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Jiao et al. Art Int Surg 2023;3:98-110 https://dx.doi.org/10.20517/ais.2023.03 Page 108

Figure 4. Incisions for extraction and port positioning for pancreatoduodenectomy using the Vinci Xi/X with arms 1 and 4 replaced with
FG18 Robinson’s drains.

[17]
our series. We had a bile leak rate of 6.3% in our first reported series , all managed conservatively, which
had reduced significantly to 2.1% after 100 RPD cases. The oncological outcome following RPD based on R
status and the number of lymph nodes harvested showed an R0 resection rate of 89.24% ± 11.95% with a
mean tumor size of 25.62 ± 3.50 mm and an average number of resected lymph nodes of 22.47 ± 10.37
[17]
respectively , more than the 15 recommended by the European Society for Medical Oncology (ESMO) .
[21]
ROBOTICS HPB SURGERY AND AI
There is little doubt that the future of surgery will be minimally invasive to avoid major trauma to patients
for faster recovery, which will inevitably offset the cost of robotic surgery. Advances in technology will
enable us to achieve this with the precision of robotic instruments and improved ergonomics leading
[22]
inevitably to the development of haptic feedback and artificial intelligence . Through robotic data
acquisition, it will be much faster for machine learning and deep learning to develop the next generation of
intelligent surgical robots to personalize surgical plans and procedures, reducing intraoperative errors and
standardizing complex operations such as PD. Furthermore, with AI, performance metrics can be applied to
future clinical practice to be used as competency tools to assess the performance and quality of a surgeon’s
skills rather than conventional morbidity and mortality data . Robotic and AI training should be
[23]
embedded in the surgical training curriculum for the future generation of surgeons to benefit patients
directly and also to encourage research collaboration for developing future intelligent robotic surgery.

Robotic surgery is a safe approach for patients requiring PD, and it may offer advantages over both open
and laparoscopic surgery. However, randomized controlled trials are still required to prove this. Notably,
the superiority of performing either a pancreaticogastrostomy or Roux-en-Y pancreaticojejunostomy has
never been shown in the open pancreatic surgical literature ; as a result, it is doubtful that future will be
[24]
able to show the superiority of either anastomosis in the robotic literature. Perhaps the most promising
advantage of current robotic surgery will be its ability to incorporate more artificial intelligence in the