Robotic General Surgery

CHAPTER 21

Pancreaticoduodenectomy Carolijn L.M.A. Nota, Izaäk Quintus Molenaar, and Jeroen Hagendoorn

THE EMERGENCE OF ROBOTIC PANCREATICODUODENECTOMY

COMPARISON WITH OPEN PANCREATODUODENECTOMY

Initially performed as a two-stage procedure to resect periampullary tumors by Kausch and later Whipple in the 1910s and 1930s, 1 what is currently the standard pancreatoduodenectomy (PD) is the result of a lengthy process of development and refinement over more than a century. Although a rapid acceleration of medical tech nology and capability in the second half of the 20th cen tury led to the decline to acceptable levels of morbidity and mortality of PD in selected large institutions, 2 it was due to the centralization of complex surgical procedures in the last 2 decades 3 that PD eventually established itself as a universally accepted standard procedure. To date, since Giulianotti’s group described the first robotic PD (RPD) in 2001, 4 RPD has been gaining ground and in many countries is now the preferred technique for min imally invasive PD. 5 Reconstruction of the anastomoses requires a higher level of dexterity than can be achieved by conventional laparoscopy. The robotic surgical sys tem provides a solution. The surgical robot has wristed instruments, and the view of the operative field is three-dimensional and magnified. Moreover, movements are scaled and ergonomics are improved. The optimized surgical dexterity makes robotic surgery in particular suited for technically complex procedures such as PD, 6 and, for example, also for other hepato-pancreato-biliary procedures that benefit from the increased dexterity, such as resections of the posterosuperior liver segments. 7

The surgical robot enables one to perform minimally invasive surgery with the same dexterity as the open approach, but with the potential benefits of an min imally invasive approach, such as less blood loss, an enhanced recovery after surgery, and shorter length of hospital stay. To date, there are no randomized stud ies available comparing open PD (OPD) with RPD. However, several large comparative studies have been published. In Table 21.1 study characteristics of three comparative studies including >200 RPDs have been dis played. 8-10 Furthermore, outcomes of these three stud ies have been summarized in Table 21.2 . These data show that RPD can be a safe and feasible alternative to the open approach, with few of the aforementioned potential benefits. This is also concluded in a recently published meta-analysis by Fu et al, including over 20 recent, comparative studies. 11 However, one should keep in mind that these studies are all nonrandomized, mostly retrospective, and therefore potentially biased.

COMPARISON WITH LAPAROSCOPIC PANCREATODUODENECTOMY

The first laparoscopic PD (LPD) was performed in 1994. 12 Presumed benefits of LPD included, among oth ers, fewer major complications and an enhanced recov ery after surgery that would potentially benefit patients

TABLE 21.1 Study Characteristics of Studies Comparing OPD With RPD Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024 Author Country Year OPD, n = RPD, n = Study Design Cai et al USA 2020 405 460 Retrospective review of prospectively collected data Aziz et al USA 2022 310 310 Retrospective, matched cohorts

Shyr et al

Taiwan

2021

169

284

Retrospective review of prospectively collected data

OPD, open pancreatoduodenectomy; RPD, robotic pancreatoduodenectomy.

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