Reduced-port robotic pancreaticoduodenectomy with optimized surgical field deployment: early results of single-site plus-two ports method

Abstract

Background: The adoption of Robotic Pancreaticoduodenectomy (RPD) is increasing globally. Meanwhile, reduced-port RPD (RPRPD) remains uncommon, requiring robot-specific techniques not possible with laparoscopy. We introduce a unique RPRPD technique optimizing surgical field exposure.

Methods: Our RPRPD utilizes a single-site plus-two ports technique, facilitated by a single-port platform through a 5-cm incision. The configuration of robotic arms (arm1, arm2, arm3, and arm4) were strategically designed for optimal procedural efficiency, with the arms2 and arm3, alongside the assistant trocar, mounted on the single-port platform, while the arms1 and arm4 were positioned laterally across the abdomen. Drainage was established via channels created at the arm1 and arm4 insertion sites. A "gooseneck traction" was principally employed with the robotic instrument to prop up the specimen rather than grasp, improving the surgical field's visibility and access. Clinical outcomes of patients who underwent RPRPD performed between August 2020 and September 2023 by a single surgeon across two centers in Taiwan and Japan were reviewed.

Results: Fifty patients underwent RPRPD using the single-site plus-two ports technique. The gooseneck traction technique enabled goodsurgical field deployment and allowed for unrestricted movement of robotic arms with no collisions with the assistant instruments. The median operative time was 351 min (250-488 min), including 271 min (219-422 min) of console time and three minutes (2-10 min) of docking time. The median estimated blood loss was 80 mL (1-872 mL). All RPRPD procedures were successfully performed without the need for conversion to open surgery. Postoperative major morbidity (i.e., Clavien-Dindo grade ≥ IIIa) was observed in 6 (12%) patients and median postoperative hospital stay was 13 days.

Conclusions: The single-site plus-two ports RPRPD with the gooseneck traction proves to be a safe, feasible option, facilitating surgical field visibility and robotic arm maneuverability.

Keywords: Minimally invasive pancreatectomy; Reduced-port robotic surgery; Robotic pancreaticoduodenectomy; Robotic surgical procedures; Single-port pancreatoduodenectomy.

Fig. 1

Robot and trocars setup. A The two robotic trocars and an assistant trocar installed on the single-port platform. B A schema of the incision. The single-port platform was installed on the 5 cm measured transumbilical incision (triangular arrow), with the robotic trocars placed on both sides of the abdomen (arrow). C Robotic arms are placed as a single-site plus-two ports technique

Fig. 2

Intraoperative pictures. Intraoperative pictures in resection of reduced-port robotic pancreaticoduodenectomy. A A gooseneck traction in the Kocher’s maneuver. B The jejunum was pulled out to the right side then the mesentery of the jejunum was divided along the first jejunal artery (dotted line). C The IPDA (arrow) was identified and clamped. D The plexus around the pancreatic head was dissected and the posterior wall of the SMV was exposed. E Following transecting the pancreas on the SMV, the specimen was taken out with only some branches resected. GCT gastrocolic trunk, IPDA inferior pancreaticoduodenal artery, Ph pancreatic head, PSPDV posterior superior pancreatoduodenal vein, SMA superior mesenteric artery, SMV superior mesenteric vein

Fig. 3

Postoperative wounds. The wound after reduced-port robotic pancreaticoduodenectomy. A 5 cm diameter incision and two drainage tubes from both sides. B One month after surgery

Fig. 4

Learning curve for perioperative outcome. A Trends in the learning curve for operative time, blood loss, and postoperative hospital stay. B Cumulative sum charts for operative time, blood loss, and postoperative hospital stay. Abbreviations, CUSUM; cumulative sum