Abstract
Purpose of Review
The purpose of this review is to summarize the current experience and literature on robotic pancreatoduodenectomy and analyze its indications, surgical technique, and related peri- and postoperative outcomes.
Recent Findings
Complex hepato-pancreatico-biliary (HPB) minimally invasive surgical procedures that were only attainable after a long learning curve by highly skilled laparoscopic surgeons are now robotically performed with a shorter learning curve by dedicated HPB surgeons. Image integration, fusion imaging, digital pathology, electronic tutoring, automation, telepresence, and telesurgery are the principal axis for further progress in robotic surgery.
Summary
Despite growing experience in the field of pancreatic surgery, which has improved surgical outcomes, pancreatoduodenectomy remains associated with high morbidity rates. The robotic approach is a promising alternative technique and although evidence from randomized clinical trials is missing, it seems to offer many of the benefits of minimally invasive surgery without compromising the oncologic outcomes achieved in open surgery. In terms of peri- and postoperative outcomes, robotic pancreatoduodenectomy (RPD) showed reduced intraoperative blood loss, conversion rate, and length of hospital stay when compared to the open and laparoscopic approaches. Concerning the oncologic outcomes, RPD was found to be equivalent to the open and laparoscopic approaches. Still, a higher lymph-node harvest, lower resection margin involvement, and higher proportion of patients receiving adjuvant therapy were reported for RPD.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Tempero MA, Malafa MP, Al-Hawary M, et al. Pancreatic adenocarcinoma, version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Cancer Netw. 2021;19(4):439–457. https://doi.org/10.6004/jnccn.2021.0017
Zhao Z, Yin Z, Hang Z, Ji G, Feng Q, Zhao Q. A systemic review and an updated meta-analysis: minimally invasive vs open pancreaticoduodenectomy. Sci Rep. 2017;7(1):2220. https://doi.org/10.1038/s41598-017-02488-4.
Peng L, Lin S, Li Y, Xiao W. Systematic review and meta-analysis of robotic versus open pancreaticoduodenectomy. Surg Endosc. 2017;31(8):3085–97. https://doi.org/10.1007/s00464-016-5371-2.
Valle V, Fernandes E, Mangano A, et al. Robotic Whipple for pancreatic ductal and ampullary adenocarcinoma: 10 years experience of a us single-center. Int J Med Robot. 2020;16(5):1–7. https://doi.org/10.1002/rcs.2135.
van Hilst J, Korrel M, de Rooij T, et al. Oncologic outcomes of minimally invasive versus open distal pancreatectomy for pancreatic ductal adenocarcinoma: a systematic review and meta-analysis. Eur J Surg Oncol. 2019;45(5):719–27. https://doi.org/10.1016/j.ejso.2018.12.003.
Weng Y, Jiang Y, Fu N, et al. Oncological outcomes of robotic-assisted versus open pancreatoduodenectomy for pancreatic ductal adenocarcinoma: a propensity score-matched analysis. Surg Endosc. 2021;35(7):3437–48. https://doi.org/10.1007/s00464-020-07791-2.
Gagner M, Pomp A. Laparoscopic pylorus-preserving pancreatoduodenectomy. Surg Endosc. 1994;8(5):408–10. https://doi.org/10.1007/BF00642443.
Giulianotti PC. Robotics in general surgery: personal experience in a large community hospital. Arch Surg. 2003;138(7):777. https://doi.org/10.1001/archsurg.138.7.777.
Giulianotti PC, Addeo P, Buchs NC, Ayloo SM, Bianco FM. Robotic extended pancreatectomy with vascular resection for locally advanced pancreatic tumors. Pancreas. 2011;40(8):1264–70. https://doi.org/10.1097/MPA.0b013e318220e3a4.
Kauffmann EF, Napoli N, Menonna F, et al. Robotic pancreatoduodenectomy with vascular resection. Langenbecks Arch Surg. 2016;401(8):1111–22. https://doi.org/10.1007/s00423-016-1499-8.
Beane JD, Zenati M, Hamad A, Hogg ME, Zeh HJ, Zureikat AH. Robotic pancreatoduodenectomy with vascular resection: outcomes and learning curve. Surgery. 2019;166(1):8–14. https://doi.org/10.1016/j.surg.2019.01.037.
Allan BJ, Novak SM, Hogg ME, Zeh HJ. Robotic vascular resections during Whipple procedure. J Vis Surg. 2018;4:13–13. https://doi.org/10.21037/jovs.2017.12.15.
Giulianotti PC, Mangano A, Bustos RE, et al. Operative technique in robotic pancreaticoduodenectomy (RPD) at University of Illinois at Chicago (UIC): 17 steps standardized technique: lessons learned since the first worldwide RPD performed in the year 2001. Surg Endosc. 2018;32(10):4329–36. https://doi.org/10.1007/s00464-018-6228-7.
Giulianotti PC, Mangano A, Bustos RE, et al. Educational step-by-step surgical video about operative technique in robotic pancreaticoduodenectomy (RPD) at University of Illinois at Chicago (UIC): 17 steps standardized technique—lessons learned since the first worldwide RPD performed in the year 2001. Surg Endosc. 2020;34(6):2758–62. https://doi.org/10.1007/s00464-020-07383-0.
Wang SE, Shyr BU, Chen SC, Shyr YM. Comparison between robotic and open pancreaticoduodenectomy with modified Blumgart pancreaticojejunostomy: a propensity score–matched study. Surgery. 2018;164(6):1162–7. https://doi.org/10.1016/j.surg.2018.06.031.
Ielpo B, Caruso R, Duran H, et al. Robotic versus standard open pancreatectomy: a propensity score-matched analysis comparison. Updates Surg. 2019;71(1):137–44. https://doi.org/10.1007/s13304-018-0529-1.
Bencini L, Tofani F, Paolini C, et al. Single-centre comparison of robotic and open pancreatoduodenectomy: a propensity score-matched study. Surg Endosc. 2020;34(12):5402–12. https://doi.org/10.1007/s00464-019-07335-3.
Kauffmann EF, Napoli N, Menonna F, et al. A propensity score-matched analysis of robotic versus open pancreatoduodenectomy for pancreatic cancer based on margin status. Surg Endosc. 2019;33(1):234–42. https://doi.org/10.1007/s00464-018-6301-2.
Jin JB, Qin K, Yang Y, et al. Robotic pancreatectomy for solid pseudopapillary tumors in the pancreatic head: a propensity score-matched comparison and analysis from a single center. Asian J Surg. 2020;43(1):354–61. https://doi.org/10.1016/j.asjsur.2019.05.016.
Shi Y, Jin J, Qiu W, et al. Short-term outcomes after robot-assisted vs open pancreaticoduodenectomy after the learning curve. JAMA Surg. 2020;155(5):389. https://doi.org/10.1001/jamasurg.2020.0021.
Baimas-George M, Watson M, Murphy KJ, et al. Robotic pancreaticoduodenectomy may offer improved oncologic outcomes over open surgery: a propensity-matched single-institution study. Surg Endosc. 2020;34(8):3644–9. https://doi.org/10.1007/s00464-020-07564-x.
Kim HS, Han Y, Kang JS, et al. Comparison of surgical outcomes between open and robot-assisted minimally invasive pancreaticoduodenectomy. J Hepatobiliary Pancreat Sci. 2018;25(2):142–9. https://doi.org/10.1002/jhbp.522.
van Oosten AF, Ding D, Habib JR, et al. Perioperative outcomes of robotic pancreaticoduodenectomy: a propensity-matched analysis to open and laparoscopic pancreaticoduodenectomy. J Gastrointest Surg. 2021;25(7):1795–804. https://doi.org/10.1007/s11605-020-04869-z.
Buchs NC, Addeo P, Bianco FM, Ayloo S, Benedetti E, Giulianotti PC. Robotic versus open pancreaticoduodenectomy: a comparative study at a single institution. World J Surg. 2011;35(12):2739–46. https://doi.org/10.1007/s00268-011-1276-3.
•• Kabir T, Tan HL, Syn NL, Wu EJ, Kam JH, Goh BKP. Outcomes of laparoscopic, robotic, and open pancreatoduodenectomy: a network meta-analysis of randomized controlled trials and propensity-score matched studies. Surgery. 2022;171(2):476–489. https://doi.org/10.1016/j.surg.2021.07.020. This is a recent meta-analysis of randomized controlled trials and propensity-score matched studies that compares outcomes of minimally invasive and open pancreatoduodenectomy.
Liu R, Zhang T, Zhao ZM, et al. The surgical outcomes of robot-assisted laparoscopic pancreaticoduodenectomy versus laparoscopic pancreaticoduodenectomy for periampullary neoplasms: a comparative study of a single center. Surg Endosc. 2017;31(6):2380–6. https://doi.org/10.1007/s00464-016-5238-6.
Nassour I, Wang SC, Porembka MR, et al. Robotic versus laparoscopic pancreaticoduodenectomy: a NSQIP Analysis. J Gastrointest Surg. 2017;21(11):1784–92. https://doi.org/10.1007/s11605-017-3543-6.
Nassour I, Choti MA, Porembka MR, Yopp AC, Wang SC, Polanco PM. Robotic-assisted versus laparoscopic pancreaticoduodenectomy: oncological outcomes. Surg Endosc. 2018;32(6):2907–13. https://doi.org/10.1007/s00464-017-6002-2.
Zimmerman AM, Roye DG, Charpentier KP. A comparison of outcomes between open, laparoscopic and robotic pancreaticoduodenectomy. HPB. 2018;20(4):364–9. https://doi.org/10.1016/j.hpb.2017.10.008.
Xourafas D, Pawlik TM, Cloyd JM. Independent predictors of increased operative time and hospital length of stay are consistent across different surgical approaches to pancreatoduodenectomy. J Gastrointest Surg. 2018;22(11):1911–9. https://doi.org/10.1007/s11605-018-3834-6.
Goh BKP, Low T, Kam J, Lee S, Chan C. Initial experience with laparoscopic and robotic surgery for the treatment of periampullary tumours: single institution experience with the first 30 consecutive cases. ANZ J Surg. 2019;89(4):E137–41. https://doi.org/10.1111/ans.15033.
• Lof S, Vissers FL, Klompmaker S, et al. Risk of conversion to open surgery during robotic and laparoscopic pancreatoduodenectomy and effect on outcomes: international propensity score-matched comparison study. British Journal of Surgery. 2021;108(1):80–87. https://doi.org/10.1093/bjs/znaa026. This European multicentre analysis compared outcomes of converted and non-converted MIS-PD procedures.
Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery. 2017;161(3):584–91. https://doi.org/10.1016/j.surg.2016.11.014.
•• Cai J, Ramanathan R, Zenati MS, et al. Robotic pancreaticoduodenectomy is associated with decreased clinically relevant pancreatic fistulas: a propensity-matched analysis. J Gastrointest Surg. 2020;24(5):1111–8. https://doi.org/10.1007/s11605-019-04274-1. Thispropensity-matchedanalysisevaluatedtheimpactoftheroboticapproachonCr-POPF
Zhang W, Huang Z, Zhang J, Che X. Safety and efficacy of robot-assisted versus open pancreaticoduodenectomy: a meta-analysis of multiple worldwide centers. Updates Surg. 2021;73(3):893–907. https://doi.org/10.1007/s13304-020-00912-5.
Vining CC, Kuchta K, Schuitevoerder D, et al. Risk factors for complications in patients undergoing pancreaticoduodenectomy: a NSQIP analysis with propensity score matching. J Surg Oncol. 2020;122(2):183–94. https://doi.org/10.1002/jso.25942.
McMillan MT, Zureikat AH, Hogg ME, et al. A propensity score-matched analysis of robotic vs open pancreatoduodenectomy on incidence of pancreatic fistula. JAMA Surg. 2017;152(4):327. https://doi.org/10.1001/jamasurg.2016.4755.
Gall TMH, Pencavel TD, Cunningham D, Nicol D, Jiao LR. Transition from open and laparoscopic to robotic pancreaticoduodenectomy in a UK tertiary referral hepatobiliary and pancreatic centre—early experience of robotic pancreaticoduodenectomy. HPB. 2020;22(11):1637–44. https://doi.org/10.1016/j.hpb.2020.03.008.
Girgis MD, Zenati MS, King JC, et al. Oncologic outcomes after robotic pancreatic resections are not inferior to open surgery. Ann Surg. 2021;274(3):e262–8. https://doi.org/10.1097/SLA.0000000000003615.
Marino MV, Podda M, Gomez Ruiz M, Fernandez CC, Guarrasi D, Gomez FM. Robotic-assisted versus open pancreaticoduodenectomy: the results of a case-matched comparison. J Robotic Surg. 2020;14(3):493–502. https://doi.org/10.1007/s11701-019-01018-w.
Mejia A, Shah J, Vivian E, Acharya P. Analysis of 102 fully robotic pancreaticoduodenectomies: clinical and financial outcomes. Pancreas. 2020;49(5):668–74. https://doi.org/10.1097/MPA.0000000000001545.
Bao PQ, Mazirka PO, Watkins KT. Retrospective comparison of robot-assisted minimally invasive versus open pancreaticoduodenectomy for periampullary neoplasms. J Gastrointest Surg. 2014;18(4):682–9. https://doi.org/10.1007/s11605-013-2410-3.
Kamarajah SK, Bundred J, Marc OS, et al. Robotic versus conventional laparoscopic pancreaticoduodenectomy a systematic review and meta-analysis. Eur J Surg Oncol. 2020;46(1):6–14. https://doi.org/10.1016/j.ejso.2019.08.007.
•• Da Dong X, Felsenreich DM, Gogna S, et al. Robotic pancreaticoduodenectomy provides better histopathological outcomes as compared to its open counterpart: a meta-analysis. Sci Rep. 2021;11(1):3774. https://doi.org/10.1038/s41598-021-83391-x. This meta-analysis on robotic and open PDs evaluated whether the robotic approach provides better clinical and pathologic outcomes compared to its open counterpart.
van Dam JL, Janssen QP, Besselink MG, et al. Neoadjuvant therapy or upfront surgery for resectable and borderline resectable pancreatic cancer: a meta-analysis of randomised controlled trials. Eur J Cancer. 2022;160:140–9. https://doi.org/10.1016/j.ejca.2021.10.023.
• Nassour I, Tohme S, Hoehn R, Adam MA, Zureikat AH, Alessandro P. Safety and oncologic efficacy of robotic compared to open pancreaticoduodenectomy after neoadjuvant chemotherapy for pancreatic cancer. Surg Endosc. 2021;35(5):2248–2254. doi:https://doi.org/10.1007/s00464-020-07638-w. This retrospective study compared the postoperative, pathological and long-term oncologic outcomes of RPD and OPD for pancreatic adenocarcinoma following neoadjuvant chemotherapy.
Hasegawa H, Takahashi A, Kakeji Y, et al. Surgical outcomes of gastroenterological surgery in Japan: report of the National Clinical Database 2011–2017. Ann Gastroenterol Surg. 2019;3(4):426–50. https://doi.org/10.1002/ags3.12258.
Liu Z, Peneva IS, Evison F, et al. Ninety day mortality following pancreatoduodenectomy in England: has the optimum centre volume been identified? HPB. 2018;20(11):1012–20. https://doi.org/10.1016/j.hpb.2018.04.008.
Nassour I, Winters SB, Hoehn R, et al. Long-term oncologic outcomes of robotic and open pancreatectomy in a national cohort of pancreatic adenocarcinoma. J Surg Oncol. 2020;122(2):234–42. https://doi.org/10.1002/jso.25958.
Giulianotti PC, Sbrana F, Bianco FM, et al. Robot-assisted laparoscopic pancreatic surgery: single-surgeon experience. Surg Endosc. 2010;24(7):1646–57. https://doi.org/10.1007/s00464-009-0825-4.
Hoehn RS, Nassour I, Adam MA, Winters S, Paniccia A, Zureikat AH. National trends in robotic pancreas surgery. J Gastrointest Surg. 2021;25(4):983–90. https://doi.org/10.1007/s11605-020-04591-w.
•• Asbun HJ, Moekotte AL, Vissers FL, et al. The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection. Ann Surg. 2020;271(1):1–14. https://doi.org/10.1097/SLA.0000000000003590. This is the most recent landmark consensus meeting that discussed important aspects of MIS pancreatic procedures.
Nassour I, Wang SC, Christie A, et al. Minimally invasive versus open pancreaticoduodenectomy: a propensity-matched study from a national cohort of patients. Ann Surg. 2018;268(1):151–7. https://doi.org/10.1097/SLA.0000000000002259.
Dreifuss NH, Cubisino A, Schlottmann F, Giulianotti PC. Robotic-assisted central pancreatectomy: a minimally invasive approach for benign and low-grade lesions. Surg Oncol. https://doi.org/10.1016/j.suronc.2022.101736
Funding
The authors received no specific funding for this work.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
Pier Cristoforo Giulianotti has a consultant agreement with Covidien/Medtronic and Ethicon Endosurgery, and he also has an institutional agreement (University of Illinois at Chicago) for training with Intuitive. All other authors have no conflict of interest.
Research Involving Human and Animal Rights
This article does not contain any studies with human or animal subjects performed by any of the authors.
Informed Consent
Not applicable.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This article is part of the Topical Collection on Robotic Surgery.
Rights and permissions
About this article
Cite this article
Cubisino, A., Valle, V., Dreifuss, N.H. et al. Robotic Pancreatoduodenectomy: From the First Worldwide Procedure to the Actual State of the Art. Curr Surg Rep 10, 126–132 (2022). https://doi.org/10.1007/s40137-022-00319-8
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40137-022-00319-8