleukin-6 increased significantly from baseline at the end of PP and 24 h after the surgery in moderate NMB group but not in deep NMB group (P_group*time = 0.036). The peak inspiratory, driving, and mean airway pressures were significantly higher in moderate NMB group than in deep NMB group at 15 min and 60 min after PP (P_group*time = 0.002, 0.003, and 0.048, respectively). In conclusion, deep NMB with low-pressure PP significantly suppressed the increase in interleukin-6 developed after PP, by significantly improving the respiratory mechanics compared to moderate NMB with high-pressure PP during robotic surgery.

Implementation of Robotic Assistance in Pancreatic Surgery: Experiences from the First 101 Consecutive Cases

Robotic assisted minimally invasive surgery has been implemented to overcome typical limitations of conventional laparoscopy such as lack of angulation, especially during creation of biliary and pancreatic anastomoses. With this retrospective analysis, we provide our experience with the first 101 consecutive robotic pancreatic resection performed at our center. Distal pancreatectomies (RDP, N = 44), total pancreatectomies (RTP, N = 3) and pancreaticoduodenectomies (RPD, N = 54) were included. Malignancy was found in 45.5% (RDP), 66.7% (RTP) and 61% (RPD). Procedure times decreased from the first to the second half of the cohort for RDP (218 min vs. 128 min, p = 0.02) and RPD (378 min vs. 271 min, p < 0.001). Overall complication rate was 63%, 33% and 66% for RPD, RPT and RDP, respectively. Reintervention and reoperation rates were 41% and 17% (RPD), 33% and 0% (RTP) and 50% and 11.4% (RPD), respectively. The thirty-day mortality rate was 5.6% for RPD and nil for RTP and RDP. Overall complication rate remained stable throughout the study period. In this series, implementation of robotic pancreas surgery was safe and feasible. Final evaluation of the anastomoses through the median retrieval incision compensated for the lack of haptic feedback during reconstruction and allowed for secure minimally invasive resection and reconstruction.

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.

Robotic and open pancreaticoduodenectomy: results from Taipei Veterans General Hospital in Taiwan

This study is to clarify the feasibility and justification of robotic pancreaticoduodenectomy (RPD) by comparing the outcomes between RPD and open pancreaticoduodenectomy (OPD) groups. All perioperative data and outcomes were prospectively collected. There were 304 (63.9%) RPD and 172 (36.1%) OPD. The median operation time was longer in RPD group than OPD (7.5 vs 7.0 h). The blood loss was much lower in RPD group, with a median of 130 vs. 400 c.c. in OPD group. Based on Clavien-Dindo classification, grade 0 (no complication) was 51.8% in RPD group, higher than 43.2% in OPD. Delayed gastric emptying was only 3.5% in RPD group, much lower than 13.6% in OPD. Wound infection rate was also lower in RPD group, 3.2% vs. 7.7% in OPD. The postoperative hospital stay was shorter in RPD group, with a median of 20 days, vs. 24 days in OPD. There was no significant difference regarding the lymph node yield, surgical mortality, postoperative pancreatic fistula, postpancreatectomy hemorrhage, chyle leakage and bile leakage between RPD and OPD groups. For pancreatic head adenocarcinoma, the survival outcome was better in RPD group, with 1-year, 3-year, and 5-year survival of 82.9%, 45.3%, and 26.8% respectively, as compared with 63.8%, 26.2%, and 17.4% in OPD. RPD is not only feasible but also justified without increasing the surgical risks and compromising the survival outcomes. Moreover, RPD might provide benefits of less blood loss, less delayed gastric emptying, lower wound infection rate and shorter length of postoperative stay, as compared with OPD.

Current statement and safe implementation of minimally invasive surgery in the pancreas

Minimally invasive pancreatic resection has become very popular in modern pancreatic surgery. Evidence of the benefits of a minimally invasive approach is accumulating thanks to prospective and randomized controlled studies. Minimally invasive surgery provides advantages to the surgeon due to the high definition of the surgical field and the freedom of fine movement of the robot, but should be considered only in selected patients and in high-volume centers. Minimally invasive distal pancreatectomy for benign and low-grade malignant tumors has established a secure position over open distal pancreatectomy, since it is associated with a shorter hospital stay, reduced blood loss, and equivalent complication rates. Minimally invasive distal pancreatectomy for pancreatic ductal adenocarcinoma appears to be a feasible, safe, and oncologically equivalent technique in experienced hands. On the other hand, the feasibility and safety of minimally invasive pancreaticoduodenectomy are still controversial compared with open pancreaticoduodenectomy. The choice of either technique among open, laparoscopic, and robotic approaches depends on surgeons' experience and hospital resources with a focus on patient safety. Further studies are needed to prove the perioperative and oncological advantages of minimally invasive surgery compared to open surgery in the pancreas. Here, we review the current status of minimally invasive pancreatic surgery and its safe implementation.

Robotic pancreaticoduodenectomy in the era of minimally invasive surgery

Minimally invasive surgery has become a worldwide trend to reduce the wound and mitigate pain. However, the role of robotic pancreaticoduodenectomy (RPD) has not been well established in the era of minimally invasive surgery. It would be nearly impossible to apply minimally invasive surgery in the tedious and complicated Whipple operation without an experienced and dedicated pancreas team. The pancreatic team led by Shyr YM and Wang SE at Taipei Veterans General Hospital have already been highly accredited with a Copper Award of Symbol of National Quality (SNQ award), entitled with "Minimally Invasive Robotic Pancreatic Surgery-Small Wound for Major Pancreatic Surgery" in Taiwan in 2019. RPD was claimed to be associated with less blood loss, less delayed gastric emptying, shorter length of postoperative stay, and lower wound infection rate, but longer operative time, as compared with the traditional open pancreaticoduodenectomy (OPD). More than 99% of the patients undergoing minimally invasive RPD are satisfied with the surgical outcomes and would like to recommend RPD to those with periampullary lesions. RPD could be recommended not only to surgeons but also to patients in terms of surgical outcomes and patient satisfaction. Moreover, our study showed a survival benefit for pancreatic head adenocarcinoma in RPD group, with 1-year, 3-year, and 5-year survival of 82.9%, 45.3%, and 26.8%, respectively, as compared with 63.8%, 26.2%, and 17.4% in OPD.