Page 107 - Read Online

Page 99 Jiao et al. Art Int Surg 2023;3:98-110 https://dx.doi.org/10.20517/ais.2023.03

INTRODUCTION
The past three decades have witnessed the rapid emergence of minimally invasive surgery which has led to a
total re-evaluation of conventional surgical approaches across all specialties. In hepato-pancreato-biliary
(HPB) surgery, there has been a slower drive to widely embrace laparoscopic techniques, particularly for the
long and technically difficult pancreatoduodenectomy (PD) operation. This operation involves precise
dissection and small-caliber lumen anastomoses. Barriers to establishing laparoscopic practice, including
operator discomfort and fatigue, long and steep learning curves during training, limited instrument motion,
and physiological tremors which are amplified through the length of the instruments, have limited the use
of these techniques in complex cases and prevented their widespread adoption in the HPB specialty. Indeed,
the LEOPARD-2 trial (minimally invasive versus open pancreatoduodenectomy) comparing laparoscopic
(LPD) and open PD (OPD) has recently terminated unexpectedly due to an increased 90-day complication-
[1]
related mortality in the laparoscopic group [LPD 5/50 (10%) vs. OPD (1/49 (2%)] . These inherent
challenges led to robotic solutions. The Da Vinci robotic system (Intuitive Surgical Inc., Mountain View,
[2]
CA) gained FDA approval in 2000 . The major advantage of robotic surgery over the normal laparoscopic
approach is that it offers a three-dimensional visual field with depth perception . Furthermore, the
[2]
instrumentations provide the “endo-wristed” natural seven-degree movement mimicking open surgery. By
doing so, it enhances dexterity and performance to carry out difficult tasks precisely in the pelvis and deep
structures for dissection and suturing that are often deemed impossible laparoscopically. Having been well-
established in urology, robotic surgery is rapidly gaining momentum in other surgical specialties .
[3-7]
In 2003, the first successful RPD was performed by Giulianotti, demonstrating the advantages of a robotic
approach to complex abdominal surgery by maximizing the benefits of minimally invasive surgery while
[8,9]
circumventing the problems related to laparoscopic surgery . Since then, there has been an increasing
number of publications worldwide on RPD confirming the feasibility and safety of robotic pancreatic
surgery with a low conversion rate to open surgery (0%-18.3%) [8,10] . These results suggest that RPD is
superior to the laparoscopic approach in terms of the learning curve, supported by the results of our own
randomized controlled trial on laparoscopic vs robotic training showing a much shorter learning curve to
acquire surgical skills in the robotic training group compared with the laparoscopic group . Furthermore,
[11]
the short-term outcomes of RPD are better than the standard open technique with regards to the length of
stay, blood loss and transfusion rate, and equivalent to lymph node yield and R0 resection rate [8,9,11-13] .
Importantly, there is no reported difference between RPD and OPD in terms of morbidity, mortality, and
oncological outcome.

We performed the 1st LPD in the UK in 2011. However, since starting our robotic HPB program in 2017
and performing the 1st RPD in the UK, we have transferred totally from laparoscopic to robotic HPB
surgery to expand the number of HPB cases suitable for minimally invasive surgery through the advantages
of the Da Vinci system. We believe that this is the best tool currently available for minimally invasive
surgery without compromising surgical and oncological outcomes. In the following section, we describe our
standardized technique for RPD using Da Vinci Xi or X system based on the largest LPD (n > 100) and RPD
(n > 100) series in the UK.

METHODS
How I do it: tips and tricks
We discuss how the RPD is performed using the following steps:

1. Patient selection