Robotic pancreaticoduodenectomy for pancreatic head cancer and periampullary lesions

Abstract Pancreaticoduodenectomy, so‐called “Whipple operation,” is a time‐consuming and technically demanding complex operation. Traditionally, this procedure has been performed most usually by open approach, which results in a large and painful wound. With the introduction of laparoscopic and robotic surgery, minimally invasive surgery (MIS) has emerged as a worldwide trend to improve wound cosmesis and to minimize wound pain. Although MIS for pancreaticoduodenectomy has also been attempted at some centers, the role of MIS, either robotic or laparoscopic approach, has not been well‐established for complex pancreaticoduodenectomy. Given that laparoscopic pancreaticoduodenectomy has been limited by its technical complexity and the high level of advanced laparoscopic skills required for pancreatic reconstruction, a robotic surgical system is introduced to overcome several limitations related to the laparoscopic approach. Providing high‐quality three‐dimensional (3‐D) vision, high optical magnification, articulation of robotic instruments, greater precision with suture targeting, and elimination of surgeon tremor, robotic surgical systems innovatively perform more delicate and complex procedures involving extensive dissection and suturing techniques such as pancreaticoduodenectomy. Although associated with longer operative time, robotic pancreaticoduodenectomy (RPD) has been claimed to have the benefits of less delayed gastric emptying, less blood loss, shorter length of postoperative stay, and lower wound infection rate, as compared with the traditional open pancreaticoduodenectomy (OPD). Moreover, RPD seems to be not only technically feasible but also justified without compromising the survival outcomes for pancreatic head and ampullary adenocarcinomas. Therefore, RPD could be recommended not only to surgeons but also to patients in terms of surgical feasibility, surgical outcomes, and patient satisfaction.

roscopic approach. Providing high-quality three-dimensional (3-D) vision, high optical magnification, articulation of robotic instruments, greater precision with suture targeting, and elimination of surgeon tremor, robotic surgical systems innovatively perform more delicate and complex procedures involving extensive dissection and suturing techniques such as pancreaticoduodenectomy. Although associated with longer operative time, robotic pancreaticoduodenectomy (RPD) has been claimed to have the benefits of less delayed gastric emptying, less blood loss, shorter length of postoperative stay, and lower wound infection rate, as compared with the traditional open pancreaticoduodenectomy (OPD). Moreover, RPD seems to be not only technically feasible but also justified without compromising the survival outcomes for pancreatic head and ampullary adenocarcinomas. Therefore, RPD could be recommended not only to surgeons but also to patients in terms of surgical feasibility, surgical outcomes, and patient satisfaction.

K E Y W O R D S
cancer, da Vinci Surgical System, pancreatic head, pancreaticoduodenectomy, periampullary

| INTRODUC TI ON
Pancreaticoduodenectomy, so-called "Whipple operation," is a time-consuming and technically demanding complex operation.
Traditionally, this procedure has been performed most usually by open approach, which results in a large and painful wound. With the introduction of laparoscopic and robotic surgery, minimally invasive surgery (MIS) has emerged as a worldwide trend with improving wound cosmesis and mitigating wound pain. [1][2][3][4][5] Although MIS for pancreaticoduodenectomy has also been attempted at some centers, the role of MIS, either by robotic or laparoscopic approach, has not been well-established for the complex pancre-

| MINIMALLY INVA S IVE SURG ERY IN PAN CRE ATICODUODENEC TOMY
Minimally invasive surgery, either laparoscopic or robotic approach, has gained popularity in many surgical fields including pancreatic surgeries. [10][11][12][13][14] Laparoscopic pancreaticoduodenectomy was introduced early in 1994, 15 but its application has been limited by its technical complexity and the high level of surgical and optical 10-15 magnification vision, articulated instruments, greater precision with suture targeting, and elimination of surgeon tremor, robotic approach can even enable complex procedures such as Whipple procedure, which involves extensive and complex resection and reconstruction of pancreas, bile duct, and gastrointestinal tract. 12,16,17 However, a major concern about the da Vinci F I G U R E 4 The cameral port indicated with "C" is placed about 5 cm to the right of umbilicus. Be this design, the robotic scope can clearly see the relationship of pancreatic head/uncinated process and superior mesenteric vessels during dissection around these vessels A 5-mm trocha as an assistant port is usually placed on the right mid-clavicular line slightly below the camera port. 5,6

| TECHNI QUE OF PAN CRE ATIC RECON S TRUC TI ON IN ROBOTI C PAN CRE ATICODUODENEC TOMY
Pancreatic reconstruction with a modified Blumgart pancreaticojejunostomy (PJ) has been previously described in detail. 1,5,6,22 Briefly, three transpancreatic U-sutures are placed for the horizon-

| ME SOPAN CRE A S DISS EC TION
"Mesopancreas dissection," proposed by Inoue et al, 23 is used to describe the extent of lymph node dissection during separation of pancreas head-uncinate process from superior mesenteric vessels.
Mesopancreas dissections can be categorized into three levels based on the extent of dissection around and along the superior mesenteric vessels, including level 1 mesopancreas dissection, simply along the right side of superior mesenteric vein (SMV), usually applied for those with benign or low-malignancy potential; level 2 mesopancreas dissection, along the right side of superior mesenteric artery (SMA), and en bloc resection of the corresponding lymph nodes and mesojejunum, but not including the nerve plexus on the SMA, applied for periampullary cancers; level 3 mesopancreas dissection, including en bloc mesopancreas resection with periadventitial tissues including nerve plexus along the right hemi-circumference of SMA from 5 to 11 o'clock, just applied for pancreatic head cancer. 8,23-25

| SURG I C AL OUTCOME S AF TER ROBOTIC PAN CRE ATICODUODENEC TOMY
It has been claimed that RPD has benefits of less delayed gastric emptying, less blood loss, lower wound infection rate, and shorter F I G U R E 7 Survival curves for ampullary adenocarcinoma after robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD) postoperative hospital stay, as compared with OPD, according to studies and literature reports. 1,5,[7][8][9][26][27][28][29] Our study showed that the biggest complications after RPD are 18.1% occurrence of chyle leakage, followed by 5.7% occurrence of postoperative pancreatic fistula, 4.8% occurrence of intra-abdominal abscess, 3.8% occurrence of delayed gastric emptying, and post pancreatectomy hemorrhage. 2 The wounds after RPD and OPD are shown in Figure 5. We conducted a study of patient satisfaction and quality of life using questionnaires for 105 RPD patients. The results revealed that almost all of the patients responded to this RPD-related survey with "fair" to "excellent" grades for all items, except one (<1%) poor grade for operation service and two (1.9%) "not good" grades for diet tolerance. More than 99% (104/105 = 99.05%) of the patients after RPD were satisfied with the surgical outcomes and would like to recommend RPD to those patients with pancreatic head cancer and periampullary lesions. 2

| SURVIVAL OUTCOME S AF TER ROBOTIC PAN CRE ATICODUODENEC TOMY
Survival outcomes after RPD have not been well-studied or reported in the literature. 9 We conducted a retrospective study for survival outcomes of pancreatic head cancer patients undergoing pancreaticoduodenectomy, comparing 85 RPD and 81 OPD patients. This study showed there was a benefit of survival in the RPD group, with 82.9% of 1-year survival, 45.3% of 3-year survival, and 26.8% 5-year survival, as compared with 63.8%, 26.2%, and 17.4%, respectively, in the OPD group, P = .004 ( Figure 6). 7 For ampullary cancer, there is no survival difference between RPD and OPD groups ( Figure 7). 7 At least, RPD is not only technically feasible but also oncologically justifiable without compromising the survival outcomes of pancreatic head and ampullary cancers, although selection bias would be inevitable in this retrospective study. 1,2,9 Prospective randomized control trials or studies of larger sample sizes with long-term follow-up are recommended to reach a reliable conclusion.

D I SCLOS U R E
Conflict of interest: All authors declare no conflict of interests for this article.