A systematic review on robotic pancreaticoduodenectomy

Abstract

Background

Robotic surgery might have several advantages in respect of the laparoscopic approach since might make more feasible the execution of a complex procedure such as pancreaticoduodenectomy (PD). The aim of the present systematic review is to evaluate the current state of the literature on robotic PD.

Methods

A systematic literature search was performed, from January 1st 2003 to July 31st 2012, for studies which reported PDs performed for neoplasm and in which at least one surgical reconstructive or resective step was robotically performed.

Results

Thirteen studies, representing 207 patients, met the inclusion criteria. The definition of the robotic approach was heterogeneous since the technique was defined as robotic, robotic-assisted, robot-assisted laparoscopic and robotic hybrid. Resection and reconstruction steps of robotic PD were also heterogeneous combining sequentially different approaches: totally robotic technique, laparoscopic–robotic resection and robotic reconstruction, laparoscopic resection and robotic reconstruction, hand port-assisted laparoscopic resection and robotic reconstruction, laparoscopic–robotic resection and reconstruction through mini-laparotomy. As regard the type of PD 66% were classic Whipple operations and 34% pylorus-preserving pancreatoduodenectomies. The management of pancreatic stump was a pancreaticogastrostomy in 23%, end-to-side pancreaticojejunostomy in 67%, and fibrin glue occlusion of the main pancreatic duct in 10% of cases. The overall procedure failure (rates of conversion to open surgery) was 14%. The overall morbidity rate was 58% and the reoperation rate was 7.3%.

Conclusions

There have been an increasing number of recent case series suggesting increased utilization of robotic PD over the past decade. The technical approach is heterogenous. For highly selected patient, robotic PD is feasible with similar morbidity and mortality compared to open or purely laparoscopic approaches. Data on cost analysis are lacking and further studies are needed to evaluate also the cost-effectiveness of the robotic approach for PD in comparison to open or laparoscopic techniques. The current state of the art analysis on robotic DP can be also useful in planning future trials.

Introduction

Since 1938, when Whipple performed the first pancreaticoduodenectomy (PD) [1] until today, more than 70 years have passed, but very little has changed. In the 1990s it has been thought that laparoscopy could have introduced a significant shift with respect to conventional surgery. However, whereas the laparoscopic distal pancreatectomy (DP) is widely performed, a laparoscopic approach for PD is currently very uncommon [2]. Indeed, this procedure represents a challenging operation requiring an extensive dissection, followed by a complex restoration of the digestive continuity. The counter intuitive movements, the use of rigid instruments and the bi-dimensional vision of the laparoscopic technique are the main reasons behind the long learning curve of this approach. As a consequence, the laparoscopic PD is only performed in highly selected patients by surgeons with considerable experience.

Robotic surgery has several benefits in respect of the laparoscopic approach such as the three-dimensional binocular vision and the high number of degrees of freedom that make more feasible the execution of complex procedures such as PD. For these reasons, robotic surgery does not only represent a useful alternative to conventional surgery for pancreatic body and tail lesions, but could be also an optimal innovation for pancreatic head lesions. Nevertheless, only few cases of robotic PD have currently been reported [3], [4].

The aim of the present systematic review is to evaluate the current state of the literature on robotic PD.