Robotic and laparoscopic surgery of the pancreas: an historical review

Abstract

Surgery of the pancreas is a relatively new field, with operative series appearing only in the last 50 years. Surgery of the pancreas is technically challenging. The entire field of general surgery changed radically in 1987 with the introduction of the laparoscopic cholecystectomy. Minimally Invasive surgical techniques rapidly became utilized worldwide for gallbladder surgery and were then adapted to other abdominal operations. These techniques are used regularly for surgery of the pancreas including distal pancreatectomy and pancreatoduodenectomy. The progression from open surgery to laparoscopy to robotic surgery has occurred for many operations including adrenalectomy, thyroidectomy, colon resection, prostatectomy, gastrectomy and others. Data to show a benefit to the patient are scarce for robotic surgery, although both laparoscopic and robotic surgery of the pancreas have been shown not to be inferior with regard to major operative and oncologic outcomes. While there were serious concerns when laparoscopy was first used in patients with malignancies, robotic surgery has been used in many benign and malignant conditions with no obvious deterioration of outcomes. Robotic surgery for malignancies of the pancreas is well accepted and expanding to more centers. The importance of centers of excellence, surgeon experience supported by a codified mastery-based training program and international registries is widely accepted. Robotic pancreatic surgery is associated with slightly decreased blood loss and decreased length of stay compared to open surgery. Major oncologic outcomes appear to have been preserved, with some studies showing higher rates of R0 resection and tumor-free margins. Patients with lesions of the pancreas should find a surgeon they trust and do not need to be concerned with the operative approach used for their resection. The step-wise approach that has characterized the growth in robotic surgery of the pancreas, in contradistinction to the frenzy that accompanied the introduction of laparoscopic cholecystectomy, has allowed the identification of areas for improvement, many of which lie at the junction of engineering and medical practice. Refinements in robotic surgery depend on a partnership between engineers and clinicians.

Keywords: Cancer; Laparoscopy; Pancreas; Robotic surgery.

Fig. 1

The DaVinci system includes three components, a patient cart, a surgeon console and a vision cart. a There are several patient carts available including the Xi (shown here), X and SP. The surgeon console and vision cart are shared among all models. The system shown here is for simulation and practice and includes two surgeon’s consoles. b The surgeon’s cart has an optical viewing system (white arrow), two manipulation handles (red arrows) and five pedals (green arrows). c The patient cart has the articulating arms which hold the instruments that are inserted into the patient. Reprinted under a Creative Commons license from Chammas J et al. Trans Vis Sci Tech 2017 6:21. doi: 10.1167/tvst.6.3.21

Fig. 2

A typical configuration of the DaVinci robot in the operating room. Note that all team members have a clear view of the Vision Cart. Adapted from Ju YY and King JC. J. Vis Surgery 2017. 3:139. doi: 10.21037/jovs.2017.08.14