Mesopancreas level 3 dissection in robotic pancreaticoduodenectomy

Shyr, Bor‐Uei; Shyr, Bor‐Shiuan; Chen, Shih‐Chin; Shyr, Yi‐Ming; Wang, Shin‐E

doi:10.1016/j.surg.2020.07.042

Cited by 21 publications

(32 citation statements)

References 32 publications

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“…It has been claimed that RPD has benefits of less delayed gastric emptying, less blood loss, lower wound infection rate, and shorter postoperative hospital stay, as compared with OPD, according to studies and literature reports. 1 , 5 , 7 , 8 , 9 , 26 , 27 , 28 , 29 Our study showed that the biggest complications after RPD are 18.1% occurrence of chyle leakage, followed by 5.7% occurrence of postoperative pancreatic fistula, 4.8% occurrence of intra‐abdominal abscess, 3.8% occurrence of delayed gastric emptying, and post pancreatectomy hemorrhage. 2 The wounds after RPD and OPD are shown in Figure 5 .…”

Section: Surgical Outcomes After Robotic Pancreaticoduodenectomymentioning

confidence: 62%

“…The pancreas team led by Y. M. Shyr and S. E. Wang at Taipei Veterans General Hospital have been endeavoring to develop robotic pancreaticoduodenectomy (RPD) since 2014. 6 With the experience of more than 1580 cases of pancreaticoduodenectomy and over 375 cases of RPD (Figure 1 ), some remarkable results have been achieved in RPD, 7 , 8 , 9 including: (a) shorter hospital stay after RPD, as early as on post‐operative day 6 in five cases of RPD; (b) better cosmesis and smaller wounds, as small as 3 ~ 4 cm by RPD, about 1/10 of the 30 ~ 40 cm wounds by traditional OPD; (c) nearly “no” blood loss in four cases of RPD, with a mean of 120‐150 c.c., as compared to 250‐500 c.c. blood loss by traditional OPD; (d) short operation time by RPD, as short as 232 minutes.…”

Section: Introductionmentioning

confidence: 99%

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Robotic pancreaticoduodenectomy for pancreatic head cancer and periampullary lesions

Shyr

Wang

Chen

et al. 2021

Annals of Gastroent Surgery

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Pancreaticoduodenectomy, so‐called “Whipple operation,” is a time‐consuming and technically demanding complex operation. Traditionally, this procedure has been performed most usually by open approach, which results in a large and painful wound. With the introduction of laparoscopic and robotic surgery, minimally invasive surgery (MIS) has emerged as a worldwide trend to improve wound cosmesis and to minimize wound pain. Although MIS for pancreaticoduodenectomy has also been attempted at some centers, the role of MIS, either robotic or laparoscopic approach, has not been well‐established for complex pancreaticoduodenectomy. Given that laparoscopic pancreaticoduodenectomy has been limited by its technical complexity and the high level of advanced laparoscopic skills required for pancreatic reconstruction, a robotic surgical system is introduced to overcome several limitations related to the laparoscopic approach. Providing high‐quality three‐dimensional (3‐D) vision, high optical magnification, articulation of robotic instruments, greater precision with suture targeting, and elimination of surgeon tremor, robotic surgical systems innovatively perform more delicate and complex procedures involving extensive dissection and suturing techniques such as pancreaticoduodenectomy. Although associated with longer operative time, robotic pancreaticoduodenectomy (RPD) has been claimed to have the benefits of less delayed gastric emptying, less blood loss, shorter length of postoperative stay, and lower wound infection rate, as compared with the traditional open pancreaticoduodenectomy (OPD). Moreover, RPD seems to be not only technically feasible but also justified without compromising the survival outcomes for pancreatic head and ampullary adenocarcinomas. Therefore, RPD could be recommended not only to surgeons but also to patients in terms of surgical feasibility, surgical outcomes, and patient satisfaction.

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Section: Surgical Outcomes After Robotic Pancreaticoduodenectomymentioning

confidence: 62%

Section: Introductionmentioning

confidence: 99%

Robotic pancreaticoduodenectomy for pancreatic head cancer and periampullary lesions

Shyr

Wang

Chen

et al. 2021

Annals of Gastroent Surgery

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“…Shyr reported on 36 RPDs with level 3 mesopancreas dissection, a procedure that corresponds to triangle RPD. When compared to RPD with less extended mesopancreas dissection (i.e., level 1 and level 2), triangle RPD was associated with longer median operation time and higher blood loss, but equivalent incidence and severity of postoperative complications, higher R0 rates, and increased number of examined lymph nodes [ 14 ]. No detail was provided on technique of periadvential artery dissection (i.e., sharp or energized).…”

Section: Discussionmentioning

confidence: 99%

“…Our group performs triangle PD for PDAC since the early 2000’s [ 13 ], taking inspiration from the Japanese studies on ExNP involvement in resectable PDAC [ 8 , 9 ]. As suggested by some groups [ 10 , 14 ], in open PD we prefer to pursue sharp (i.e., “cold”) periadvential dissection of large peripancreatic arteries (also named arterial divestment).…”

mentioning

confidence: 99%

Feasibility of “cold” triangle robotic pancreatoduodenectomy

et al. 2022

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Background Triangle pancreatoduodenectomy adds to the conventional procedure the en bloc removal of the retroperitoneal lympho-neural tissue included in the triangular area bounded by the common hepatic artery (CHA), the superior mesenteric artery (SMA), and the superior mesenteric vein/portal vein. We herein aim to show the feasibility of “cold” triangle robotic pancreaticoduodenectomy (C-Tr-RPD) for pancreatic cancer (PDAC). Methods Cold dissection corresponds to sharp arterial divestment performed using only the tips of robotic scissors. After division of the gastroduodenal artery, triangle dissection begins by lateral-to-medial divestment of the CHA and anterior-to-posterior clearance of the right side of the celiac trunk. Next, after a wide Kocher maneuver, the origin of the SMA, and the celiac trunk are identified. After mobilization of the first jejunal loop and attached mesentery, the SMA is identified at the level of the first jejunal vein and is divested along the right margin working in a distal-to-proximal direction. Vein resection and reconstruction can be performed as required. C-Tr-RPD was considered feasible if triangle dissection was successfully completed without conversion to open surgery or need to use energy devices. Postoperative complications and pathology results are presented in detail. Results One hundred twenty-seven consecutive C-Tr-RPDs were successfully performed. There were three conversions to open surgery (2.3%), because of pneumoperitoneum intolerance (n = 2) and difficult digestive reconstruction. Thirty-four patients (26.7%) required associated vascular procedures. No pseudoaneurysm of the gastroduodenal artery was observed. Twenty-eight patients (22.0%) developed severe postoperative complications (≥ grade III). Overall 90-day mortality was 7.1%, declining to 2.3% after completion of the learning curve. The median number of examined lymph nodes was 42 (33–51). The rate of R1 resection (7 margins < 1 mm) was 44.1%. Conclusion C-Tr-RPD is feasible, carries a risk of surgical complications commensurate to the magnitude of the procedure, and improves staging of PDAC. Graphical abstract

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“…The idea of the mesopancreas was presented by Adham and Singhirunnusorn, and a recent study presented robotic mesopancreatic resections on 289 patients [ 14 ]. In all, with an increasing number of centres implementing this idea together with clinical data into daily practices, this technique has already shown huge potential in this area [ 14 , 15 ].…”

Section: Introductionmentioning

confidence: 99%

Complete Mesogastric Excisions Involving Anatomically Based Concepts and Embryological-Based Surgeries: Current Knowledge and Future Challenges

et al. 2021

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Surgeries for gastrointestinal tract malignancies are based on the paradigm that we should remove the tumour together with its lymphatic drainage in one block. This concept was initially proposed in rectal surgery and called a total mesorectal excision. This procedure gained much interest and has improved oncological results in rectal cancer surgery. The same idea for mesogastric and complete mesogastric excisions was proposed but, because of the complexity of the gastric mesentery, it has not become a standard technique. In this review, we analysed anatomical and embryological factors, proposed technical aspects of this operation and incorporated the available initial results of this concept. We also discussed analogies to other gastrointestinal organs, as well as challenges to this concept.

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Mesopancreas level 3 dissection in robotic pancreaticoduodenectomy

Cited by 21 publications

References 32 publications

Robotic pancreaticoduodenectomy for pancreatic head cancer and periampullary lesions

Robotic pancreaticoduodenectomy for pancreatic head cancer and periampullary lesions

Feasibility of “cold” triangle robotic pancreatoduodenectomy

Complete Mesogastric Excisions Involving Anatomically Based Concepts and Embryological-Based Surgeries: Current Knowledge and Future Challenges

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