Robotic spleen-preserving distal pancreatectomy using the first domestic surgical robot platform (the hinotori™ Surgical Robot System): a case report

BACKGROUND

Robotic pancreatectomy has been performed worldwide mainly using the da Vinci® Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA, USA). Recently, because of the death of some patents related to the da Vinci® system, new surgical robot systems have been introduced that are characterized by unique technical refinements. In Japan, the hinotori™ Surgical Robot System (Medicaroid Corporation, Kobe, Japan) was approved for use in gastroenterological surgery in October 2022. Since then, we have attempted complicated procedures using this robot. In this report, we report our first experience performing spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein using this first Japanese domestic surgical robot.

CASE PRESENTATION

The patient was a 58-year-old woman with a mass in the pancreatic tail identified during medical screening. Further examinations resulted in a diagnosis of a pancreatic neuroendocrine tumor. The patient consented to surgical resection, and we planned robotic spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein, using the hinotori™. Five trocars, including one port for the assistant surgeon, were placed in the upper abdomen. The operating unit was rolled in from the patient's right side. The pivot position was set for each robotic arm, and this setting was specific to the hinotori™. The cockpit surgeon performed all surgical procedures, excluding port placement and pancreatic transection. There were no unrecoverable device errors during the operation. The operation time was 531 min, and blood loss was 192 ml. The postoperative course was uneventful. We were able to safely perform this highly complicated surgery for a pancreatic tumor using the first Japanese domestic surgical robot platform.

CONCLUSIONS

The first Japanese domestic surgical robot platform, hinotori™, has different features from those of the da Vinci® and performed sufficiently as a surgical robot system in highly advanced pancreatic surgery.

Learning curve of robotic-assisted splenic vessel-preserving spleen-preserving distal pancreatectomy by one single surgeon: a retrospective cohort study

AIM

Splenic vessel-preserving spleen-preserving distal pancreatectomy (SVP-SPDP) has a lower risk of splenic infarction than the splenicvessel-sacrificing SPDP, but it is more technically demanding. Learning curve of robotic-assisted SVP-SPDP (RSVP-SPDP) remains unreported. This study sought to analyze the perioperative outcomes and learning curve of RSVP-SPDP by one single surgeon.

METHODS

Seventy-four patients who were intended to receive RSVP-SPDP at the First Affiliated Hospital of Sun Yat-sen University between May 2015 and January 2023 were included. The learning curve were retrospectively analyzed by using cumulative sum (CUSUM) analyses.

RESULTS

Sixty-two patients underwent RSVP-SPDP (spleen preservation rate: 83.8%). According to CUSUM curve, the operation time (median, 318 vs. 220 min; P < 0.001) and intraoperative blood loss (median, 50 vs. 50 mL; P = 0.012) was improved significantly after 16 cases. Blood transfusion rate (12.5% vs. 3.4%; P = 0.202), postoperative major morbidity rate (6.3% vs. 3.4%; P = 0.524), and postoperative length-of-stay (median, 10 vs. 8 days; P = 0.120) improved after 16 cases but did not reach statistical difference. None of the patients had splenic infarction or abscess postoperatively.

CONCLUSION

RSVP-SPDP was a safe and feasible approach for selected patients after learning curve. The improvement of operation time and intraoperative blood loss was achieved after 16 cases.

Minimally invasive vessel-preservation spleen preserving distal pancreatectomy-how I do it, tips and tricks and clinical results

BACKGROUND

Minimally invasive spleen-preserving distal pancreatectomy (SPDP) has emerged as a parenchyma-preserving approach and has become the standard treatment for pancreatic benign and low-grade malignant lesions. Nevertheless, minimally invasive SPDP is still technically challenging, especially when vessel preservation is intended. This study aims to describe the technique and outcomes of laparoscopic (LSPDP) and robot-assisted spleen-preserving distal pancreatectomy (RSPDP) with intended vessel preservation, highlighting the important tips and tricks to overcome technical obstacles and optimize surgical outcomes.

METHODS

A retrospective observational study of consecutive patients undergoing LSPDP and RSPDP with intended vessel preservation by a single surgeon in two different centers. A video demonstrating both surgical techniques is attached.

RESULTS

A total of 50 patients who underwent minimally invasive SPDP were included of which 88% underwent LSPDP and 12% RSPDP. Splenic vessels were preserved in 37 patients (74%) while a salvage vessel-resecting technique was performed in 13 patients (26%). The average surgery time was 178 ± 74 min for the vessel-preserving and 188 ± 57 for the vessel-resecting technique (p = 0.706) with an estimated blood loss of 100 mL in both groups (p = 0.663). The overall complication rate was 46% (n = 23) with major complications (Clavien Dindo ≥ III) observed in 14% (n = 7) of the patients. No conversions occurred. The median length of hospital stay was 4 days.

CONCLUSION

This study presented the results after minimally invasive SPDP with intended vessel preservation by a highly experienced pancreatic surgeon. It provided tips and tricks to successfully accomplish a minimally invasive SPDP, which can contribute to quick patient rehabilitation and optimal postoperative results.

Preliminary experience with a new robotic technique to facilitate distal pancreatectomy with spleen preservation: left lateral approach in right lateral decubitus position

Spleen-preserving distal pancreatectomy (SP-DP), for patients with benign or small low-grade malignant tumors of the body or tail of the pancreas, is the ideal procedure although it is technically demanding. The robotic da Vinci system has been introduced to overcome these technical challenges and reduce operative risks. We report our experience of a new variation in surgical technique: the left lateral approach robotic spleen-preserving distal pancreatectomy (RSP-DP) in right lateral decubitus position. We performed this new variant of SP-DP, in five patients, using the da Vinci Xi system. Technical and clinical feasibility are described. The mean age and body mass index were 53.4 years and 31.4 kg/m², respectively. The mean total operative time was 323 min. The estimated mean blood loss was 240 ml. In all patients, the spleen could be preserved. In four patients, the splenic vessels were also preserved. One patient required a Warshaw technique due to significant fibrosis attached to the splenic vein. The postoperative period of all patients was uneventful except the presence of biochemical leak (BL) in two patients that only required maintenance of the drainage at home. The mean length of hospital stay was 6 days after surgery. The left lateral approach robotic SP-DP in right lateral decubitus position is a feasible and safe procedure for distal benign or small low-grade malignant tumors of the left pancreas. The right lateral decubitus position associated to robotic surgery can facilitate this complex procedure, especially when splenic vessels preservation is indicated, with a lower risk of conversion and shortening of the learning curve.

Comparison of splenic vessel preserving distal pancreatectomy and the Warshaw technique for solid pseudopapillary neoplasm in children

PURPOSE

Spleen-preserving distal pancreatectomy (SPDP) such as splenic vessel preservation (SVP) for solid pseudopapillary neoplasms (SPNs) in the body or tail of the pancreas in children prevents post-splenectomy infection and hematologic disorders. However, SVP could be technically challenging, and the Warshaw technique (WT) could be an alternative technique that has been reported to be safe and effective in adults. We, therefore, compared the perioperative outcomes of SVP and WT in pediatric patients.

METHODS

We retrospectively reviewed the medical records of pediatric patients with SPN who underwent SPDP using SVP or WT between November 2002 and November 2018 at a large-sized tertiary referral center.

RESULTS

Twenty-eight patients were included. Sixteen (57.1%) patients underwent SVP and 12 (42.9%) patients underwent WT. There were no significant differences in the baseline characteristics between the two groups. Postoperative complications occurred in 8 patients each in the SVP (50%), and the WT (66.7%) groups. Two (12.5%) in the SVP group and 1 (8.3%) in the WT group required additional intervention. During a median follow-up duration of 49 months, there were no significant differences in the incidence of splenic infarctions or perigastric varices between the two groups.

CONCLUSIONS

There were no significant differences in the surgical outcomes between WT and SVP in pediatric patients with SPN. WT could be a safe and feasible alternative technique for SVP in challenging cases.

The Gastrohepatic Ligament Approach in Robotic Spleen-Preserving Distal Pancreatectomy with Resection of the Splenic Vessels: The Superior Window Approach in the Warshaw Technique

BACKGROUND

There have been few studies reporting on the surgical approaches of minimally invasive spleen-preserving distal pancreatectomy (SPDP). Herein, we present two cases who underwent robotic SPDP with resection of the splenic vessels using our novel gastrohepatic ligament approach (the superior window approach in the Warshaw technique).

METHODS

Our gastrohepatic ligament approach in robotic SPDP consists of four steps: step 1, the gastrohepatic ligament transection; step 2, dissection around the pancreas; step 3, transection of the pancreas; and step 4, resection of the splenic vessels (the Warshaw technique).

RESULTS

Starting with the gastrohepatic ligament transection, the pancreas was directly dissected with neither dissecting the gastrocolic ligament nor retracting the stomach. The mean operative time was 217 min with minimal estimated blood loss. Both of the patients had no postoperative morbidity.

CONCLUSIONS

The gastrohepatic ligament approach may be helpful and optional in robotic SPDP with the Warshaw technique.

Resection versus drainage in the management of patients with AAST-OIS grade IV blunt pancreatic injury: A single trauma centre experience

INTRODUCTION

We aimed to compare outcomes of pancreatic resection with that of peripancreatic drainage for American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) grade IV blunt pancreatic injury in order to determine the optimal treatment method.

MATERIALS AND METHODS

Nineteen surgical patients with AAST-OIS grade IV blunt pancreatic injury between 1994 and 2016 were retrospectively studied.

RESULTS

Among the 19 patients, 14 were men and 5 were women (median age: 33 years). Twelve patients underwent pancreatic resection (spleen-sacrificing distal pancreatectomy, n = 6; spleen-preserving distal pancreatectomy, n = 3; and central pancreatectomy with Roux-en-Y anastomosis, n = 3), and seven underwent peripancreatic drainage. After comparing these two groups, no significant differences were found in terms of gender, shock at triage, laboratory data, injury severity score, associated injury, length of hospital stay, and complication. The only significant difference was that in the drainage group, the duration from injury to surgery was longer than that from injury to resection (median, 48 hours vs. 24 hours; P = 0.036). In the drainage group, three patients required reoperation, and another three required further pancreatic duct stent therapy.

CONCLUSIONS

In the surgery of the grade IV blunt pancreatic injury, pancreatic resection is warranted in early, conclusive MPD injury; if surgery is delayed or MPD injury has not been clearly assessed, peripancreatic drainage is an alternative method. However, peripancreatic drainage alone is not adequate and further pancreatic duct stent or reoperation is required. Further studies should be conducted to confirm our conclusions.

How to divide the pancreatic parenchyma in patients with a portal annular pancreas: laparoscopic spleen-preserving distal pancreatectomy for serous cystic neoplasms

Background

Portal annular pancreas (PAP) is a rare pancreatic anomaly in which the uncinate process wraps annularly around the portal vein and fuses to the body of the pancreas. PAP is highly relevant to the development of postoperative pancreatic fistula (POPF) in pancreatic surgery. Here, we describe our experience and surgical technique of laparoscopic spleen-preserving distal pancreatectomy using Warshaw’s procedure for patients with the PAP.

Case presentation

A 49-year-old woman with PAP was referred to our hospital for a suspicious mucinous cystic neoplasms 1.5 cm in diameter in the pancreatic tail. Laparoscopic spleen-preserving distal pancreatectomy using Warshaw’s procedure was performed. Mobilization of the pancreatic tail was first performed, and then, the splenic artery was cut. After dividing the pancreatic tail from the splenic hilum, the ventral pancreatic parenchyma was divided using a stapler. After cutting the splenic vein, complete mobilization of the pancreatic body and tail enabled easy division of the PAP. Finally, the PAP was also divided using the stapler. Although grade B POPF occurred, she was discharged on the 9th postoperative day.

Conclusions

Surgeons should understand the anatomical characteristics of PAP and be aware of the possibility of POPF.

Laparoscopic spleen-preserving distal pancreatectomy for a solid-cystic intraabdominal desmoid tumor at a gastro-pancreatic lesion: a case report

Background

We report a case of an intraabdominal desmoid tumor that occurred at a gastro-pancreatic lesion with spontaneous cystic features, and present the successful laparoscopic resection of the tumor.

Case presentation

A 20-mm retroperitoneal cystic mass with a solid component was found adjacent to the stomach and pancreatic body in a 52-year-old woman with no history of familial adenomatous polyposis. Laparoscopic spleen-preserving distal pancreatectomy with wedge resection of the stomach was performed, and complete resection was achieved without intraoperative and postoperative complications. Histopathological examination by immunohistochemistry enabled diagnosis of a desmoid tumor that had originated from the stomach and invaded the pancreatic parenchyma with a spontaneous cystic change. We herein report an extremely rare case of an intraabdominal desmoid tumor with a spontaneous cystic change.

Conclusion

Regardless of its rarity, desmoid tumor should be included in the preoperative differential diagnosis of a cystic intraabdominal mass, and laparoscopic function-preserving surgery may be an optimal treatment option.

Lessons learned from isolated blunt major pancreatic injury: Surgical experience in one trauma centre

INTRODUCTION

The aim of this study was to present our surgical experience of isolated blunt major pancreatic injury (IBMPI), and to compare its characteristic outcomes with that of multi-organ injury.

MATERIALS AND METHODS

From 1994-2015, 31 patients with IBMPI and 54 patients with multi-organ injury, who underwent surgery, were retrospectively studied.

RESULTS

Of the 31 patients with IBMPI, 22 were male and 9 were female. The median age was 30 years (interquartile range, 20-38). Twenty-one patients were classified as the American Association for the Surgery of Trauma-Organ Injury Scale Grade III, and 10 patients as Grade IV. Patients with IBMPI had significantly lower shock-at-triage rates, lower injury severity scores, longer injury-to-surgery time, and shorter length of hospital stay than those with multi-organ injury. There were no statistically significant differences in sex, age, trauma mechanism, laboratory data, surgical procedures, and complications between the two groups. Eight patients with IBMPI underwent endoscopic retrograde pancreatography, and 5 patients with complete major pancreatic duct (MPD) disruption underwent pancreatectomy eventually. The remaining 3 patients had partial MPD injury and two of them received a pancreatic duct stent for the treatment of existing postoperative pancreatic fistula. Spleen-sacrificing distal pancreatectomy (SSDP) was performed in 13 patient with IBMPI, followed by spleen-preserving distal pancreatectomy (n = 12), peripancreatic drainage (n = 4), and central pancreatectomy with Roux-en-Y reconstruction (n = 2). The overall complication rates, related to the SSDP, SPDP, peripancreatic drainage, and central pancreatectomy, were 10/13 (77%), 4/12 (33%), 3/4 (75%), and 2/2 (100%), respectively. Three patients died resulting in a 10% mortality rate, and the other 16 patients developed intra-abdominal complications resulting in a 52% morbidity rate. In the subgroup analysis of the 25 patients who underwent distal pancreatectomy, SPDP was associated with a shorter injury-to-surgery time than SSDP.

CONCLUSIONS

Patients with IBMPI have longer injury-to-surgery times, compared to those with multi-organ injury. Of the distal pancreatectomy patients, the time interval from injury to surgery was a significant associated factor in preserving or sacrificing the spleen.

Male gender and increased body mass index independently predicts clinically relevant morbidity after spleen-preserving distal pancreatectomy

AIM

To identify risk factors for clinically relevant complications after spleen-preserving distal pancreatectomy (SPDP). No previous studies explored potential predictors of morbidity after SPDP.

METHODS

The data of 41 patients who underwent a SPDP in a single surgical center between 2000 and 2015 were retrospectively reviewed from a prospectively maintained electronic database established in our Department of Surgery. The database included demographic, clinical, bioumoral, pathological, intraoperative and postoperative parameters. Uni- and multivariate analyses were performed to assess potential predictors of clinically relevant morbidity. Postoperative morbidity was defined as in-hospital complications and mortality was assessed at 90 d. Clinically relevant morbidity was defined as complication ≥ grade 2 Dindo.

RESULTS

Overall morbidity rate was 34.1% (14 patients): grade I (6 patients, 14.6%), grade II (2 patients, 4.8%), grade IIIa (1 patient, 2.4%), and grade IIIb (5 patients, 12.2%). A number of 5 patients (12.2%) required re-laparotomy for postoperative complications. There was no postoperative mortality. Thus, at least one clinically relevant complication occurred in 8 patients (19.5%). Univariate analysis identified male gender (P = 0.034), increased body mass index (P = 0.002) and neuroendocrine pathology (P = 0.013) as statistically significant risk factors. Multivariate analysis identified male gender [odds ratio (OR): 1.29, 95%CI: 1.07-1.55, P = 0.005] and increased body mass index (OR: 23.18, 95%CI: 1.72-310.96, P = 0.018) as the only independent risk factors of clinically relevant morbidity after SPDP.

CONCLUSION

Male gender and increased body mass index are independently associated with increased risk of clinically relevant morbidity after SPDP. These findings may assist a surgeon in clinical decision-making to better select patients suitable for SPDP.

Successful treatment of a pancreatic schwannoma by spleen-preserving distal pancreatectomy

Schwannomas are neurogenic tumors that arise from the neural sheaths of peripheral nerves. These tumors can be located in any area of the human body; the most common locations are the head, neck, trunk and extremities. Pancreatic schwannomas are very rare. Over the past 40 years, only 67 cases of pancreatic schwannomas have been reported in the English literature. Here we present a case of pancreatic schwannoma in a 62-year-old male. The tumor was revealed by ultrasound and computed tomography in the neck and body of the pancreas. An accurate diagnosis was difficult to obtain preoperatively. The patient consented to the performance of a laparotomy, and the mass was found in the neck and body of the pancreas and successfully treated using a spleen-preserving distal pancreatectomy with splenic artery and vein preservation. The procedure has only been reported in one other case of pancreatic schwannoma; here we present the second reported case. Macroscopically, the tumor was well circumscribed, gray-white in color and 3.3 cm × 2.8 cm in size. Microscopically, the tumor cells were spindle-shaped and had a palisading arrangement with no atypia, which are results compatible with a benign tumor. Both hypercellular and hypocellular areas were visible. Immunohistochemically, the tumor cells were strongly positive for S-100 protein. The tumor was definitively diagnosed as a schwannoma of the pancreatic neck and body. The patient was followed for 72 mo and has been doing well without any complications.

Successful treatment of a pancreatic schwannoma by spleen-preserving distal pancreatectomy

Schwannomas are neurogenic tumors that arise from the neural sheaths of peripheral nerves. These tumors can be located in any area of the human body; the most common locations are the head, neck, trunk and extremities. Pancreatic schwannomas are very rare. Over the past 40 years, only 67 cases of pancreatic schwannomas have been reported in the English literature. Here we present a case of pancreatic schwannoma in a 62-year-old male. The tumor was revealed by ultrasound and computed tomography in the neck and body of the pancreas. An accurate diagnosis was difficult to obtain preoperatively. The patient consented to the performance of a laparotomy, and the mass was found in the neck and body of the pancreas and successfully treated using a spleen-preserving distal pancreatectomy with splenic artery and vein preservation. The procedure has only been reported in one other case of pancreatic schwannoma; here we present the second reported case. Macroscopically, the tumor was well circumscribed, gray-white in color and 3.3 cm × 2.8 cm in size. Microscopically, the tumor cells were spindle-shaped and had a palisading arrangement with no atypia, which are results compatible with a benign tumor. Both hypercellular and hypocellular areas were visible. Immunohistochemically, the tumor cells were strongly positive for S-100 protein. The tumor was definitively diagnosed as a schwannoma of the pancreatic neck and body. The patient was followed for 72 mo and has been doing well without any complications.

The Straightened Splenic Vessels Method Improves Surgical Outcomes of Laparoscopic Distal Pancreatectomy

BACKGROUND

In laparoscopic distal pancreatectomy (LDP), isolating the splenic artery and vein requires advanced techniques. This study aimed to assess the efficacy of a novel method termed the 'straightened splenic vessels' (SSV) method for isolating the splenic vessels in LDP.

METHODS

In SSV, to adjust the instrument axis, the splenic artery was straightened by grasping 2 points of its nerve sheath. Then, the layer between the splenic artery's nerve sheath and the pancreatic parenchyma was dissected. Next, the pancreas was mobilized from body to tail, and the splenic vein was straightened by 3-point retraction before isolation. To evaluate this method's efficacy, we investigated 51 patients who underwent LDP.

RESULTS

In 39 patients who underwent LDP with splenectomy, the mean operating time was significantly shorter in the SSV group than in the conventional group (p = 0.004). In 12 patients who underwent LDP with preserving the splenic vessels, the mean intraoperative blood loss in the SSV group was 27.6 ml, which was significantly lower than that in the conventional group (p = 0.012).

CONCLUSION

This method may be applied as a standard procedure with little blood loss and short operation time for LDP. Larger prospective studies are needed to further evaluate the feasibility.

Minimally Invasive Approach for Spleen-Preserving Distal Pancreatectomy: a Comparative Analysis of Postoperative Complication Between Splenic Vessel Conserving and Warshaw's Technique

BACKGROUND

Spleen-preserving distal pancreatectomy with Warshaw's technique (WT) was reported to have higher spleen-related complication. The aim of this study was to evaluate the postoperative complication between the splenic vessel-conserving technique (SVC) and the WT when they were performed by the minimally invasive approach.

METHODS

From January 2006 to June 2015, data of the patients who had laparoscopic or robotic-assisted spleen-preserving distal pancreatectomy for benign or borderline malignant tumors were retrospectively reviewed. Patients were divided into SVC and the WT group for comparison.

RESULTS

Of the 89 patients who had the spleen-preserving distal pancreatectomy, 63 were SVC, whereas 26 were WT. The CT scans showed that patients who had WT were found to have higher rate of splenic infarction (P < 0.001) and had significantly higher rate of collateral vessel formation at 1 year (P < 0.001). All the splenic infarctions were low grade and asymptomatic which resolved spontaneously. None of the patients with collateral formation experienced gastrointestinal bleeding. The postoperative complication of SVC and WT did not differ significantly.

CONCLUSION

SVC and WT were found to have comparable outcome. Both techniques can be used to achieve higher spleen-preserving rate.

Dual-incision laparoscopic spleen-preserving distal pancreatectomy

Laparoscopic spleen-preserving distal pancreatectomy has been widely performed for benign and borderline malignancy in the body or tail of the pancreas when there are not oncologic indications for splenectomy. As the need for minimally invasive procedures to reduce postoperative morbidity and improve the quality of life is increasing, many surgeons have attempted to reduce the number of trocars and incision size to minimize access trauma and scarring. Single-port laparoscopic spleen-preserving distal pancreatectomy is the result of these efforts; however it has many limitations such as technical difficulty and prolonged operation time. In this article, we report the first case of dual-incision laparoscopic spleen-preserving distal pancreatectomy, proving that it can be a safe and feasible minimally invasive procedure for benign or borderline malignant tumors in the body or tail of the pancreas.

Traumatic pancreatic fistula with sinistral portal hypertension: Surgical management

Combined ductal and vascular injuries are awesome complications of pancreatic injury. We report on a 29-year-old male unrestrained driver who sustained a blunt abdominal injury from the steering wheel in a high velocity head-on car collision. He developed a pancreatic fistula, portosplenic venous thrombosis and sinistral portal hypertension as a result of complete duct disruption at the pancreatic neck. We describe a safe surgical strategy of spleen-preserving distal pancreatectomy after failed medical and endoscopic management.