Robotic General Surgery

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CHAPTER 21 • Pancreaticoduodenectomy

needing adjuvant chemotherapy. 13 However, widespread implementation of LPD has not been realized, despite the introduction of this technique over 2 decades ago, while at the same time concerns over benefit and safety were raised based on ambiguous outcomes in the literature. 14 Safety concerns on widespread implementation of LPD were further raised since a randomized trial comparing conventional LPDs with OPDs was terminated prema turely and showed an increased complication-related mortality in the laparoscopic group, although not signif icant. 15 It was speculated that the technical limitations of conventional laparoscopy (two-dimensional vision, rigid instruments) make the technique unsuited for general adoption of a complex procedure such as PD, although one should keep in mind that the outcomes of this study might have been influenced by the procedural learning curve and small hospital volumes. The use of the surgical robot potentially overcomes these limitations inherent to conventional laparoscopy, having several benefits such as a decreased conversion rate and less blood loss com pared with conventional laparoscopy. Although there are no randomized data available comparing LPD with RPD, several comparative stud ies have been published. Study characteristics of three comparative studies (including >90 procedures in both groups) are displayed in Table 21.3 . 16-18 Outcomes are summarized in Table 21.4 , including the hypothe sized decreased conversion rate in favor of the robotic approach in two of those studies. This is also confirmed in a comprehensive meta-analysis comparing both tech niques by Ouyang et al. 19 Moreover, this study also demonstrated that the robotic approach was associated with less blood loss and an increased number of retrieved lymph nodes, compared with LPD. SHORT SUMMARY OF PROCEDURE Indications and preoperative evaluations for RPD are comparable with open procedures. No hard contraindi cations exist. The whole range of resections from easily resectable pancreatic neuroendocrine tumors to locally advanced pancreatic tumors in combination with vascu lar resections have been described. However, when setting up a program it is essential to start with the less complex procedures. This means easy resections and more diffi cult reconstructions. The main reason for this strategy

is the option to train the reconstruction using LAELAPS or LEARNBOT programs. 20,21 Neuroendocrine tumors, pancreatic ductal adenocarcinomas, and distal cholan giocarcinomas without vascular contact are excellent cases to start a program. Selecting the ideal patient also contains obvious patient factors like previous abdomi nal operations, a history of pancreatitis, and body mass index (preferably <30). 22 This description of a surgical technique for RPD is employed as standard at the authors’ institution. We conduct RPD using a two-surgeon approach and follow the general lines of the procedure as laid out in the train ing curriculum pioneered by Zeh and Hogg. 23,24 Patient Positioning and Robot Installation The patient is placed in supine position on a split leg table. If needed, the operating table can be repositioned at an up to 90° angle from anesthesia to allow for robot docking (which is over the head for da Vinci X and from the right for da Vinci Xi). We use 8-mm robotic ports (X/Xi) for arms 1-2-3-4 while, optionally, a 12-mm robotic port is used for arm 4 when applying the robotic stapler (for the gastroduo denal artery and/or common bile duct [CBD]). In addi tion, we use standard laparoscopic ports including a 5-mm port (Mediflex retractor), a 12-mm port, and a 15-mm port. In case the specimen is taken out directly after resection (before reconstruction), a Pfannenstiel incision can be used for specimen extraction. Port place ment and insufflation of the abdomen are done via local protocol. We generally apply a Veress needle for insuf flation in the left upper quadrant, insert robotic port of arm 3 (camera trocar) with the stump dissector on the patient’s right side of the umbilicus, introduce the camera, place robotic ports 1-2-4, and place the laparo scopic assistant port only after docking and targeting the robot ( Figure 21.1 ). The room setup and a photograph of the docked da Vinci Robotic system is (Intuitive Surgical, Sunnyvale, CA) shown in Figure 21.2 with the Xi robot positioned at the right of the patient in the right upper quadrant setting (or over the head of the patient for da Vinci X). The areas for resection and reconstruction are the same as open or laparoscopic pancreaticoduodenectomy ( Figure 21.3 ). The relevant anatomic structures are shown in the schematic in Figure 21.4 .

TABLE 21.3 Study Characteristics of Studies Comparing LPD to RPD Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024

Author

Country

Year

LPD, n =

RPD, n =

Study Design

Van Oosten et al

The Netherlands

2020

90

90

Retrospective, propensity matched

Nassour et al

USA

2018

1,458

165

Retrospective

Xourafas et al

USA

2018

418

409

Retrospective

LPD, laparoscopic pancreatoduodenectomy; RPD, robotic pancreatoduodenectomy.