Outcomes of a Multicenter Training Program in Robotic Pancreatoduodenectomy (LAELAPS-3).

OBJECTIVE: To assess feasibility and safety of a multicenter training program in robotic pancreatoduodenectomy (RPD) adhering to the IDEAL framework for implementation of surgical innovation. BACKGROUND: Good results for RPD have been reported from single center studies. However, data on feasibility and safety of implementation through a multicenter training program in RPD are lacking. METHODS: A multicenter training program in RPD was designed together with the University of Pittsburgh Medical Center, including an online video bank, robot simulation exercises, biotissue drills, and on-site proctoring. Benchmark patients were based on the criteria of Clavien. Outcomes were collected prospectively (March 2016-October 2019). Cumulative sum analysis of operative time was performed to distinguish the first and second phase of the learning curve. Outcomes were compared between both phases of the learning curve. Trends in nationwide use of robotic and laparoscopic PD were assessed in the Dutch Pancreatic Cancer Audit. RESULTS: Overall, 275 RPD procedures were performed in seven centers by 15 trained surgeons. The recent benchmark criteria for low-risk PD were met by 125 (45.5%) patients. The conversion rate was 6.5% (n = 18) and median blood loss 250ml [interquartile range (IQR) 150-500]. The rate of Clavien-Dindo grade ≥III complications was 44.4% (n = 122), postoperative pancreatic fistula (grade B/C) rate 23.6% (n = 65), 90-day complication-related mortality 2.5% (n = 7) and 90-day cancer-related mortality 2.2.% (n = 6). Median postoperative hospital stay was 12 days (IQR 8-20). In the subgroup of patients with pancreatic cancer (n = 80), the major complication rate was 31.3% and POPF rate was 10%. Cumulative sum analysis for operative time found a learning curve inflection point at 22 RPDs (IQR 10-35) with similar rates of Clavien-Dindo grade ≥III complications in the first and second phase (43.4% vs 43.8%, P = 0.956, respectively). During the study period the nationwide use of laparoscopic PD reduced from 15% to 1%, whereas the use of RPD increased from 0% to 25%. CONCLUSIONS: This multicenter RPD training program in centers with sufficient surgical volume was found to be feasible without a negative impact of the learning curve on clinical outcomes.

Pan-European survey on the implementation of robotic and laparoscopic minimally invasive liver surgery.

BACKGROUND: Laparoscopic and robotic minimally invasive liver surgery (MILS) is gaining popularity. Recent data and views on the implementation of laparoscopic and robotic MILS throughout Europe are lacking. METHODS: An anonymous survey consisting of 46 questions was sent to all members of the European-African Hepato-Pancreato-Biliary Association. RESULTS: The survey was completed by 120 surgeons from 103 centers in 24 countries. Median annual center volume of liver resection was 100 [IQR 50-140]. The median annual volume of MILS per center was 30 [IQR 16-40]. For minor resections, laparoscopic MILS was used by 80 (67%) surgeons and robotic MILS by 35 (29%) surgeons. For major resections, laparoscopic MILS was used by 74 (62%) surgeons and robotic MILS by 33 (28%) surgeons. The majority of the surgeons stated that minimum annual volume of MILS per center should be around 21-30 procedures/year. Of the surgeons performing robotic surgery, 28 (70%) felt they missed specific equipment, such as a robotic-CUSA. Seventy (66%) surgeons provided a formal MILS training to residents and fellows. In 5 years' time, 106 (88%) surgeons felt that MILS would have superior value as compared to open liver surgery. CONCLUSION: In the participating European liver centers, MILS comprised about one third of all liver resections and is expected to increase further. Laparoscopic MILS is still twice as common as robotic MILS. Development of specific instruments for robotic liver parenchymal transection might further increase its adoption.

Oncologic outcomes after robot-assisted versus laparoscopic distal pancreatectomy: Analysis of the National Cancer Database.

BACKGROUND: How the oncologic outcomes after robotic distal pancreatectomy (RDP) compare to those after laparoscopic distal pancreatectomy (LDP) remains unknown. METHODS: Using the National Cancer Database (NCDB), we analyzed all patients undergoing LDP or RDP for resectable pancreatic adenocarcinoma over a 4-year period (2010-2013). RESULTS: Of the 704 eligible patients, 605 (86%) underwent LDP and 99 (14%) underwent RDP. The median follow-up for patients was 25 months. There were no differences in the two groups with respect to sociodemographic, clinicopathologic, or treatment characteristics. On comparing LDP versus RDP, there was no difference in the margin-positive rate (15% vs 16%; P = 0.84); lymph nodes examined (12 vs 11; P = 0.67); overall survival (hazard ratio [HR], 1.1, 95% confidence intervals [CI], 0.7 to 1.7; 28 vs 25 months; P = 0.71); hospital stay (6 vs 5 days; P = 0.14); time to chemotherapy (50 vs 52 days; P = 0.65); 30-day readmission (9.4% vs 9.1%; P = 0.92); and mortality (1% vs 0%; P = 0.28). Patients undergoing LDP had a significantly higher conversion rate to open or minimally invasive pancreatic cancer resections compared with RDP (27% vs 10%; P < 0.001). CONCLUSION: The early national experience with RDP demonstrates similar oncologic outcomes to LDP, with a significantly lower conversion rate.

Robotic liver resection including the posterosuperior segments: initial experience.

BACKGROUND: Robot-assisted laparoscopy has been introduced to overcome the limitations of conventional laparoscopy. This technique has potential advantages over laparoscopy, such as increased dexterity, three-dimensional view, and a magnified view of the operative field. Therefore, improved dexterity may make a robotic system particularly suited for liver resections, which require nonlinear manipulation, such as curved parenchymal transection, hilar dissection, and resection of posterosuperior segments. METHODS: Between August 2014 and March 2016, 16 patients underwent robot-assisted laparoscopic liver resection at University Medical Center Utrecht. RESULTS: Fifteen robot-assisted laparoscopic liver resections were performed in a minimally invasive manner. One procedure was converted. In eight patients, we performed a resection of a posterosuperior segment (segment 7 or 8). Median operating time was 146 (60-265) min, and median blood loss was 150 (5-600) mL. Four patients had a Clavien-Dindo grade III complication. Median length of stay was 4 (1-8) days. There was no mortality. CONCLUSIONS: This prospective study reporting on our initial experience with robot-assisted laparoscopic liver resection demonstrates that this technique is easily adopted, safe, and feasible for minor hepatectomies in selected patients. Moreover, it shows that the robotic platform also enables fully laparoscopic resections of the posterior segments.

Robotic distal pancreatectomy for a neuroendocrine tumor in an 11-year-old child.

INTRODUCTION: Over the past decade, robotic pancreatic surgery has gained popularity. Although anatomically comparable, the small size of pediatric patients might impede the use of the surgical robot due to the size of the robotic arms. Pediatric pancreatic resection is rarely indicated, hence only few cases of pediatric robotic pancreatic resection have been described (Hagendoorn et al., 2018; Lalli Raj, 2019-4) [1,2]. To the best our knowledge, no video literature exists on robotic pediatric pancreatic tail resections. Aim of this video was to demonstrate the set-up and surgical technique of robotic distal pancreatectomy in a child. METHODS: This video illustrates fully robotic distal pancreatectomy in an eleven-year-old child. The patient had a past medical history of tuberous sclerosis complex. On surveillance imaging a non-functional neuroendocrine tumor was detected in the pancreatic tail for which a distal pancreatectomy was indicated. RESULTS: After general anesthesia, the patient was placed in supine position on a split-leg table in anti-Trendelenburg. Four robotic trocars were placed and the da Vinci Xi robotic system was docked. Two laparoscopic assistant ports were placed. A spleen-preserving distal pancreatectomy was performed. Postoperative recovery was unremarkable and the patient was discharged on postoperative day 6. CONCLUSION: This video illustrates robotic distal pancreatectomy in an eleven-year-old child. Meticulous port placement, adjusted to the patient's habitus, is an essential element.

Robotic right hepatectomy for a central liver tumor- A video of the surgical technique.

BACKGROUND: Robotic surgery is gaining momentum in liver resection. Instrumentation of the surgical robot is articulated, movements are scaled and the view of the operative field is 3-dimensional and magnified[1, 2]. Thus, these technical enhancements allow for a more precise dissection and curved work axes, as needed in liver resection. Aim of this video was to demonstrate the feasibility of fully robotic right hepatectomy with dissection of the variant right hepatic pedicles for a centrally located liver tumor. METHODS: This video illustrates robotic right hepatectomy in a 77-year-old male. A liver tumor in segment 5/8 with concurrent biliary dilation was detected on a CT-scan made in the course of his cardiac history. An additional MRI scan suggested the diagnosis of hepatocellular carcinoma or intrahepatic cholangiocarcinoma for which a right hepatectomy was indicated. RESULTS: After anesthesia, the patient was placed supine on a split-leg table in anti-Trendelenburg and left lateral tilt position. Four robotic trocars were placed and the da Vinci Xi robotic system was docked. Two laparoscopic ports were placed for tableside assistance. Right hepatectomy was performed including separate dissection of the posterior and anterior pedicles. The robotic Vessel Sealer was employed as main parenchymal transection device. Postoperative hospital stay was unremarkable. The patient was discharged on postoperative day 6. CONCLUSION: This video illustrates the feasibility of a robotic approach to right hepatectomy. The increased surgical dexterity, as provided by the articulating robotic instrumentation, allows for precise dissection of the liver hilum, as needed in resection of centrally located tumors.

Robotic Developments in Cancer Surgery.

Indications for robotic surgery have been rapidly expanding since the first introduction of the robotic surgical system in the US market in 2000. As the robotic systems have become more sophisticated over the past decades, there has been an expansion in indications. Many new tools have been added with the aim of optimizing outcomes after oncologic surgery. Complex abdominal cancers are increasingly operated on using robot-assisted laparoscopy and with acceptable outcomes. In this article, the authors discuss robotic developments, from the past and the future, with an emphasis on cancer surgery.

[Robot-assisted Whipple resection; results of the first 100 procedures in the Netherlands]. / Robotgeassisteerde Whipple-operatie.

OBJECTIVE: Investigation into the results of robot-assisted Whipple resection in the Netherlands. These results were compared with those of open Whipple procedures on the basis of recent large case series of patients. DESIGN: Case series of patients and systematic literature review. METHOD: We carried out a post hoc analysis of prospectively collected data on the first 100 consecutive patients who underwent robot-assisted Whipple procedures in the period from March 2016 until March 2018 at the Erasmus MC, the Maasstad hospital or the Regional Academic Cancer Centre Utrecht. We were mainly interested in surgery characteristics and postoperative outcomes. We compared our results with those of case series of patients with more than 500 open Whipple procedures carried out in a single hospital, published in the last 5 years. RESULTS: There were one or more serious complications in 22 patients (22%) and 2 patients (2%) developed multiple organ failure. 7 patients (7%) underwent reoperation. There was no postoperative mortality. In 14 case series (n = 12,708), complications occurred in 38% of patients and 7% of patients underwent reoperation. Mean mortality rate was 3%. CONCLUSION: Our findings show that robotic Whipple procedures can be carried out safely in the Netherlands. The number of complications and mortality rates are comparable with results of large case series of patients who underwent open Whipple procedures in a centre of expertise.

Robotic pancreatoduodenectomy for a solid pseudopapillary tumor in a ten-year-old child.

BACKGROUND: Pancreatoduodenectomy (Whipple resection) in children is feasible though rarely indicated. In several pediatric malignancies of the pancreas, however, it may be the only curative strategy [1]. With the emergence of robotic pancreatoduodenectomy as at least a clinically equivalent alternative to open surgery [2], it remains to be determined whether the pediatric population may potentially benefit from this minimally invasive procedure. Here we present, for the first time, a video of setup and surgical technique of robotic pancreatoduodenectomy in a child. METHODS: A 10-year-old girl presented with complaints of fullness and abdominal pain in the upper quadrants. Investigations including a diffusion-weighted, pancreatic MR scan suggested the diagnosis of solid pseudopapillary tumor (Frantz's tumor). The patient was considered for robotic pancreatoduodenectomy. RESULTS: After anesthesia, the patient was placed supine on a split-leg table. Trocar placement was adjusted to accommodate the child's length and body weight, according to pre-operatively calculated positions that would allow for maximum working space and minimize inadvertent collision between the robotic arms. The da Vinci Si surgical robot was positioned in-line towards the surgical target and all four robotic arms were docked, while two additional laparoscopic ports were placed for tableside assistance. After standard pancreatoduodenectomy, a conventional loop reconstruction was performed including an end-to-side pancreaticojejunostomy with duct-to-mucosa technique and stapled side-to-side gastrojejunostomy. We suggest that in this patient group, pylorus preserving pancreatoduodenectomy with end-to-side duodenojejunostomy may be a suitable alternative. Postoperative recovery was complicated by delayed gastric emptying but otherwise unremarkable. Hospital length of stay was 12 days. Final pathology demonstrated a solid pseudopapillary tumor with negative surgical margins. CONCLUSION: This case illustrates the feasibility of robotic pancreatoduodenectomy in children. Essential elements of this procedure are a well-running robotic pancreatic surgery program as well as careful preoperative port placement planning.

Robot-assisted Laparoscopic Fenestration of Giant Hepatic Cysts.

BACKGROUND: Traditionally, nonparasitic hepatic cysts are marsupialized using laparotomy. In the last 2 decades, laparoscopic fenestration has become the preferred treatment for hepatic cysts. However, this technique is limited by 2-dimensional view and the limited mobility of straight laparoscopic instruments. These limitations may be overcome by the use of a robotic system. We describe laparoscopic fenestration of giant hepatic cysts using the da Vinci Si robotic system with the use of the Endowrist One Vessel Sealer. METHODS: Our first patient is a 32-year-old female with a solitary hepatic cyst. The second patient is a 51-year-old female with polycystic liver disease. RESULTS: We performed robot-assisted laparoscopic cyst fenestration with good clinical outcome. No intraoperative complications occurred and patients recovered rapidly. CONCLUSION: These data show that the da Vinci Si robotic system is eminently suited for the laparoscopic fenestration of large hepatic cysts and that this procedure is associated with rapid recovery.