Impact of shifting from laparoscopic to robotic surgery during 600 minimally invasive pancreatic and liver resections

Abstract

Background Many centers worldwide are shifting from laparoscopic to robotic minimally invasive hepato-pancreato-biliary resections (MIS-HPB) but large single center series assessing this process are lacking. We hypothesized that the introduction of robot-assisted surgery was safe and feasible in a high-volume center. Methods Single center, post-hoc assessment of prospectively collected data including all consecutive MIS-HPB resections (January 2010–February 2022). As of December 2018, all MIS pancreatoduodenectomy and liver resections were robot-assisted. All surgeons had participated in dedicated training programs for laparoscopic and robotic MIS-HPB. Primary outcomes were in-hospital/30-day mortality and Clavien-Dindo ≥ 3 complications. Results Among 1875 pancreatic and liver resections, 600 (32%) were MIS-HPB resections. The overall rate of conversion was 4.3%, Clavien-Dindo ≥ 3 complications 25.7%, and in-hospital/30-day mortality 1.8% (n = 11). When comparing the period before and after the introduction of robotic MIS-HPB (Dec 2018), the overall use of MIS-HPB increased from 25.3 to 43.8% (P < 0.001) and blood loss decreased from 250 ml [IQR 100–500] to 150 ml [IQR 50–300] (P < 0.001). The 291 MIS pancreatic resections included 163 MIS pancreatoduodenectomies (52 laparoscopic, 111 robotic) with 4.3% conversion rate. The implementation of robotic pancreatoduodenectomy was associated with reduced operation time (450 vs 361 min; P < 0.001), reduced blood loss (350 vs 200 ml; P < 0.001), and a decreased rate of delayed gastric emptying (28.8% vs 9.9%; P = 0.009). The 309 MIS liver resections included 198 laparoscopic and 111 robotic procedures with a 3.6% conversion rate. The implementation of robotic liver resection was associated with less overall complications (24.7% vs 10.8%; P = 0.003) and shorter hospital stay (4 vs 3 days; P < 0.001). Conclusion The introduction of robotic surgery was associated with greater implementation of MIS-HPB in up to nearly half of all pancreatic and liver resections. Although mortality and major morbidity were not affected, robotic surgery was associated with improvements in some selected outcomes. Ultimately, randomized studies and high-quality registries should determine its added value. Graphical Abstract

Current status and outlook of robotic surgery in the Nordic countries

“…In liver surgery, laparoscopic surgery has been proven beneficial, and RAS has been found to facilitate the shift to MIS in hepato-pancreato-biliary (HPB)-surgery showing improvements in selected outcomes. 4 In pancreatic surgery, no difference in major morbidity (defined as Clavien–Dindo grade IIIA and higher) was seen when comparing laparoscopic distal pancreatectomy to robotic distal pancreatectomy, but the RAS group had lower conversion rates, lower readmission rates, and higher rates of spleen preservation potentially reducing long-term post splenectomy sequela. 5 Hernias are responsible for patient morbidity and healthcare costs.…”

Safe implementation of a minimally invasive hepatopancreatobiliary program, a narrative review and institutional experience

“…Compared to other subspecialities, such as urology and colorectal surgery, there has been delay in widespread use of MIS approaches to HPB operations, particularly for pancreaticoduodenectomy and major hepatectomy due to concerns about safety, cost, lack of efficacy, and perceived benefit 3,4 . However, as technology improves, higher levels of evidence, and more experience accumulate demonstrating benefit of these MIS approaches in select patients, there has been increased interest in utilization of MIS HPB techniques, particularly robot‐assisted procedures 5–16 …”

“…3,4 However, as technology improves, higher levels of evidence, and more experience accumulate demonstrating benefit of these MIS approaches in select patients, there has been increased interest in utilization of MIS HPB techniques, particularly robot-assisted procedures. [5][6][7][8][9][10][11][12][13][14][15][16] As surgeons and medical centers contemplate initiating and expanding MIS programs for complex HPB surgical operations, there are many factors to consider. The objective of this review is to provide a narrative summary of the existing literature on implementation of best practices and share our institutional experience in starting and building a MIS robotic program for minimally invasive pancreatic resection (MIPR) and minimally invasive hepatectomy (MIH).…”

Pretreatment Nutritional Status in Combination with Inflammation Affects Chemotherapy Interruption in Women with Ovarian, Fallopian Tube, and Peritoneal Cancer

“…The outcomes of cancer treatments such as surgery, radiation therapy, and chemotherapy have improved owing to medical advances [ 3 , 4 ]. Advances in surgical therapy, including robotic surgery, has been applied and enables precision surgery [ 5 , 6 , 7 ]. The introduction of molecular targeted therapies such as anti-angiogenesis agents including vascular endothelial growth factor (VEGF) antibodies and receptor tyrosine kinase (RTK) inhibitors has resulted in improved therapeutic response and reduced systemic toxicity [ 8 ].…”