Skip to main content
SpringerLink
Log in

Which one is better? Laparoscopic versus robotic reconstruction in the remnant soft pancreas with a small pancreatic duct following pancreaticoduodenectomy: a multicenter study with propensity score matching analysis

  • 2022 SAGES Oral
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Evidence of the advantages of robotic pancreaticoduodenectomy (RPD) over laparoscopic pancreaticoduodenectomy (LPD) is limited. Thus, this study aimed to compare the surgical outcomes of laparoscopic reconstruction L-recon) versus robotic reconstruction (R-recon) in patients with soft pancreas and small pancreatic duct.

Method

Among 429 patients treated with minimally invasive pancreaticoduodenectomy (MIPD) between October 2012 and June 2020 by three surgeons at three institutions, 201 patients with a soft pancreas and a small pancreatic duct (< 3 mm) were included in this study.

Results

Sixty pairs of patients who underwent L-recon and R-recon were selected after propensity score matching. The perioperative outcomes were comparable between the reconstruction approaches, with comparable clinically relevant postoperative pancreatic fistula (CR-POPF) rates (15.0% [L-recon] vs. 13.3% [R-recon]). The sub-analysis according to the type of MIPD procedure also showed comparable outcomes, but only a significant difference in postoperative hospital stay was identified. During the learning curve analysis using the cumulative summation by operation time (CUSUMOT), two surgeons who performed both L-recon and R-recon procedures reached their first peak in the CUSUMOT graph earlier for the R-recon group than for the L-recon group (i.e., 20th L-recon case and third R-recon case of surgeon A and 43rd L-recon case and seventh R-recon case of surgeon B). Surgeon C, who only performed R-recon, demonstrated the first peak in the 22nd case. The multivariate regression analysis for risk factors of CR-POPF showed that the MIPD procedure type, as well as other factors, did not have any significant effect.

Conclusion

Postoperative pancreatic fistula rates and the overall perioperative outcomes of L-recon and R-recon were comparable in patients with soft-textured pancreas and small pancreatic duct treated by experienced surgeons.

Graphical abstract

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Gagner M, Pomp A (1994) Laparoscopic pylorus-preserving pancreatoduodenectomy. Surg Endosc 8(5):408–410

    Article  CAS  PubMed  Google Scholar 

  2. Palanivelu C, Senthilnathan P, Sabnis SC, Babu NS, Srivatsan Gurumurthy S, Anand Vijai N, Nalankilli VP, Praveen Raj P, Parthasarathy R, Rajapandian S (2017) Randomized clinical trial of laparoscopic versus open pancreatoduodenectomy for periampullary tumours. Br J Surg 104(11):1443–1450

    Article  CAS  PubMed  Google Scholar 

  3. Wang M, Li D, Chen R, Huang X, Li J, Liu Y, Liu J, Cheng W, Chen X, Zhao W, Li J, Tan Z, Huang H, Li D, Zhu F, Qin T, Ma J, Yu G, Zhou B, Zheng S, Tang Y, Han W, Meng L, Ke J, Feng F, Chen B, Yin X, Chen W, Ma H, Xu J, Liu Y, Lin R, Dong Y, Yu Y, Liu J, Zhang H, Qin R, Minimally Invasive Treatment Group in the Pancreatic Disease Branch of China’s International Exchange and Promotion Association for Medicine and Healthcare (MITG-P-CPAM) (2021) Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours: a multicentre, open-label, randomised controlled trial. Lancet Gastroenterol Hepatol 6(6):438–447

    Article  Google Scholar 

  4. Kamarajah SK, Bundred J, Marc OS, Jiao LR, Manas D, Abu Hilal M, White SA (2020) Robotic versus conventional laparoscopic pancreaticoduodenectomy a systematic review and meta-analysis. Eur J Surg Oncol 46(1):6–14

    Article  PubMed  Google Scholar 

  5. Kostakis ID, Sran H, Uwechue R, Chandak P, Olsburgh J, Mamode N, Loukopoulos I, Kessaris N (2019) Comparison between robotic and laparoscopic or open anastomoses: a systematic review and meta-analysis. Robot Surg 6:27–40

    PubMed  PubMed Central  Google Scholar 

  6. Ricci C, Casadei R, Taffurelli G, Pacilio CA, Ricciardiello M, Minni F (2018) Minimally invasive pancreaticoduodenectomy: what is the best “Choice”? A systematic review and network meta-analysis of non-randomized comparative studies. World J Surg 42(3):788–805

    Article  PubMed  Google Scholar 

  7. Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer CM Jr (2013) A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg 216(1):1–14

    Article  PubMed  Google Scholar 

  8. Kim HS, Han Y, Kang JS, Kim H, Kim JR, Kwon W, Kim SW, Jang JY (2018) Comparison of surgical outcomes between open and robot-assisted minimally invasive pancreaticoduodenectomy. J Hepatobiliary Pancreat Sci 25(2):142–149

    Article  PubMed  Google Scholar 

  9. Shi Y, Jin J, Qiu W, Weng Y, Wang J, Zhao S, Huo Z, Qin K, Wang Y, Chen H, Deng X, Peng C, Shen B (2020) Short-term outcomes after robot-assisted vs open pancreaticoduodenectomy after the learning curve. JAMA Surg 155(5):389–394

    Article  PubMed  Google Scholar 

  10. Montagnini AL, Røsok BI, Asbun HJ, Barkun J, Besselink MG, Boggi U, Conlon KC, Fingerhut A, Han HS, Hansen PD, Hogg ME, Kendrick ML, Palanivelu C, Shrikhande SV, Wakabayashi G, Zeh H, Vollmer CM, Kooby DA (2017) Standardizing terminology for minimally invasive pancreatic resection. HPB (Oxford) 19(3):182–189

    Article  PubMed  Google Scholar 

  11. Schulz KF, Altman DG, Moher D (2010) CONSORT 2010 statement: Updated guidelines for reporting parallel group randomised trials. J Pharmacol Pharmacother 1(2):100–107

    Article  PubMed  PubMed Central  Google Scholar 

  12. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250(2):187–196

    Article  PubMed  Google Scholar 

  13. Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, Allen P, Andersson R, Asbun HJ, Besselink MG, Conlon K, Del Chiaro M, Falconi M, Fernandez-Cruz L, Fernandez-Del Castillo C, Fingerhut A, Friess H, Gouma DJ, Hackert T, Izbicki J, Lillemoe KD, Neoptolemos JP, Olah A, Schulick R, Shrikhande SV, Takada T, Takaori K, Traverso W, Vollmer CR, Wolfgang CL, Yeo CJ, Salvia R, Buchler M, International Study Group on Pancreatic Surgery (2017) The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 161(3):584–591.

  14. Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Yeo CJ, Büchler MW (2007) Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 142(1):20–25

    Article  PubMed  Google Scholar 

  15. Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Buchler MW (2007) Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 142(5):761–768

    Article  PubMed  Google Scholar 

  16. Koch M, Garden OJ, Padbury R, Rahbari NN, Adam R, Capussotti L, Fan ST, Yokoyama Y, Crawford M, Makuuchi M, Christophi C, Banting S, Brooke-Smith M, Usatoff V, Nagino M, Maddern G, Hugh TJ, Vauthey JN, Greig P, Rees M, Nimura Y, Figueras J, DeMatteo RP, Büchler MW, Weitz J (2011) Bile leakage after hepatobiliary and pancreatic surgery: A definition and grading of severity by the International Study Group of Liver Surgery. Surgery 149(5):680–688

    Article  PubMed  Google Scholar 

  17. Varco RL (1945) A method of implanting the pancreatic duct into the jejunum in the Whipple operation for carcinoma of the pancreas; case report. Surgery 18:569–573

    CAS  PubMed  Google Scholar 

  18. Greene BS, Loubeau JM, Peoples JB, Elliott DW (1991) Are pancreatoenteric anastomoses improved by duct-to-mucosa sutures? Am J Surg 161(1):45–49; discussion 49–50.

  19. Kakita A, Yoshida M, Takahashi T (2001) History of pancreaticojejunostomy in pancreaticoduodenectomy: development of a more reliable anastomosis technique. J Hepatobiliary Pancreat Surg 8(3):230–237

    Article  CAS  PubMed  Google Scholar 

  20. Navarro JG, Kang CM (2019) Pitfalls for laparoscopic pancreaticoduodenectomy: need for a stepwise approach. Ann Gastroenterol Surg 3(3):254–268

    Article  PubMed  PubMed Central  Google Scholar 

  21. Kim H, Park SY, Park Y, Kwon J, Lee W, Song KB, Hwang DW, Kim SC, Lee JH (2022) Assessment of learning curve and oncologic feasibility of robotic pancreaticoduodenectomy: a propensity score-based comparison with open approach. J Hepatobiliary Pancreat Sci 29(6):649–658

    Article  PubMed  Google Scholar 

  22. Chong EH, Choi SH (2019) Hybrid laparoscopic and robotic hepatopancreaticoduodenectomy for cholangiocarcinoma. J Gastrointest Surg 23(9):1947–1948

    Article  PubMed  Google Scholar 

  23. Hong SS, Chong JU, Hwang HK, Lee WJ, Kang CM (2021) Laparoscopic pancreaticoduodenectomy reduces incidence of clinically relevant postoperative pancreatic fistula in soft pancreas with a smaller than 2 mm pancreatic duct. Surg Endosc 35(12):7094–7103

    Article  PubMed  Google Scholar 

  24. Kang I, Hwang HK, Lee WJ, Kang CM (2020) First experience of pancreaticoduodenectomy using Revo-i in a patient with insulinoma. Ann Hepatobiliary Pancreat Surg 24(1):104–108

    Article  PubMed  PubMed Central  Google Scholar 

  25. Choi M, Rho SY, Kim SH, Hwang HK, Lee WJ, Kang CM (2022) Total laparoscopic versus robotic-assisted laparoscopic pancreaticoduodenectomy: which one is better? Surg Endosc. https://doi.org/10.1007/s00464-022-09347-y

    Article  PubMed  PubMed Central  Google Scholar 

  26. Navarro JG, Hwang HS, Kim JS, Lee WJ, Kang CM (2021) Revo-i assisted minimally invasive pancreaticoduodenectomy: how I do it. Ann Robot Innov Surg 2(1):7–14

    Article  Google Scholar 

  27. Lonjon G, Porcher R, Ergina P, Fouet M, Boutron I (2017) Potential pitfalls of reporting and bias in observational studies with propensity score analysis assessing a surgical procedure: a methodological systematic review. Ann Surg 265(5):901–909

    Article  PubMed  Google Scholar 

  28. Biau DJ, Porcher R (2010) A method for monitoring a process from an out of control to an in control state: application to the learning curve. Stat Med 29(18):1900–1909

    Article  PubMed  Google Scholar 

  29. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, STROBE initiative, (2014) The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg 12(12):1495–1499

    Article  Google Scholar 

  30. Nickel F, Haney CM, Kowalewski KF, Probst P, Limen EF, Kalkum E, Diener MK, Strobel O, Muller-Stich BP, Hackert T (2020) Laparoscopic versus open pancreaticoduodenectomy: a systematic review and meta-analysis of randomized controlled trials. Ann Surg 271(1):54–66

    Article  PubMed  Google Scholar 

  31. Han SH, Kang CM, Hwang HK, Yoon DS, Lee WJ (2020) The Yonsei experience of 104 laparoscopic pancreaticoduodenectomies: a propensity score-matched analysis with open pancreaticoduodenectomy. Surg Endosc 34(4):1658–1664

    Article  PubMed  Google Scholar 

  32. Panni RZ, Guerra J, Hawkins WG, Hall BL, Asbun HJ, Sanford DE (2019) National pancreatic fistula rates after minimally invasive pancreaticoduodenectomy: a NSQIP analysis. J Am Coll Surg 229(2):192-199.e1

    Article  PubMed  Google Scholar 

  33. Nassour I, Wang SC, Porembka MR, Yopp AC, Choti MA, Augustine MM, Polanco PM, Mansour JC, Minter RM (2017) Robotic versus laparoscopic pancreaticoduodenectomy: a NSQIP analysis. J Gastrointest Surg 21(11):1784–1792

    Article  PubMed  PubMed Central  Google Scholar 

  34. Kim H, Choi SH, Jang JY, Choi M, Lee JH, Kang CM (2022) Multicenter comparison of totally laparoscopic and totally robotic pancreaticoduodenectomy: propensity score and learning curve-matching analyses. J Hepatobiliary Pancreat Sci 29(3):311–321

    Article  PubMed  Google Scholar 

  35. Tajima Y, Kuroki T, Tsutsumi R, Fukuda K, Kitasato A, Adachi T, Mishima T, Kanematsu T (2006) Risk factors for pancreatic anastomotic leakage: the significance of preoperative dynamic magnetic resonance imaging of the pancreas as a predictor of leakage. J Am Coll Surg 202(5):723–731

    Article  PubMed  Google Scholar 

  36. Winter JM, Cameron JL, Campbell KA, Chang DC, Riall TS, Schulick RD, Choti MA, Coleman J, Hodgin MB, Sauter PK, Sonnenday CJ, Wolfgang CL, Marohn MR, Yeo CJ (2006) Does pancreatic duct stenting decrease the rate of pancreatic fistula following pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg 10(9):1280–1290; discussion 1290.

  37. Belyaev O, Herden H, Meier JJ, Muller CA, Seelig MH, Herzog T, Tannapfel A, Schmidt WE, Uhl W (2010) Assessment of pancreatic hardness-surgeon versus durometer. J Surg Res 158(1):53–60

    Article  PubMed  Google Scholar 

  38. Hashimoto Y, Sclabas GM, Takahashi N, Kirihara Y, Smyrk TC, Huebner M, Farnell MB (2011) Dual-phase computed tomography for assessment of pancreatic fibrosis and anastomotic failure risk following pancreatoduodenectomy. J Gastrointest Surg 15(12):2193–2204

    Article  PubMed  Google Scholar 

  39. Lin JW, Cameron JL, Yeo CJ, Riall TS, Lillemoe KD (2004) Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula. J Gastrointest Surg 8(8):951–959

    Article  PubMed  Google Scholar 

  40. Eshmuminov D, Schneider MA, Tschuor C, Raptis DA, Kambakamba P, Muller X, Lesurtel M, Clavien PA (2018) Systematic review and meta-analysis of postoperative pancreatic fistula rates using the updated 2016 International Study Group Pancreatic Fistula definition in patients undergoing pancreatic resection with soft and hard pancreatic texture. HPB (Oxford) 20(11):992–1003

    Article  PubMed  Google Scholar 

  41. Watkins AA, Kent TS, Gooding WE, Boggi U, Chalikonda S, Kendrick ML, Walsh RM, Zeh HJ 3rd, Moser AJ (2018) Multicenter outcomes of robotic reconstruction during the early learning curve for minimally-invasive pancreaticoduodenectomy. HPB (Oxford) 20(2):155–165

    Article  PubMed  Google Scholar 

  42. Napoli N, Kauffmann EF, Palmeri M, Miccoli M, Costa F, Vistoli F, Amorese G, Boggi U (2016) The learning curve in robotic pancreaticoduodenectomy. Dig Surg 33(4):299–307

    Article  CAS  PubMed  Google Scholar 

  43. Kim H, Choi HZ, Kang BM, Lee JW (2022) Learning curve in laparoscopic pancreaticoduodenectomy: using risk-adjusted cumulative summation methods. J Laparoendosc Adv Surg Tech A 32(4):401–407

    Article  PubMed  Google Scholar 

  44. Wang M, Meng L, Cai Y, Li Y, Wang X, Zhang Z, Peng B (2016) Learning curve for laparoscopic pancreaticoduodenectomy: a CUSUM analysis. J Gastrointest Surg 20(5):924–935

    Article  PubMed  Google Scholar 

Download references

Author information

Author notes

  1. Jae Young Jang and Chang Moo Kang contributed equally to this work and both should be considered first author.

Authors and Affiliations

  1. Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea

    Jae Young Jang & Sung Hoon Choi

  2. Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea

    Chang Moo Kang

  3. Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Asan Medical Center, Ulsan University, Seoul, Republic of Korea

    Hyeyeon Kim & Jae Hoon Lee

  4. Department of Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea

    Munseok Choi

  5. Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, South Korea

    Jae Hoon Lee

  6. Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, CHA Bundang Medical Center, CHA University College of Medicine, CHA Global Clinical Trials Center, Building #417, 64 Yatap-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 13496, Korea

    Sung Hoon Choi

Authors
  1. Jae Young Jang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Chang Moo Kang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hyeyeon Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Munseok Choi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jae Hoon Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Sung Hoon Choi
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

(I) Study conception and design: JYJ, CMK, HK, MC, JHL, and SHC. (II) Data acquisition: JYJ, HK, and MC. (III) Quality control of data and algorithms: JYJ, CMK, HK, MC, JHL, and SHC. (IV) Data analysis and interpretation: JYJ, CMK, HK, MC, JHL, and SHC. (V) Statistical analysis: JYJ, CMK, JHL, and SHC. (VI) Manuscript preparation: JYJ and CMK. (VII) Manuscript editing: JYJ, CMK, HK, MC, JHL, and SHC. (VIII) Manuscript reviewing: JYJ, CMK, HK, MC, JHL, and SHC.

Corresponding authors

Correspondence to Jae Hoon Lee or Sung Hoon Choi.

Ethics declarations

Disclosures

Jae Young Jang, Chang Moo Kang, Hyeyeon Kim, Munseok Choi, Jae Hoon Lee, and Sung Hoon Choi have no conflicts of interest or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Jang, J.Y., Kang, C.M., Kim, H. et al. Which one is better? Laparoscopic versus robotic reconstruction in the remnant soft pancreas with a small pancreatic duct following pancreaticoduodenectomy: a multicenter study with propensity score matching analysis. Surg Endosc 37, 4028–4039 (2023). https://doi.org/10.1007/s00464-022-09602-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-022-09602-2

Keywords

Search

Navigation