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. 2023 Apr;37(4):2659-2672.
doi: 10.1007/s00464-022-09735-4. Epub 2022 Nov 18.

Impact of shifting from laparoscopic to robotic surgery during 600 minimally invasive pancreatic and liver resections

Anouk M L H Emmen  1   2 , B Görgec  1   2 , M J W Zwart  1   2 , F Daams  2   3 , J Erdmann  1   2 , S Festen  1   2   4 , D J Gouma  1   2 , T M van Gulik  1   2 , J van Hilst  1   2 , G Kazemier  2   3 , S Lof  1   2 , S I Sussenbach  1   2 , P J Tanis  1   2 , B M Zonderhuis  2   3 , O R Busch  1   2 , R J Swijnenburg  1   2   3 , M G Besselink  5   6 ; for HPB-Amsterdam
Affiliations

Impact of shifting from laparoscopic to robotic surgery during 600 minimally invasive pancreatic and liver resections

Anouk M L H Emmen et al. Surg Endosc. 2023 Apr.

Erratum in

Abstract

Background: Many centers worldwide are shifting from laparoscopic to robotic minimally invasive hepato-pancreato-biliary resections (MIS-HPB) but large single center series assessing this process are lacking. We hypothesized that the introduction of robot-assisted surgery was safe and feasible in a high-volume center.

Methods: Single center, post-hoc assessment of prospectively collected data including all consecutive MIS-HPB resections (January 2010-February 2022). As of December 2018, all MIS pancreatoduodenectomy and liver resections were robot-assisted. All surgeons had participated in dedicated training programs for laparoscopic and robotic MIS-HPB. Primary outcomes were in-hospital/30-day mortality and Clavien-Dindo ≥ 3 complications.

Results: Among 1875 pancreatic and liver resections, 600 (32%) were MIS-HPB resections. The overall rate of conversion was 4.3%, Clavien-Dindo ≥ 3 complications 25.7%, and in-hospital/30-day mortality 1.8% (n = 11). When comparing the period before and after the introduction of robotic MIS-HPB (Dec 2018), the overall use of MIS-HPB increased from 25.3 to 43.8% (P < 0.001) and blood loss decreased from 250 ml [IQR 100-500] to 150 ml [IQR 50-300] (P < 0.001). The 291 MIS pancreatic resections included 163 MIS pancreatoduodenectomies (52 laparoscopic, 111 robotic) with 4.3% conversion rate. The implementation of robotic pancreatoduodenectomy was associated with reduced operation time (450 vs 361 min; P < 0.001), reduced blood loss (350 vs 200 ml; P < 0.001), and a decreased rate of delayed gastric emptying (28.8% vs 9.9%; P = 0.009). The 309 MIS liver resections included 198 laparoscopic and 111 robotic procedures with a 3.6% conversion rate. The implementation of robotic liver resection was associated with less overall complications (24.7% vs 10.8%; P = 0.003) and shorter hospital stay (4 vs 3 days; P < 0.001).

Conclusion: The introduction of robotic surgery was associated with greater implementation of MIS-HPB in up to nearly half of all pancreatic and liver resections. Although mortality and major morbidity were not affected, robotic surgery was associated with improvements in some selected outcomes. Ultimately, randomized studies and high-quality registries should determine its added value.

Keywords: Distal pancreatectomy; Liver surgery; Minimally invasive; Pancreatoduodenectomy.

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Conflict of interest statement

M.G. Besselink has received an Intuitive grant for the LEARNBOT European Robotic Pancreatoduodenectomy training program, the DIPLOMA-2 trial and the E-MIPS quality registry. A Medtronic grant for the investigator-initiated DIPLOMA trial. An Ethicon grant for the PANDORINA trial and the E-MIPS quality registry. A.M.L.H. Emmen, B. Görgec, M.J.W. Zwart, F. Daams, J. Erdmann, S. Festen, D.J. Gouma, T.M. van Gulik, J. van Hilst, G. Kazemier, S. Lof, S.I. Sussenbach, P.J. Tanis, B.M. Zonderhuis, O.R. Busch, R.J. Swijnenburg have no conflict of interest or financial ties to disclose.

Figures

Fig. 1
Fig. 1
Flow diagram of all minimally invasive HPB procedures
Fig. 2
Fig. 2
Total volume and annual rate of MIS-HPB in relation to all pancreatic and liver resections
Fig. 3
Fig. 3
Competency learning curve of operative time in minimally invasive pancreatoduodenectomy and liver resections. A & C The X-axis indicated groups of 10 consecutive cases, color indicated per approach (laproscopic = blue squares, robotics = red dots), and the Y-axis indicates the combined operative time expressed in minutes (for liver resection, this way adjusted for extend of resection). The fit line indicated the mean operative time during the maturation of experience with grey lines indication in 95% confidence interval. B & D The X-axis indicates consecutive cases, color indicated per approach (laproscopic = blue squares, robotics = red dots) and the Y-axis indicates the CUSUM operative time expressed in standard deviations. In pancreatoduodenectomy, the label (n = 54) indicated the top turning point of the learning curve, hereafter, the learning curve follows a downward slope. In liver resections, the label [10] indicates the turning point where after both technically major- and anatomically major liver resections were performed. Hereafter, the label [174] indicates the top turning point of the learning curve for liver resections overall
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