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Page 107 Jiao et al. Art Int Surg 2023;3:98-110 https://dx.doi.org/10.20517/ais.2023.03

used for stabilizing the stomach.

Jejuno-Jejunostomy
This anastomosis is reconstructed at 30-40 cm distal to hepaticojejunostomy and 15-20 cm proximal to
gastrojejunostomy using straight endo GIA 45 mm stapler inserted through the assistant port after making
enterotomy using hook diathermy. Then the enterotomy is closed using 2/0 FILBLOC or V-Loc. The
Cadiere forceps in arm 4 is used to stabilize the jejunum during this step. This completes the reconstruction
after RPD.

Hemostasis and drains
At the end of reconstruction, hemostasis is checked around the anastomoses, and the fluid is suctioned.
Two 20 FG Robinson drains are inserted through arms 1 and arm 4 after the swab and instrument count
after the de-docking of arms 1 and 4. The right drain is placed in the right subhepatic space and the left
drain is placed is placed over the left subhepatic space covering the anterior aspect of pancreatic-jejunal
anastomosis. Finally, the de-docking of arms 2 and 3, and the removal of ports is completed. The skin is
closed with 3/0 monocrystal and the wound is dressed [Figure 4].

Operation time, conversion to open PD, and blood transfusion
Although some series report a longer mean operating time for RPD compared with OPD, a meta-analysis of
[16]
RPD vs. OPD involving a total of 680 patients did not find any significant difference in operating time .
The median operating time for our whole RPD series was 287 min, with a lower conversion rate to open
[17]
operation compared with LPD . In our updated robotic series of over 100 RPD, our conversion rate was
5.3%. Only two patients in our series had an estimated blood loss of > 500 mLs and required a perioperative
blood transfusion. This is consistently reported as a major advantage for minimally invasive PD [8,11-13] .

Postoperative complications and length of stay
Minimally invasive procedures do not result in a perioperative cortisol peak compared to a cortisol surge in
open surgery, irrespective of procedure duration . Therefore, despite potentially longer operating times,
[18]
there is likely a reduced surgical stress response in robotics compared to the OPD. Also, they require
reduced use of analgesics compared to OPD procedure. Respiratory complications are rare in RPD due to
the avoidance of retractors as in open surgery. The wound complications are reduced due to the use of
regular endo-bags. To reduce wound complications, we are covering the umbilical port with betadine-
soaked gauze at the time of specimen extraction. We have observed that patients who undergo RPD are less
aware of the magnitude of the surgery and are well motivated to mobilize from day one of the postoperative
period, which reduces the respiratory complications and early return of bowel movement. An improvement
in length of stay for robotic compared to open PD has been observed in meta-analyses [19,20] , and may also be
[17]
shorter compared to laparoscopic PD .

Morbidity, mortality, and oncological outcomes
There is no significant difference in morbidity and mortality between RPD and OPD, with the published
review articles reporting a serious morbidity of 21.14% ± 6.95% with postoperative pancreatic fistula (POPF)
of 20.39% ± 9.64% and 90-day mortality of 3.45% ± 1.37% [19,20] . Our series showed a morbidity rate for
Clavien-Dindo > 2 of 27.1%, with one mortality from myocardial infarction on postoperative Day 7 (0.83%).
[17]
All our POPF were biochemical grade A leaks . This may be due to the precision of the robotic
instruments and suturing with a magnified view with less trauma from handling the pancreatic remnant.
Also, the drains are kept until they become dry. The drain amylase level is routinely measured prior to their
removal in patients who continue to drain after 21 days. There was no gastric or jejunal anastomosis leak in