Robotic Surgery for Benign and Low-Grade Malignant Diseases of the Duodenum

Abstract

Robotic duodenal surgery (RDS) is a treatment option for many benign and low-grade malignant duodenal conditions that are not amenable to endoscopic intervention and can avoid morbidity related to open surgery. A retrospective review of all patients undergoing RDS (non-Whipple) at a tertiary care center from 2010–2017 was carried out. Indications, procedural details, and outcomes were reviewed. Twenty-four patients underwent RDS during the study period: transduodenal resection in 6 patients (25%), wedge resection in 6 patients (25%), transduodenal ampullectomy in 5 patients (21%), sleeve (segmental) resection in 5 patients (21%), duodenojejunostomy bypass in 1 patient (4%), and duodenal diverticulectomy in 1 patient (4%). Median age was 68 years, 54 per cent were male, and median BMI was 27. Adenoma was the most common diagnosis (68%) followed by neuroendocrine tumor (25%), duodenal diverticulum (4%), and refractory superior mesenteric artery syndrome (4%). Seventy-one per cent were symptomatic with gastroinstestinal bleed being the most common presentation. Median tumor size was 27 mm, and the most common location was D2 (58%) followed by D3/D4 (25%) and D1 (17%). Median operating time was 205 minutes and estimated blood loss was 50cc with no patient requiring intraoperative transfusion. Median length of stay was five days (3–21 days). Overall complication rate was 41 per cent (10/24): minor biliopancreatic leak in three patients; ileus in three patients; bleeding, arrhythmia, hypoxia, and headache in one patient each. Three (12%) patients had significant complications (Clavien-Dindo grade ≥ 3) requiring laparoscopic or robotic reoperation, but all three were discharged on or before POD 6 with resolution of complication. Ninety-day readmission rate was 8 per cent and 90-day mortality was 0. Recurrent disease or strictures were not seen in any patient after a median follow-up of 16 months. It has been concluded that RDS is a safe alternative to open or laparoscopic duodenal resection for benign and low-grade malignant conditions not amenable to endoscopic intervention.

Robotic Revision of Hepaticojejunostomy for Benign Biliary Stricture

“…A robotic approach may overcome many of the technical challenges associated with a laparoscopic approach while maintaining the advantages of minimally invasive surgery. [21][22][23][24][25] For example, the robotic platform allows fine suture/small needle use, [17][18][19][20][21][22] and the wristed instruments provide additional degrees of freedom to facilitate suturing and a complete sweep of the biliary tree to remove stones/sludge. 22 Similarly, the ability to efficiently suture the enterotomy from the previous anastomosis precludes the need for stapling to preserve Roux length, while minimizing mobilization and undue tension on the new anastomosis.…”

“…[13][14][15][16] Literature related to complex surgical procedures performed using a robotic surgical platform suggest potential technical advantages for revision of biliary strictures. [17][18][19][20][21][22] In this study, we detail our technical approach to robotassisted revision of strictured biliary anastomoses and report outcomes related to its implementation.…”

Robotic limited local resection of duodenal juxta‐ampullary neoplasms

“…Furthermore, identification of the location of the tumour and the appropriate resection line from the serosal surface is challenging. Recent studies have shown that robotic surgical systems could be helpful for intricate manipulations of duodenal pathologies 6,29,30 . Our team also previously introduced a technique for robotic transduodenal ampullectomy 7 .…”

“…However surgical systems could be helpful for intricate manipulations of duodenal pathologies. 6,29,30 Our team also previously introduced a technique for robotic transduodenal ampullectomy. 7 The unique feature of our technique is the patient's left semilateral positioning for efficient exposure of duodenal lesions.…”

Duodenaladenome und -karzinome: chirurgische Therapiekonzepte

“…Neben der klassischen offenen Ampullektomie mehren sich derzeit die Fallberichte zu laparoskopischen oder ro- botergestützten Operationen [29,30]. Dabei ist das prinzipielle Vorgehen unverändert (Box OP-Schritte und Tricks).…”