Bridging the gap between open and minimally invasive pancreaticoduodenectomy: the hybrid approach

Abstract

Background: Minimally invasive pancreatic surgery has evolved rapidly, but total laparoscopic pancreaticoduodenectomy has not been widely adopted owing to its technical complexity. Hybrid laparoscopy-assisted pancreaticoduodenectomy (HLAPD) combines the relative ease of open surgery with the benefits of a minimally invasive approach. This study evaluates the safety and effectiveness of the hybrid approach compared with open surgery. Methods:We retrospectively analyzed data of consecutive patients undergoing either hybrid or open pancreaticoduodenectomy (OPD) at our institution between September 2009 and December 2013. Demographic, operative and oncologic data were collected to compare outcomes between HLAPD and OPD.Results: Our analysis included 33 patients (HLAPD: n = 13; OPD: n = 20). There were no differences in patient demographics, comorbidities or surgical indications. The HLAPD group had significantly lower intraoperative blood loss (450 mL v. 1000 mL, p = 0.023) and shorter length of hospital stay (8 v. 12 d, p = 0.025) than the OPD group. Duration of surgery did not differ significantly between the groups. There were no differences in postoperative analgesic requirements, Clavien grade I/II or grade III/IV complications or 90-day mortality. Oncologic outcomes showed no significant differences in tumour size, R1 resection rate or number of lymph nodes harvested. Conclusion:In select patients, HLAPD is a safe and effective procedure with comparable outcomes to conventional open surgery. Wider adoption of the hybrid approach will allow a greater number of patients to benefit from a less invasive procedure while facilitating the transition toward purely minimally invasive pancreaticoduodenectomy.Contexte : La chirurgie pancréatique minimalement effractive a rapidement évolué, mais la pancréatoduodénectomie laparoscopique totale n'a pas été largement adoptée en raison de sa complexité technique. La pancréatoduodénectomie hybride sous laparoscopie (PDHL) allie la relative facilité de la chirurgie ouverte aux avantages d'une approche minimalement effractive. Cette étude compare l'innocuité et l'efficacité de l'approche hybride à celles de la chirurgie ouverte.Méthodes : Nous avons analysé de manière rétrospective les données concernant des patients consécutifs soumis à une pancréatoduodénectomie hybride ou ouverte (PDO) dans notre établissement entre septembre 2009 et décembre 2013. Les données démographiques, opératoires et oncologiques ont été recueillies pour comparer les résultats entre la PDHL et la PDO.

Early experience with robotic pancreatic surgery in a Canadian institution

“…The median LOS was 7.5 (range 5-57) days in the RAPD group, as compared to 8 (range [6][7][8][9][10][11][12][13][14] days in the HLAPD group (p = 0.78), and mean total 7-day opioid use was 142.599 ± 68.2 mg of intravenous morphine equivalents in the RAPD group versus 176.9 ± 112.7 mg of intravenous morphine equivalents in the HLAPD group (Fig. 2).…”

“…6,7,17 These long operations, despite our centre's experience with the hybrid laparoscopic approach, may be in part attributed to the added complexity of malignant pathology in most of our patients (91.7%) and to the increased care in executing an adequate resection to preserve oncologic outcomes comparable to the open ex perience. Similar lymphadenectomy rates (22.5 nodes, range 4-44) were achieved as with HLAPD and in the range described by Zureikat and colleagues 18 using a completely robotic approach (17 nodes, range 5-37).…”

“…In our previous study comparing 13 HLAPD and 20 open cases, with similar demographic parameters, we found significantly decreased blood loss (450 mL v. 1000 mL, p = 0.023) and postoperative LOS (8 v. 12 d, p = 0.025), with no difference in complication rates, pancreatic leak rates or mortality. 7 This initial experience with a hybrid approach allowed us not only to master the laparoscopic resection, which is iden tical to the resection performed in RAPD, but also to focus on the reconstruction phase and maximize the robotic plat form's advantages for magnification, stability and increased ability for challenging suturing of smallcalibre ducts. 6 As such, the present study compares outcomes of RAPD with HLAPD to truly determine if there is any difference in the robotic reconstruction as compared with a hybrid approach and if it is safe and feasible to incorporate it in a centre with previous laparoscopic experience.…”

“…We previously reported that patients in the HLAPD group who were converted to the OPD group did not contribute to worse outcomes for this group or favour outcomes of the minimally invasive group. 7 Thus, any patient in whom a conversion to an open operation was required was included in the open group. All patients for whom a mini-laparotomy was used for reconstruction following a totally laparoscopic resection were included in the HLAPD group.…”

“…This ex perience has provided us with the tools needed to adopt an MIS approach for nearly all pancreatic surgery at our centre within well-established inclusion criteria. 7 Furthermore, the experience with the hybrid approach, where the pancreaticoduodenectomy resection is completed laparoscopically and the reconstruction completed through a mini-laparotomy, provided our group with the necessary preparation to transition from an open reconstruction to a robotic reconstruction, as previously described by Zureikat and colleagues. 6 The purpose of the present study was to determine the safety and feasibility of robotic pancreatic surgeries during the initial phase of our institutional learning curve and to compare these results to our previously validated outcomes for HLAPD.…”