Safety and Feasibility of Robotic-Assisted Drainage of Symptomatic Pancreatic Pseudocysts: A Case-Series Analysis (with video).

Background: The surgical treatment of pancreatic pseudocysts (PPs) in patients who fail nonoperative management has evolved from aggressive open to a minimally invasive approach. The application of robotic surgery in this setting is scarcely reported. The aim of this study is to analyze the safety and feasibility of the robotic approach to pancreatic pseudocyst drainage. Methods: A single centre retrospective review of consecutive patients undergoing robotic-assisted pancreatic pseudocyst surgeries in an academic tertiary institution was performed. Results: There were 14 patients studied, of whom 10 underwent cystogastrostomy and 4 Roux-En- Y cystojejunostomy. Eight patients had gallstone pancreatitis and 3 patients alcoholic pancreatitis. The mean size of cyst was 8.9 +-1cm and 57.1% located at the pancreatic body. The overall operative time of the procedure was 135 +-34 minutes. There were no open conversions. The overall success rate was 92.8%, while the primary success rate 85.7%. The major morbidity rate was 14.3% and there was no 30-day mortality. The mean post-operative hospital stay was 7 +-3 days with one recurrence of the pancreatic pseudocyst on follow-up requiring endoscopic drainage without further recurrence. Conclusions: The robotic approach for the drainage of symptomatic pancreatic pseudocyst is safe and feasible and can be considered as a viable modality for operative intervention in well-selected patients.

Robotic-Assisted versus Laparoscopic Distal Pancreatectomy: The Results of a Case-Matched Analysis from a Tertiary Care Center.

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) has been adopted relatively slowly despite the benefits of minimally invasive approach. The robotic approach can overcome the limitations of LDP, thus increasing the acceptance of minimally invasive distal pancreatectomy. METHODS: We performed a 1:1 retrospective case-matched comparison among 2 groups of 35 patients who underwent robotic-assisted distal pancreatectomy (RDP) or LDP from August 2014 to April 2017. RESULTS: The operative time was similar in both groups (230 RDP vs. 205 LDP min, p = 0.382). The robotic group had a lower estimated blood loss (95 vs. 275 mL, p = 0.035). The spleen preservation rate was higher in the RDP group (100 vs. 66.7%, p = 0.027), while the conversion rate to open surgery was higher in the laparoscopic group (14.3 vs. 2.9%, p = 0.048). The overall complication rate was lower in the robotic group (25.7 vs. 37.1%, p = 0.044). There was no statistically significant difference in oncologic outcomes between the groups in terms of R0 resection rate (100% RDP vs. 85% LDP, p = 0.233) and number of harvested lymph nodes (14.4 RDP vs. 10.8 LDP, p = 0.678). CONCLUSIONS: The RDP showed a lower estimated blood loss, conversion, and morbidity rate. It offered a higher spleen preservation rate in comparison to LDP while maintaining comparable oncologic outcomes.

Robotic-assisted repair of iatrogenic common bile duct injury after laparoscopic cholecystectomy: Surgical technique and outcomes.

BACKGROUND: Bile duct injury after cholecystectomy can be a life-threatening complication. Use of robotic approach to manage a complex biliary injury is in an early phase. METHODS: We have performed an analysis of our prospectively maintained database that included 12 patients who underwent robotic-assisted repair of bile duct injury after laparoscopic cholecystectomy between 2014 and 2017. RESULTS: All patients underwent robotic biliary repair within 2 weeks after primary injury. No conversion to open surgery was necessary, the estimated mean blood loss was 252 mL, and the mean operative time was 260 minutes. The mean length of stay was 9.4 days. The 30-day complication events were a subhepatic abscess and a recurrent episode of cholangitis. One patient underwent the reoperation. The mortality was null. CONCLUSION: Robotic-assisted bile duct injury repair seems to be safe and feasible. It offers promising results, thus potentially capable of modifying the management of biliary injury.

Comparative Study of the Initial Experience in Performing Robotic and Laparoscopic Right Hepatectomy with Technical Description of the Robotic Technique.

BACKGROUND: Despite potential benefits of robotic liver surgery, it is still considered a "development in progress" technique. METHODS: The outcomes of 14 patients undergoing robotic right hepatectomy were analyzed and compared with the results of 20 laparoscopic right hepatectomies consecutively performed by the same young surgeon. RESULTS: The overall mean operative time was less in robotic arm (425 ± 139 vs. 565.18 ± 183.73, p = 0.022) and the estimated blood loss was similar (335.15 ± 139.8 vs. 423.95 ± 205.15, p = 0.17); no blood transfusion was required. Two patients in robotic group and 5 in laparoscopic group (p = 0.454) underwent conversion to open surgery; the overall morbidity was 21.4 and 15% in studied arms, respectively (p = 0.634). Pathology reports showed a mean surgical margin of 26.02 ± 3.9 in robotic arm, 28.76 ± 4.6 for laparoscopic, (p = 0.079) and we achieved a R0 resection rate of 91.66 and 85%, respectively. Reoperation and 90-days mortality rate were both null in robotic arm. One patient in laparoscopic group was reoperated due to postoperative hemorrhage. One-year overall and disease free-survival rate were 92.3 and 84.6%, respectively in robotic arm and 90 and 85% in laparoscopic arm. CONCLUSIONS: Robotic right hepatectomy is a safe and feasible technique providing promising short-term outcomes and oncological results also in the initial phase of learning curve.

Fully robotic left hepatectomy for malignant tumor: technique and initial results.

Robotic liver surgery has been considered as a unique opportunity to overcome the traditional limitations of laparoscopy; thus, it can potentially extend the indications of minimally invasive liver surgery. From April 2015 to May 2017, 35 patients underwent fully robotic left hepatectomy. The mean operative time was 315 min (200-445 min) and the mean estimated blood loss was 245 ml (125-628 ml). Pringle maneuver was required in six cases. Cancer was the indication for surgery in all patients (14 liver metastases, 18 hepatocellular carcinomas and 3 cholangiocarcinomas). There were one to four lesions in a patient and the mean lesion size was 39.2 mm (15-85 mm). The average length of hospital stay was 6.5 days (5-14 days). Perioperative morbidity rate was 17.2%. Two patients underwent conversion to open surgery. The 90-day mortality rate was nil. The mean surgical resection margin was 12 (1-22) mm, and R0-resection was reached in 33 out of 35 cases. The robotic left hepatectomy provides interesting surgical outcomes and good oncologic adequacy. It can be safely applied for the management of liver malignancies.

From Illusion to Reality: A Brief History of Robotic Surgery.

PURPOSE: Robotic surgery is currently employed for many surgical procedures, yielding interesting results. METHODS: We performed an historical review of robots and robotic surgery evaluating some critical phases of its evolution, analyzing its impact on our life and the steps completed that gave the robotics its current popularity. RESULTS: The origins of robotics can be traced back to Greek mythology. Different aspects of robotics have been explored by some of the greatest inventors like Leonardo da Vinci, Pierre Jaquet-Droz, and Wolfgang Von-Kempelen. Advances in many fields of science made possible the development of advanced surgical robots. Over 3000 da Vinci robotic platforms are installed worldwide, and more than 200 000 robotic procedures are performed every year. CONCLUSION: Despite some potential adverse events, robotic technology seems safe and feasible. It is strictly linked to our life, leading surgeons to a new concept of surgery and training.