Robotic left pancreatectomy for pancreatic solid pseudopapillary tumor

Retroperitoneoscopic distal pancreatectomy: a new surgical approach

Introduction

The traditional laparoscopic surgery is difficult to deal with the deep lesions of the body and tail of the pancreas, which may damage the visceral organs of the abdominal cavity and cause abdominal adhesion and other related complications.

Aim

This paper introduces the operation procedure of retroperitoneoscopy in pancreatic surgery, and evaluates its feasibility in clinical application.

Material and methods

Retrospective analysis was performed on patients with retroperitoneal pancreatectomy in our hospital. The anatomical features of the fascia, surgical plane composition and surgical pathway of the fascia of the retroperitoneoscopic pancreatectomy were observed during the operation, and the surgical safety and feasibility were analyzed. The following parameters were evaluated: operation time, blood loss, pancreatic fistula, postoperative gastro-intestinal recovery, hospital stay.

Results

All 3 patients had a smooth operation and no serious complications occurred. During retroperitoneal laparoscopic pancreatectomy, there is a vascularized plane between the posterior fascia of the pancreas and the prerenal fascia, which can avoid injury of the visceral organs and retroperitoneal vessels. The anterior renal fascia should be used as the posterior boundary of the safe separation plane.

Conclusions

The surgical plane based on the anatomy of the fascia and interstitial dissection is the theoretical basis of modern surgery, which is safe, fast and effective. The inter-prerenal fascia plane is the correct and safe anatomical plane of posterior laparoscopic surgery.

Systematic Review and Meta-analysis of Minimally Invasive Pancreatectomies for Solid Pseudopapillary Neoplasms of the Pancreas

OBJECTIVES

We report the first systematic review and meta-analysis on minimally invasive pancreatectomy (MIP) for solid pseudopapillary neoplasms (SPPN) of the pancreas.

METHODS

A systematic review of all studies reporting patient characteristics and outcomes of MIP for SPPN was conducted.

RESULTS

We reviewed 27 studies comprising 149 patients with SPPN managed via MIP. Five were comparative retrospective cohort studies, comprising 46 and 60 patients in the minimally-invasive and open groups, respectively. Tumor size was smaller in the minimally-invasive group (mean difference, -2.20; 95% confidence interval (CI), -3.09 to -1.32; P < 0.001). The MI group had lower intraoperative blood loss (mean difference, -180.19; 95% CI, -344.28 to -16.09; P = 0.03) and transfusion requirement (relative risk, 0.24; 95% CI, 0.06-0.94; P = 0.04), and a shorter time to diet (mean difference, -2.99; 95% CI, -3.96 to -2.03; P < 0.001) and length of stay (mean difference, -3.61; 95% CI, -6.98 to -0.24; P = 0.04). There was no significant difference in operating time, margin positivity, postoperative morbidity, and postoperative pancreatic fistula rates.

CONCLUSIONS

Minimally invasive pancreatectomy for SPPN is associated with decreased intraoperative blood loss and transfusion requirements and a shorter postoperative time to diet and hospital stay.

Minimally Invasive Surgery for Pancreatic Disease - Current Status

Laparoscopic procedures have advanced to represent the new gold standard in many surgical fields. Although application in pancreatic surgery is hampered by the friable nature of the gland and the difficulty of its exposure, advanced technology and surgeons' experience are leading to an expansion of minimally invasive pancreatic surgery. Addressing the whole range of main operative procedures, this review analyzes the literature data so far to give an overview about the current status of minimally invasive pancreatic surgery, its indications and limitations. In acute pancreatitis, a step-up approach from percutaneous drainage to retroperitoneoscopic necrosectomy seems beneficial. Transgastric necrosectomy also preserves the retroperitoneal compartment in contrast to the laparoscopic approach, which has widely been abandoned. In tumor pathology, laparoscopic access is adequate for small benign lesions in the pancreatic tail and body. Oncological outcome shows to be at least equal to the open procedure. Concerning laparoscopic pancreaticoduodenectomy, there is no evidence for a patients' benefit currently although several studies prove that it can be done.

Outcomes of robotic surgery for pancreatic ductal adenocarcinoma

BACKGROUND

To explore the effectiveness, safety, and efficacy of the robot-assisted surgery in the radical resection of pancreatic ductal adenocarcinoma (PDAC).

METHODS

The clinical data of 72 patients with PDAC who underwent radical resection using the da Vinci Surgical System from April 2010 to December 2014 were retrospectively analyzed.

RESULTS

Among these 72 patients, three were converted to conventional laparotomy due to the vascular invasion or due to the difficulties in tissue isolation from the surrounding organs. Among 39 patients who underwent the pancreatoduodenectomy, the average operative time was 395.3±118.8 min, and the mean intra-operative blood loss was 447.3±269.9 mL. Among 31 patients who underwent the distal pancreatectomy (DP), the average operative time was 185.5±74.1 min, and the mean intra-operative blood loss was 267.1±305.3 mL. In two patients who received the middle pancreatectomy (MP), the average operative time was 225 min and mean intra-operative blood loss was 100 mL. Among all the 72 patients, an average of 4.2±2.6 lymph nodes were dissected, with an average hospital stay of 22.6±10.7 days. Complications were observed in 18 patients, which included pancreatic fistula (n=11), bile leak (n=5), anastomotic bleeding (n=2), pancreatic fistula complicated with portal vein thrombosis (n=1), and anastomotic bleeding complicated with acute renal failure (n=1). Except that one patient died due to post-operative bleeding and acute renal failure, all the other patients were cured after conservative treatment. These 72 patients were followed for 1-45 (15.6±5.8) months, during which 10 patients died. Eleven patients suffered from recurrence or metastasis, among which 6 had local recurrence, 4 had liver metastasis, and 1 had ascites accompnaied with incision site tumor metastasis.

CONCLUSIONS

Radical resection of PDAC by robotic surgical system is safe and feasible. It has less surgical trauma and enables faster post-operative recovery, and therefore can achieve the lymph node dissection scope and tumor resection margin required by the standards of radical resection for pancreatic cancer. Nevertheless, its long-term efficacy requires further validation.

Laparoscopic distal pancreatectomy for adenocarcinoma: safe and reasonable?

As a result of technological advances during the past two decades, surgeons now use minimally invasive surgery (MIS) approaches to pancreatic resection more frequently, yet the role of these approaches for pancreatic ductal adenocarcinoma resections remains uncertain, given the aggressive nature of this malignancy. Although there are no controlled trials comparing MIS technique to open surgical technique, laparoscopic distal pancreatectomy for pancreatic adenocarcinoma is performed with increasing frequency. Data from retrospective studies suggest that perioperative complication profiles between open and laparoscopic distal pancreatectomy are similar, with perhaps lower blood loss and fewer wound infections in the MIS group. Concerning oncologic outcomes, there appear to be no differences in the rate of achieving negative margins or in the number of lymph nodes (LNs) resected when compared to open surgery. There are limited recurrence and survival data on laparoscopic compared to open distal pancreatectomy for pancreatic adenocarcinoma, but in the few studies that assess long term outcomes, recurrence rates and survival outcomes appear similar. Recent studies show that though laparoscopic distal pancreatectomy entails a greater operative cost, the associated shorter length of hospital stay leads to decreased overall cost compared to open procedures. Multiple new technologies are emerging to improve resection of pancreatic cancer. Robotic pancreatectomy is feasible, but there are limited data on robotic resection of pancreatic adenocarcinoma, and outcomes appear similar to laparoscopic approaches. Additionally fluorescence-guided surgery represents a new technology on the horizon that could improve oncologic outcomes after resection of pancreatic adenocarcinoma, though published data thus far are limited to animal models. Overall, MIS distal pancreatectomy appears to be a safe and reasonable approach to treating selected patients with pancreatic ductal adenocarcinoma, though additional studies of long-term oncologic outcomes are merited. We review existing data on MIS distal pancreatectomy for pancreatic ductal adenocarcinoma.

Retrospective analysis of short term outcomes after spleen-preserving distal pancreatectomy for sodid pseudopapillary tumours

Solid pseudopapillary pancreatic tumour (SPN) is a rare pancreatic tumour representing 0.1%-3% of all exocrine pancreatic tumours. Most SPN show benign and low-grade malignant behaviour; malignant degeneration is observed in 10-15% of the patients. More than 40% of SPN involve the tail of the pancreas leading to a minimal invasive distal pancreatectomy approach. In this report we present the case of a young 22 Caucasian woman suffering from SPN who successfully underwent laparoscopic spleen-preserving distal pancreatectomy. Postoperative course was uneventful. A CT scan control at six months was negative for recurrences. We have also made an analysis of all the laparoscopic treatment of SPN reported in English literature.

[Comparative results of open robot-assisted and laparoscopic distal pancreatic resection]

It was performed a retrospective analysis of the results of distal pancreatic resections (DPR) in 89 patients with different tumors. Conventional open operations were performed in 60 patients, robot-assisted - in 19 patients, laparoscopic - in 10 cases. Absolute indication for open surgery was pancreatic cancer T3-4 stages. Mini-invasive distal resections (robot-assisted and laparoscopic) were performed in cases of pancreatic cancer T1-2 stages, benign tumors and tumors with low potential of malignancy and diameter up to 4-5 cm. Results of robot-assisted and laparoscopic interventions are similar but robot-assisted technique provides more precise surgery. It improves quality of lymphadenectomy, decreases probability of intraoperative bleeding. Duration of robot-assisted and open operation did not differ significantly. Blood loss was significantly lower in group of robot-assisted method (mean 470 ml) while in cases of open and laparoscopic techniques this parameter was 1013.8 and 833.3 ml respectively. Postoperative complications in open, laparoscopic and robot-assisted groups developed in 45.1, 52.6 and 50% of observations respectively. Pancreatic fistulas were revealed in 58.8, 80 and 58.3% of cases respectively. There were not deaths after laparoscopic and robot-assisted pancreatic resections. 2 patients died after open surgery.

State of the art of robotic pancreatic surgery

More than a decade has passed since robotic technology was adopted for abdominal surgery, and virtually every gastrointestinal operation has since been shown to be feasible, safe, and reproducible using the robotic approach. Robotic pancreatic surgery had been left behind at the beginning, because they were technically challenging, requiring not only being very familiar with the robotic technology but also having a perfect knowledge of the anatomical variations, very frequent in this area. Nonetheless in the last few years many authors have approached the robot for pancreatic surgery with very promising results in terms of surgical and oncological outcomes. The aim of this article is to review the literature on robotic pancreatic surgery and to define the state of the art use of the robotic approach for pancreatic disease.

Robotic spleen preserving distal pancreatectomy: how I do it (with video)

Laparoscopic hepatobiliary surgery, although technically demanding, gains popularity due to the patient benefits of a mini-invasive approach. Laparoscopic distal pancreatectomy is a technically feasible and reproducible operation that doesn't require complex digestive reconstruction. It requires advanced laparoscopic skill for vascular dissection and control. Due to the absence of trials proving its oncological results it is mainly indicated for benign or borderline tumours of the pancreatic body and tail. Since for these tumours there is no indication for a lymph node dissection, there are benefits for the patient if the spleen is preserved. There is some evidence that robotic assistance facilitates the procedure and makes it accessible to surgeons diminishing the necessity of advanced laparoscopic skills. In this technical multimedia article, we present our method for a robotic mini-invasive spleen preserving distal pancreatectomy with preservation of the splenic vessels. The technique is presented in a stepwise approach with an accompanying video. We believe that the use of the Da Vinci robotic platform facilitates this demanding procedure.

Robotic distal pancreatectomy with or without preservation of spleen: a technical note

Background

Distal pancreatectomy (DP) is a surgical procedure performed to remove the pancreatic tail jointly with a variable part of the pancreatic body and including a spleen resection in the case of conventional distal pancreatectomy or not in the spleen-preserving distal pancreatectomy.

Methods

In this article, we describe a standardized operative technique for fully robotic distal pancreatectomy.

Results

In the last decade, the use of robotic systems has become increasingly common as an approach for benign and malignant pancreatic disease treatment. Robotic Distal Pancreatectomy (RDP) is an emerging technology for which sufficient data to draw definitive conclusions in surgical oncology are still not available because the follow-up period after surgery is too short (less than 2 years).

Conclusions

RDP is an emerging technology for which sufficient data to draw definitive conclusions of value in surgical oncology are still not available, however this techniques is safe and reproducible by surgeons that possess adequate skills.

Robotic distal pancreatectomy

The authors found that robotic distal pancreatectomy, with or without splenic preservation, can be performed safely for patients with lesions of the distal pancreas.

Background:

A robotic-assisted minimal invasive approach has the potential to overcome the limitations of conventional laparoscopic pancreatectomies. We analyzed the outcomes of robotic-assisted distal pancreatectomies (RDPs) to demonstrate the safety and feasibility of robotic distal pancreas resection, including spleen preservation.

Methods:

We performed a descriptive retrospective analysis of 40 RDPs. Statistical comparisons were performed between two groups of patients undergoing robotic-assisted spleen-preserving distal pancreatectomy (SPDP) and distal pancreatectomy with splenectomy (SDP). Survival analysis was performed using the Kaplan-Meier method.

Results:

Of 49 attempted RDPs, 40 were completed with robotic assistance, with a conversion rate of 18.4%. Compared with the published reports of laparoscopic distal pancreatotomy (DP) and robotic DP, the spleen preservation rate (30%), operating time (203 minutes), major complications rate (5%), fistula rate (20%), and length of hospital stay (5 days) were similar in our RDP patients. Also, the perioperative outcomes of the SPDP and SDP groups did not differ significantly. The median survival was 12.5 months for the patients undergoing RDP for pancreatic ductal adenocarcinoma.

Conclusions:

Robotic-assisted distal pancreatectomy, with or without splenic preservation, can be safely performed for lesions of the distal pancreas, with appropriate indications.

Solid pseudo papillary tumor of pancreas: Presenting as acute abdomen in a female child

Solid pseudo papillary tumor (SPT) or Frantz's tumor is a slow-growing low-grade malignant tumor, commonly seen in young patients with a female predominance, which is commonly located in the body and tail of the pancreas. We report a case of SPT arising from the body of the pancreas in a 12-year-old girl who presented with acute abdomen and was treated successfully by local excision of the tumor with preservation of head of pancreas and spleen.

Current status of robotic distal pancreatectomy: a systematic review

OBJECTIVE

The aim of this systematic review is to determine the potential advantages of robotic distal pancreatectomy (RDP).

STUDY SELECTION

Both randomized and non-randomized studies.

DATA EXTRACTION

Two investigators independently selected studies for inclusion by article abstraction and full text reviewing.

DATA SYNTHESIS

Five non-RCTs were included in the review. The feasibility of RDP (95.4%) and spleen-preserving rate is between 50% and 100%. Mean OT varied between 298 min and 398 min with only completely robotic procedures, whereas mean OT was 293 in "laparoscopic/robotic" technique. Postoperative length of hospital stay ranged from 7 days to 13.7 days. The 30-day postoperative overall morbidity resulted between 0 and 18% of patients.

CONCLUSIONS

RDP is an emergent technology for which there are not yet sufficient data to draw definitive conclusions with respect to conventional or laparoscopic surgery. The mean duration of RDP is longer with Da Vinci robot, but hospital stay is shorter even if it is influenced by hospital protocols. We cannot make any conclusions comparing the outcomes to laparoscopic or open procedures here, since none of these studies are randomized, and we all know that most of these surgeons selected the easier cases for robotic procedures. For these reasons randomized controlled trials are recommended to better evaluate RDP cost-effectiveness.

Role of laparoscopic distal pancreatectomy for solid pseudopapillary tumor

BACKGROUND

Since the first case report regarding laparoscopic distal pancreatectomy (DP) for solid pseudopapillary tumor (SPT), few additional articles have been published. The objective of this study was to evaluate the feasibility, safety, and long-term outcome of the laparoscopic DP based on a series of adult SPT patients.

METHODS

In a single-center study, we screened all adult patients undergoing a laparoscopic DP for SPT. Preoperative, operative, and postoperative data were retrospectively analysed and compared to the results of open DP for SPT published in the medical literature.

RESULTS

From April 2000 to June 2010, 5 adult female patients (median age 34 y) underwent a laparoscopic DP for an SPT. No conversion to open surgery was required. The median size of the tumor was 45 mm. The postoperative mortality rate was 0%, and serious complications (Dindo IV) occurred in 2 patients. The postoperative quality of life was not significantly altered by the laparoscopic procedure. At a median follow-up of 60 mo, all patients were alive and without evidence of local recurrence, distant metastasis, diabetes, or exocrine insufficiency.

CONCLUSION

Laparoscopy may offer an alternative to open surgery in the treatment of SPT of the distal pancreas in adult female patients. The laparoscopic procedure impacts neither the oncologic outcome nor the quality of life. However, due to the risk of postoperative complications, this procedure should be reserved for specialized centers.

Robotic-assisted pancreatic resection: a report of 47 cases

BACKGROUND

There are few reports of robot-assisted pancreatic surgery. Our purpose was to report our surgical and clinical experiences and outcomes of 47 cases of robot-assisted pancreatic resection to show that minimally invasive pancreatic surgery is both feasible and effective.

METHODS

The medical records of 47 patients who underwent robot-assisted pancreatic resections for adenocarcinoma, cystic tumours or other pancreatic diseases at our institution by a single surgical team from March 2010 to December 2011 were retrospectively analysed.

RESULTS

There were 32 females and 15 males with a mean age of 48.7 ± 15.4 years, of whom 13 patients had pathologically diagnosed malignancies, 25 had cystic tumours or chronic pancreatitis, three had solid pseudopapillary tumours of pancreas, and six had other lesions. Sixteen patients underwent pancreatoduodenectomy, 16 distal pancreatectomies (nine of which had spleen resections), 10 middle pancreatectomies, four Beger's procedure, and one had enucleation of a pancreatic lesion. The mean surgical time was 299.2 ± 133.5 (range 70-540) min and mean blood loss was 431.8 ± 309.0 (range 50-1100) ml. Nine patients required a blood transfusion (mean transfusion volume 597.2 ± 543.3 ml). There were no conversions to laparotomy. The mean hospital stay was 29.4 ± 9.1 (range 8-41) days. Pancreatic fistula occurred in 20 cases, anastomotic bleeding in three patients and anastomotic leakage in one patient. Two patients, one who received a PD and one who received a distal pancreatectomy, required a second surgery. All other complications were resolved with conservative management. Surgical margins were negative in all cases, with a postoperative histopathological diagnosis of malignancy. Eleven of the 13 patients with malignancies were alive and well without recurrence at the time of publication, while two patients died.

CONCLUSIONS

Our series of 47 robot-assisted pancreatic resections adds further evidence that this technique is feasible and effective.

Laparoscopic distal pancreatectomy: Up-to-date and literature review

Pancreatic surgery represents one of the most challenging areas in digestive surgery. In recent years, an increasing number of laparoscopic pancreatic procedures have been performed and laparoscopic distal pancreatectomy (LDP) has gained world-wide acceptance because it does not require anastomosis or other reconstruction. To date, English literature reports more than 300 papers focusing on LDP, but only 6% included more than 30 patients. Literature review confirms that LDP is a feasible and safe procedure in patients with benign or low grade malignancies. Decreased blood loss and morbidity, early recovery and shorter hospital stay may be the main advantages. Several concerns still exist for laparoscopic pancreatic adenocarcinoma excision. The individual surgeon determines the technical conduction of LDP, with or without spleen preservation; currently robotic pancreatic surgery has gained diffusion. Additional researches are necessary to determine the best technique to improve the procedure results.

Laparoscopic pancreatectomy for malignancy

Utilization of laparoscopic techniques for resection of the pancreas has slowly gained acceptance in specific situations and is now being applied to more challenging endeavors, such as pancreaticoduodenectomy for cancer. This review provides a summary of laparoscopic applications for pancreatic malignancy, with specific attention to the most common methods of pancreatic resection and their respective oncologic outcomes, including margin status, lymph node retrieval, and survival.

The current state of robotic-assisted pancreatic surgery

Pancreatic surgery is challenging for both surgeon and patient. With the advent of minimally invasive surgical techniques, patient morbidity could be reduced. However, these techniques must conform to established principles of open pancreatic surgery with regards to meticulous dissection, haemostasis and oncologic results. The robotic platform is utilized in all facets of surgery, and is being increasingly applied in pancreatic surgery. As with the introduction of any new technology, this approach must undergo rigorous examination before widespread adoption of the technique. In this article, we review the techniques and outcomes of robotic-assisted pancreatic resections, focusing on robotic-assisted pancreaticoduodenectomy, robotic-assisted distal pancreatectomy and robotic-assisted central pancreatectomy. As the outcomes of robotic-assisted surgery have yet to be rigorously evaluated against the gold standard of open surgery, this Review also highlights major laparoscopic pancreatic series in an effort to summarize the available literature on minimally invasive pancreatic surgery.

da Vinci robotic single-incision cholecystectomy and hepatectomy using single-channel GelPort access

BACKGROUND/PURPOSE

Minimally invasive surgery including laparoscopic and robotic surgery was recently approved for clinical use in hepatobiliary surgery. The purpose of this article is to evaluate the feasibility and technical aspects of robotic single incision for hepatobiliary surgery using the GelPort laparoscopic system in a preliminary animal study.

METHODS

We performed eight robotic single-incision laparoscopic surgery (SILS) procedures, including four cholecystectomies and four lateral segmentectomy of the liver, in a porcine study using the da Vinci S-HD Surgical System. A single-channel GelPort access was placed through a 2.5-cm single incision for robotic access. A 12-mm camera port, two 8-mm ports for the robotic arms and one 5-mm port for the patient-side assistant were inserted. A Mini Loop Retractor was applied to retract the fundus of the gallbladder. The EndoWrist dissector and grasping forceps was introduced to fine-dissect Calot's triangle. The instruments were crossed to avoid "sword fighting" and clashing of instruments in the abdomen. The cystic duct was divided after double ligation and the gallbladder was removed. Hepatic transection was performed with bipolar Harmonic shears and LigaSure for vascular pedicles.

RESULTS

All robotic SILS procedures were completed (8/8, 100%). The cholecystectomies and hepatectomies were safely performed in average operating times of 70 min (±15) and 60 min (±20), respectively, with minimal blood loss. There were no conversions, re-interventions or extension of the skin incision.

CONCLUSIONS

Robotic hepatobiliary SILS is technically feasible and safe using GelPort as a single-incision access platform. Robotic SILS is becoming established and is enormously advantageous to the patient.