Minimally Invasive Distal Pancreatectomy: Review of the English Literature

Is the robotic approach the future of distal pancreatectomy with splenectomy? A propensity score matched analysis

Our study provides a comparative analysis of the Laparo-Endoscopic Single Site (LESS) and robotic surgical approaches for distal pancreatectomy and splenectomy, examining their cosmetic advantages, patient outcomes, and operative efficiencies through propensity score matching (PSM). We prospectively followed 174 patients undergoing either the LESS or robotic procedure, matched by cell type, tumor size, age, sex, and BMI from 2012 to 2023. Propensity score matching (PSM) was utilized for data adjustment, with results presented as median (mean ± SD). Post-PSM analysis showed no significant differences in age or BMI between the two groups. LESS approach exhibited a shorter operative duration (180(180 ± 52.0) vs. 248(262 ± 78.5) minutes, p = 0.0002), but increased estimated blood loss (200(317 ± 394.4) vs. 100 (128 ± 107.2) mL, p = 0.04). Rates of intraoperative and postoperative complications, length of hospital stay, readmissions within 30 days, in-hospital mortalities, and costs were comparably similar between the two procedures. While the robotic approach led to lower blood loss, LESS was more time-efficient. Patient outcomes were similar in both methods, suggesting that the choice between these surgical techniques should balance cosmetic appeal with technical considerations.

Preliminary experience in laparoscopic distal pancreatectomy using the AEON™ endovascular stapler

Background

The aim of this study is to investigate the effects of using a new innovative endovascular stapler, AEON™, on the pancreatic leak rates and other outcome measures.

Methods

In a retrospective review of prospectively collected data from a secure tertiary unit registry, patients undergoing distal or lateral pancreatectomy were analyzed for any differences on pancreatic fistula rates, length of stay, comprehensive complication index (CCI), and demographics after using AEON™ compared with other commonly used staplers. Statistical significance was defined as <0.05.

Results

There were no differences in the demographics between the two groups totaling 58 patients over 2 years from 2019 to 2021. A total of 43 and 15 patients underwent pancreatic transection using other staplers and AEON™ endovascular stapler, respectively. The comparison of the two groups revealed a significantly reduced rate of mean drain lipase at postoperative day 3 with AEON™ (446 U/L) versus the other staplers (4,208 U/L) (p = 0.018) and a subsequent reduction of postoperative pancreatic fistula (POPF) from 65% to 20%. A reduction in the mean CCI, from 13.80 when other staplers were used to 4.97 when AEON™ was used, was also observed (p = 0.087). Mean length of stay was shorter by 3 days in the AEON™ group compared with that in the other staplers (6 and 9 days, respectively; p = 0.018).

Conclusion

AEON™ stapler when used to transect the pancreas demonstrated a significantly reduced pancreatic fistula rate, length of stay in hospital, and a leaning towards a reduced CCI. Its use should be further evaluated in larger cohorts with the encouraging results to determine whether this is possibly related to the technology used in the design of the AEON™ stapler.

Considerations in laparoscopic resection of giant pancreatic cystic neoplasms

Background:

Laparoscopic distal pancreatectomy (LDP) with (LDPS) or without splenectomy for cystic tumours in the body and tail has become the standard of care. Data on patients with large tumours of the body and tail of the pancreas are sparse.

Patients and Methods:

A retrospective analysis of a prospectively maintained database of patients who were managed with laparoscopic surgery for pancreatic cystic neoplasm since 2010 was done. Patients with cysts more than 8 cm were analysed. Clinical presentation, imaging, details of the surgical procedure and the outcomes were looked into.

Results:

Five patients of giant pancreatic cystic neoplasm (GPCN) were managed with LDPS. Four patients were female, mean age was 45 years (range 15–69 years). The mean cyst size was 11.2 cms (range 8–15 cm). The splenic vein was either stretched or thrombosed in all patients. Three patients had sinistral portal hypertension. All patients were operated with a modified five-port placement. None of the patients required conversion. Mean operative duration was 3½ h, blood loss was 80 ml approximately and none required a blood transfusion. One patient had a biochemical leak. All patients were discharged from the hospital by 3^rd postoperative day. Drain removal was done before discharge except in the patient with biochemical leak (removed on day 6). On a median follow-up of 89 months (range 1–120 months), two patients developed diabetes. There has been no Overwhelming post-splenectomy infections (OPSI).

Conclusion:

Laparoscopic distal pancreatectomy is feasible in patients with GPCN and offers the all the short-term benefits, namely lesser pain, no wound infections, early return of bowel activity, early return to orals and early discharge and early return to work. Splenectomy was required in all patients because of splenic vein thrombosis and portal hypertension in three and for technical reasons in the rest.

LAPAROSCOPIC DISTAL PANCREATECTOMY WITH OR WITHOUT SPLEEN PRESERVATION: COMPARATIVE ANALYSIS OF SHORT AND LONG-TERM OUTCOMES

Background:

Laparoscopic distal pancreatectomy (LDP) is the preferred approach for resection of tumors in the distal pancreas because of its many advantages over the open approach.

Aim:

To analyse and compare short and long-term outcomes from LDP performed through two different techniques: with splenectomy vs. spleen preservation and splenic vessel preservation.

Method:

Fifty-eight patients were operated and subsequently divided between two groups: Group 1, LDP with splenectomy (LDPS); and Group 2, LDP with spleen preservation and preservation of splenic vessels (LDPSPPSV).

Results:

The epidemiological characteristics were statistically similar between the two groups (age, gender, BMI and lesion size). Both the mean of operative time (p=0.04) and the mean of intra-operative blood loss (p=0,03) were higher in Group 1. The mean of resected lymph nodes was also higher in Group 1 (p<0.000). There were no statistic differences between the groups in relation to open conversion, morbidity or early postoperative mortality. The mean hospital stay was similar between groups. Pancreatic fistula (grade B and C) was similar between the groups. The mean of overall follow-up was 37.6 months (5-96). Late complications were similar between the groups.

Conclusion:

Both techniques were superimposable; however, LDPS presented, respectively, higher intra-operative bleeding, longer duration of the operation and higher number of lymph nodes resected. No differences were observed in the studied period in relation to the appearance of infections or neoplasm related to splenectomy during follow-up. Maintenance of the spleen avoided periodic immunizations in patients in LDPSPSV. It is indicated in small pancreatic lesions with indolent course.

Laparoscopic distal pancreatectomy: better than open?

Distal pancreatectomy is well suited to the laparoscopic approach. Laparoscopic distal pancreatectomy (LDP) provides the same postoperative recovery advantages reputed to minimal access surgery. However, there have been fears as to the safety of LDP in terms of life-threatening intra-operative events and post-operative complications, adequate carcinological outcomes as compared to traditional (open) distal pancreatectomy (ODP) when performed for cancer, as well as to whether the laparoscopic approach is well adapted to the variety of diseases that may affect the pancreas (ranging from trauma to benign or malignant disease) and whether the minimal access approach is well adapted to perform pancreatic surgery safely in the obese, the elderly or the frail. In this review of the literature, we sought to determine whether LDP was as safe, provided the same oncological outcomes and was applicable to all diseases involving the body and tail of the pancreas, and to particular patient characteristics, compared to the traditional open approach. Last we looked at cost issues. We concluded that this review of the literature allowed to state that laparoscopic distal pancreatectomy is feasible and safe for a wide range of diseases, both benign and malignant. Morbidity, mortality, and probably, also, carcinological outcomes are comparable to open surgery. The overall costs are similar but the advantages of minimal access surgery make it the preferred approach, once the surgical expertise is acquired and present.

Evolution of minimally invasive distal pancreatectomies at a single institution

Introduction

This study aims to study the changing trends and outcomes associated with the adoption of minimally invasive distal pancreatectomy (MIDP) at a single centre.

Materials and Methods

Retrospective review of sixty consecutive patients who underwent MIDP from September 2006 to November 2016 at a single institution. To study the evolution of MIDP, the study population was divided into three groups consisting of twenty patients (Group I, Group II and Group III).

Results

Sixty patients underwent MIDP with 11 (18.3%) requiring open conversions. The median operation time was 305 (range: 85-775) min and the median post-operative stay was 6 (range: 3-73) days. Fifteen procedures were spleen-saving pancreatectomies. Major post-operative morbidity (>Grade 2) occurred in 12 (20.0%) patients and there was no mortality or reoperations. There were 33 (55.0%) pancreatic fistulas, of which 15 (25.0%) were Grade B fistulas of which 12 (20.0%) required percutaneous drainage. Comparison between the three groups demonstrated a statistically significant increase in the frequency of procedures performed, increase in robotic-assisted procedures and proportion of asymptomatic tumours resected. There also tended to be non-significant decrease in open conversion rates from 25% to 5% between the three groups and increase in tumour size resected from 24 to 40 mm.

Conclusion

Comparison between the three groups demonstrated that MIDP was performed with increased frequency. There was a statistically significant increase in the frequency of resections performed for asymptomatic tumours and resections performed through robotic assistance. There was also a non-significant trend towards a decrease in open conversions and increase in the size of tumours resected.

Advances in Robotic Transaxillary Thyroidectomy in Europe

PURPOSE OF REVIEW

The robotic surgical approach for minimally invasive thyroid surgery has been well described from the Korean surgeons and shows a wide spread diffusion in Asian area. This paper gives a systematic review aiming to pointed out the interest and the way of behaving of the European surgeons about the role of the robotic thyroidectomy (RT).

RECENT FINDINGS

A literature search was performed using Pubmed, MEDLINE, Cochrane and ClinicalTrials.gov databases, including only papers wrote from european surgeons enrolling patients operated in Europe. Outcomes of interest included patients characteristics, patients position, surgical devices, surgical technique, surgical outcomes, and complications. Eighteen studies have been included in the analysis, published from 2011 to 2017. An overall number of 1108 patients were treated in studies included. In the 44.4% of studies (eight trials), the Kuppersmith position was chosen, whereas in the 22.2% (four trials), the Chung position was selected, with a mean length on axilla skin incision of 5.8 ± 1.5 cm. Considering the characteristics of the surgical technique, the mean total surgical time was 166.8 ± 36.6 min (including total thyroidectomy and loboisthmectomy together), divided three consecutive phases, such as mean working space was 50.7 ± 21.8 min, mean docking time 16.0 ± 11.9 min and mean console time 102.87 ± 38.8 min. Considering the complications, only 50% of studies included reported data about acute complications. In particular, the most frequent was hypocalcemia, occurring in 32 cases (2.9%). RLN palsy occurred in 29 patients (2.6%), definitive in 13.8% of these cases and transient in 86.2%. Only nine studies reported the discharge time, with a mean of 2.4 ± 1.2 days after surgery.

SUMMARY

Despite the papers included in the study show a different way of collecting data, the transaxillary approach for robotic thyroidectomy for European patients is both feasible and safe. This procedure has to be carried out by surgeons expert in thyroid surgery with knowledge in robotic procedure. In the future, the incoming of dedicated instruments could improve and developed this technique.