Robotic distal pancreatectomy for a neuroendocrine tumor in an 11-year-old child

IntroductionOver the past decade, robotic pancreatic surgery has gained popularity. Although anatomically comparable, the small size of pediatric patients might impede the use of the surgical robot due to the size of the robotic arms. Pediatric pancreatic resection is rarely indicated, hence only few cases of pediatric robotic pancreatic resection have been described (Hagendoorn et al., 2018; Lalli Raj, 2019-4) [1,2]. To the best our knowledge, no video literature exists on robotic pediatric pancreatic tail resections. Aim of this video was to demonstrate the set-up and surgical technique of robotic distal pancreatectomy in a child.MethodsThis video illustrates fully robotic distal pancreatectomy in an eleven-year-old child. The patient had a past medical history of tuberous sclerosis complex. On surveillance imaging a non-functional neuroendocrine tumor was detected in the pancreatic tail for which a distal pancreatectomy was indicated.ResultsAfter general anesthesia, the patient was placed in supine position on a split-leg table in anti-Trendelenburg. Four robotic trocars were placed and the da Vinci Xi robotic system was docked. Two laparoscopic assistant ports were placed. A spleen-preserving distal pancreatectomy was performed. Postoperative recovery was unremarkable and the patient was discharged on postoperative day 6.ConclusionThis video illustrates robotic distal pancreatectomy in an eleven-year-old child. Meticulous port placement, adjusted to the patient's habitus, is an essential element.     

Minimally invasive versus open pancreatoduodenectomy for pancreatic ductal adenocarcinoma: Individual patient data meta-analysis of randomized trials

ObjectiveAssessment of minimally invasive pancreatoduodenectomy (MIPD) in patients with pancreatic ductal adenocarcinoma (PDAC) is scarce and limited to non-randomized studies. This study aimed to compare oncological and surgical outcomes after MIPD compared to open pancreatoduodenectomy (OPD) for patients after resectable PDAC from published randomized controlled trials (RCTs).MethodsA systematic review was performed to identify RCTs comparing MIPD and OPD including PDAC (Jan 2015–July 2021). Individual data of patients with PDAC were requested. Primary outcomes were R0 rate and lymph node yield. Secondary outcomes were blood-loss, operation time, major complications, hospital stay and 90-day mortality.ResultsOverall, 4 RCTs (all addressed laparoscopic MIPD) with 275 patients with PDAC were included. In total, 128 patients underwent laparoscopic MIPD and 147 patients underwent OPD. The R0 rate (risk difference(RD) −1%, P = 0.740) and lymph node yield (mean difference(MD) +1.55, P = 0.305) were comparable between laparoscopic MIPD and OPD. Laparoscopic MIPD was associated with less perioperative blood-loss (MD -91ml, P = 0.026), shorter length of hospital stay (MD -3.8 days, P = 0.044), while operation time was longer (MD +98.5 min, P = 0.003). Major complications (RD -11%, P = 0.302) and 90-day mortality (RD -2%, P = 0.328) were comparable between laparoscopic MIPD and OPD.ConclusionsThis individual patient data meta-analysis of MIPD versus OPD in patients with resectable PDAC suggests that laparoscopic MIPD is non-inferior regarding radicality, lymph node yield, major complications and 90-day mortality and is associated with less blood loss, shorter hospital stay, and longer operation time. The impact on long-term survival and recurrence should be studied in RCTs including robotic MIPD.     

Robotic liver resection of segment 7: A step-by-step description of the technique

BackgroundRobotic surgery is increasingly employed in complex procedures such as liver resection. Minor resections of the posterosuperior segments might benefit in particular from a robotic approach, since the size of the incision dominates the postoperative recovery rather than the extent of the resection [1]. We aimed to provide a standardized, step-wise guide to robotic liver resection of segment 7.MethodsThis video illustrates, step-by-step, robotic segment 7 resection. Patients are placed in left lateral position, slight anti-Trendelenburg. Three robotic ports are used and one conventional laparoscopic port is placed for bedside assistance. Next, segment 7 is mobilized. Intraoperative ultrasound is used to delineate the tumor and ensure a safe oncologic margin. The EndoWrist ® One™ Vessel Sealer (Extend) (Intuitive Surgical Inc., Sunnyvale, CA, USA) is used for transection of the hepatic parenchyma, combined with a bipolar Maryland Forceps (Intuitive Surgical, Sunnyvale, California, USA). Hem-o-lok clips (Teleflex Inc., Morrisville, NC, USA) or laparoscopic staplers (Medtronic, Minneapolis, MN, USA) are used to control the hepatic pedicle. A pringle manoeuvre is applied when deemed appropriate. To ensure hemostasis and biliostasis, TachoSil (Takeda Nederland b.v. Takeda, Zurich, Switzerland) is applied to the resection surface. The specimen is extracted through an enlarged trocar incision.ResultsThis video illustrates robotic liver resection of segment 7 in a 72-year-old male with a past medical history of colorectal cancer. New, resectable liver metastases were detected during follow-up. The procedure was completed fully robotically. No postoperative complications occurred and the patient was discharged on postoperative day one.ConclusionThis video provides a step-by-step guide to robotic liver resection of segment 7.     

Robotic pancreaticoduodenectomy for pancreatic adenocarcinoma: role in 2014 and beyond

Minimally invasive surgery (MIS) for pancreatic adenocarcinoma has found new avenues for performing pancreaticoduodenectomy (PD) procedures, a historically technically challenging operation. Multiple studies have found laparoscopic PD to be safe, with equivalent oncologic outcomes as compared to open PD. In addition, several series have described potential benefits to minimally invasive PD including fewer postoperative complications, shorter hospital length of stay, and decreased postoperative pain. Yet, despite these promising initial results, laparoscopic PDs have not become widely adopted by the surgical community. In fact, the vast majority of pancreatic resections performed in the United States are still performed in an open fashion, and there are only a handful of surgeons who actually perform purely laparoscopic PDs. On the other hand, robotic assisted surgery offers many technical advantages over laparoscopic surgery including high-definition, 3-D optics, enhanced suturing ability, and more degrees of freedom of movement by means of fully-wristed instruments. Similar to laparoscopic PD, there are now several case series that have demonstrated the feasibility and safety of robotic PD with seemingly equivalent short-term oncologic outcomes as compared to open technique. In addition, having the surgeon seated for the procedure with padded arm-rests, there is an ergonomic advantage of robotics over both open and laparoscopic approaches, where one has to stand up for prolonged periods of time. Future technologic innovations will likely focus on enhanced robotic capabilities to improve ease of use in the operating room. Last but not least, robotic assisted surgery training will continue to be a part of surgical education curriculum ensuring the increased use of this technology by future generations of surgeons.     

Safety and feasibility of robotic major hepatectomy for novice surgeons in robotic liver surgery: A prospective multicenter pilot study

BackgroundRobotic liver resection has not yet been widely implemented. We aimed to evaluate the feasibility and safety of robotic major liver resection by performing a prospective multicenter study.MethodsFrom July 2017 to December 2018, five surgeons from five tertiary hospitals who were novices in robotic liver resection but experienced in open and laparoscopic liver resection performed 46 cases of robotic major anatomical liver resections. Perioperative clinical data and surgical data, including detailed procedure times were prospectively collected. All operations were performed according to a protocol for unify surgical techniques and instruments.ResultsTwenty-two cases of left hemihepatectomy, one case of extended left hemihepatectomy, 14 cases of right hemihepatectomy, two cases of right anterior sectionectomy, six cases of right posterior sectionectomy, and one case of central bisectionectomy were performed. The most common indications were hepatocellular carcinoma (21 cases) followed by intrahepatic duct stones (10 cases), intrahepatic cholangiocellular carcinoma (7 cases), liver metastases (3 cases), intraductal papillary neoplasms (2 cases), sarcoma (1 case), mucinous cystic neoplasm (1 case), and hemangioma (1 case). Surgical resection margins for all tumor cases were negative. The mean operation time was 378.58 ± 124.31 (190–696) minutes and the estimated intraoperative blood loss was 276.67 ± 397.41 mL (range, 10–2600 mL). Overall complications developed in 16 cases (34.8%). There were three cases of severe surgical complications (Clavien-Dindo classification of III or more). Only one of 46 cases was converted to conventional open left hemihepatectomy because of bleeding. The mean hospital stay was 7.3 ± 2.5 (4–18) days.ConclusionsThe results of this study indicate that robotic anatomic major liver resection can be safely performed by robotic beginners who are advanced open and laparoscopic liver surgeons.     

Robotic central hepatectomy for hepatocarcinoma by glissonean approach (with video)

BackgroundCentral bisegmentectomy of the liver implies excising Couinaud's segments IV, V and VIII (Couinaud and Le Foie, 1957) [1]. In a recent classification of laparoscopic liver resections, it belongs to the highly advanced level procedure group (Kawaguchi and et al., 2018 Jan) [2]. Improvement in laparoscopic devices should lead to a wider accessibility of such indications that are currently expert prerogatives. In order to illustrate the assets of robotic-assistance in the management of highly difficult mini-invasive hepatic resections, we present the case of a robotic central hepatectomy.MethodsThis video illustrates robotic central hepatectomy in a 70-year-old male. A liver tumor involving segments IV, V and VIII was incidentally detected during abdominal ultrasonography. CT scan and MRI suggested the diagnosis of a seventy-millimeter centrally located hepatocellular carcinoma and surgical resection was decided.ResultsThe patient was placed supine in anti-Trendelenburg position. Four robotic trocars were placed and the da Vinci X robotic system was docked. Two laparoscopic ports were placed for the second surgeon (ultrasonic dissector and suction/irrigation set). Central hepatectomy was performed with a glissonean approach. Robotic irrigated bipolar coagulation and laparoscopic ultrasonic dissector was used for parenchymal transection. Postoperative course was uneventful. The patient was discharged on postoperative day eight.ConclusionThe recent publication of an International consensus statement demonstrates the growing involvement of robotics in liver surgery (Liu and et al., 2019 March 28) [3]. Robotic advantages (flexibility, absence of fulcrum effect and visual field stability) could improve accessibility to minimal invasive approach for difficult liver resection.     

Robotic curative para-aortic lymph node dissection via INfra-mesocolon for gastric cancer: Robotic CAVING approach

BackgroundTwo major surgical complications in D2 plus para-aortic nodal dissection (PAND) for gastric cancer (GC) have been pancreatic fistula and abdominal abscess [1]. The increase in these complications is due to the excessive mobilization of the pancreas. We previously reported a laparoscopic Curative PAND Via INfra-mesocolon for GC (CAVING), which minimizes mobilization of the pancreas [2]. Robotic surgery may be more comfortable than laparoscopic surgery for the surgeon performing this CAVING approach because robotic surgery has ergonomic benefits and advantages, such as native wrist-like motion and three-dimensional vision. We initially report successful robotic CAVING approach on a 72-year-old male with GC with para-aortic nodal metastases (clinical stage IV) [3].MethodsWe apply PAND after chemotherapy to patients with resectable gastric cancer who are suspected of having metastases to the lymph nodes around the para-aorta. CAVING approach minimizes mobilization of the pancreas and maximizes the view from the caudal side, which has been likened to cave exploration, a specialty of robotic surgery. The caudal side of the root of the superior mesenteric artery (SMA) can be dissected via the infra-pancreas, and only the cranial side of the SMA root requires a suprapancreatic approach.ResultsAfter neoadjuvant chemotherapy using trastuzumab plus S-1 and oxaliplatin, robotic subtotal gastrectomy plus D2 with PAND was performed. The operation took 491 min (105 min for PAND) with no intraoperative complications, and blood loss of 92 ml. Final pathological examination showed complete response, yp stage 0 [3]. The patient was discharged uneventfully on postoperative day 17.ConclusionsRobotic CAVING approach is feasible and safe in advanced GC with para-aortic nodal metastases, but its oncological value has yet to be determined.     

Long term outcome after minimally invasive and open Warshaw and Kimura techniques for spleen-preserving distal pancreatectomy: International multicenter retrospective study

BackgroundThe Warshaw (WT) and the Kimura (KT) techniques are both used for open or minimally invasive (MI) spleen preserving distal pancreatectomy (SPDP). Multicenter studies on long-term outcome of WT and KT are lacking.MethodsMulticenter retrospective study with transversal follow-up moment, including patients who underwent SPDP from 2000 to 2017 at three high-volume centers in Italy and the Netherlands. Primary endpoint was the incidence of short and long term complications. Patients without regular follow-up were interviewed about symptoms and complications.ResultsIn total, 164 patients were enrolled, 55 WT (33.5%) and 109 kT (66.5%), of which 95 (57.9%) MI. There was no 30-day mortality (0%).The only significant difference in short-term outcome was more delayed gastric emptying (DGE) after WT (9.1% vs 1.8%, p = 0.043). MI-SPDP was associated with less blood loss (median 150 vs 250 ml, respectively, p < 0.001), less DGE (0% vs 10%, p = 0.002), less abdominal abscesses (8.4% vs 18.4%, p = 0.03) and less splenic infarctions (3.2% vs. 13%, p = 0.042), than open SPDP. Long-term follow-up (median 41 months) was available for 111 patients (67.7%) of whom 18 (16.2%) had an SPDP-related long-term sequela, mostly perigastric varices (n = 11, 9%) but without differences between WT and KT. Less long-term sequelae were reported after MI as compared to open SPDP (12.5% vs 21.2%, p = 0.032).ConclusionsIn this international retrospective study, the WT and KT had comparable short- and long-term outcomes. If a KT does not seem feasible during SPDP, a WT is recommended, rather than performing a splenectomy. MI-SPDP was associated with less short- and long term complications as compared to an open SPDP.     

Robotic technologies in surgical oncology training and practice

The modern-day surgeon is frequently exposed to new technologies and instrumentation. Robotic surgery (RS) has evolved as a minimally invasive technique aimed to improve clinical outcomes. RS has the potential to alleviate the inherent limitations of laparoscopic surgery such as two dimensional imaging, limited instrument movement and intrinsic human tremor. Since the first reported robot-assisted surgical procedure performed in 1985, the technology has dramatically evolved and currently multiple surgical specialties have incorporated RS into their daily clinical armamentarium. With this exponential growth, it should not come as a surprise the ever growing requirement for surgeons trained in RS as well as the interest from residents to receive robotic exposure during their training. For this reason, the establishment of set criteria for adequate and standardized training and credentialing of surgical residents, fellows and those trained surgeons wishing to perform RS has become a priority. In this rapidly evolving field, we herein review the past, present and future of robotic technologies and its penetration into different surgical specialties.     

Simultaneous,single-docking robotic resection for right colon cancer with synchronous liver metastases

BackgroundHow best to manage colorectal cancer patients presenting resectable synchronous liver metastasis is still a matter of debate. A number of different available therapeutic strategies exist, with significant differences in terms of optimal timing and/or sequence of resection of the primary tumor and liver disease [1]. Over the last years, simultaneous resections are increasingly adopted for properly selected patients [[1], [2], [3]]. However, the application of minimally invasive surgery to combined colorectal and liver surgery is still controversial, especially in the case of liver disease requiring technically demanding resections [2,3].VideoThe presented video illustrates the details of a single-docking robotic right colectomy combined with ultrasound-guided, parenchymal-sparing resection of liver segments 6 and 7, as performed to treat a patient with locally advanced colorectal cancer and metastatic disease isolated to the right liver. Port placement strategy and main instrumentation employed are illustrated in Fig. 1, and Fig. 2, respectively. The total duration of surgery was 380 minutes. The hepatic hilum was encircled to allow extracorporeal Pringle maneuver during liver resection, though no clamping was eventually required. Right colectomy with central vascular ligation was thus carried out and an intracorporeal ileocolic anastomosis performed. The patient had an uneventful postoperative course.ConclusionsWhen feasible, minimally invasive simultaneous resection may offer distinct advantages over conventional surgery while respecting the tenets of appropriate oncological resection [2,3]. The well-known benefits of minimally invasive surgery, including shorter overall hospital length of stay, reduced morbidity, and lower blood loss, are combined with the need to recover from a single major surgery. Robotic resection may be particularly suited for technically challenging procedures, such as colectomy combined with liver metastasectomies with unfavorable anatomical accessibility [3,4].     

Robotic versus open total mesorectal excision for rectal cancer: Comparative study of short and long-term outcomes

Background

Despite the several series in which the short-term outcomes of robotic-assisted surgery were investigated, data concerning the long-term outcomes are still scarce.

Methods

The prospectively collected records of 65 consecutive patients with extraperitoneal rectal cancer who underwent robotic total mesorectal excision (RTME) were compared with those of 109 consecutive patients treated with open surgery (OTME). Patient characteristics, pathological findings, local and systemic recurrence rates and 5-year survival rates were compared.

Results

There were no statistically significant differences in postoperative complications, reoperation and 30-day mortality. There were significant differences comparing groups: number of lymph nodes harvested (RTME: 20.1 vs. OTME: 14.1, P < 0.001), estimated blood loss (RTME: 0 vs. OTME: 150 ml, P = 0.003), operation time (RTME: 299.0 vs. OTME: 207.5 min, P < 0.001) and length of postoperative stay (RTME: 6 vs. OTME: 9 days, P < 0.001). The rate of circumferential resection margin involvement and distal resection margin were not statistically different between groups. There were no statistically significant differences at the 5-year follow-up: overall survival, disease-free survival and cancer-specific survival. The cumulative local recurrence rate was statistically lower in the robotic group (RTME: 3.4% vs. OTME: 16.1%, P = 0.024).

Conclusion

RTME showed a significant reduction in local recurrence rate and a higher, although not statistically significant, long-term cancer-specific survival with respect to OTME. Prospective randomized studies are needed to confirm or deny significantly better local control rates with robotic surgery.     

Robotic versus conventional laparoscopic pancreaticoduodenectomy a systematic review and meta-analysis

BackgroundRobotic pancreaticoduodenectomy (RPD) offers theoretical advantages to conventional laparoscopic surgery including improved instrument dexterity, 3D visualization and better ergonomics. This review aimed to determine if these theoretical advantages translate into improved patient outcomes comparing patients having either robotic pancreaticoduodenectomy or laparoscopic (LPD) equivalent.MethodA systematic literature search was conducted for studies reporting minimally invasive surgery for pancreaticoduodenectomy either robotic assisted or totally laparoscopic. Meta-analysis of intra-operative (blood loss, operating times, conversion and R0 resections) and postoperative outcomes (overall complications, pancreatic fistula, length of hospital stay) was performed using a random effects model.ResultThis review identified 44 studies, of which six were non-randomised comparative studies including 3462 patients (1025 robotic and 2437 laparoscopic). Intraoperatively, RPD was associated with significantly lower conversion rates (OR 0.45, p < 0.001) and transfusion rates (OR: 0.60, p = 0.002) compared to LPD. However, no significant difference in blood loss (mean: 220 vs 287 mL, p = 0.1), operating time (mean: 405 vs 418 min, p = 0.3) was noted. Postoperatively RPD was associated with a shorter hospital stay (mean: 12 vs 11 days, p < 0.001) but no significant difference was noted in postoperative complications, incidence of pancreatic fistulae and R0 resection rates.ConclusionRPD appears to offer some advantages compared to conventional laparoscopic surgery, although both approaches appear to offer equivalent clinical outcomes. Importantly, the quality of evidence is generally limited to cohort studies and a high-quality randomised trial comparing both techniques is needed.     

Transanal endoscopic microsurgical submucosal dissection (TEM-ESD): A novel approach to the local treatment of early rectal cancer

BackgroundComplete local resection is currently the treatment of choice for low-risk early rectal cancer; however, the ideal resection technique for such tumours is still debated. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a new technique which combines the ergonomic advantages of transanal endoscopic microsurgery (TEM) with the minimally invasive approach of endoscopic submucosal dissection (ESD). The aim of our study was to assess the feasibility, safety, and long-term outcomes of TEM-ESD in treating early rectal cancer.Materials and methodsWe retrospectively analysed all cases of rectal adenocarcinomas treated with TEM-ESD in Karlsruhe Municipal Hospital between 2012 and 2019, as well as the perioperative and follow-up data of the patients.ResultsWe identified 40 cases (19 low-risk and 21 high-risk carcinomas) matching our criteria. The median size of the lesions was 3.8 cm and the median operating time 48.5 min. En bloc resection was possible in all cases, while histologically complete resection was confirmed in 18 of 19 low-risk tumours and in 30 out of all lesions. The resection was curative in 19 cases. No scarring of the mesorectum was reported during the completion of total mesorectal excision for high-risk tumours. There was only 1 case of local recurrence among patients treated with curative intent, with an overall survival rate of 100% and a disease-free survival rate of 96% at both 2 and 5 years for these patients.ConclusionTEM-ESD is a safe and feasible therapeutic option for resecting early rectal cancer, offering very good long-term outcomes.