Page 41 - Read Online

Page 10 of 12 Tschuor et al. Mini-invasive Surg 2020;4:72 I http://dx.doi.org/10.20517/2574-1225.2020.39

times but lower estimated blood loss. The learning curve to decrease rates of conversion to an open
procedure was found to be as high as 20 robotic PDs. Overall morbidity rates were comparable between the
robot and open groups. Mortality rates also did not differ between the two approaches and ranged between
1%-12.5%. Delayed gastric emptying, however, was found to be lower with the robotic approach [25,26] . An
NSQIP study comparing 30-day outcomes between laparoscopic and robotic PDs found that there was no
[10]
difference in 30-day morbidity or mortality between the two approaches . However, they did find that the
rates of conversion to an open procedure were higher for patients undergoing laparoscopic PD (26% vs.
11.3%).

Increasing proficiency with robotic pancreatic surgery is reflected in a decrease in operative times as well
as conversion rates. Other more sophisticated factors may include number of lymph nodes resected, blood
[8]
loss, R-status, hospital stay, and 90-day complications and readmission as well . Our initial experience
with robotic pancreatic surgery revealed a conversion rate of one in four decreasing to one in 32 cases after
overcoming the learning curve. In line with this, procedural duration decreased significantly over time.
[12]
Boone et al. reported that blood loss and conversion rate decrease significantly after 20 robotic PD cases.
The clinically relevant Grade B/C pancreatic fistulas rate (POPF) decreased by half after 40 cases along with
a significant decrease in operative times after 80 cases.

While laparoscopic skills enhance the learning curve in our experience, training in robotic surgery should
be structured. In a first phase basic skills and procedure specific skills with the help of simulation, biotissue
[27]
drills, video libraries, live case observations, and training courses have to be achieved . The second phase
consists of fellowships, and proctoring programs to ensure patient safety during the first procedures.
During the third phase the surgeon’s aim is to safely implement the procedure into standard practice, while
minimizing the learning curve related to excess morbidity and mortality. Adequate training and high
[28]
procedural volume are key to implementing robotic pancreatic surgery safely .

CONCLUSION
Robotic hepatopancreatobiliary surgery has undergone rapid evolvement over the last two decades. Its
adoption has been tempered by the complexity of the procedures. The combination of superior articulation,
better optics and elimination of tremor provides technical and ergonomic advantages over conventional
laparoscopy. At high-volume centers, once the learning curve has been surpassed, robotic PD has been
shown to be non-inferior to open PD in terms of POPF development and other perioperative outcomes.
The higher operative cost of the procedure may be offset by lower hospital length of stays associated with a
minimally invasive approach. However, more robust data in the form of a randomized controlled trial and
other cost benefit studies are needed.

DECLARATIONS
Authors’ contributions
Made substantial contributions to the design of the work, interpretation of data, and drafting and
substantive revision of the manuscript: Tschuor C, Nagarkatti SS, Salibi PN, Vrochides D, Martinie JB

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
John B. Martinie is a proctor for Intuitive. Christoph Tschuor’s fellowship salary is granted by Intuitive.