Tips and tricks for robotic pancreatoduodenectomy with superior mesenteric/portal vein resection and reconstruction

Current trends in types of pancreatoduodenectomy: Focus on the advancement of robot-assisted pancreatoduodenectomy with 630 consecutive cases

BACKGROUND

Pancreatoduodenectomy (PD) is a complex abdominal surgery, and the adoption of robotic PD has been on the rise because of its numerous benefits. This study aimed to investigate the current PD trends, focusing on advancements in robotic surgery.

METHODS

Between 2015 and 2023, 1231 patients underwent open PD, whereas 630 underwent robot-assisted PD (RAPD). Demographics and surgical outcomes were analyzed according to the time period. Moreover, a propensity score-matched (PSM) analysis was performed to evaluate the clinical outcomes.

RESULTS

The proportion of RAPD cases gradually increased from 6.3% in 2015 to 50.9% in 2020, reaching a plateau of >50% thereafter. The proportion of patients receiving neoadjuvant chemotherapy increased during the late period (11.4% vs. 17.6%), with many of these patients undergoing open PD. Additionally, RAPD was performed in patients with a high probability of postoperative pancreatic fistula. However, the two groups demonstrated no significant difference in the occurrence of clinically relevant postoperative pancreatic fistula (10.6% vs. 9.5%, p = .532). Among periampullary cancer cases, RAPD demonstrated comparable survival outcomes to open PD after PSM (5-year survival rate: 61.8% vs. 49.8%, p = .189).

CONCLUSIONS

RAPD has become a stable approach, accounting for over 50% of all PD cases in high-volume centers, and it can be safely performed. However, open PD remains important owing to the development of neoadjuvant therapy and the aging population. Therefore, establishing appropriate indications to maximize the benefits of both RAPD and open PD is necessary.

Robotic Pancreatoduodenectomy: Increasing Complexity and Decreasing Complications with Experience: Single-Center Results from 150 Consecutive Patients

BACKGROUND

This report describes the authors' experience with 150 consecutive robotic pancreatoduodenectomies.

METHODS

The study enrolled 150 consecutive patients who underwent robotic pancreatoduodenectomy between 2018 and 2023. Pre- and intraoperative variables such as age, gender, indication, operation time, diagnosis, and tumor size were analyzed. The patients were divided into two groups. Group 1 comprised the first 75 patients, and group 2 comprised the last 75 cases. The median age of the patients was 62.4 years and did not differ between the two groups.

RESULTS

Morbidity was lower in group 2. The mortality rate was 0.7% at 30 days and 1.3% at 90 days, and there was no difference between the groups. There was a significant reduction (p < 0.05) in operative time, resection time, reconstruction time, and conversion to open surgery in group 2. Partial resection of the portal vein was performed in 17 patients and more common in group 2 (p < 0.01). The number of resected lymph nodes was higher in group 2. The indication for pancreatoduodenectomy did not differ between the two groups. There was no difference in tumor size or clinical characteristics of the patients.

CONCLUSIONS

The robotic platform is useful for pancreatoduodenectomy, facilitates adequate lymphadenectomy, and is helpful for digestive tract reconstruction after resection. Robotic pancreatoduodenectomy is safe and feasible for selected patients. It should be performed in specialized centers by surgeons experienced in open and minimally invasive pancreatic surgery.

Postoperative results, learning curve, and outcomes of pancreatectomy with arterial resection: a single-center retrospective cohort study on 236 procedures

BACKGROUND

Newer chemotherapy regimens are reviving the role of pancreatectomy with arterial resection (PAR) in locally advanced pancreatic cancer. However, concerns about the early outcomes and learning curve of PAR remain. This study aimed to define the postoperative results and learning curve of PAR and provide preliminary data on oncologic outcomes.

MATERIALS AND METHODS

A single center's experiences (1993-2023) were retrospectively analyzed to define the postoperative outcomes and learning curve of PAR. Oncologic results were also reported.

RESULTS

During the study period 236 patients underwent PAR. Eighty PAR (33.9%) were performed until 2012, and 156 were performed thereafter (66.1%). Pancreatic cancer was diagnosed histologically in 183 patients (77.5%). Induction therapy was delivered to 18 of these patients (31.0%) in the early experience and to 101 patients (80.8%) in the last decade ( P <0.0001). The superior mesenteric artery (PAR-SMA), celiac trunk/hepatic artery (PAR-CT/HA), superior mesenteric/portal vein, and inferior vena cava were resected in 95 (40.7%), 138 (59.2%), 189 (80.1%), and 9 (3.8%) patients, respectively. Total gastrectomy was performed in 35 (18.5%) patients. The 30-day mortality rate was 7.2% and 90-day mortality rate was 9.7%. The learning curve for mortality was 106 PAR [16.0 vs. 4.6%; odds ratio, OR=0.25 (0.10-0.67), P =0.0055]. Comparison between the PAR-SMA and PAR-CT/HA groups showed no differences in severe postoperative complications (25.3 vs. 20.6%), 90-day mortality (12.6 vs. 7.8%), and median overall survival. Vascular invasion was confirmed in 123 patients (67.2%). The median number (interquartile range) of examined lymph nodes was 60.5 (41.3-83) and rate of R0 resection was 66.1% (121/183). Median overall survival for PAR was 20.9 (12.5-42.8) months, for PAR-SMA was 20.2 (14.4-44) months, and for PAR-CT/HA was 20.2 (11.4-42.7). Long-term prognosis improved by study decade [1993-2002: 12.0 (5.4-25.9) months, 2003-2012: 15.1 (9.8-23.4) months, and 2013-present: 26.2 (14.3-51.5) months; P <0.0001].

CONCLUSIONS

In recent times, PAR is associated with improved outcomes despite a steep learning curve. Pancreatic surgeons should be prepared to face the technical challenge posed by PAR.

Robot-assisted vascular surgery: literature review, clinical applications, and future perspectives

Although robot-assisted surgical procedures using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA) have been performed in more than 13 million procedures worldwide over the last two decades, the vascular surgical community has yet to fully embrace this approach (Intuitive Surgical Investor Presentation Q3 (2023) https://investor.intuitivesurgical.com/static-files/dd0f7e46-db67-4f10-90d9-d826df00554e . Accessed February 22, 2024). In the meantime, endovascular procedures revolutionized vascular care, serving as a minimally invasive alternative to traditional open surgery. In the pursuit of a percutaneous approach, shorter postoperative hospital stay, and fewer perioperative complications, the long-term durability of open surgical vascular reconstruction has been compromised (in Lancet 365:2179-2186, 2005; Patel in Lancet 388:2366-2374, 2016; Wanhainen in Eur J Vasc Endovasc Surg 57:8-93, 2019). The underlying question is whether the robotic-assisted laparoscopic vascular surgical approaches could deliver the robustness and longevity of open vascular surgical reconstruction, but with a minimally invasive delivery system. In the meantime, other surgical specialties have embraced robot-assisted laparoscopic technology and mastered the essential vascular skillsets along with minimally invasive robotic surgery. For example, surgical procedures such as renal transplantation, lung transplantation, and portal vein reconstruction are routinely being performed with robotic assistance that includes major vascular anastomoses (Emerson in J Heart Lung Transplant 43:158-161, 2024; Fei in J Vasc Surg Cases Innov Tech 9, 2023; Tzvetanov in Transplantation 106:479-488, 2022; Slagter in Int J Surg 99, 2022). Handling and dissection of major vascular structures come with the inherent risk of vascular injury, perhaps the most feared complication during such robotic procedures, possibly requiring emergent vascular surgical consultation. In this review article, we describe the impact of a minimally invasive, robotic approach covering the following topics: a brief history of robotic surgery, components and benefits of the robotic system as compared to laparoscopy, current literature on "vascular" applications of the robotic system, evolving training pathways and future perspectives.

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.

Robotic Versus Open Pancreatoduodenectomy With Vein Resection and Reconstruction: A Propensity Score-Matched Analysis

Objective

This study aimed to compare robotic pancreatoduodenectomy with vein resection (PD-VR) based on the incidence of severe postoperative complications (SPC).

Background

Robotic pancreatoduodenectomy has been gaining momentum in recent years. Vein resection is frequently required in this operation, but no study has compared robotic and open PD-VR using a matched analysis.

Methods

This was an intention-to-treat study designed to demonstrate the noninferiority of robotic to open PD-VR (2011-2021) based on SPC. To achieve a power of 80% (noninferiority margin:10%; α error: 0.05; ß error: 0.20), a 1:1 propensity score-matched analysis required 35 pairs.

Results

Of the 151 patients with PD-VR (open = 115, robotic = 36), 35 procedures per group were compared. Elective conversion to open surgery was required in 1 patient with robotic PD-VR (2.9%). One patient in both groups experienced partial vein thrombosis. SPC occurred in 7 (20.0%) and 6 patients (17.1%) in the robotic and open PD-VR groups, respectively (P = 0.759; OR: 1.21 [0.36-4.04]). Three patients died after robotic PD-VR (8.6%) and none died after open PD-VR (P = 0.239). Robotic PD-VR was associated with longer operative time (611.1 ± 13.9 minutes vs 529.0 ± 13.0 minutes; P < 0.0001), more type 2 vein resection (28.6% vs 5.7%; P = 0.0234) and less type 3 vein resection (31.4% vs 71.4%; P = 0.0008), longer vein occlusion time (30 [25.3-78.3] minutes vs 15 [8-19.5] minutes; P = 0.0098), less blood loss (450 [200-750] mL vs 733 [500-1070.3] mL; P = 0.0075), and fewer blood transfusions (intraoperative: 14.3% vs 48.6%; P = 0.0041) (perioperative: 14.3% vs 60.0%; P = 0.0001).

Conclusions

In this study, robotic PD-VR was noninferior to open PD-VR for SPC. Robotic and open PD-VR need to be compared in randomized controlled trials.

Comparison of laparoscopic versus open pancreaticoduodenectomy combined with portal vein/superior mesenteric vein resection and reconstruction for pancreatic cancer: a propensity score matching analysis

BACKGROUND

Open surgery is gradually replaced by minimally invasive surgery, but few studies have reported the feasibility of laparoscopic pancreaticoduodenectomy (LPD) combined with vascular resection and reconstruction. The present study compared the efficacy of LPD with open pancreaticoduodenectomy (OPD) combined with portal vein/superior mesenteric vein (PV/SMV) resection and reconstruction for pancreatic cancer.

METHODS

The clinical data of patients who underwent PD combined with PV/SMV resection and reconstruction from March 2016 to August 2022 at our institution were retrospectively analyzed. The perioperative outcomes and survival outcomes were compared after propensity score matching (PSM).

RESULTS

The original cohort included 64 patients. Sixteen pairs of patients were obtained by 1:1 PSM. The intraoperative blood loss was greater in the OPD group than in the LPD group (550 vs. 200 mL, P=0.04), and the PV clamp time was longer in the LPD group than in the OPD group (29.4 vs. 18.8 min, P<0.001). There was no significant difference in the incidence of postoperative complications. The median overall survival and progression-free survival were comparable between the two groups (P>0.05).

CONCLUSIONS

LPD combined with PV/SMV resection and reconstruction is safe and feasible in selected patients and results in similar perioperative outcomes and prognosis as open surgery.

What are the true benefits of robotic pancreaticoduodenectomy for patients with pancreatic cancer?

INTRODUCTION

Pancreatic ductal adenocarcinoma (PDAC) is a devastating disease, and multimodal treatment including high-quality surgery can improve survival outcomes. Pancreaticoduodenectomy (PD) has evolved with minimally invasive approaches including the implementation of robotic PD (RPD). In this special report, we review the literature whilst evaluating the 'true benefits' of RPD compared to open approach for the treatment of PDAC.

AREAS COVERED

We have performed a mini-review of studies assessing PD approaches and compared intraoperative characteristics, perioperative outcomes, post-operative complications and oncological outcomes.

EXPERT OPINION

RPD was associated with similar or longer operative times, and reduced intra-operative blood loss. Perioperative pain scores were significantly lower with shorter lengths of stay with the robotic approach. With regards to post-operative complications, post-operative pancreatic fistula rates were similar, with lower rates of clinically relevant fistulas after RPD. Oncological outcomes were comparable or superior in terms of margin status, lymph node harvest, time to chemotherapy and survival between RPD and OPD. In conclusion, RPD allows safe implementation of minimally invasive PD. The current literature shows that RPD is either equivalent, or superior in certain aspects to OPD. Once more centers gain sufficient experience, RPD is likely to demonstrate clear superiority over alternative approaches.

Robotic Vascular Resection in Pancreatic Ductal Adenocarcinoma: A Systematic Review

(1) Background: This study comprehensively compared robotic pancreatic surgery with vascular resection (RPS-VR) to other surgical procedures in the treatment of pancreatic ductal adenocarcinoma (PDAC). (2) Methods: A systematic review of relevant literature was conducted to assess a range of crucial surgical and oncological outcomes. (3) Results: Findings indicate that robotic surgery with vascular resections (VRs) significantly prolongs the duration of surgery compared to other surgical procedures, and they notably demonstrate an equal hospital stay. While some studies reported a lower conversion rate and a higher rate of blood loss and blood transfusion in the RPS-VR group, others found no significant disparity. Furthermore, RPS-VR consistently correlated with comparable recurrence rates, free margins R0, postoperative mortality, and complication rates. Concerning the last one, certain reviews reported a higher rate of major complications. Overall survival and disease-free survival remained comparable between the RPS-VR and other surgical techniques in treating PDAC. (4) Conclusions: The analysis emphasizes how RPS-VR is a resembling approach in terms of surgical outcomes and aligns with existing literature findings in this field.

[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.

Ca 125 is an independent prognostic marker in resected pancreatic cancer of the head of the pancreas

The prognostic value of carbohydrate antigen 125 (Ca 125) is emerging also in pancreatic cancer (PDAC). In this study, we aim to define the prognostic value of Ca 125 in resected PDAC of the head of the pancreas. This is a single-center, retrospective study. Data from patients with a pre-operative assay of Ca 125 who underwent a pancreatic resection for PDAC between 2010 and 2018 were analyzed. As per National Comprehensive Cancer Guidelines, tumors were classified in resectable (R-PDAC), borderline resectable (BR-PDAC), and locally advanced (LA-PDAC). The Kaplan-Meier method was used to evaluate the overall survival. Cox proportional hazard regression was used to evaluate the role of pre-operative Ca 125 in predicting survival (while adjusting for confounders). The maximally selected log-rank statistic was used to identify a Ca 125 cut-off defining two groups with different survival probability. Inclusion criteria were met by 207 patients (R-PDAC: 80, BR-PDAC: 91, and LA-PDAC: 36). Ca 125 predicted overall survival before and after adjusting for confounding factors in all categories of anatomic resectability (R-PDAC: HR = 4.3; p = 0.0249) (BR-PDAC: HR = 7.82; p = 0.0024) (LA-PDAC: HR = 11.4; p = 0.0043). In BR-PDAC and LA-PDAC (n = 127), the division in two groups (high vs. low Ca 125) correlated with T stage (p = 0.0317), N stage (p = 0.0083), mean LN ratio (p = 0.0292), and tumor grading (p = 0.0143). This study confirmed the prognostic value of Ca125 in resected pancreatic cancer and, therefore, the importance of biologic over anatomic resectability. Ca 125 should be routinely assayed in surgical candidates with PDAC.

A single-center initial experience on laparoscopic pancreatic operation combined with hepatic arterial resection and reconstruction

Objective

This study aims to summarize our single-center initial experience in laparoscopic pancreatic operation (LPO) combined with hepatic arterial resection and reconstruction, as well as to demonstrate the feasibility, safety, and key surgical procedure for LPO.

Methods

We retrospectively analyzed 7 patients who had undergone LPO combined with hepatic arterial resection and reconstruction in our center from January 2021 to December 2022. The clinical data of these 7 patients were collected and analyzed.

Results

In our case series, two patients underwent passive arterial resection and reconstruction due to iatrogenic arterial injury, and five patients underwent forward arterial resection and reconstruction due to arterial invasion. The arterial anastomosis was successful in 5 cases, including 2 cases of end-to-end in situ and 3 cases of arterial transposition, and the vascular reconstruction time was 38.28 ± 15.32 min. There were two conversions to laparotomy. The postoperative recovery of all patients was uneventful, with one liver abscess (Segment 4) and no Clavien III-IV complications. We also share valuable technical feedback and experience gained from the initial practice.

Conclusions

Based on the surgeon's proficiency in open arterial resection and reconstruction and laparoscopic technique. This study demonstrated the feasibility of total laparoscopic hepatic arterial resection and reconstruction in properly selected cases of arterial involvement or iatrogenic arterial injury. Our initial experience provides valuable information for laparoscopic pancreas surgery with arterial resection and reconstruction.