Robotic central pancreatectomy

Abstract

Central pancreatectomy (CP) is a parenchyma-sparing procedure that can be utilized in the resection of tumors of the neck or the proximal body of the pancreas. Among 872 open CP reported since 1993, the mean rate of morbidity was 43.2% and mean rate of mortality was 0.24%. The mean pancreatic fistula rate was 28%. The rate of clinically significant pancreatic fistulas with ISGPF Grades B and C was 19%. The rate of development of post-operative diabetes mellitus was at 2% and the average incidence of exocrine insufficiency experienced by patients undergoing open CP was 4.4%. Also, the mean length of hospital stay was around 15 days. In comparison, a total of 100 patients underwent either laparoscopic or robotic CP with a mean rate of morbidity of 37.3% and mean rate of mortality of 0%. Also, the mean rate of development of pancreatic fistula was 36.6%. The rate of clinically significant pancreatic fistulas with ISGPF Grades B and C was 17%. The rate of development of post-operative diabetes mellitus was at 1.5%. None of the patients included in these series developed any postoperative exocrine insufficiency. The mean length of hospital stay was around 13 days. Standard procedures such as DP and PD are associated with lower rates of short-term morbidity such as pancreatic fistula development but are also accompanied with a higher rate of long-term endocrine and exocrine insufficiency due to the significant loss of normal pancreatic parenchyma when compared to CP. It can be inferred, albeit from limited and small retrospective studies and case reports, that conventional and robotic-assisted laparoscopic approaches to CP are safe and feasible in highly specialized centers.

Keywords: Robotic surgery; central pancreatectomy (CP); minimally invasive surgery; pancreas.

Figure 1

Ports for robotic central pancreatectomy. C, 12-mm camera port; R1, 8-mm robotic port; R2, 8-mm robotic port; R3, 8-mm robotic port; A1, 5-mm laparoscopic assistant port; A2, 12-mm assistant port; LR, 5-mm liver retractor port.

Figure 2

Intraoperative images from robotic-assisted central pancreatectomy. (A) Intraoperative ultrasound is used to identify the tumor, determine the lesion’s borders and mark the margins of resection; (B) stapling of pancreatic neck with a vascular stapler. The neck is usually thin allowing for this method of transection. Depending on the thickness and consistency of the pancreas, it may be necessary to use a larger stapler or transect with scissors; (C) transecting distal pancreas with scissors.

Figure 3

Technique for robotic-assisted central pancreatectomy (12). Available online: http://www.asvide.com/articles/1591