Robotic and laparoscopic hybrid pancreaticoduodenectomy: surgical techniques and early outcomes

Abstract

In recent years, the use of minimally invasive surgery in pancreas has been gradually rising in importance. There has been growing interest in performing pancreatectomy by the laparoscopic approach. However, laparoscopic pancreaticoduodenectomy (LPD) is very complicated and difficult to control and requires surgeons to have a high level of laparoscopic skills. Since LPD provides no significant benefits in terms of blood loss, morbidity rate, or median hospital stay, robotic pancreaticoduodenectomy (RPD) gained surgeons’ attention. The increased dexterity granted by endo-wristed instruments, the improved threedimensional vision, and the computer filtration of the surgeon's movements have brought minimally invasive surgery into a new era.1 RPD can overcome most of the natural limitations and drawbacks of LPD mentioned above. Therefore, we propose a hybrid of laparoscopic and robotic approaches (RLPD), which may be more beneficial and effective to pancreaticoduodenectomy as it combines the advantages of both LPD and RPD. In this paper, we report our initial experience with the new method RLPD and analyze its surgical techniques and early outcomes. METHODS We prospectively collected data for all patients undergoing RLPD from October 2010 through March 2012 in the Institute of General Surgery of Jinling Hospital. The main exclusion criteria were having tumors adjacent to the portal vein or superior mesenteric vein on CT or MRI imaging for which venous resection may be necessary. Among the 10 patients retrieved from our database, their medical records were reviewed to collect the following variables: age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, TNM stage, carcinoembryonic antigen (CEA) and cancer antigen 19-9, 125 (CA199, CA-125) levels, previous disease history, chief complaints when admitted, and complete pathology diagnosis. Demographic data, success rate of RLPD, duration of operation, estimated operation blood loss, length of incision, complications of surgery, length of postoperative hospital stay, pathological data, cost of the operation, cost of hospitalization and early clinical follow-up were also retrospectively collected. Our trial was approved by the hospital's ethics committee and patients’ consent was obtained. The nasogastric tube and urethral catheter were placed before the surgery. The patients were brought to the operating room and placed in reverse Trendelenberg position with legs wide apart and the angle of elevation by 30 degree to the right. Surgical techniques were briefly shown as in Table 1. Descriptive statistics were used in the following analysis. Normally distributed data are expressed as mean and standard deviation (SD) while skewed data are represented as median.Table 1: . Surgical techniques of RLPDRESULTS A total of six males and four females were included, with a median age of 57.6 years. According to preoperative CT and MRI scanning results, obstructions of common bile duct in the inferior extremity were confirmed in eight cases, while two cases had pancreatic head masses. The patients were distributed according to the WHO BMI classification for Chinese people as the following: normal (18.5-24.9): 8; overweigh (25.0-27.5): 2. According to the ASA score system, three patients were classified Grade I and seven Grade II. Five cases were Stage T1 and three cases were T2 based on cancer TNM Classification. Obstructive jaundice presented in eight patients, all of whom underwent ERCP before operation. Two patients suffered from epigastric malaise and distension. CEA elevated ((26.3±12.5) ng/ml) in five patients, and CA199 elevated ((232.5±87.2) U/ml) in seven patients. Of the 10 patients selected, nine underwent RLPD while the remaining one had to be converted to open pancreaticoduodenectomy owing to uncontrolled bleeding when dissecting the pancreatic head and uncinate. The mean operative time was (7.3±3.6) hours. The intraoperative bleeding was estimated as (320.0±123.