Robotic Pancreatoduodenectomy

Pancreatoduodenal (PD) resection, so called Whipple procedure, is performed for attempted cure of periampullary carcinomas (head of pancreas, ampulla of Vater, duodenal wall, or distal common bile duct); other tumors in the head of the pancreas like: malignant islet cell neoplasms, mucinous cystic neoplasms or mucinous cystadenocarcinoma, after-effects from chronic cephalic pancreatitis with secondary pancreatic duct, common bile duct and/or duodenal obstruction. The mass is staged before resection to confirm the absence of hepatic, celiac nodal, and peritoneal metastases or regional invasion into the portal vein, superior mesenteric vessels, inferior vena cava or aorta. Traditional resection for cure includes the head, neck and, sometimes a portion of the body of the pancreas; the entire duodenum; the gallbladder and the distal common bile duct; the antrum of the stomach. An alternate approach is the pylorus-preserving technique (PPPD) in which the stomach and a 2 cm. cuff of proximal duodenum are preserved to improve the patient’s long-term nutritional status. Short- and long-term survival rates after this operation are similar to those with standard PD. Reconstruction is accomplished by anastomosis of the jejunumto the ends of the remaining pancreas, common bile duct and stomach (or duodenum in PPPD). Experienced surgical teams perform PD in 3 ½ to 5 hours with a blood replacement of 1 to 4 units. In high-volume centers the morbidity is around 30-40% and mortality rate is around 2-3%. The expected postoperative hospital stay is 10-20 days, with a median of 17 days. The major issue is the relatively high percentage of postoperative complication like pancreatic fistula, occurring in 15% to 25%, and intra-abdominal fluid collection (caused by a leak from the pancreatojejunostomy or the choledochojejunostomy) occurring in 5% to 10%; unfortunately these occur quite apart from the kind of surgery.

Whereas some laparoscopic procedures of the pancreas have rapidly emerged as good alternatives to open surgery, major laparoscopic resections of the pancreas, including distal pancreatectomy and pancreaticoduodenectomy, are being adopted at a rather slower pace and seem confined to a few selected centers. Among the reasons for the slower acceptance are concern about whether it is an adequate cancer operation as well as technical difficulties that require a highly skilled laparoscopic surgeon.

Robotic surgery has successfully addressed the limitations of traditional laparoscopic surgery, thus allowing completion of complex and advanced surgical procedures, like pancreatectomy, with increased precision in a minimally invasive approach. In contrast to the awkward positions that are required for laparoscopic surgery, the surgeon is seated comfortably on the robotic control consol, an arrangement that reduces the surgeon’s physical burden. Instead of the flat, 2-dimensional image that is obtained through the regular laparoscopic camera, the surgeon receives a 3-dimensional view that enhances depth perception; camera motion is steady and conveniently controlled by the operating surgeon with a manual master control. Also manipulation of robotic arm instruments, endowristed at the tip, improves range of motion (360 degree) allowing the surgeon to perform more complex surgical movements. In particular, in case of pancreatoduodenectomy, robotic technology provides evident advantages in regard to:

1. better micro-dissection especially near to the uncinate process, where with the endowristed instruments is possible to do a careful and precise dissection of the superior mesenteric vessels;
2. a very meticulous dissection in the detachment of the retroportal lamina and
3. a technically superior suturing in the pancreatojejunostomy and choledochojejunostomy;

The practical results of these features are decreased blood losses, better lymphadenectomy with improved radicality, less anastomotic leakages, less conversion rate, less surgical trauma. So robotic technology in major pancreatic resection allows benefiting for the advantages of minimally invasive surgery (less pain, faster recovery, reduced postoperative morbidity) overcoming the drawbacks of standard laparoscopy.