Robotic pancreatic surgery: old concerns, new perspectives

Short-term and long term morbidity in robotic pancreatic surgery: a systematic review

Background

Pancreatic cancer is one of the most aggressive and lethal tumours in Western society. Pancreatic surgery can be considered a challenge for open and laparoscopic surgeons, even if the accuracy of gland dissection, due to the close relationship between pancreas, the portal vein, and mesenteric vessels, besides the reconstructive phase (in pancreaticoduodenectomy), lead to significant difficulties for laparoscopic technique. Minimally invasive pancreatic surgery changed utterly with the development of robotic surgery. However, this review aims to make more clarity on the influence of robotic surgery on long-term morbidity.

Methods

A systematic literature search was performed in PubMed, Cochrane Library, and Scopus to identify and analyze studies published from November 2011 to September 2020 concerning robotic pancreatic surgery. The following terms were used to perform the search: "long term morbidity robotic pancreatic surgery".

Results

Eighteen articles included in the study were published between November 2011 and September 2020. The review included 2041 patients who underwent robotic pancreatic surgery, mainly for a malignant tumour. The two most common robotic surgical procedures adopted were the robotic distal pancreatectomy (RDP) and the robotic pancreaticoduodenectomy (RPD). In two studies, patients were divided into groups; on the one hand, those who underwent a robotic pancreaticoduodenectomy (RPD), on the other hand, those who underwent robotic distal pancreatectomy (RDP). The remaining items included surgical approach such as robotic middle pancreatectomy (RMP), robotic distal pancreatectomy and splenectomy, robotic-assisted laparoscopic pancreatic dissection (RALPD), robotic enucleation of pancreatic neuroendocrine tumours.

Conclusions

Comparison between robotic surgery and open surgery lead to evidence of different advantages of the robotic approach. A multidisciplinary team and a surgical centre at high volume are essential for better postoperative morbidity and mortality.

Robotic-assisted Pancreaticoduodenectomy: Technique Description and Performance Evaluation After 60 Cases

PURPOSE

Robotic pancreaticoduodenectomy (RPD) remains one of the most challenging abdominal operations. During the implementation of new surgical technologies, safety and efficacy outcomes must be rigorously monitored and the learning curve clearly identified.

MATERIALS AND METHODS

The authors investigated their experience during the adoption of RPD, analyzing the outcomes of our first 60 consecutive cases, divided into group A (1 to 30) and group B (31 to 60). The cumulative sum (CUSUM) analysis was used to define the learning curve.

RESULTS

The authors observed a reduction in operative time (125 min) and estimated blood loss (185 mL) between the firsts 1 to 30 and the latest 30 cases. The overall rate of complications showed the tendency to decrease during the experience (46.7% vs. 23.3%, P=0.02), conversely, severe complications and the rate of clinically relevant postoperative pancreatic fistula did not show a significant reduction in the incidence (P=0.37 and P=0.67, respectively). The mean number of lymph nodes harvested improved significantly after 30 cases (P=0.004).

CONCLUSION

Surgical performance improved significantly after the first 30 cases.

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.

Fully robotic left hepatectomy for malignant tumor: technique and initial results

Robotic liver surgery has been considered as a unique opportunity to overcome the traditional limitations of laparoscopy; thus, it can potentially extend the indications of minimally invasive liver surgery. From April 2015 to May 2017, 35 patients underwent fully robotic left hepatectomy. The mean operative time was 315 min (200-445 min) and the mean estimated blood loss was 245 ml (125-628 ml). Pringle maneuver was required in six cases. Cancer was the indication for surgery in all patients (14 liver metastases, 18 hepatocellular carcinomas and 3 cholangiocarcinomas). There were one to four lesions in a patient and the mean lesion size was 39.2 mm (15-85 mm). The average length of hospital stay was 6.5 days (5-14 days). Perioperative morbidity rate was 17.2%. Two patients underwent conversion to open surgery. The 90-day mortality rate was nil. The mean surgical resection margin was 12 (1-22) mm, and R0-resection was reached in 33 out of 35 cases. The robotic left hepatectomy provides interesting surgical outcomes and good oncologic adequacy. It can be safely applied for the management of liver malignancies.