Technical Detail for Robot Assisted Pancreaticoduodenectomy

Summary

The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

Abstract

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic platform, including three-dimensional vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate the principles of open pancreatoduodenectomy allowing safe oncologic dissection, hemostasis, and meticulous reconstruction. Over the course of the past decade, significant strides have been achieved in outlining the safety, feasibility, and learning curve of the robotic Whipple. When performed by high volume pancreatic surgeons experienced in RPD, recent comparative effectiveness studies show potential advantages compared to the open technique, including reductions in hospital stay and morbidity. National data also show reductions in conversion rates compared to its laparoscopic counterpart. Although long-term oncologic data are still needed, short-term oncologic surrogates of margin resection and lymph node harvest suggest no compromise in oncologic outcomes. As pancreatic surgeons increasingly integrate robotics into their practice, proficiency-based training and credentialing will be necessary for the safe application and dissemination of RPD. Here, we provide the detailed steps of a robotic pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center. 

Introduction

Pancreaticoduodenectomy (PD) is a complex operation that combines a challenging resection and a meticolous reconstruction. During its early inception, the traditional open approach was frought with high complication rates and a mortality rate approaching 25%. In the last three decades, improvements in the surgical technique and perioperative care led to corresponding improvements in outcomes, with a reduction in mortality to less than 5%, especially at high volume centers^1,2,3. Despite this, morbidity remains substantial. With advancements in surgical technology, minimally in....

Protocol

This protocol follows the guidelines of the University of Pittsburg Medical Center human research ethics comittee (Institutional Review Board: PRO15040497)

1. Preoperative workup and selection

1. Check the triphasic CT scan (i.e., chest, abdomen, and pelvis with the primary imaging modality) to evaluate the extent of disease, rule out metastasis, and delineate aberrant or anomalous arterial vasculature. 
2. Perform EUS and endoscopic retrograde cholangiopancreatography (ERCP) for the tissue diagnosis and biliary decompression, especially in the setting of the planned neoadjuvant chemotherapy for pancreatic cancer.
....

Results

In the representative case, the total operative time was 225 min with an estimated blood loss (EBL) of 50 mL (Table 1). The patient was admitted to the surgical ward. Her postoperative course followed the UPMC institutional ERAS pathway. We routinely assess JP amylase at POD#1 and #3 to assess for pancreatic fistula and practice early drain removal on POD 3-5 when possible. The patient’s JP amylase levels were 403 U/L and 68 U/L, respectively. Therefore, the drain was removed on POD#3. The patient was di.......

Discussion

With advances in the surgical technology, laparoscopic and robot-assisted surgeries are being increasingly used in gastrointestinal and hepatobiliary procedures. Conventional laparoscopy is associated with benefits over open surgery for many procedures. However, inherent limitations such as decreased surgical dexterity, suboptimal ergonomics, lack of wristed instruments, and 2-D visualization, have limited its dissemination to complex gastrointestinal operations such as PD. 

Contrary to l.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
3-0 V-Loc sutures	Medtronic (Minneapolis, MN)	VLOCMo614	Barbed Absorable Suture
4-5 Fr Freeman Pancreatic Flexi-Stent	Hobbs Medical (Stafford Springs, CT)	6542, 6552	Pancreatic Duct Stent
5-0 PDS (polydiosxanone)	Ethicon (Somerville, NJ)	D10063	Synthetic Absorbable Suture
Cadíere forceps	Intuitive (Sunnyvale, CA)	470049	Surgical Robot Instrument
Da Vinci Si	Intuitive (Sunnyvale, CA)		Surgical Robot
Da Vinci Xi	Intuitive (Sunnyvale, CA)		Surgical Robot
Endo Clip 10 mm Applier	Covidien (Dublin, Ireland)	176619	Laparoscopic Titanium Clip Applier
Endo GIA 45 mm Curved Tip Articulating Vascular Stapler with Tri-Stapler Technology	Covidien (Dublin, Ireland)	EGIA45CTAVM	Laparoscopic Surgical Stapler
Endo GIA 60 mm Articulating Stapler with Tri-Stapler Technology	Covidien (Dublin, Ireland)	EGIA60AMT	Laparoscopic Surgical Stapler
Endo GIA 60 mm Curved Tip Articulating Vascular Stapler with Tri-Stapler Technology	Covidien (Dublin, Ireland)	EGIA60CTAVM	Laparoscopic Surgical Stapler
EndoCatch Gold 10 mm Specimen Pouch	Medtronic (Minneapolis, MN)	173050G	Specimen Extraction Bag
EndoCatch II 15 mm Specimen Pouch	Medtronic (Minneapolis, MN)	173049	Specimen Extraction Bag
Fenestrated bipolar forceps	Intuitive (Sunnyvale, CA)	470205	Surgical Robot Instrument
GelPOINT Mini Advanced Access Platform	Applied Medical (Rancho Santa Margarita, CA)	CNGL3	Laparoscopic Abdominal Access Platform
Large needle driver	Intuitive (Sunnyvale, CA)	470006	Surgical Robot Instrument
Large SutureCut needle driver	Intuitive (Sunnyvale, CA)	470296	Surgical Robot Instrument
LigaSure Blunt Tip Laparoscopic Sealer/Divider	Medtronic (Minneapolis, MN)	LF1844	Laparoscopic Bioplar Device
Mediflex liver retractor	Mediflex (Islandia NY)		Laparoscopic Liver Retractor
Monopolar curved scissors	Intuitive (Sunnyvale, CA)	470179	Surgical Robot Instrument
Permanent cautery hook	Intuitive (Sunnyvale, CA)	470183	Surgical Robot Instrument
ProGrasp forceps	Intuitive (Sunnyvale, CA)	470093	Surgical Robot Instrument