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Page 2 of 12 Tschuor et al. Mini-invasive Surg 2020;4:72 I http://dx.doi.org/10.20517/2574-1225.2020.39

The robotic platform provides significant dexterity-related advantages, enabling pancreatic procedures
to be performed with surgeon- and patient-related benefits. Complex demanding procedures such as
pancreaticoduodenectomies (PDs) involving dissection of the hepatoduodenal ligament and resection of
the pancreatic head, uncinate process and duodenum, followed by a complex reconstruction with delicate
[2]
anastomoses become technically feasible using a minimally invasive approach . Adjuncts such as built-in
TM
TM
fluorescence imaging FireFly and TilePro picture overlay while performing intraoperative ultrasound
add to operative safety and efficiency. At our high-volume center, we have performed more than 180
robotic PDs since 2012 and over 200 distal pancreatectomies with splenectomy (DPS) since 2008. We have
found lower complication rates for robotic PD along with no differences in total costs when compared with
[3,4]
the open PD, but more importantly, robotic PD may offer improved oncologic outcomes .
When starting a robotic program for pancreatic surgery, a dedicated team with prior experience in open
as well as minimally invasive pancreatic surgery and, first and foremost, a structured training is the key to
[5]
[6]
success . During the early stages of the learning curve, proficiency in DPS should be achieved . However,
learning curves can be considerably diminished by appropriate training, proficient mentorship and an
[7-9]
experienced multidisciplinary team .
The aim of this article is to describe the technical aspects of robotic PD and DPS. Our own expertise as well
as the current literature on feasibility, safety and early postoperative outcomes will be discussed.

TM
TECHNIQUE OF ROBOTIC PANCREATIC SURGERY (XI SYSTEM)
Patient selection
Patient selection plays a crucial role during the early learning curve for successful robotic pancreatic
2
2
surgery. Patients with a very high or very low body mass index (BMI > 40 kg/m ; BMI < 17 kg/m ), petite
body habitus and relevant comorbidities, elderly frail patients and those with multiple previous abdominal
[10]
surgeries should be evaluated thoroughly . Patients with chronic pancreatitis, neuroendocrine tumors,
cystic neoplasms, ampullary cancers and distal cholangiocarcinomas may be considered as ideal PD
candidates for surgeons with juvenile robotic experience. Tumor entity, location and extent are important
factors in determining whether a robotic approach is beneficial for the patient. Borderline resectable
pancreatic tumors may require concomitant vascular or multi visceral resection demand for robotic
expertise as well as master skills and should be avoided during the learning curve. A recent NSQIP
database study comparing early postoperative outcomes for patients undergoing laparoscopic or robotic
PD reported higher overall complications and conversion rates for the robotic approach if the procedure is
[10]
combined with vascular or multivisceral resection .
Equipment and preoperative measures
As for robotic pancreas procedures using the Xi system, we recommend the use of Prograsp TM forceps,
fenestrated bipolar and mono-polar scissors as well. The robotic vessel sealer TM is the key device in
facilitating dissection while achieving adequate hemostasis. Fortunately, a new sealing device with a more
TM
delicate articulating tip and shorter seal time is soon to be launched (SynchroSeal ). Locking robotic
plastic clips (Hemolok , Weck ) are used prior to the division of larger vessels. Pancreatic transection
TM
TM
may be achieved with the help of the robotic stapler. Cutting or non-cutting needle drivers may be used
for reconstruction according to surgeon’s preference. A commonly used suture for our robotic pancreatic
procedures is 4-0 or 5-0 Monocryl [Table 1].

Most surgical departments have designated robotic operating suites. Placement of the robotic cart,
console(s), and audio/video towers in relation to the patient, scrub team and anesthesia is set up according
to the surgeon’s preferences ahead of surgery. The patient table is placed at 45 degrees to the anesthesia
team. Both arms are abducted, and the patient is positioned supine with slight flexion and slight reverse
Trendelenburg. The robot cart docks from the right of the patient table.