Surg Endosc DOI 10.1007/s00464-014-4043-3
and Other Interventional Techniques
A prospective non-randomised single-center study comparing laparoscopic and robotic distal pancreatectomy Giovanni Butturini • Isacco Damoli • Lorenzo Crepaz • Giuseppe Malleo Giovanni Marchegiani • Despoina Daskalaki • Alessandro Esposito • Sara Cingarlini • Roberto Salvia • Claudio Bassi
•
Received: 5 August 2014 / Accepted: 11 December 2014 Ó Springer Science+Business Media New York 2014
Abstract Background Laparoscopic distal pancreatectomy (LDP) is increasing in popularity thanks to the benefits that have been recently demonstrated by many authors. The Da VinciÒ Surgical System could overcome some limits of laparoscopy, helping the surgeons to perform safer and faster difficult procedures. Nowadays, prospective clinical trials comparing LDP to robotic distal pancreatectomy (RDP) are lacking. The aim of this study is to present a prospective comparison between the two techniques. Methods Since November 2011, all patients suitable for minimally invasive distal pancreatectomy were assigned either to LDP or RDP, depending on the availability of the Da VinciÒ Surgical System for our Surgical Unit. Demographics, clinical, and intra- and postoperative data, including estimated costs of the procedure, were prospectively collected. Follow-up included cross-sectional imaging ended on April 2014. Results Twenty-two patients underwent RDP and 21 LDP; patients’ characteristics were similar. The median operative time was longer and procedures’ cost was double in RDP group. The conversion to open rate and the median length of postoperative hospital stay were 4.5 % and 7 days, respectively, in both groups. Pancreatic fistula
G. Butturini (&) I. Damoli L. Crepaz G. Malleo G. Marchegiani D. Daskalaki A. Esposito R. Salvia C. Bassi General Surgery B, The Pancreas Institute, Verona University Hospital Trust, Piazzale L.A. Scuro, 10, 37134 Verona, Italy e-mail: [email protected] S. Cingarlini Department of Oncology, The Pancreas Institute, Verona University Hospital Trust, Piazzale L.A. Scuro, 10, 37134 Verona, Italy
developed in 57.1 % (12/21) and 50 % (11/22) of LDP and RDP, respectively (p = 0.870), being grade A the most frequent. Mortality was nil and an R0 resection was achieved in all Patients. The overall number of lymph nodes harvested was similar between the two groups. Conclusions Both RDP and LDP are valid techniques for the treatment of distal pancreatic tumors. The advantages of RDP are claimed by many but still under investigation. Some of these advantages are more subjective than objective, and it seems difficult to demonstrate a real superiority of one technique over the other in a standardized fashion. In our experience, laparoscopy has not been abandoned in favor of the robot: we continue to perform both approaches choosing upon single patient’s characteristics. Keywords Distal pancreatectomy Laparoscopy Robotic surgery Prospective study Pancreatic surgery Robot-assisted surgery
The minimally invasive approach for pancreatic surgery represents one of the most recent and challenging fields in abdominal surgery. The laparoscopic approach has been applied for benign and borderline malignant neoplasms of the left pancreas more than 20 years ago [1]. Despite the fact that randomized clinical trials are still lacking, laparoscopic distal pancreatectomy (LDP) is nowadays widely accepted and preferred over the traditional open approach because of its clinical benefits in terms of lower blood loss and reduced length of stay [2–5]. The use of laparoscopy for malignant tumors is still matter of debate, although some Authors have reported no differences compared to the open approach [6–11].
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At the end of the last century, the introduction of robotic technology allowed to overcome some of the limits of laparoscopy [12]. The first robotic distal pancreatectomy (RDP) was reported by Melvin et al. in 2003 [13], and in the same year Giulianotti et al. published their experience on a first series of five RDPs [14]. The principal advantages of robotic technology over laparoscopy include reduction of natural tremors, absence of fulcrum effect, threedimensional and high-definition vision, seven degrees of freedom compared to three (Endowrist technologyÒ), and improved ergonomics for the surgeon. All these features facilitate performing challenging procedures, maintaining all the benefits of a minimally invasive approach [15–17]. Nevertheless, randomized clinical trials are still lacking in order to demonstrate that these potential advantages correspond to an actual superiority of the robot-assisted distal pancreatectomy over the laparoscopic. Finally, it is well established that robotic surgery increases operative costs. However, it could be argued that the increasing precision and safety of robotic technology can potentially reduce postoperative complications, hospital stay, and consequently the overall costs. The aim of this prospective non-randomized study is to compare the intra-operative results, costs, and short-term outcomes between patients undergoing laparoscopic and robot-assisted distal pancreatectomy.
Materials and methods The study was approved by the Institutional Review Board. From November 2011 to January 2014, after obtaining the informed consent, all patients suitable for minimally invasive distal pancreatectomy were assigned either to LDP or RDP depending on the availability of the Da VinciÒ Surgical System, since our system is shared with the Departments of Urology and Thoracic surgery. The decision on whether to perform a minimally invasive distal pancreatectomy was taken by senior surgeons and was discussed in the context of a multidisciplinary institutional meeting. Indications for minimally invasive approach during the study period were: neoplasms \10 cm with benign or borderline features on cross-sectional imaging or small adenocarcinomas without evidence of major vessel involvement. Demographics, clinical, and intra- and postoperative data, including estimated costs of the procedure, were prospectively collected. Moreover, in order to gain insight into the learning process, we compared the RDP and LDP operative times with a historical group of LDP performed by the same surgeon, during his initial experience (GB, from August 2005 to April 2008).
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Costs were calculated by including only the price of the surgical instruments and do not take into account the operating room functioning and postoperative costs. Follow-up was conducted through clinical examination, routine blood tests, and cross-sectional imaging, as appropriate. For the purposes of this study, the last followup visit was scheduled on April 2014. Technical details The spleen preservation was attempted whenever possible, and the preferred technique for splenic salvage was that described by Kimura et al. (splenic vessels conservation) [18]. LDP was performed as previously described by this group [19]. In the study period, we favored parenchymal transection using an ultrasonic device (harmonic shears). An endostapler was employed in case of a particularly thick pancreatic gland. In RDP, pneumoperitoneum was induced using the Verres needle, and the robotic camera was introduced via a supraumbilical access. Four other trocars were inserted, and then the gastrocolic ligament was divided using an ultrasonic device (harmonic shears). Afterward, we proceed with the docking of the robotic system, and the subsequent surgical steps were the same as for the laparoscopic technique. In both LDP and RDP, an intraoperative ultrasound was performed, whenever necessary, to exactly identify and characterize the tumor. After the procedure completion, a single Penrose-like drain was placed close to the pancreatic stump. Definition of postoperative complications Pancreatic fistula (PF) was defined and classified according to the ISGPF [20]; a fluid collection was identified through CT scan or US as the presence of fluid greater than 5 cm in diameter, with or without clinical relevance; acute pancreatitis was defined as a threefold increase of normal plasmatic amylase or lipase values from the 4th postoperative day, confirmed by CT scan findings and clinical course; early postoperative hemorrhage was defined according to the ISGPS [21]. Statistical analysis Continuous variables were expressed as medians with range, and non-parametric tests (Mann–Whitney U) were employed for statistical comparison. v2 test (with Yates continuity correction in a 2 9 2 contingency table) was used for nominal data, and two-tailed Fisher’s exact test was used in the case of a small expected frequency. Data were considered significant for p \ 0.05. SPSS (rel. 21)
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programs were used for statistical analysis (SPSS Inc., Chicago, IL).
of the two study groups, compared with an historic group of LDP. The median operative time was 195 min (145–415) for LDP and 265 min (145–420) for RDP (p = 0.003). RDP was associated with an increased operative time. In this group, the mean docking time was 25 min, and the mean console time was 160 min. The reasons for conversion to open procedures were an uncontrolled bleeding during pancreatic transection from the splenic artery in the patient undergoing RDP, and strong adhesions between the tumor and the splenic vessels
Results A total of 43 patients underwent minimally invasive distal pancreatectomy during the study period. In particular, 22 patients underwent an RDP, and 21 patients an LDP. Table 1 summarizes the demographic and surgical details
Table 1 Demographic and operative details of patients undergoing minimally invasive distal pancreatectomy Laparoscopic DP n = 21 (%)
Robotic DP n = 22 (%)
Historic laparoscopic n = 22 (%)
p value
Male
6 (28.5)
5 (22.7)
5 (22.7)
0.929
Female
15 (71.5)
17 (77.3)
17 (77.3)
55 (20–71)
54 (26–77)
49 (28–73)
0.009
I
5 (23.8)
3 (13.6)
NA
0.573
II
16 (76.2)
18 (81.8)
III
0
1 (4.5)
Sex
Median age, years (range) ASA class
IV Median BMI (Kg/m2)
0
0
24.19
25.33
22.7
0.263
13 (61.9) 8 (38.1)
15 (68.2) 7 (31.8)
15 (68.2) 7 (31.8)
0.911 0.011
Previous abdominal surgery Yes No Median operative time, min (range)
195
265
227,5
(145–415)
(145–420)
(135–340)
Yes
1 (4.7)
1 (4.5)
2 (9.1)
No
20 (95.7)
21 (95.5)
20 (90.9)
Yes
4 (19)
6 (27.3)
8 (36.4)
No
17 (81)
16 (72.7)
14 (63.2)
Yes
6 (28.6)
10 (45.4)
8 (36.4)
No
15 (71.4)
12 (54.6)
14 (63.6)
Cholecistectomy
5
4
4
Left adrenalectomy
1
1
0
Peritoneal biopsy
1
1
1
Hepatic biopsy Hernia repair
0 0
2 2
2 0
Annessiectomy
0
0
1
Yes
0
3 (13)
1 (4.5)
No
21 (100)
19 (87)
21 (95.5)
Conversion 0.842
Spleen preservation 0.782
Associated procedures 0.516
Blood transfusions
Procedure costs, Euros (range)
1500
3000
1450
(1434–1674)
(2700–3190)
(1250–1674)
0.312 0.001
ASA American Society of Anesthesiologists classification, BMI body mass index
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pancreatitis with multiple fluid collections, which required surgical drainage. Of note, these two latter patients were re-admitted and re-operated in other hospitals with emergency procedures. Two additional patients underwent reoperation at our Institution. The former underwent splenectomy on POD 4 via open approach because of multiple splenic infarctions after a spleen-preserving RDP and was discharged on POD 17. The latter underwent two reoperations on POD 6 and POD 8 after a spleen-preserving LDP, both for abdominal bleeding. The two surgeries consisted of a laparoscopic toilette first and a laparoscopic splenectomy after. The patient was eventually discharged on POD 26. Overall, one patient in the LDP (4.7 %) and three in the RDP (13.6 %) group, respectively, experienced a clinically significant complication (Grade III–IV) according to the Clavien– Dindo Classification [22] (p = 0.611). Table 3 summarizes the pathologic details. An R0 resection was achieved in all cases. At a median follow-up of 12 months (Table 4), all patients were alive. Among the five Patients with pancreatic ductal adenocarcinoma, two developed metastatic disease, 9 and 10 months after surgery.
in the patient undergoing the laparoscopic procedure. In the LDP group, transection of the pancreatic parenchyma was performed via ultrasonic shears in 18 patients (85.7 %), and a linear endostapler was used in the three remaining cases (14.3 %). In all the cases completed robotically, ultrasonic shears were used. Costs of an LDP procedure ranged between 1,434 and 1,674 Euros, depending on the instrument used for the pancreatic transection (being the stapler more expensive), while costs of an RDP were in the range 2,700–3,190 Euros, depending on the type of ultrasonic shears used in the operation (being the robotic one more expensive). Table 2 outlines the postoperative results. Fifteen patients in each group had a complicated postoperative course (71.4 % in the LDP group and 68.2 % in the RDP group, p = 0.887). Although the rate of PF was in excess of 50 %, the majority of these fistulas were not clinically relevant (grade A). The only patient requiring readmission in LDP group had portal vein thrombosis and fever. Among the four patients re-admitted in the RDP group, two had a peripancreatic fluid collection treated conservatively; one had an abdominal abscess surgically drained, and one developed severe postoperative acute
Table 2 Postoperative results after laparoscopic and robotic distal pancreatectomy
Laparoscopic DP n = 21 (%) Median LOS, days (range)
Robotic DP n = 22 (%)
7 (3–33)
7 (4–28)
12 (57.1) 9 (42.9)
11 (50.0) 11 (50.0)
p value 0.835
Pancreatic fistula Yes No Grade A
8
8
Grade B
4
2
Grade C
0
1
0.605*
Peripancreatic fluid collection Yes
3 (14.3)
7 (31.8)
No
18 (85.7)
15 (68.2)
Yes
2 (2.5)
1 (4.5)
No
19 (97.5)
21 (96.5)
0.318
Blood transfusions 0.314
Discharged with drainage Yes
7 (33.3)
9 (40.9)
No
14 (66.7)
13 (50.1)
6 (28.5)
7 (31.8)
15 (71.5)
15 (68.2)
0.841
Extra-abdominal complications Yes No Reoperation within 90 days Yes
1 (4.7)
3 (13.6)
No
20 (95.3)
19 (88.4)
1
0.634
Readmission within 90 days
* Fistula yes versus Fistula no
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Yes
1 (4.7)
4 (18.2)
No
20 (95.3)
18 (81.8)
0.344
Surg Endosc Table 3 Pathology Laparoscopic DP n = 21
Robotic DP n = 22
p value
Pathologic diagnosis Neuroendocrine neoplasms
9
8
MCN (invasive)
7 (1)
6
SCN
2
0
SPN
1
3
PDAC
2
3
Ectopic spleen
0
1
Other
0
1
0.397
Median number of lymph nodes harvested (range)
15 (1–47)
11.5 (0–37)
0.313
Median tumor size, mm (range)
35 (15–75)
25.5 (5–90)
0.116
MCN mucinous cystic neoplasms, SCN serous cystic neoplasms, SPN solid pseudopapillary neoplasms, PDAC pancreatic ductal adenocarcinoma
Table 4 Follow-up
Laparoscopic DP n = 21 (%) Median follow-up, months Diabetes mellitus
15
Robotic DP n = 22 (%)
p value
10.5
0.465
Yes
1 (4.7)
1 (4.5)
No
20 (95.3)
21 (95.5)
0.744
Incisional hernia Yes
1 (4.7)
1 (4.5)
No
20 (95.3)
21 (95.5)
0.744
Post-splenectomy thrombocytosisa Yes
1 (5.5)
4 (25)
No
17 (94.5)
12 (75.0)
Yes
14 (77.7)
14 (87.5)
No
4 (22.3)
2 (12.5)
0.164
Post-splenectomy vaccinesa 0.660
Development of metastatic disease a
These data pertain to patients who underwent associated splenectomy
Yes No
Discussion The present study shows the results of a prospective nonrandomized analysis of 43 patients undergoing minimally invasive DP at the authors’ institution. Because the current literature is limited and the reported outcomes are controversial [12, 22], we sought to investigate possible differences in intra- and postoperative results between robotics and laparoscopy. The median operative time was longer in the robotic group as already reported in other studies [23, 24]. This finding is explainable in part by the docking time (inexistent in laparoscopy) and in part by the burden of the learning curve. Of note, only one study [12] reported that RDP requires a shorter mean operative time (293 vs. 371 min) compared to LDP. When our last 21 LDP cases
0
2 (9)
21 (100 %)
0.488
20 (91)
were compared to a historic LDP group (n = 22) with similar population characteristics, we found that they required a shorter operative time (mean 212.6 vs. 239.1 min, p = 0.381), but the difference resulted as not significant. Other studies already showed that the learning curve for LDP could decrease the operative time, as well as the conversion to open rate. The minimum number of procedures required to achieve an optimal result is reported to be between 10 and 20 [25, 26]. The largest series[27] of RDP (n = 83) is included in a consecutive series of 250 robotic pancreatic resections analyzed for safety and feasibility. In the RDP group, the incidence of clinically significant complications (Clavien– Dindo grade III or IV) was 13 %. Examining the pancreatoduodenectomy, but not DP cohort, they were able to demonstrate a decreasing trend in the incidence of severe
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complications in the last 40 cases (16 vs. 30 %, p \ 0.05). Also, operative time both for pancreatoduodenectomy and DP groups showed a positive trend over the course of the experience, eventually becoming equivalent to both the laparoscopic and open series. In the present series, four patients experienced severe complications needing reoperation: three were in the RDP (13.6 %) and only one in the LDP (4.7 %). The difference is not statistically significant, but we could not claim any superiority of the robot-assisted technique at least in the present series which represents the first 22 robotic operations of our surgical team. Nevertheless, our 13.6 % rate of clinically significant complications after RDP is similar to the one of the largest experience published [27]. We could argue that once a surgeon has gained a relevant experience in the LDP, his results are probably difficult to be matched via a robotic approach, at least for the first 40–50 cases. We believe that the interest and the efforts of the surgical community should be addressed toward developing new tools, in order to increase our ability with the robot approach in a training setting. PF is the most common abdominal complication after distal pancreatectomy. The reported incidence ranges between 0 and 45.7 %, without any difference between stapler and suture closure according to a large meta-analysis [28]. In our practice, we prefer using the ultrasonic device for the transection of the pancreatic parenchyma. Since a thicker parenchyma seems to be a risk factor for POPF, we prefer to use a linear endostapler in these cases, as suggested by Eguchi et al. in their retrospective analysis [29]. Only one patient out of 22 RDPs (4.5 %) required a conversion to open because of an uncontrolled bleeding from a branch of the splenic artery during pancreatic transection. The patient requiring conversion to open in the laparoscopic group was affected by a PDAC infiltrating the tissue around the splenic vessels, so the surgeon preferred to have direct, manual control of the vessels in order to prevent unexpected bleeding. A recent study [30] on robotic hepato-biliary and pancreatic surgery compared 77 patients with laparoscopic and open controls with the aim to analyze possible predictors for conversion. Major indications for conversion were inability to safely proceed with the surgery and/or technical difficulty with it, obesity, excessive bleeding, and instruments malfunctioning or inadequacy. In the group of pancreatic procedures (n = 71), they performed 39 RDPs (22 SPDP) and 15 patients (38.5 %) were converted to hand-assisted laparoscopy or open procedure. The Authors underline how visceral fat is the most important factor associated with conversion, because it can make robotic dissection, movement, or retraction impossible. Comparing LDP and RDP, the conversion rate was higher in the robotic group (39 vs. 22 %) and the main common indication was
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different too (major bleeding vs. technical difficulty). However, the incidence of conversions decreased with the increase of the learning curve. The spleen preservation rate in our series is lower when compared to others [16, 24], but indications for splenectomy need to be discussed. In fact, splenectomy can be planned before performing a distal pancreatectomy, in order to increase the oncological radicality or because of the anatomical relationship between the tumor, the splenic vessels, and the pancreatic tail seen at imaging. Either way, splenectomy might become necessary intraoperatively because of bleeding or the inability to ensure an adequate blood supply to the spleen. The pathologic findings of our patients, the majority being malignant or ‘‘borderline’’ tumors, justify the relevant number of splenectomies of our series. The size of the present study is too small to demonstrate a possible superiority of the robotic approach in achieving a higher spleen preservation rate. Nonetheless, we believe that the superior technical characteristics of the robot, such as the augmented, high-quality, 3-D vision and the precise, endowrist instrument motion, are enough to explain the potential superiority of the robot, which has been already established in larger studies [23, 31, 32]. Long-life expectancy associated with pancreatic benign tumors exposes the patients to potential post-splenectomy critical infections like overwhelming post-splenectomy infection (OPSI), even many years after surgery [33], confirming the indication to SPDP whenever indicated. Our intra-operative perception is that the robot can increase the spleen preservation rate through the same advantages that can reduce the conversion to open risk, since in both conditions the critical point is represented by the vascular control. In the present series, the median number of harvested lymph nodes was similar between LDP and RDP. Other authors showed that lymph node clearance is similar between minimally invasive DP and open DP (12 vs. 11) [34] and similar between RDP and open DP (12.5 vs. 13.2), but lower for LDP (5) [35]. With regards to pancreatic ductal adenocarcinoma, Daouady et al. [12] found final better outcomes with robotic techniques compared to laparoscopic. These were represented by R1 margin status of 0 versus 36 % (p \ 0.05) and a median nodal harvest of 19 (IQR 17, 24) versus 9 (IQR 7, 11) in RDP and LDP groups, respectively. In the present series, we treated five patients affected by PDAC, achieving in all cases an R0 and adequate number of harvested lymph nodes. Nevertheless, two of these 5 patients had liver metastases within 1 year from the operation and they both were treated with the robot. The first had a 27 mm G2 PDAC, associated to 2 peripancreatic metastatic lymph nodes out of 33 collected, while the mass was 1 cm distant from the neck resection margin. The tumor was in
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proximity to the peritoneum and there was infiltration of the peripancreatic adipose tissue and of the splenic vein. The second patient had a 35 mm G3 PDAC with very aggressive microscopic characteristics, such as massive infiltration of the peripancreatic adipose tissue, massive infiltration of vascular structures including the splenic vein, and obvious involvement of the peritoneum. In this case, two out of 22 nodes were found to be metastatic. The scarce number of PDAC in the present series does not allow any conclusions; however it looks clear that the intrinsic nature of cancer rather than the resection technique plays a major role in determining the prognosis. We found that RDP is more expensive than LDP. In the light of reducing the costs but at the same time aimed to explore new technologies, we adopted a ‘‘hybrid’’ approach for RDP using laparoscopic ultrasonic shears instead of the robotic. As a result, 500 € were saved for each procedure. We could also save 250 € using the laparoscopic ultrasonic shears for the pancreatic gland transection instead of the linear endostapler (of note, none of the two instruments is superior in reducing the incidence of POPF) [28]. Since the incidence of postoperative complications was not statistically different between the two groups, we can say that the difference in costs is procedure-related only. The economic advantage in favor of the robotic approach (including the costs of the instruments and of the hospitalization that are mainly complication related) is still under debate since different studies report different conclusions. Waters et al. [23] found that robotics is associated with a shorter LOS (4 vs. 8 vs. 6 days) and lower overall costs (10.588$ vs. 16.059$ vs. 12.986$), despite the more expensive equipment, when compared to either open and laparoscopic approach. Authors conclude that RDP is safe and costeffective in selected cases. Kang et al. analyzed a total of 45 Patients (25 laparoscopic and 20 robotic) undergoing distal pancreatectomy and showing that the robotic system has higher surgery-associated costs (8,304 vs. 3,861 USD). Interestingly, in this study the increased intraoperative costs were not balanced by a shorter LOS (7.1 vs. 7.3 days). While clinical and economic advantages are still under discussion, robotic technology has some non-measurable benefits: it is ergonomically more comfortable, it gives a feeling of stability and security, the surgeon feels that each surgical step of the procedure is safer and faster, and that the result is more precise. As a consequence, surgeons who have the opportunity to use the robot prefer RDP to LDP, even though a proper evidence-based superiority is still lacking. Another reason is that RDP represents a relatively young procedure, and it still needs to be explored in more robust clinical studies. Although the present study is the first prospective comparison between RDP and LDP, it has major limitations. First, the indications to minimally invasive approach
for left-sided pancreatic lesions are not clearly standardized. Second, the choice between laparoscopic and robotic approach is not randomized, although the criterion was the availability of the system for our surgical unit. Finally, the experience of the team was wider for laparoscopic techniques than for robotic, which started at the beginning of the present study period.
Conclusions Both RDP and LDP are valid techniques for the minimal invasive treatment of the neoplasms of the distal pancreas. The advantages of RDP are claimed by many but still under investigation. Some of these advantages are more subjective than objective, and it seems difficult to demonstrate a real superiority of one technique over the other in a standardized fashion. In our experience, laparoscopy has not been abandoned in favor of the robot and we continue to perform both approaches choosing upon the characteristics of the single patient. Independently from the approach, the safety of the patients and the need for oncological radicality are the milestones of the minimally invasive surgery of the left pancreas. In a recent paper by Heemskerk et al. [36], a provocative question arose: Are we already facing the end of robot-assisted laparoscopy? In their critical appraisal, the Authors analyzed the results of clinical studies in many fields of surgery regarding the application of the robotic techniques. Pancreatic resections are not included among the gastrointestinal surgeries. However, we agree with their conclusion, since we strongly believe that robot-assisted distal pancreatectomies are yet to be abandoned. Disclosures Dr. G. Butturini, Dr. I. Damoli, Dr. L. Crepaz, Dr. G. Malleo, Dr. G. Marchegiani, Dr. D. Daskalaki, Dr. A. Esposito, Dr. S. Cingarlini, Dr. R. Salvia, and Prof. C. Bassi have no conflicts of interests or financial ties to disclose.
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21. Wente MN et al (2007) Postpancreatectomy hemorrhage (PPH): an international study group of pancreatic surgery (ISGPS) definition. Surgery 142:20–25 22. Clavien PA et al (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250:187–196 23. Waters JA et al (2010) Robotic distal pancreatectomy: cost effective? Surgery 148:814–823 24. Kang CM, Kim DH, Lee WJ, Chi HS (2011) Conventional laparoscopic and robot-assisted spleen-preserving pancreatectomy: does da Vinci have clinical advantages? Surg Endosc 25:2004–2009 25. Ricci C et al (2015) Laparoscopic distal pancreatectomy: what factors are related to the learning curve? Surg Today 45:50–56 26. Braga M et al (2012) Learning curve for laparoscopic distal pancreatectomy in a high-volume hospital. Updat Surg 64: 179–183 27. Zureikat AH et al (2013) 250 robotic pancreatic resections: safety and feasibility. Ann Surg 258:554–559 discussion 559-562 28. Zhou W et al (2010) Stapler vs suture closure of pancreatic remnant after distal pancreatectomy: a meta-analysis. Am J Surg 200:529–536 29. Eguchi H et al (2011) A thick pancreas is a risk factor for pancreatic fistula after a distal pancreatectomy: selection of the closure technique according to the thickness. Dig Surg 28:50–56 30. Hanna EM et al (2013) Robotic hepatobiliary and pancreatic surgery: lessons learned and predictors for conversion. Int J Med Robot Comput Assist Surg 9:152–159 31. Hwang HK et al (2013) Robot-assisted spleen-preserving distal pancreatectomy: a single surgeon’s experiences and proposal of clinical application. Surg Endosc 27:774–781 32. Strijker M et al (2013) Robot-assisted pancreatic surgery: a systematic review of the literature. HPB 15:1–10 33. Dalla Bona E, Beltrame V, Liessi F, Sperti C (2012) Fatal pneumococcal sepsis eleven years after distal pancreatectomy with splenectomy for pancreatic cancer. JOP 13:693–695 34. Magge D et al (2013) Comparative effectiveness of minimally invasive and open distal pancreatectomy for ductal adenocarcinoma. JAMA Surg 148:525–531 35. Duran H et al (2014) Does robotic distal pancreatectomy surgery offer similar results as laparoscopic and open approach? A comparative study from a single medical center. Int J Med Robot Comput Assist Surg 10:280–285 36. Heemskerk J, Bouvy ND, Baeten CG (2014) The end of robotassisted laparoscopy? A critical appraisal of scientific evidence on the use of robot-assisted laparoscopic surgery. Surg Endosc 28:1388–1398
and Other Interventional Techniques
A prospective non-randomised single-center study comparing laparoscopic and robotic distal pancreatectomy Giovanni Butturini • Isacco Damoli • Lorenzo Crepaz • Giuseppe Malleo Giovanni Marchegiani • Despoina Daskalaki • Alessandro Esposito • Sara Cingarlini • Roberto Salvia • Claudio Bassi
•
Received: 5 August 2014 / Accepted: 11 December 2014 Ó Springer Science+Business Media New York 2014
Abstract Background Laparoscopic distal pancreatectomy (LDP) is increasing in popularity thanks to the benefits that have been recently demonstrated by many authors. The Da VinciÒ Surgical System could overcome some limits of laparoscopy, helping the surgeons to perform safer and faster difficult procedures. Nowadays, prospective clinical trials comparing LDP to robotic distal pancreatectomy (RDP) are lacking. The aim of this study is to present a prospective comparison between the two techniques. Methods Since November 2011, all patients suitable for minimally invasive distal pancreatectomy were assigned either to LDP or RDP, depending on the availability of the Da VinciÒ Surgical System for our Surgical Unit. Demographics, clinical, and intra- and postoperative data, including estimated costs of the procedure, were prospectively collected. Follow-up included cross-sectional imaging ended on April 2014. Results Twenty-two patients underwent RDP and 21 LDP; patients’ characteristics were similar. The median operative time was longer and procedures’ cost was double in RDP group. The conversion to open rate and the median length of postoperative hospital stay were 4.5 % and 7 days, respectively, in both groups. Pancreatic fistula
G. Butturini (&) I. Damoli L. Crepaz G. Malleo G. Marchegiani D. Daskalaki A. Esposito R. Salvia C. Bassi General Surgery B, The Pancreas Institute, Verona University Hospital Trust, Piazzale L.A. Scuro, 10, 37134 Verona, Italy e-mail: [email protected] S. Cingarlini Department of Oncology, The Pancreas Institute, Verona University Hospital Trust, Piazzale L.A. Scuro, 10, 37134 Verona, Italy
developed in 57.1 % (12/21) and 50 % (11/22) of LDP and RDP, respectively (p = 0.870), being grade A the most frequent. Mortality was nil and an R0 resection was achieved in all Patients. The overall number of lymph nodes harvested was similar between the two groups. Conclusions Both RDP and LDP are valid techniques for the treatment of distal pancreatic tumors. The advantages of RDP are claimed by many but still under investigation. Some of these advantages are more subjective than objective, and it seems difficult to demonstrate a real superiority of one technique over the other in a standardized fashion. In our experience, laparoscopy has not been abandoned in favor of the robot: we continue to perform both approaches choosing upon single patient’s characteristics. Keywords Distal pancreatectomy Laparoscopy Robotic surgery Prospective study Pancreatic surgery Robot-assisted surgery
The minimally invasive approach for pancreatic surgery represents one of the most recent and challenging fields in abdominal surgery. The laparoscopic approach has been applied for benign and borderline malignant neoplasms of the left pancreas more than 20 years ago [1]. Despite the fact that randomized clinical trials are still lacking, laparoscopic distal pancreatectomy (LDP) is nowadays widely accepted and preferred over the traditional open approach because of its clinical benefits in terms of lower blood loss and reduced length of stay [2–5]. The use of laparoscopy for malignant tumors is still matter of debate, although some Authors have reported no differences compared to the open approach [6–11].
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At the end of the last century, the introduction of robotic technology allowed to overcome some of the limits of laparoscopy [12]. The first robotic distal pancreatectomy (RDP) was reported by Melvin et al. in 2003 [13], and in the same year Giulianotti et al. published their experience on a first series of five RDPs [14]. The principal advantages of robotic technology over laparoscopy include reduction of natural tremors, absence of fulcrum effect, threedimensional and high-definition vision, seven degrees of freedom compared to three (Endowrist technologyÒ), and improved ergonomics for the surgeon. All these features facilitate performing challenging procedures, maintaining all the benefits of a minimally invasive approach [15–17]. Nevertheless, randomized clinical trials are still lacking in order to demonstrate that these potential advantages correspond to an actual superiority of the robot-assisted distal pancreatectomy over the laparoscopic. Finally, it is well established that robotic surgery increases operative costs. However, it could be argued that the increasing precision and safety of robotic technology can potentially reduce postoperative complications, hospital stay, and consequently the overall costs. The aim of this prospective non-randomized study is to compare the intra-operative results, costs, and short-term outcomes between patients undergoing laparoscopic and robot-assisted distal pancreatectomy.
Materials and methods The study was approved by the Institutional Review Board. From November 2011 to January 2014, after obtaining the informed consent, all patients suitable for minimally invasive distal pancreatectomy were assigned either to LDP or RDP depending on the availability of the Da VinciÒ Surgical System, since our system is shared with the Departments of Urology and Thoracic surgery. The decision on whether to perform a minimally invasive distal pancreatectomy was taken by senior surgeons and was discussed in the context of a multidisciplinary institutional meeting. Indications for minimally invasive approach during the study period were: neoplasms \10 cm with benign or borderline features on cross-sectional imaging or small adenocarcinomas without evidence of major vessel involvement. Demographics, clinical, and intra- and postoperative data, including estimated costs of the procedure, were prospectively collected. Moreover, in order to gain insight into the learning process, we compared the RDP and LDP operative times with a historical group of LDP performed by the same surgeon, during his initial experience (GB, from August 2005 to April 2008).
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Costs were calculated by including only the price of the surgical instruments and do not take into account the operating room functioning and postoperative costs. Follow-up was conducted through clinical examination, routine blood tests, and cross-sectional imaging, as appropriate. For the purposes of this study, the last followup visit was scheduled on April 2014. Technical details The spleen preservation was attempted whenever possible, and the preferred technique for splenic salvage was that described by Kimura et al. (splenic vessels conservation) [18]. LDP was performed as previously described by this group [19]. In the study period, we favored parenchymal transection using an ultrasonic device (harmonic shears). An endostapler was employed in case of a particularly thick pancreatic gland. In RDP, pneumoperitoneum was induced using the Verres needle, and the robotic camera was introduced via a supraumbilical access. Four other trocars were inserted, and then the gastrocolic ligament was divided using an ultrasonic device (harmonic shears). Afterward, we proceed with the docking of the robotic system, and the subsequent surgical steps were the same as for the laparoscopic technique. In both LDP and RDP, an intraoperative ultrasound was performed, whenever necessary, to exactly identify and characterize the tumor. After the procedure completion, a single Penrose-like drain was placed close to the pancreatic stump. Definition of postoperative complications Pancreatic fistula (PF) was defined and classified according to the ISGPF [20]; a fluid collection was identified through CT scan or US as the presence of fluid greater than 5 cm in diameter, with or without clinical relevance; acute pancreatitis was defined as a threefold increase of normal plasmatic amylase or lipase values from the 4th postoperative day, confirmed by CT scan findings and clinical course; early postoperative hemorrhage was defined according to the ISGPS [21]. Statistical analysis Continuous variables were expressed as medians with range, and non-parametric tests (Mann–Whitney U) were employed for statistical comparison. v2 test (with Yates continuity correction in a 2 9 2 contingency table) was used for nominal data, and two-tailed Fisher’s exact test was used in the case of a small expected frequency. Data were considered significant for p \ 0.05. SPSS (rel. 21)
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programs were used for statistical analysis (SPSS Inc., Chicago, IL).
of the two study groups, compared with an historic group of LDP. The median operative time was 195 min (145–415) for LDP and 265 min (145–420) for RDP (p = 0.003). RDP was associated with an increased operative time. In this group, the mean docking time was 25 min, and the mean console time was 160 min. The reasons for conversion to open procedures were an uncontrolled bleeding during pancreatic transection from the splenic artery in the patient undergoing RDP, and strong adhesions between the tumor and the splenic vessels
Results A total of 43 patients underwent minimally invasive distal pancreatectomy during the study period. In particular, 22 patients underwent an RDP, and 21 patients an LDP. Table 1 summarizes the demographic and surgical details
Table 1 Demographic and operative details of patients undergoing minimally invasive distal pancreatectomy Laparoscopic DP n = 21 (%)
Robotic DP n = 22 (%)
Historic laparoscopic n = 22 (%)
p value
Male
6 (28.5)
5 (22.7)
5 (22.7)
0.929
Female
15 (71.5)
17 (77.3)
17 (77.3)
55 (20–71)
54 (26–77)
49 (28–73)
0.009
I
5 (23.8)
3 (13.6)
NA
0.573
II
16 (76.2)
18 (81.8)
III
0
1 (4.5)
Sex
Median age, years (range) ASA class
IV Median BMI (Kg/m2)
0
0
24.19
25.33
22.7
0.263
13 (61.9) 8 (38.1)
15 (68.2) 7 (31.8)
15 (68.2) 7 (31.8)
0.911 0.011
Previous abdominal surgery Yes No Median operative time, min (range)
195
265
227,5
(145–415)
(145–420)
(135–340)
Yes
1 (4.7)
1 (4.5)
2 (9.1)
No
20 (95.7)
21 (95.5)
20 (90.9)
Yes
4 (19)
6 (27.3)
8 (36.4)
No
17 (81)
16 (72.7)
14 (63.2)
Yes
6 (28.6)
10 (45.4)
8 (36.4)
No
15 (71.4)
12 (54.6)
14 (63.6)
Cholecistectomy
5
4
4
Left adrenalectomy
1
1
0
Peritoneal biopsy
1
1
1
Hepatic biopsy Hernia repair
0 0
2 2
2 0
Annessiectomy
0
0
1
Yes
0
3 (13)
1 (4.5)
No
21 (100)
19 (87)
21 (95.5)
Conversion 0.842
Spleen preservation 0.782
Associated procedures 0.516
Blood transfusions
Procedure costs, Euros (range)
1500
3000
1450
(1434–1674)
(2700–3190)
(1250–1674)
0.312 0.001
ASA American Society of Anesthesiologists classification, BMI body mass index
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pancreatitis with multiple fluid collections, which required surgical drainage. Of note, these two latter patients were re-admitted and re-operated in other hospitals with emergency procedures. Two additional patients underwent reoperation at our Institution. The former underwent splenectomy on POD 4 via open approach because of multiple splenic infarctions after a spleen-preserving RDP and was discharged on POD 17. The latter underwent two reoperations on POD 6 and POD 8 after a spleen-preserving LDP, both for abdominal bleeding. The two surgeries consisted of a laparoscopic toilette first and a laparoscopic splenectomy after. The patient was eventually discharged on POD 26. Overall, one patient in the LDP (4.7 %) and three in the RDP (13.6 %) group, respectively, experienced a clinically significant complication (Grade III–IV) according to the Clavien– Dindo Classification [22] (p = 0.611). Table 3 summarizes the pathologic details. An R0 resection was achieved in all cases. At a median follow-up of 12 months (Table 4), all patients were alive. Among the five Patients with pancreatic ductal adenocarcinoma, two developed metastatic disease, 9 and 10 months after surgery.
in the patient undergoing the laparoscopic procedure. In the LDP group, transection of the pancreatic parenchyma was performed via ultrasonic shears in 18 patients (85.7 %), and a linear endostapler was used in the three remaining cases (14.3 %). In all the cases completed robotically, ultrasonic shears were used. Costs of an LDP procedure ranged between 1,434 and 1,674 Euros, depending on the instrument used for the pancreatic transection (being the stapler more expensive), while costs of an RDP were in the range 2,700–3,190 Euros, depending on the type of ultrasonic shears used in the operation (being the robotic one more expensive). Table 2 outlines the postoperative results. Fifteen patients in each group had a complicated postoperative course (71.4 % in the LDP group and 68.2 % in the RDP group, p = 0.887). Although the rate of PF was in excess of 50 %, the majority of these fistulas were not clinically relevant (grade A). The only patient requiring readmission in LDP group had portal vein thrombosis and fever. Among the four patients re-admitted in the RDP group, two had a peripancreatic fluid collection treated conservatively; one had an abdominal abscess surgically drained, and one developed severe postoperative acute
Table 2 Postoperative results after laparoscopic and robotic distal pancreatectomy
Laparoscopic DP n = 21 (%) Median LOS, days (range)
Robotic DP n = 22 (%)
7 (3–33)
7 (4–28)
12 (57.1) 9 (42.9)
11 (50.0) 11 (50.0)
p value 0.835
Pancreatic fistula Yes No Grade A
8
8
Grade B
4
2
Grade C
0
1
0.605*
Peripancreatic fluid collection Yes
3 (14.3)
7 (31.8)
No
18 (85.7)
15 (68.2)
Yes
2 (2.5)
1 (4.5)
No
19 (97.5)
21 (96.5)
0.318
Blood transfusions 0.314
Discharged with drainage Yes
7 (33.3)
9 (40.9)
No
14 (66.7)
13 (50.1)
6 (28.5)
7 (31.8)
15 (71.5)
15 (68.2)
0.841
Extra-abdominal complications Yes No Reoperation within 90 days Yes
1 (4.7)
3 (13.6)
No
20 (95.3)
19 (88.4)
1
0.634
Readmission within 90 days
* Fistula yes versus Fistula no
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Yes
1 (4.7)
4 (18.2)
No
20 (95.3)
18 (81.8)
0.344
Surg Endosc Table 3 Pathology Laparoscopic DP n = 21
Robotic DP n = 22
p value
Pathologic diagnosis Neuroendocrine neoplasms
9
8
MCN (invasive)
7 (1)
6
SCN
2
0
SPN
1
3
PDAC
2
3
Ectopic spleen
0
1
Other
0
1
0.397
Median number of lymph nodes harvested (range)
15 (1–47)
11.5 (0–37)
0.313
Median tumor size, mm (range)
35 (15–75)
25.5 (5–90)
0.116
MCN mucinous cystic neoplasms, SCN serous cystic neoplasms, SPN solid pseudopapillary neoplasms, PDAC pancreatic ductal adenocarcinoma
Table 4 Follow-up
Laparoscopic DP n = 21 (%) Median follow-up, months Diabetes mellitus
15
Robotic DP n = 22 (%)
p value
10.5
0.465
Yes
1 (4.7)
1 (4.5)
No
20 (95.3)
21 (95.5)
0.744
Incisional hernia Yes
1 (4.7)
1 (4.5)
No
20 (95.3)
21 (95.5)
0.744
Post-splenectomy thrombocytosisa Yes
1 (5.5)
4 (25)
No
17 (94.5)
12 (75.0)
Yes
14 (77.7)
14 (87.5)
No
4 (22.3)
2 (12.5)
0.164
Post-splenectomy vaccinesa 0.660
Development of metastatic disease a
These data pertain to patients who underwent associated splenectomy
Yes No
Discussion The present study shows the results of a prospective nonrandomized analysis of 43 patients undergoing minimally invasive DP at the authors’ institution. Because the current literature is limited and the reported outcomes are controversial [12, 22], we sought to investigate possible differences in intra- and postoperative results between robotics and laparoscopy. The median operative time was longer in the robotic group as already reported in other studies [23, 24]. This finding is explainable in part by the docking time (inexistent in laparoscopy) and in part by the burden of the learning curve. Of note, only one study [12] reported that RDP requires a shorter mean operative time (293 vs. 371 min) compared to LDP. When our last 21 LDP cases
0
2 (9)
21 (100 %)
0.488
20 (91)
were compared to a historic LDP group (n = 22) with similar population characteristics, we found that they required a shorter operative time (mean 212.6 vs. 239.1 min, p = 0.381), but the difference resulted as not significant. Other studies already showed that the learning curve for LDP could decrease the operative time, as well as the conversion to open rate. The minimum number of procedures required to achieve an optimal result is reported to be between 10 and 20 [25, 26]. The largest series[27] of RDP (n = 83) is included in a consecutive series of 250 robotic pancreatic resections analyzed for safety and feasibility. In the RDP group, the incidence of clinically significant complications (Clavien– Dindo grade III or IV) was 13 %. Examining the pancreatoduodenectomy, but not DP cohort, they were able to demonstrate a decreasing trend in the incidence of severe
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complications in the last 40 cases (16 vs. 30 %, p \ 0.05). Also, operative time both for pancreatoduodenectomy and DP groups showed a positive trend over the course of the experience, eventually becoming equivalent to both the laparoscopic and open series. In the present series, four patients experienced severe complications needing reoperation: three were in the RDP (13.6 %) and only one in the LDP (4.7 %). The difference is not statistically significant, but we could not claim any superiority of the robot-assisted technique at least in the present series which represents the first 22 robotic operations of our surgical team. Nevertheless, our 13.6 % rate of clinically significant complications after RDP is similar to the one of the largest experience published [27]. We could argue that once a surgeon has gained a relevant experience in the LDP, his results are probably difficult to be matched via a robotic approach, at least for the first 40–50 cases. We believe that the interest and the efforts of the surgical community should be addressed toward developing new tools, in order to increase our ability with the robot approach in a training setting. PF is the most common abdominal complication after distal pancreatectomy. The reported incidence ranges between 0 and 45.7 %, without any difference between stapler and suture closure according to a large meta-analysis [28]. In our practice, we prefer using the ultrasonic device for the transection of the pancreatic parenchyma. Since a thicker parenchyma seems to be a risk factor for POPF, we prefer to use a linear endostapler in these cases, as suggested by Eguchi et al. in their retrospective analysis [29]. Only one patient out of 22 RDPs (4.5 %) required a conversion to open because of an uncontrolled bleeding from a branch of the splenic artery during pancreatic transection. The patient requiring conversion to open in the laparoscopic group was affected by a PDAC infiltrating the tissue around the splenic vessels, so the surgeon preferred to have direct, manual control of the vessels in order to prevent unexpected bleeding. A recent study [30] on robotic hepato-biliary and pancreatic surgery compared 77 patients with laparoscopic and open controls with the aim to analyze possible predictors for conversion. Major indications for conversion were inability to safely proceed with the surgery and/or technical difficulty with it, obesity, excessive bleeding, and instruments malfunctioning or inadequacy. In the group of pancreatic procedures (n = 71), they performed 39 RDPs (22 SPDP) and 15 patients (38.5 %) were converted to hand-assisted laparoscopy or open procedure. The Authors underline how visceral fat is the most important factor associated with conversion, because it can make robotic dissection, movement, or retraction impossible. Comparing LDP and RDP, the conversion rate was higher in the robotic group (39 vs. 22 %) and the main common indication was
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different too (major bleeding vs. technical difficulty). However, the incidence of conversions decreased with the increase of the learning curve. The spleen preservation rate in our series is lower when compared to others [16, 24], but indications for splenectomy need to be discussed. In fact, splenectomy can be planned before performing a distal pancreatectomy, in order to increase the oncological radicality or because of the anatomical relationship between the tumor, the splenic vessels, and the pancreatic tail seen at imaging. Either way, splenectomy might become necessary intraoperatively because of bleeding or the inability to ensure an adequate blood supply to the spleen. The pathologic findings of our patients, the majority being malignant or ‘‘borderline’’ tumors, justify the relevant number of splenectomies of our series. The size of the present study is too small to demonstrate a possible superiority of the robotic approach in achieving a higher spleen preservation rate. Nonetheless, we believe that the superior technical characteristics of the robot, such as the augmented, high-quality, 3-D vision and the precise, endowrist instrument motion, are enough to explain the potential superiority of the robot, which has been already established in larger studies [23, 31, 32]. Long-life expectancy associated with pancreatic benign tumors exposes the patients to potential post-splenectomy critical infections like overwhelming post-splenectomy infection (OPSI), even many years after surgery [33], confirming the indication to SPDP whenever indicated. Our intra-operative perception is that the robot can increase the spleen preservation rate through the same advantages that can reduce the conversion to open risk, since in both conditions the critical point is represented by the vascular control. In the present series, the median number of harvested lymph nodes was similar between LDP and RDP. Other authors showed that lymph node clearance is similar between minimally invasive DP and open DP (12 vs. 11) [34] and similar between RDP and open DP (12.5 vs. 13.2), but lower for LDP (5) [35]. With regards to pancreatic ductal adenocarcinoma, Daouady et al. [12] found final better outcomes with robotic techniques compared to laparoscopic. These were represented by R1 margin status of 0 versus 36 % (p \ 0.05) and a median nodal harvest of 19 (IQR 17, 24) versus 9 (IQR 7, 11) in RDP and LDP groups, respectively. In the present series, we treated five patients affected by PDAC, achieving in all cases an R0 and adequate number of harvested lymph nodes. Nevertheless, two of these 5 patients had liver metastases within 1 year from the operation and they both were treated with the robot. The first had a 27 mm G2 PDAC, associated to 2 peripancreatic metastatic lymph nodes out of 33 collected, while the mass was 1 cm distant from the neck resection margin. The tumor was in
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proximity to the peritoneum and there was infiltration of the peripancreatic adipose tissue and of the splenic vein. The second patient had a 35 mm G3 PDAC with very aggressive microscopic characteristics, such as massive infiltration of the peripancreatic adipose tissue, massive infiltration of vascular structures including the splenic vein, and obvious involvement of the peritoneum. In this case, two out of 22 nodes were found to be metastatic. The scarce number of PDAC in the present series does not allow any conclusions; however it looks clear that the intrinsic nature of cancer rather than the resection technique plays a major role in determining the prognosis. We found that RDP is more expensive than LDP. In the light of reducing the costs but at the same time aimed to explore new technologies, we adopted a ‘‘hybrid’’ approach for RDP using laparoscopic ultrasonic shears instead of the robotic. As a result, 500 € were saved for each procedure. We could also save 250 € using the laparoscopic ultrasonic shears for the pancreatic gland transection instead of the linear endostapler (of note, none of the two instruments is superior in reducing the incidence of POPF) [28]. Since the incidence of postoperative complications was not statistically different between the two groups, we can say that the difference in costs is procedure-related only. The economic advantage in favor of the robotic approach (including the costs of the instruments and of the hospitalization that are mainly complication related) is still under debate since different studies report different conclusions. Waters et al. [23] found that robotics is associated with a shorter LOS (4 vs. 8 vs. 6 days) and lower overall costs (10.588$ vs. 16.059$ vs. 12.986$), despite the more expensive equipment, when compared to either open and laparoscopic approach. Authors conclude that RDP is safe and costeffective in selected cases. Kang et al. analyzed a total of 45 Patients (25 laparoscopic and 20 robotic) undergoing distal pancreatectomy and showing that the robotic system has higher surgery-associated costs (8,304 vs. 3,861 USD). Interestingly, in this study the increased intraoperative costs were not balanced by a shorter LOS (7.1 vs. 7.3 days). While clinical and economic advantages are still under discussion, robotic technology has some non-measurable benefits: it is ergonomically more comfortable, it gives a feeling of stability and security, the surgeon feels that each surgical step of the procedure is safer and faster, and that the result is more precise. As a consequence, surgeons who have the opportunity to use the robot prefer RDP to LDP, even though a proper evidence-based superiority is still lacking. Another reason is that RDP represents a relatively young procedure, and it still needs to be explored in more robust clinical studies. Although the present study is the first prospective comparison between RDP and LDP, it has major limitations. First, the indications to minimally invasive approach
for left-sided pancreatic lesions are not clearly standardized. Second, the choice between laparoscopic and robotic approach is not randomized, although the criterion was the availability of the system for our surgical unit. Finally, the experience of the team was wider for laparoscopic techniques than for robotic, which started at the beginning of the present study period.
Conclusions Both RDP and LDP are valid techniques for the minimal invasive treatment of the neoplasms of the distal pancreas. The advantages of RDP are claimed by many but still under investigation. Some of these advantages are more subjective than objective, and it seems difficult to demonstrate a real superiority of one technique over the other in a standardized fashion. In our experience, laparoscopy has not been abandoned in favor of the robot and we continue to perform both approaches choosing upon the characteristics of the single patient. Independently from the approach, the safety of the patients and the need for oncological radicality are the milestones of the minimally invasive surgery of the left pancreas. In a recent paper by Heemskerk et al. [36], a provocative question arose: Are we already facing the end of robot-assisted laparoscopy? In their critical appraisal, the Authors analyzed the results of clinical studies in many fields of surgery regarding the application of the robotic techniques. Pancreatic resections are not included among the gastrointestinal surgeries. However, we agree with their conclusion, since we strongly believe that robot-assisted distal pancreatectomies are yet to be abandoned. Disclosures Dr. G. Butturini, Dr. I. Damoli, Dr. L. Crepaz, Dr. G. Malleo, Dr. G. Marchegiani, Dr. D. Daskalaki, Dr. A. Esposito, Dr. S. Cingarlini, Dr. R. Salvia, and Prof. C. Bassi have no conflicts of interests or financial ties to disclose.
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