Surg Endosc DOI 10.1007/s00464-014-3819-9
and Other Interventional Techniques
Laparoscopic robot-assisted versus open total pancreatectomy: a case-matched study Ugo Boggi • Simona Palladino • Gabriele Massimetti • Fabio Vistoli • Fabio Caniglia • Nelide De Lio • Vittorio Perrone • Linda Barbarello • Mario Belluomini • Stefano Signori • Gabriella Amorese • Franco Mosca
Received: 22 February 2014 / Accepted: 12 August 2014 Ó Springer Science+Business Media New York 2014
Abstract Background The enhanced dexterity offered by robotic assistance could be excessive for distal pancreatectomy but not enough to improve the outcome of laparoscopic pancreaticoduodenectomy. Total pancreatectomy retains the challenges of uncinate process dissection and digestive reconstruction, but avoids the risk of pancreatic fistula, and could be a suitable operation to highlight the advantages of robotic assistance in pancreatic resections. Methods Eleven laparoscopic robot-assisted total pancreatectomies (LRATP) were compared to 11 case-matched open total pancreatectomies. All operations were performed by one surgeon during the same period of time. Robotic assistance was employed in half of the patients, based on robot availability at the time of surgery. Variables examined included age, sex, American Society of Anesthesiologists score, body mass index, estimated blood loss, need for blood transfusions, operative time, tumor type, tumor size, number of examined lymph nodes, margin status, post-operative complications, 90-day or in-hospital mortality, length of hospital stay, and readmission rate. Results No LRATP was converted to conventional laparoscopy, hand-assisted laparoscopy or open surgery despite U. Boggi (&) S. Palladino F. Vistoli F. Caniglia N. De Lio V. Perrone L. Barbarello M. Belluomini S. Signori F. Mosca Division of General and Transplant Surgery, Pisa University Hospital Pisa, Via Paradisa 2, 56124 Pisa, Italy e-mail:
[email protected] G. Massimetti Division of Psychiatry, Pisa University Hospital, Pisa, Italy G. Amorese Division of General and Vascular Anesthesia and Intensive Care, Pisa University Hospital, Pisa, Italy
two patients (18.1 %) required vein resection and reconstruction. LRATP was associated with longer mean operative time (600 vs. 469 min; p = 0.014) but decreased mean blood loss (220 vs. 705; p = 0.004) than open surgery. Post-operative complications occurred in similar percentages after LRATP and open surgery. Complications occurring in most patients (5/7) after LRATP were of mild severity (Clavien-Dindo grade I and II). One patient required repeat laparoscopic surgery after LRATP, to drain a fluid collection not amenable to percutaneous catheter drainage. One further patient from the open group required repeat surgery because of bleeding. No patient had margin positive resection, and the mean number of examined lymph nodes was 45 after LRATP and 36 after open surgery. Conclusions LRATP is feasible in selected patients, but further experience is needed to draw final conclusions. Keywords Total pancreatectomy Laparosocopy Robot Da Vinci
Introduction The da Vinci surgical systemÒ (dVss) (Intuitive Surgical, Sunnyvale, California, USA) enhances surgical dexterity in laparoscopic operations [1]. On a priori grounds, considering also the added costs of the new technology [2], robotic assistance could be worth using if permitting otherwise unfeasible minimally invasive operations or improving patient outcomes. In fact, robotic assistance has minimally expanded the range of feasibility of laparoscopic operations [3], and improvement in patient outcomes, proposed for many operations [4–6], has not been unambiguously demonstrated yet [7].
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Pancreatic resections could be a valid test bench for robotic assistance because of the combined challenge of keeping clear surgical margins, controlling hemorrhage, and dealing with pancreatic and biliary anastomosis. Although advantages of robotic assistance have been reported also for the ‘‘easier’’ distal pancreatectomy [8, 9], a greater improvement would be making pancreaticoduodenectomy safely, effectively, and reproducibly feasible. Evidence is cumulating that robotic assistance permits safe pancreaticoduodenectomy, in selected patients, but there is no convincing proof that it translates into reduced morbidity mostly because of the unsolved problem of pancreatic fistula [10–13]. From a technical point of view, total pancreatectomy stands just in between pancreaticoduodenectomy and distal pancreatectomy, and could highlight the advantages of robotic assistance in pancreatic resections. Indeed, while the risk of pancreatic fistula is avoided by definition, delicate digestive reconstructions are still needed, and the challenge of uncinate process/posterior margin dissection is unchanged [14]. We herein present our experience with laparoscopic robot-assisted total pancreatectomy (LRATP) and provide a case-matched comparison with the open operation.
Materials and methods Between October 1st 2008 and August 31st 2013, 136 patients underwent laparoscopic robot-assisted pancreatic resection, including 11 total pancreatectomies. Selection criteria for LRATP were: no history of previous major upper abdominal surgery, no general medical conditions that would limit prolonged anesthesia with concurrent carbon dioxide pneumoperitoneum, body mass index not exceeding 35 kg/m2, and a preoperative diagnosis excluding locally advanced malignancy. A control group of patients undergoing open total pancreatectomy, who met the inclusion criteria for LRATP, was randomly selected from the large pool of patients available in a prospectively collected database. Patients were selected by a one-to-one case-matched methodology, where each patient undergoing LRATP was matched with a patient undergoing open total pancreatectomy according to the following matching criteria: age (classified according to decades of ages), gender, American society of anesthesiologists score, and body mass index. The 22 patients analyzed herein (25.5 %) are part of a larger series of patients (n = 86) undergoing total pancreatectomy over the same time period at our Institution. The majority of these patients were not considered for robot-assisted laparoscopy because of oncologic or physiologic reasons. The 22 patients presented herein could all
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Tabel 1 Baseline characteristics Robot-assited
Open
p value
Patients, number
11
11
Sex (M: F)
6: 5
7: 4
NS
Age, mean (range)
61.81 y (50–74)
68.45 y (49–78)
NS
Body mass index, mean (range)
24.8 kg/m2 (18.4–35.0)
25.0 kg/m2 (17.9–30.8)
NS
ASA physical status classification, number (%) II
4 (36.36 %)
3 (27.27 %)
III
7 (63.63 %)
8 (72.72 %)
4 (36.36 %)
7 (63.63 %)
Arterial hypertension, number (%)
NS NS
Diabetes, number (%)
5 (45.45 %)
6 (54.54 %)
NS
Heart disease, number (%) Renal failure, number (%)
2 (18.18 %)
2 (18.18 %)
NS
1 (9.09 %)
1 (9.09 %)
NS
4 (36.36 %)
8 (72.72 %)
NS
Symptoms, number (%)
ASA American Society of Anesthesiologists, NS not significant
have been operated by robot-assisted laparoscopy, but this was possible only in half of them because of robot availability at the time of scheduled surgery. All operations, either laparoscopic or open, were performed by the same surgeon (UB). As shown in Table 1, the two groups were comparable at the baseline. Examined variables were analyzed retrospectively after Institutional Review Board approval. Variables examined included age, sex, American Society of Anesthesiologists (ASA) score, body mass index (BMI), estimated blood loss, need for blood transfusions, operative time, tumor type, tumor size, number of examined lymph nodes, margin status, post-operative complications, 90-day or in-hospital mortality, length of hospital stay, and readmission rate. Post-operative complications were graded using the Clavien-Dindo classification [15]. Laparoscopic robot-assisted total pancreatectomy Patients are placed supine with the legs parted. The table is positioned at 20° in the reverse Trendelenburg position and slightly tilted to the left side. The tower of the dVss is docked over the head of the patient, with two operating arms on the patient’s left side. The robotic surgeon operates from the dVss console, while the laparoscopic surgeon stands between the patient’s legs. A total of five ports are placed, as previously described for pancreaticoduodenectomy [10]. In some patients, the operation begins as in pancreaticoduodenectomy [10] and is converted to total pancreatectomy because of intraoperative findings and/or
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of frozen section histology. In the other patients, after exploratory laparoscopy, the greater omentum is dissected along the border of the transverse colon. After entering the lesser sac, the position and the course of the left gastric vein are noted. When a splenectomy is planned, the left gastric vein is dissected off along its entire course, in order to assure adequate venous drainage from the stomach [16, 17]. Then the distal pancreas is mobilized either en-bloc with the spleen or it is dissected off the splenic vessels, depending on the type of resection. This maneuver does not require repositioning of the table, such as tilting to the right, but the first duodenal portion should not be sectioned until dissection of the body and tail of the pancreas is completed to keep the left hypochondrium clear. Once the distal pancreas is fully mobilized, attention is turned to the right. The right colonic flexure is mobilized, and the right gastroepiploic vessels are identified, dissected off, clipped by Hem-o-lokÒ (Teleflex Medical, Research Triangle Park, North Carolina, USA), and divided. The gallbladder, pulled upward and cephalad, is used as a handle to retract the liver thus exposing the hepatoduodenal ligament. The right gastric vessels are divided between ligatures, and the first part of the duodenum is divided with a laparoscopic stapler. The gastroduodenal artery is doubleligated proximally using 0 linen and divided. The common bile duct is divided between clips or ligatures, to avoid bile spillage. By lifting and retracting the duodenum to the left side, a Kocher maneuver is performed until the first jejunal loop can be brought to the right of the superior mesenteric vessels. The jejunal mesentery is divided using a HarmonicÒ scalpel (Ethicon Endo-Surgery, Johnson & Johnson, Somerville, New Jersey, USA), but the bowel is not divided to facilitate rotation around mesenteric vessels at the time of reconstruction. Mobilization of the third duodenal portion and division of the ligament of Treitz are performed working entirely from the right of mesenteric vessels, thus avoiding patient and robot repositioning, that could be needed if the same maneuver was performed working from the left of mesenteric vessels in the inframesocolic compartment. In case on en-bloc splenectomy, the splenic vessels are ligated and divided at this time. After dividing the short venous tributaries, the superior mesenteric/portal vein (SMV/PV) is mobilized, and dissection proceeds along the right margin of the superior mesenteric artery. Vessels, either arteries or veins, are preferentially secured by ligature or clip. Energy devices are used judiciously during this phase of the operation. After dividing the first jejunal loop, the specimen is removed in a 15-mm ENDO CATCHTM II (Covidien, Mansfield, Massachusetts, USA) via a small transverse suprapubic incision. When, despite pre-operative selection, the tumor is attached to the SMV/PV, an artery first approach is
employed, and the specimen is detached fully from the retroperitoneal margin without attempting any dissection in the area with suspected tumor abutment. In open surgery, venous reconstruction is usually achieved by direct anastomosis, after full intestinal mobilization [18]. In laparoscopy, the use of a jump graft is necessary [10]. The superior mesenteric artery is crossclamped first, to reduce bowel congestion, followed by the SMV/PV. Reconstruction is then performed using standard methods [18], but 6/0 expanded polytetrafluoroethylene is preferred to polypropylene because it is more resistant to robotic needle-driver manipulations [19, 20]. Digestive reconstruction is performed on a single bowel loop passing through the window behind the mesenteric vessels, which is closed by anchoring the jejunum and its mesentery to the posterior plane. Hepaticojejunostomy is performed first, end-to-side in a double layer, using half running sutures of 6/0 or 5/0 polydioxanone. The duodenojejunostomy or gastrojejunostomy is done next in two layers 10–15 cm downstream from the hepaticojejunostomy. At the end of the operation, two closed-suction 12-Fr diameter drains are placed in Morrison’s pouch and two in the bed of distal pancreas. Statistical analysis Analysis was carried out on an intent-to-treat basis. Fisher’s exact test was used to define associations between categorical factors and surgical groups. Continuous variables were compared using Student’s t test (for two groups) or analysis of variance (ANOVA). A p value B0.05 was considered statistically significant.
Results No LRATP was converted to conventional laparoscopy, hand-assisted laparoscopy or open surgery despite two patients (18.1 %) required resection and reconstruction of the SMV/PV. The entire stomach was preserved in all but one patient in either groups. The spleen, along with the splenic vessels, was preserved in three patients in each group. In every patient, the decision to proceed with splenectomy was based on oncologic reasons. It never occurred because of technical reasons or surgical misadventure. The main operative results are summarized in Table 2. LRATP was associated with longer operative time but decreased blood loss than open surgery. Reduced blood loss did not result in fewer patients receiving blood transfusions although more patients were transfused in the open group (36 vs. 18 %). Patients requiring vein resection and reconstruction and longer operative times in either groups.
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Surg Endosc Tabel 2 Operative and post-operative results Robot-assited
Open
Table 3 Post-operative recovery measures p value
Robotassited
Open
p value
Out of the bed without assistance, days; mean (range)
1.6 (1–3)
3.9 (3–5)
\0.0001
Able to stand and walk without assistance, days; mean (range)
2.2 (1–4)
5.6 (5–7)
\0.0001
Conversion, number (%)
0
–
Pylorus preserving, number (%)
10 (90.9 %)
10 (90.9 %)
NS
Spleen preserving, number (%) SMV/PV resection, number (%)
3 (27.2 %)
3 (27.2 %)
NS
2 (18.1 %)
2 (18.1 %)
NS
Operative time, mean (range)
600 min (400–800)
469 min (300–660)
0.014
First flatus, days; mean (range)
2 (1–4)
3.8 (3–5)
0.0002
Estimated blood loss, mean (range)
220 (100–450) mL
705 (200–900) mL
0.004
First bowel movement, days; mean (range)
3.5 (3–5)
5.1 (4–6)
\0.0001
2.8 (2–4)
4.6 (4–6)
\0.0001
Transfused patients, number (%)
2 (18.1 %)
4 (36.3 %)
NS
First liquid diet, days; mean (range)
5.2 (4–8)
7.9 (6–12)
ICU stay, mean (range)
0.7 (0–1) d
1.1 (1–2) d
NS
Full oral diet, days; mean (range)
LOS, mean (range)
27 days (12–88) 7 (63.6 %)
17 days (12–34) 5 (45.4 %)
NS
Visual pain analog score on day 1; mean (range)
3.2(2–5)
5.6 (3–7)
\0.0001
NS
Visual pain analog score on day 3; mean (range)
1.7 (1–3)
3.4 (2–4)
\0.0001
NS
Analgesic tramadol on day 1, mg; mean (range)
168.2 (150–200)
213.6 (150–250)
0.0015
2 (18.1 %)
81.8 (50–100)
113.6 (100–150)
0.0181
Morbidity, number (%)
Clavien-Dindo scale, number (%) I–II
5 (45.4 %)
0.0007
III–IV
2 (18.1 %)
3 (27.2 %)
NS
V
0
0
–
Analgesic tramadol on day 3, mg; mean (range)
Repeat surgery, number (%)
1 (9.0 %)
1 (9.0 %)
NS
mg Milligrams
90-day readmission, number (%) 90-day mortality, number (%)
1 (9.0 %)
0
NS
0
0
–
Pathology results are shown in Table 4. It is worth noting that no patient had margin positive resection, and that the mean number of examined lymph nodes, all resected en-bloc with the specimen, was 45 in LRATP and 36 in open total pancreatectomy.
ICU Intensive care unit, LOS length of hospital stay, d days, min minutes, NS not significant
Discussion Post-operative complications were recorded in similar percentages after LRATP and open surgery. Complications occurring in most patients (5/7) after LRATP were of mild severity (Clavien-Dindo grade I and II). One patient required repeat laparoscopic surgery after LRATP, to drain a fluid collection not amenable to percutaneous catheter drainage. One further patient from the open group required repeat surgery because of bleeding. There were no postoperative deaths. One patient (LRATP) was readmitted because of chest pain, caused by cardiologic reasons. Table 3 shows several additional parameters recorded in the early post-operative period. Patients undergoing LRATP achieved independent mobility sooner than patients undergoing open surgery. Similarly, LARTP patients pass their first flatus, had their first bowel movement, and received their first liquid and full oral diets earlier than open surgery patients. Pain scores and need for analgesics were also improved after LRATP, both at postoperative day 1 and 3.
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In the late ‘70 s and in the ‘80 s, total pancreatectomy became popular because of the absence of pancreatic anastomosis and its attendant morbidity, and because pancreatic cancer was thought to be multicentric in approximately 30 % of patients [21–23]. During that time, the rate of total pancreatectomy surpassed 40 % [24], but enthusiasm was soon mitigated by emerging evidence. Ductal adenocarcinoma of the pancreas is rarely multicentric [25, 26], and total pancreatectomy per se does not improve cancer-free survival [27]; although pancreatic fistula is avoided by definition, post-operative mortality is not reduced [28]. Further quality of life is worsened because of brittle diabetes and nutritional problems [29]. Nowadays, total pancreatectomy is rarely pursued and comprises some 6 % of all pancreatic resections [30]. In most patients, total pancreatectomy becomes necessary because of tumor spread to involve most or the entire gland [31], because of documented cancer infiltration at the
Surg Endosc Table 4 Pathology Robotassited
Open
p value
Tumor Type, number (%) Malignant IPMN
3 (27.2 %)
6 (54.5 %)
NS
Pre-malignant IPMN
5 (45.4 %)
4 (36.6 %)
NS
Pancreatic ductal adenocarcinoma
2 (18.1 %)
0
NS
Chronic pancreatitis
1 (9.0 %)
1 (9.0 %)
NS
Examined lymph nodes, mean (range)
45.2 (18–85)
36.72 (16–63)
NS
Malignant tumors, number (%)
5 (45.4 %)
6 (54.5 %)
NS
Lymph node status, number/malignant tumors (%) N0
3/5 (60.0 %)
1/6 (16.6 %)
NS
N1
2/5 (40.0 %)
5/6 (83.3 %)
NS
Tumor status, number/malignant tumors (%) T1
2/5 (40.0 %)
0
NS
T2
1/5 (20 %)
0
NS
T3
2/5 (40.0 %)
6/6 (100 %)
NS
T4
0
0
NS
Margin status, number/malignant tumors (%) R0
5/5 (100 %)
6/6 (100 %)
NS
R1
0
0
–
R2
0
0
–
IPMN intraductal papillary mucinous neoplasm, NS not significant
pancreatic transection margin during pancreaticoduodenectomy [32], or because of locally advanced tumors requiring arterial resection and reconstruction [33]. Most of these patients are not currently eligible for laparoscopy, irrespective of the availability of robotic assistance. There are however several patients in which total pancreatectomy could be conveniently performed laparoscopically, like those with multifocal endocrine tumors [31, 34, 35], metastatic tumors [36], diffuse intraductal papillary mucinous tumors [14, 35], and history of familial pancreatic cancer harboring premalignant lesions [31]. Also patients with chronic pancreatitis and refractory pain, requiring total pancreatectomy plus islet autotransplantation [37], may be good candidates for a laparoscopic operation. Recently, total pancreatectomy followed by islet autotransplantation has been proposed in patients with soft gland and small ducts as an alternative to high-risk pancreaticoenterostomy [38]. In these patients, pancreatic resection may be straightforward, making laparoscopy an appealing alternative to open surgery, in properly selected patients. Digestive reconstruction, however, remains challenging,
especially in patients with non-dilated common bile duct, making robotic assistance potentially useful. Quite surprisingly, despite this background, there are just few case reports [35, 39, 40], and only some small case series [14, 34, 41] reporting on either laparoscopic total pancreatectomy or LRATP. We have reported on a series of 11 consecutive patients undergoing LRATP and have provided a case-matched comparison with the open operation. Our results show that LRATP is feasible in selected patients. The 22 total pancreatectomies presented herein represent 25 % of contemporary total pancreatectomies, while the 11 LRATP represent 8 % of contemporary laparoscopic robot-assisted pancreatic resections, approaching the percentage reported for open pancreatic resections [30]. Overall, during the same period of time, over 600 pancreatic resections were performed at our Institution. In our opinion, major laparoscopic pancreatic resections should be carefully pursued only in selected patients. Robotic assistance cannot surrogate experience and expertise in both laparoscopy and pancreatic surgery. It could rather allow qualified surgeons to improve the outcome of laparoscopic surgery of the pancreas and/or making this type of surgery more easily reproducible. We discourage the use of robotic assistance to pursue major pancreatic resection in the occasional patient. In our patients, LRATP was feasible, without conversion to hand assistance or open surgery even in patients requiring en-bloc resection of the SMV/PV and reconstruction. It is worth underscoring that in these patients, tumor adherence to mesenteric-portal vein was incidentally discovered during surgery and was therefore of limited extent. We do not proceed to robotic surgery in patients with borderline resectable malignant tumors of the pancreas. In our patients, we decided that conversion to open surgery could be avoided after careful evaluation of local tumor spread and because of permissive patient anatomy. A low threshold to conversion was however maintained. Conversion should indeed be considered prudent practice and not treatment failure. Conversion under emergency conditions should be avoided, whenever possible. A case of intraoperative death caused by portal vein injury during laparoscopic robot-assisted pancreaticoduodenectomy has already been described [13]. It should also be noted that our current experience with resection and reconstruction of large vessels, during open pancreatectomy, comprises over 400 vascular segments in more than 320 patients (unpublished data). It is possible that acquaintance with vein resection and reconstruction in the open setting has played a role in allowing us to reproduce this challenging operation laparoscopically, under robotic assistance. Vein resection and reconstruction during laparoscopic [42] and robot-assisted [43] pancreatic resections have
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already been reported. Kendrick and Sclabas reported on 11 patients undergoing mostly tangential (n = 10) resection during pancreaticoduodenectomy. Venous reconstruction included tangential stapling (n = 2), primary suture venorrhaphy (n = 4), and patch venorrhaphy (n = 4) [42]. Giulianotti et al. reported on 3 further patients undergoing vein resection during distal splenopancreatectomy (n = 1) or pancreaticoduodenectomy (n = 2). Venous reconstruction included tangential stapling (n = 1) and polytetrafluoroethylene patch venorrhaphy [43]. In our experience, including also laparoscopic robot-assisted pancreaticoduodenectomy [10], we have always elected to pursue segmental vein resection and to use an autologous jump vein graft for reconstruction, if needed. Reasons for this decision have been outlined in our open experience [18], and we believe that the same principles should be adopted during laparoscopic operations. Otherwise, conversion should occur. The main difference that we can see between open and laparoscopic operations concerns the need to always use a jump graft in laparoscopy because of the inability to pull the intestine cephalad and put the vein stumps close enough to allow end-to-end anastomosis. The use of a jump graft requires that the laparoscopic operation be paused, during procurement of the autologous vein graft and the execution of two anastomoses. These maneuvers clearly prolong operative time, but we would be hesitant to modify this wellestablished technique [18], only because of the technical limitations of robot-assisted laparoscopy. Length of hospital stay was not reduced after LRATP in our series. This goal was not achieved even when the length of hospital stay of a patient discharged on post-operative day 88 was not considered, despite reduction of 6 days in the mean length of hospital stay after LRATP. Reducing hospital stay is considered one of the main outcome measures of laparoscopy and robot-assisted laparoscopy, not only from the patient side but also from the hospital perspective, in order to reduce in-hospital costs. However, early discharge of patients undergoing complex abdominal operations in Italy is mostly prevented by the lack of intermediate care facilities. All patients must be discharged home. Giulianotti et al. reported a difference of 16 days in the median length of hospital stay between patients in Italy and the USA [44]. Further, since some 70 % of our pancreatic resections are carried out on patients referred from long-distance, patients must be fully independent when discharged from the hospital, including also education on how to manage their diabetes, that is often of new onset. Despite similar length of hospital stay, it is worth noting that analysis of several additional parameters recorded in the early post-operative period showed quicker and smoother recovery after LRATP. Patients undergoing
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laparoscopic resection showed earlier independent mobility, quicker recovery of bowel functions, and lower pain scores despite use of lower analgesic dosages. Interestingly enough, these early advantages did not translate into shorter length of hospital stay in our initial experience. A possible explanation may be that most of these advantages are short-lived and are soon replaced by the need to face new onset diabetes and dietary adjustments. Preoperative patient and family education could reduce the impact of these predictable post-operative occurrences, and eventually reduce the length of hospital stay [45]. It is worth noting that only one patient required repeat, laparoscopic, surgery because of a fluid collection not amenable to percutaneous catheter drainage, and no patient was readmitted because of surgical problems. Further, as already shown in distal pancreatectomy [46] and pancreaticoduodenectomy [13], LRATP was associated with decreased blood loss. Although the current series represents only our initial experience, LRATP seems as safe as the well-established open operation. Reported experience on robotic pancreaticoduodenectomy shows that incidence and severity of post-operative complications decrease after approximately 90 operations [12]. Performing an average of 30 robotic pancreatic resections per year, we have seen an improvement in the outcome of pancreaticoduodenectomy and distal pancreatectomy. Considering the rarity of total pancreatectomy, the learning curve could take longer for this operation. Results of LRATP should be evaluated also long-term, especially in patients with benign disease or low-grade pancreatic tumors, which constitute the majority of patients in whom this approach could be indicated. Laparoscopy is indeed known to decrease the risk of several complications, like adhesions and incisional hernias, which can occur years after the initial surgery [47]. In conclusion, we have shown the feasibility of LRATP in a series of 11 patients without conversion to open surgery, despite 2 patients required vein resection and reconstruction. Data from this initial experience compare favorably with case-matched open operations. Our results are in keeping with the few information currently provided by the medical literature [14, 34, 35, 39, 40]. Further experience is needed to clarify the role of LRATP in the management of selected patients with pancreatic disease, and a final assessment will be eventually provided only by a prospective randomized study.
Disclosures Ugo Boggi, Simona Palladino, Gabriele Massimetti, Fabio Vistoli, Fabio Caniglia, Nelide De Lio, Vittorio Perrone, Linda Barbarello, Mario Belluomini, Stefano Signori, Gabriella Amorese, and Franco Mosca have no conflicts of interest or financial ties to disclose.
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