Introduction of a new surgical robot platform "hinotori™" in an institution with established da Vinci surgery™ for digestive organ operations.

BACKGROUND: New platforms for robotic surgery have recently become available for clinical use; however, information on the introduction of new surgical robotic platforms compared with the da Vinci™ surgical system is lacking. In this study, we retrospectively determined the safe introduction of the new "hinotori™" surgical robot in an institution with established da Vinci surgery using four representative digestive organ operations. METHODS: Sixty-one patients underwent robotic esophageal, gastric, rectal, and pancreatic operations using the hinotori system in our department in 2023. Among these, 22 patients with McKeown esophagectomy, 12 with distal gastrectomy, 11 with high- and low-anterior resection of the rectum, and eight with distal pancreatectomy procedures performed by hinotori were compared with historical controls treated using da Vinci surgery. RESULTS: The console (cockpit) operation time for distal gastrectomy and rectal surgery was shorter in the hinotori group compared with the da Vinci procedure, and there were no significant differences in the console times for the other two operations. Other surgical results were almost similar between the two robot surgical groups. Notably, the console times for hinotori surgeries showed no significant learning curves, determined by the cumulative sum method, for any of the operations, with similar values to the late phase of da Vinci surgery. CONCLUSIONS: This study suggests that no additional learning curve might be required to achieve proficient surgical outcomes using the new hinotori surgical robotic platform, compared with the established da Vinci surgery.

Relationship between pancreatic thickness and staple height is relevant to the occurrence of pancreatic fistula after distal pancreatectomy.

BACKGROUND: A triple-row stapler is widely used to divide the pancreas in distal pancreatectomy (DP). However, the selection criteria of the stapler cartridge to prevent postoperative pancreatic fistula (POPF) remain unclear. The objective of this study was to determine if factors concerning pancreatic thickness or staple size affect POPF after DP. METHODS: Datasets of patients from the Mayo Clinic and National Cancer Center Hospital East who underwent DP using a triple-row stapler were merged. Risk of POPF was analyzed using clinicopathological variables, including data for pancreatic thickness and staple height. A compression index was defined as the designated staple height (mm) after closure divided by the pancreatic thickness (mm). RESULTS: Among the 277 patients, POPF occurred in 65 (23%) patients. The median pancreatic thickness was 13.7 mm and the median compression index was 0.137. Multivariable logistic models showed that a greater pancreatic thickness (odds ratio, 1.190, P < 0.001) and a compression index ≤0.160 (odds ratio, 4.754, P < 0.001) were independently related with POPF. CONCLUSION: In patients undergoing DP using a triple-row stapler, the thickness of the pancreas was related with the occurrence of POPF. Selection of the stapler cartridge with a compression index of ≤0.160 may reduce the occurrence of POPF.

[Manual suture or stapler closure: management of pancreatic stump during distal pancreatectomy].

Postoperative pancreatic fistula is the most common complication after distal pancreatectomy.With the update of the domestic and international guidelines or consensuses, the definition of pancreatic fistula has become more standardized.And the classification of pancreatic fistula is able to represent the severity of clinical outcomes more accurately.Currently, the determination of risk factors of pancreatic fistula after distal pancreatectomy, the establishment of prediction model, and the surgical closure mode of pancreatic stump still remain the major topics.With the rapid development of laparoscopic and robotic surgery in pancreatectomy, there are more and more selectionsin transection and managing the pancreatic stump after distal pancreatectomy for prevention of pancreatic fistula.However, there has not been a uniform fashion in terms of manual suture or stapler use to close the pancreatic stump.Herein the current status and development of pancreatic fistula after distal pancreatectomy are reviewed.The strategy of managing the pancreatic stump after distal pancreatectomy should be adopted individually according to the texture and thickness of pancreatic parenchyma.

Robotic-assisted versus laparoscopic left pancreatectomy at a high-volume, minimally invasive center.

INTRODUCTION: While minimally invasive left pancreatectomy has become more widespread and generally accepted over the last decade, opinions on modality of minimally invasive approach (robotic or laparoscopic) remain mixed with few institutions performing a significant portion of both operative approaches simultaneously. METHODS: 247 minimally invasive left pancreatectomies were retrospectively identified in a prospectively maintained institutional REDCap™ database, 135 laparoscopic left pancreatectomy (LLP) and 108 robotic-assisted left pancreatectomy (RLP). Demographics, intraoperative variables, postoperative outcomes, and OR costs were compared between LLP and RLP with an additional subgroup analysis for procedures performed specifically for pancreatic adenocarcinoma (35 LLP and 23 RLP) focusing on pathologic outcomes and 2-year actuarial survival. RESULTS: There were no significant differences in preoperative demographics or indications between LLP and RLP with 34% performed for chronic pancreatitis and 23% performed for pancreatic adenocarcinoma. While laparoscopic cases were faster (p < 0.001) robotic cases had a higher rate of splenic preservation (p < 0.001). Median length of stay was 5 days for RLP and LLP, and rate of clinically significant grade B/C pancreatic fistula was approximately 20% for both groups. Conversion rates to laparotomy were 4.3% and 1.8% for LLP and RLP approaches respectively. RLP had a higher rate of readmission (p = 0.035). Pathologic outcomes and 2-year actuarial survival were similar between LLP and RLP. LLP on average saved $206.67 in OR costs over RLP. CONCLUSIONS: This study demonstrates that at a high-volume center with significant minimally invasive experience, both LLP and RLP can be equally effective when used at the discretion of the operating surgeon. We view the laparoscopic and robotic platforms as tools for the modern surgeon, and at our institution, given the technical success of both operative approaches, we will continue to encourage our surgeons to approach a difficult operation with their tool of choice.

Ultrasound-Guided Robotic Enucleation of Pancreatic Neuroendocrine Tumors.

BACKGROUND: Pancreatic neuroendocrine tumors (PanNETs) are relatively rare neoplasms with a low to mild malignant potential. They can be further divided into functioning and nonfunctioning, according to their secretive activity. Surgery is an optimal approach, but the classic open approach is challenging, with some patients having long hospitalization and potentially life-threatening complications. The robotic approach for PanNETs may represent an option to optimize their management. METHODS: We retrospectively reviewed our prospectively maintained databases from 2 high-volume Italian centers for pancreatic surgery. Demographics, pathological characteristics, perioperative outcome, and medium-term follow-up of patients who underwent robotic pancreatic enucleations were collected. RESULTS: Twelve patients with final diagnosis of PanNET were included. The mean age of the patients was 53.8 years (25-77). The median body mass index was 26 (24-29). Three lesions were functioning insulinomas, while the others were nonfunctioning tumors. No deaths occurred. Mild postoperative complications occurred, except for 1 grade B pancreatic fistula. The mean postoperative stay was 3.9 days (2-5). CONCLUSIONS: Our results confirm that robotic enucleation is a feasible and safe approach for the treatment of PanNETs, with short hospital stay and low incidence of morbidity.

A blunt dissection technique using the LigaSure vessel-sealing device improves perioperative outcomes and postoperative splenic-vessel patency after laparoscopic spleen- and splenic-vessel-preserving distal pancreatectomy.

BACKGROUND: We have recently performed a blunt dissection technique using LigaSure technology for laparoscopic spleen- and splenic-vessel-preserving distal pancreatectomy to reduce the risk of bleeding during the dissection of the splenic vessels. The aim of this study was to compare the utility of the blunt dissection technique and a conventional dissection technique during laparoscopic spleen- and splenic-vessel-preserving distal pancreatectomy. METHODS: Fifty-five patients who underwent laparoscopic spleen- and splenic-vessel-preserving distal pancreatectomy performed by a single surgeon between March 2003 and December 2015 were enrolled in this retrospective single-center study. The patients were divided into the LigaSure group (n = 23) and non-LigaSure group (n = 26). Perioperative clinical outcomes and the postoperative patency of the preserved splenic vessels in the two groups were compared. RESULTS: The patient and tumor characteristics did not differ significantly between the two groups. The incidence of postoperative complications was similar in the two groups. However, the mean operative time (145 vs. 231.1 min, P = 0.001), intraoperative blood loss (95.6 vs. 360 ml, P = 0.001), and postoperative hospital stay (6.4 vs. 9.8 days, P = 0.001) were significantly lower in the LigaSure group than in the non-LigaSure group, respectively. The splenic artery patency rate was similar in both groups, but the splenic vein patency was significantly better in the LigaSure group than in the non-LigaSure group (total occlusion rate: 4.5 vs. 30.8%, respectively, P = 0.017). CONCLUSION: The results of this study suggest that the blunt dissection technique using a LigaSure reduces the operating time and intraoperative blood loss during laparoscopic spleen- and splenic-vessel-preserving distal pancreatectomy and increases the patency of the preserved splenic vessels.

Application of a commercial single-port device for robotic single-incision distal pancreatectomy: initial experience.

PURPOSE: Laparoscopic distal pancreatectomy has proven to be feasible and safe. Moreover, robotic surgery provides unique advantages for pancreatic procedures, although single-incision robotic pancreatic surgery is rarely discussed. We applied the single-port modified platform to accomplish robotic distal pancreatectomy in a series of patients. METHODS: The subjects of this study were ten patients who underwent robotic distal pancreatectomy in our hospital between July 1, 2015 and Dec 31, 2016. All patients were placed supine in the reverse Trendelenburg position with the legs abducted. Surgery was performed via a trans-umbilical 5.0-cm incision, using a modified single-port platform (LAGIPORT®) combined with the da Vinci Si Surgical System. The three arms and scope (30-degree up) were inserted through the LAGIPORT® and positioned in a triangle. Endoscopic ultrasound was used to localize the tumor and plan the resection margin. We recorded the surgical time, operation time, blood loss, postoperative pain score, hospital stay, and complications. RESULTS: The surgical time was 236 ± 32 min, the operation time was 172 ± 30 min, and the blood loss was 149 ± 65 ml. All patients underwent robot-assisted distal pancreatectomy without conversion. The average pain score on postoperative day (POD) 3 was 4.5 ± 1. Complications included subsplenic hematoma (n = 1) and minor pancreatic leakage (n = 2). There was no surgical mortality. CONCLUSIONS: Our results demonstrate the safety and efficiency of robotic single-incision distal pancreatectomy via the modified platform (LAGIPORT®).

Laparoscopic Spleen Preserving Distal Pancreatectomy with Splenic Vessels Preservation.

Spleen preserving Distal Pancreatectomy (SPDP) is commonly applied in patients with benign or low-grade malignant tumors in the body and tail of the pancreas. Our aim is to present our technique and the early results in performing laparoscopic spleen preserving distal pancreatectomy with splenic vessel preservation (LSPDP-SVP) during 2017-2018 in Ponderas Academic Hospital.

[Application of enhanced recovery program in laparoscopic distal pancreatectomy].

Objective: To evaluate the feasibility and safety of applying enhanced recovery after surgery (ERAS) protocol in patients undergoing laparoscopic distal pancreatectomy. Methods: Data of 36 patients undergoing laparoscopic distal pancreatectomy from May 2016 to May 2017 in the First Affiliated Hospital, Zhejiang University School of Medicine were reviewed. The patients were divided into ERAS group (n=12) and control group (n=24). The patients in ERAS group received a series of enhanced recovery procedures, including multimodal analgesia, early off-bed activity and early oral food-taking, etc. Operation time, intraoperative blood loss, time to first flatus, postoperative complications, and length of postoperative hospital stay were evaluated. Results: There were no statistically significant differences in operation time and intraoperative blood loss between ERAS group and control group (all P>0.05). The time to first flatus and length of postoperative hospital stay were significantly shortened in ERAS group (all P<0.05). The ERAS group had lower incidence of postoperative complications (41.7% vs. 66.7%), and the complications in ERAS group tended to be milder, but the differences failed to show statistical significance (all P>0.05). Conclusion: The ERAS protocol for laparoscopic distal pancreatectomy can significantly promote gastrointestinal function recovery and shorten postoperative hospital stay, and may reduce the incidence of postoperative complications.

[POTENTIAL FOR THREE-DIMENSIONAL ANALYSIS UTILIZATION IN PANCREATECTOMY].

Preoperative simulation and intraoperative navigation using three-dimensional (3D) analysis has been established and is indispensable in liver surgery. However, 3D analysis has not been developed in pancreatic surgery. Recently, we have been able to perform 3D analysis of the pancreas and make 3D models of it with surrounding vascular structures and tumors using a 3D printer. Preoperative computed tomography (CT) images were reconstructed in a 3D configuration, including the pancreatic parenchyma, tumors, pancreatic duct, bile duct, portal venous system, and hepatic and superior mesenteric arteries. Pancreas models with internal structures in color were made of soft resin with a 3D printer. The 3D printed models were made in cases when patients were to undergo laparoscopic distal pancreatectomy and pancreatoduodenectomy with anomalies of the hepatic arteries, i.e., the replaced right hepatic artery. Preoperatively, the surgeons simulated surgical plans using the 3D model and acquired real images of surgical procedures. Intraoperatively, the surgeons performed pancreatic resection with navigation using the 3D pancreas model in a sterilization bag. Simulation and navigation using 3D analysis and 3D printed pancreas models can be useful in pancreatic surgery, in cases of laparoscopic surgery, and in patients with vascular anomalies.

A multicenter randomized controlled trial comparing pancreatic leaks after TissueLink versus SEAMGUARD after distal pancreatectomy (PLATS) NCT01051856.

BACKGROUND: Pancreatic leak is common after distal pancreatectomy. This trial sought to compare TissueLink closure of the pancreatic stump to that of SEAMGUARD. METHODS: A multicenter, prospective, trial of patients undergoing distal pancreatectomy randomized to either TissueLink or SEAMGUARD. RESULTS: Enrollment was closed early due to poor accrual. Overall, 67 patients were enrolled, 35 TissueLink and 32 SEAMGUARD. The two groups differed in American Society of Anesthesiologist class and diagnosis at baseline and were relatively balanced otherwise. Overall, 37 of 67 patients (55%) experienced a leak of any grade, 15 (46.9%) in the SEAMGUARD arm and 22 (62.9%) in the TissueLink arm (P = 0.19). The clinically significant leak rate was 17.9%; 22.9% for TissueLink and 12.5% for SEAMGUARD (P = 0.35). There were no statistically significant differences in major or any pancreatic fistula-related morbidity between the two groups. CONCLUSIONS: This is the first multicentered randomized trial evaluating leak rate after distal pancreatectomy between two common transection methods. Although a difference in leak rates was observed, it was not statistically significant and therefore does not provide evidence of the superiority of one technique over the other. Choice should remain based on surgeon comfort, experience, and pancreas characteristics.

Endoscopic therapy for infected pancreatic necrosis using fully covered self-expandable metal stents: combination of transluminal necrosectomy, transluminal and percutaneous drainage.

BACKGROUND/AIMS: Endoscopic transluminal therapy has become the standard of care as a less invasive alternative to surgery. In a retrospective case series of two tertiary referral centers we report on an individualized concept combining EUS-guided drainage with self-expanding metal stents, direct transluminal debridement und percutaneous drainage. METHODS: We treated 13 patients with infected pancreatic necrosis. Initially in all patients an EUS-guided drainage with plastic stents was performed under antibiotic protection (transduodenal: 2, transgastral: 11). After clinical consolidation (after 9.6 ±â€Š9.4 days) a covered self-expanding metal stent (Niti-S, Taewoong medical Co., Seoul, Korea) was inserted by performing direct endoscopic necrosectomy in 2.9 ±â€Š1.7 sessions through the stent. In cases of disrupted duct syndromes a pancreatic plastic stent was inserted (5 of 13 patients). In 5 of 13 cases additional percutaneous drainage was applied because of extended necrosis. In one patient percutaneous endoscopic drainage using the percutaneous access was needed. RESULTS: A sustained clinical success was achieved in 12 of 13 cases (CRP before therapy 23.5 ±â€Š14.4 mg/L, after 3.1 ±â€Š2.6 mg/lL). Discharge occurred after 2.5 ±â€Š22.4 days. The self-expanding metal stent was extracted after 82.5 ±â€Š56.6 days. Mean follow up was 8.5 ±â€Š5.9 months. CONCLUSION: Our concept of combining transluminal drainage, direct endoscopic necrosectomy and percutaneuos drainage offers a safe and reliable alternative to surgery, even in case of extended necrosis.

[Robotic Pancreatic Surgery]. / Roboterchirurgie des Pankreas.

Pancreatic surgery is one of the most challenging fields in visceral surgery. However, laparoscopic pancreatic surgery has not become the standard of care as yet, especially because of the very demanding reconstruction of anastomoses in pancreaticoduodenectomy. Robotic surgery has been a recent advance in laparoscopy. Its benefits are a better 3D view, a greater degree of freedom corresponding to that of the human hand, and tremor elimination. These factors greatly facilitate the intracorporeal suturing and knot-tying, which offers a technical advantage in performing pancreaticojejunostomy as compared with laparoscopic resections. However, only a few centres are offering this procedure for pancreatic resections. Retrospective analyses show that robotic pancreatic resections are safe und oncologically adequate if performed by experienced surgeons. Prospective, randomised trials comparing laparoscopic and robotic pancreatic resection techniques are not available to date.

[COMBINED LAPAROSCOPICALLY AND RETROPERITONEOSCOPICALLY ASSISTED PANCREATONECRSEQUESTRECTOMY].

Combined method of laparoscopically and retroperitoneoscopically assisted necrsequestrectomy, consisting of staged application of miniinvasive methods with simultaneous laparoscopic and retroperitoneoscopic control of necrsequestrectomy, was elaborated with the objective to improve surgical treatment of an acute pancreatitits. The procedure has significant advantages over open operative intervention in purulent complications of necrotic purulent pancreatitis: reduction of the local and systemic operative treatment severity, minimization of microbial metabolites coming into the blood, total visual control of intervention, reduction of the vascular injuries risk, аdequate surgical sanation with saving of viable pancreatic parenchyma, absence of conditions for the purulent complications occurrence while the operative wound healing is going on, preservation of possibility for an adequate draining, using drains of a large diameter.

Signal intensity of the pancreas on magnetic resonance imaging: Prediction of postoperative pancreatic fistula after a distal pancreatectomy using a triple-row stapler.

BACKGROUND/OBJECTIVES: The aim of this study was to evaluate the impact of the pancreatic signal intensity (SI) on magnetic resonance imaging (MRI) findings for predicting the development of pancreatic fistula (PF) after a distal pancreatectomy (DP) involving a triple-row stapler closure. METHODS: A multivariate logistic regression analysis was used to identify risk factors for clinical PF, as defined by the International Study Group on Pancreatic Fistula grade B or C. The pancreas-to-muscle SI ratio was evaluated using fat-suppressed T1-weighted MRI. RESULTS: Of the 41 enrolled patients, 8 (19.5%) developed clinical PF. The pancreatic thickness (≥15 mm) and SI ratio (≥1.3) were identified as independent predictors of clinical PF in a multivariate analysis. Clinical PF was observed in one patient with a thick pancreas and a low SI ratio (14.3%), whereas it was observed in 60% of the patients with a thick pancreas and a high SI ratio. The area under the receiver operating characteristic curve for a predictive model consisting of the two factors was 0.87 (95% confidence interval, 0.75 to 0.99), the level of which tended to be greater than that for pancreatic thickness alone (0.81, p = 0.09). CONCLUSIONS: The SI ratio as evaluated using MRI might be useful for predicting clinical PF in patients with the pancreatic thickness ≥15 mm after DP involving a stapler closure.

A novel, new robotic platform for natural orifice distal pancreatectomy.

Laparoendoscopic technology has revolutionized the practice of surgery; however, surgeons have not widely accepted laparoscopic techniques for pancreatic surgeries due to the complexity of the operation. Natural orifice transluminal endoscopic surgery (NOTES) offers a great new potential for pancreatic procedures, with early data showing benefits of reduced visible scarring and the potential for decreased wound infections, hernias, pain, and postoperative complications. However, there are significant limitations to the currently used flexible endoscopy tools, including a diminished visual field, spatial orientation and tissue manipulation issues, and 2-dimensional visual feedback. We have adopted a novel snake-like robot, the minimally invasive cardiac surgery (MICS) robot, which addresses these issues. In the current pilot study, the MICS robot was evaluated for transrectal distal pancreas exploration and resection in 2 nonsurvival porcine models. Abdominal navigation and accessing the pancreas was investigated in the first pig, and based on its success, pancreas resection was studied in pig 2. The MICS robot was successful in accessing and visualizing the right upper, left upper, and left lower quadrants of the abdomen in pig 1 and was able to perform a successful complex NOTES procedure with distal pancreas resection in pig 2, with only minimal laparoscopic retraction assistance. In conclusion, preliminary results showing the MICS robot in natural orifice distal pancreatectomy are positive. Enhancements to optics and instrumentation will help further increase the usability in pancreatic interventions. Future indications may include transgastric NOTES approaches, endoluminal procedures, and single-port applications.

[THE PLACE OF PANCREATICODUODENAL RESECTION IN SURGICAL TREATMENT OF COMPLICATED FORMS OF CHRONIC PANCREATITIS].

Results of surgical treatment of 120 patients, suffering complicated forms of chronic pancreatitis, were analyzed. In 5 patients pancreaticoduodenal resection in accordance to Whipple method have constituted the operation of choice. The indications for operation were: impossibility to exclude completely the malignant process inside pancreatic head; enhancement of the pancreatic head, causing duodenal, common biliary duct and the pancreatoduodenal zone vessels compression; cystic changes of pancreatic head with several episodes of hemorrhage inside the cyst and duodenum. The immediate, short-term and intermediate results of the operation were estimated as good and satisfactory.

[MINIINVASIVE SURGICAL INTERVENTIONS FOR AN ACUTE NECROTIC PANCREATITIS].

A differentiated staged surgical tactics for treatment of an acute necrotic pancreatitis, based on theory of an acute necrotic pancreatitis phased course, was elaborated and introduced. Sanation and drainage under ultrasonographic control have promoted the patients state stabilization with further stage of laparotomic intervention, in 26.87% of patients of the main group were a residual interventions performed, while in a control group--in 13.19%. Efficacy of a videocontrolled sanation and drainage of retroperitoneal space, using nephroscope, was proved. New methods of miniinvasive surgical treatment of pancreonecrosis, the septic-purulent complications prophylaxis were elaborated. The rate of laparotomy performance was reduced from 57.14%--in a control group down to 33.07%--in the main group. Lethality in the main group was 6.72%, postoperative lethality--9.83%, a morbidity rate in patients have reduced in 2.26 times.

Effects of the closing speed of stapler jaws on bovine pancreases.

BACKGROUND: The division of the pancreatic parenchyma using a stapler is important in pancreatic surgery, especially for laparoscopic surgery. However, this procedure has not yet been standardized. METHODS: We analyzed the effects of the closing speed of stapler jaws using bovine pancreases for each method. Furthermore, we assigned 10 min to the slow compression method, 5 min to the medium-fast compression method, and 30 s to the rapid compression (RC) method. The time allotted to holding (3 min) and dividing (30 s) was equal under each testing situation. RESULTS: We found that the RC method showed a high-pressure tolerance compared with the other two groups (rapid, 126 ± 49.0 mmHg; medium-fast, 55.5 ± 25.8 mmHg; slow, 45.0 ± 15.7 mmHg; p < 0.01), although the histological findings of the cut end were similar. The histological findings of the pancreatic capsule and parenchyma after the compression by staple jaws without firing also were similar. CONCLUSIONS: RC may provide an advantage as measured by pressure tolerance. A small series of distal pancreatectomy with a stapler that compares the speed of different stapler jaw closing times is required to prove the feasibility of these results after the confirmation of the advantages of the RC method under various settings.