pc giulianotti, md, facs robotic pancreatic surgery professor and chief division of general,...

PC Giulianotti, PC Giulianotti, MD, FACSMD, FACS

Robotic Pancreatic SurgeryRobotic Pancreatic Surgery

Professor and ChiefDivision of General, Minimally Invasive and Robotic Surgery

University of Illinois Medical Center at Chicago

http://www.clinicalrobotics.com/

Laparoscopic Pancreatic Surgery: Background

1994 Gagner M, Pomp A.Laparoscopic pylorus-preserving pancreatoduodenectomySurg Endosc 1994;8(5):408-10.

1994 Soper NJ et al.

Laparoscopic distal pancreatectomy in the porcine model

Surg Endosc 1994;8(1):57-60.

Robotic Biliary Surgery: backgroundRobotic Liver Surgery: backgroundLaparoscopic Pancreatic SurgeryLaparoscopic Pancreatic Surgery BackgroundsBackgrounds

Laparoscopic Pancreaticoduodenectomy: Background

Laparoscopic Whipple procedure is not only feasible but also safe, with low mortality and acceptable rates of complications.

146 procedures reported between 1994 and 2009

Morbidity: 16%Mortality: 1.3%Conversion Rate: 46% (12-100%)Fistula Rate: 7.5%

Laparoscopic Pancreatic Surgery: BackgroundRobotic Biliary Surgery: backgroundRobotic Liver Surgery: backgroundLaparoscopic PancreaticoduodenectomyLaparoscopic PancreaticoduodenectomyBackgroundsBackgrounds

Laparoscopic Whipple procedure is not only feasible but also safe, with low mortality and acceptable rates of complications.

146 procedures reported between 1994 and 2009

Laparoscopic Pancreaticoduodenectomy: BackgroundLaparoscopic Pancreatic Surgery: BackgroundRobotic Biliary Surgery: backgroundRobotic Liver Surgery: backgroundLaparoscopic PancreaticoduodenectomyLaparoscopic PancreaticoduodenectomyBackgroundsBackgrounds

Laparoscopic pancreaticoduodenectomy is feasible, safe, effective, and holds promise for providing advantages seen with minimally invasive approaches in other procedures.

54 totally laparoscopic procedures8 robot-assisted procedures

Morbidity: 41.9%Mortality: 1.6%Conversion Rate: 4.6%Fistula Rate: 17.7%

Laparoscopic Pancreaticoduodenectomy: BackgroundLaparoscopic Pancreatic Surgery: BackgroundRobotic Biliary Surgery: backgroundRobotic Liver Surgery: background

Pancreas. 2009 Nov 12.Robotic and Laparoscopic Pancreaticoduodenectomy: A Hybrid Approach.Narula VK et al.

5 patientsLaparoscopic dissection

Robot-assisted reconstruction: pancreaticojejunostomy and choledocojejunostomy

Mean operative time: 420 minutes

Mean hospital stay: 9.6 days

At 6 months: all patients were disease-free.

Complex procedures such as PD can be accomplished with minimally invasive surgical techniques using robotic instrumentation.

Robotic PancreaticoduodenectomyRobotic PancreaticoduodenectomyBackgroundsBackgrounds

Robotic Pancreaticoduodenectomy

Robotic surgery enables difficult technical maneuvers to be performed that facilitate the success of pancreatic minimally invasive surgery. The results in this series demonstrate that it is feasible and safe.

134 pancreatic procedures

Morbidity: 26%Mortality: 2.2%Conversion Rate: 10.4%Fistula Rate: 20.9%

Laparoscopic Pancreaticoduodenectomy: BackgroundLaparoscopic Pancreatic Surgery: BackgroundRobotic Biliary Surgery: backgroundRobotic Liver Surgery: backgroundRobotic PancreaticoduodenectomyRobotic PancreaticoduodenectomyBackgroundsBackgrounds

1. Port setting - Diagnostic laparoscopy-Mobilization of right colon

2. Kocker maneuver

3. Hepatic hilum dissection

4. Doudeno-jejunal mobilization

5. Division of pancreas

6. Dissection of uncinate process

7. Reconstruction

Steps

Robotic PancreaticoduodenectomyRobotic Pancreaticoduodenectomy

Step 1 Port setting

Reverse trendelemburg

Slight left rotation

Arms tucked to the side

Parted legs


A

2

3O

1

Step 1 Port setting

Arm 1 8mm

Assistant port 12mm

Optic Port 12mm

Arm 2

Arm 3


Step 2 Kocher Maneuver


Step 3 Hepatic HilumRobotic PancreaticoduodenectomyRobotic Pancreaticoduodenectomy

Step 4 Duodeno-jejunal flexure


Step 5 Pancreatic transection



Uncinate Process Dissection

• The increasing retraction capabilities (IVth arm) combined with the stability of the system makes easier the exposure of the SMV and SMA

• Microsuturing makes easier and safer the control of bleeding.

• The stability of the system allows a better and selective delivery of energy (Harmonic)

Robotic PancreaticoduodenectomyLaparoscopic Pancreaticoduodenectomy: BackgroundLaparoscopic Pancreatic Surgery: BackgroundRobotic Biliary Surgery: backgroundRobotic Liver Surgery: backgroundRobotic PancreaticoduodenectomyRobotic PancreaticoduodenectomyStep 6 Uncinate process


Reconstruction

• Challenging in laparoscopy • Surgeon fatigue

• Inability to deal with fine microsuturing (5/0 – 6/0)

• Vision sometimes inadequate

Robotic PancreaticoduodenectomyRobotic PancreaticoduodenectomyLaparoscopic Pancreaticoduodenectomy: BackgroundLaparoscopic Pancreatic Surgery: BackgroundRobotic Biliary Surgery: backgroundRobotic Liver Surgery: backgroundRobotic PancreaticoduodenectomyRobotic PancreaticoduodenectomyStep 7 Reconstruction

Reconstruction: hepatico-jejunostomy

Robotic PancreaticoduodenectomyRobotic PancreaticoduodenectomyStep 7 Reconstruction


Lymphadenectomy

• Extended lymphadenectomy for pancreatic cancerhas a still undefined role (staging, cure).

• The accuracy of stadiation depends on the number of nodal retrieval.

• Extended lymphadenectomy may be challenging (celiac trunk, SMA).

Robotic PancreaticoduodenectomyRobotic PancreaticoduodenectomyLaparoscopic Pancreaticoduodenectomy: BackgroundLaparoscopic Pancreatic Surgery: BackgroundRobotic Biliary Surgery: backgroundRobotic Liver Surgery: backgroundRobotic PancreaticoduodenectomyRobotic Pancreaticoduodenectomy

Celiac trunk Lymphadenectomy


Lymphadenectomy: results

Nodes harvested: Average 19 (range: 12 - 27)

Gagner and Palermo

Systematic review of published laparoscopic pancreaticoduodenectomy

146 cases since 1994

Mean number of lymph nodes in the pathology was 19 (13–26).

Gagner et al. J Hepatobiliary Pancreat Surg 2009;16:726-30.



Personal Experience

87 Robotic Pancreaticoduodenectomies

PARAMETERS of US Series (49 patients)

Conversion rate: 4.1%Mean op. time: 444 minutes (range: 240-720)Transfusion: Postoperative: 22.2%Morbidity: 32.7% Mortality: 4.1% Fistula rate: 16.3%Mean Blood Loss: 387 mlLength of Stay: 13 days

Robotic PancreaticoduodenectomyRobotic PancreaticoduodenectomyLaparoscopic Pancreaticoduodenectomy: BackgroundLaparoscopic Pancreatic Surgery: BackgroundRobotic Biliary Surgery: backgroundRobotic Liver Surgery: backgroundRobotic PancreaticoduodenectomyRobotic Pancreaticoduodenectomy

US experience: 36 cases of pancreatic malignancy (73.5%)

Median Follow Up: 12 months (range: 4-24)

Alive without recurrence

Alive with recurrence

Died

Pancreatic head adenocarcinoma

71.4% 14.3% 14.3%

Periampullary tumors 83.3% 0 16.7%

Distal bile duct carcinoma

0 0 100%*

Duodenal adenocarcinoma

100% 0 0

*: after a median survival of 13 months

R0 rate: 90.9%R0 rate: 90.9%

Lymph nodes harvested: 16.8 Lymph nodes harvested: 16.8

Robotic PancreaticoduodenectomyRobotic PancreaticoduodenectomyRobotic PancreaticoduodenectomyLaparoscopic Pancreaticoduodenectomy: BackgroundLaparoscopic Pancreatic Surgery: BackgroundRobotic Biliary Surgery: backgroundRobotic Liver Surgery: backgroundRobotic PancreaticoduodenectomyRobotic PancreaticoduodenectomyFor cancerFor cancer

Technically challenging high percentage of unecessary splenectomies

Associated with longer operative times

Greater potential for bleeding

Pryor A et al.Laparoscopic distal pancreatectomy with spleen preservation.Surg Endosc 2007;21:2326-30.

By a laparoscopic approach

Laparoscopic distal pancreatectomy: BackgroundLaparoscopic Pancreatic Surgery: BackgroundRobotic Biliary Surgery: backgroundRobotic Liver Surgery: backgroundDistal PancreatectomyDistal Pancreatectomy

BackgroundsBackgrounds

Robotic distal pancreatectomyRobotic PancreaticoduodenectomyRobotic PancreaticoduodenectomyRobotic PancreaticoduodenectomyLaparoscopic Pancreaticoduodenectomy: BackgroundLaparoscopic Pancreatic Surgery: BackgroundRobotic Biliary Surgery: backgroundRobotic Liver Surgery: backgroundRobotic Distal PancreatectomyRobotic Distal Pancreatectomy




32 open vs. 28 laparoscopic vs. 17 robotic distal pancreatectomies

Similar cost

Shorter hospital stay for the robotic group

Higher rate of spleen preserving cases in the robotic group

Increased operative time for the robotic approach

Robotic distal pancreatectomy

Personal experience

55 robotic distal pancreatectomies

PARAMETERS (US)

Conv. rate: 3.4%Mean op. time: 281 min (140-510)Transfusion: 10%Morbidity: 17.2%, 2 fistulaMortality: NO MORTALITYBlood loss: 240 ml (10-1000)Length of stay: 7 days (3-19)

Robotic PancreaticoduodenectomyRobotic PancreaticoduodenectomyRobotic PancreaticoduodenectomyLaparoscopic Pancreaticoduodenectomy: BackgroundLaparoscopic Pancreatic Surgery: BackgroundRobotic Biliary Surgery: backgroundRobotic Liver Surgery: backgroundRobotic Distal PancreatectomyRobotic Distal Pancreatectomy

Robotic distal pancreatectomy with spleen preservation

Personal experience

24 Spleen Preserving out of 55 distal pancreatectomies

ADVANTAGES of Robot

• Splenic vessels dissection• Hemostasis• Spleen preserved

PARAMETERS (US)

Conv. rate: NO CONVERSIONMean op. time: 250 min (140-510)Transfusion: NO TRANSFUSIONMorbidity: 20%, 1 fistulaMortality: NO MORTALITYBlood loss: 115 ml (10-300)Length of stay: 6 days (3-13)


With spleen preservationWith spleen

preservation

pancreatic malignancy (39.7%)

R0 rate: 87%R0 rate: 87%

Lymph nodes harvested: 16 Lymph nodes harvested: 16

Follow upFollow up

50% of patients are alive without recurrence at a mean FU of 51 months

33% are dead

Robotic distal pancreatectomy with spleen preservationRobotic distal pancreatectomyRobotic PancreaticoduodenectomyRobotic PancreaticoduodenectomyRobotic PancreaticoduodenectomyLaparoscopic Pancreaticoduodenectomy: BackgroundLaparoscopic Pancreatic Surgery: BackgroundRobotic Biliary Surgery: backgroundRobotic Liver Surgery: backgroundRobotic Distal PancreatectomyRobotic Distal Pancreatectomy

For cancerFor cancer

7 robotic total pancreatectomies, 42.9% spleen preserving

PARAMETERS (US)

Conv. rate: 28.6%Mean op. time: 485 min (300-630)Transfusion: 28.6% Morbidity: 28.5%Mortality: NO MORTALITYBlood loss: 450 ml (50-1200)Length of stay: 8.7 days (5-15)

1 associated with autologus islets transplantation

3 patients with malignant disease3 patients with malignant disease

Robotic distal pancreatectomy with spleen preservationRobotic distal pancreatectomyRobotic PancreaticoduodenectomyRobotic PancreaticoduodenectomyRobotic PancreaticoduodenectomyLaparoscopic Pancreaticoduodenectomy: BackgroundLaparoscopic Pancreatic Surgery: BackgroundRobotic Biliary Surgery: backgroundRobotic Liver Surgery: backgroundRobotic Total PancreatectomyRobotic Total Pancreatectomy

Our experienceOur experience

Personal experience

3 robotic middle pancreatectomies

No ConversionNo intra-operative transfusionNo morbidityNo mortality

Mean operative time: 245 minutes (240-255)

Pathology: 3 Cystadenomas

Giulianotti PC et al. J Laparoendosc Adv Surg Techn. In press

Robotic Middle PancreatectomyRobotic Middle Pancreatectomy

Vascular resection

Buchs NC et al. World J Gastroenterol 2010;16:818-31.

• One of the most important challenge in pancreatic surgery

• Surgical exploration remains the gold standard

• A recent review of the literature:

If an arterial invasion still remains a relative contra-indication, a venous invasion should not be considered as a contra-indication

A venous resection and reconstruction is feasible and reliable

But what about a minimally invasive vascular resection?

Robotic pancreatic surgeryRobotic pancreatic surgeryExtending the

limitsExtending the

limits

A technical challenge

A technical challenge

Robotic vascular resectionRobotic vascular resection

Our experienceOur experience in robotic vascular resection associated with pancreatic resection:

2 modified Appleby operations2 modified Appleby operations (splenopancreatectomy associated with celiac axis resection)

2 portal vein resections associated with pancreaticoduodenectomy2 portal vein resections associated with pancreaticoduodenectomy

1 portal vein resection associated with distal splenopancreatectomy1 portal vein resection associated with distal splenopancreatectomy

1 portal vein resection associated with a total pancreatectomy1 portal vein resection associated with a total pancreatectomy

Median age 60 years

Performed between May 2007 and December 2010

No Conversion

Mean operating time: 392 minutes (range: 310-460)

Mean Blood loss: 200 ml (range: 150-300)

No transfusion

No mortality

One reoperation for duodenal ulcer perforation

Hospital stay: 9.5 days

At a median FU of 6 months (range: 3-20): 4 patients alive and

disease-free

Robotic vascular resectionRobotic vascular resection A technical

challengeA technical

challenge

Robotic portal vein resection and reconstruction Associated with a robotic splenopancreatectomy

Robotic vascular resectionRobotic vascular resection

CONCLUSIONS

ROBOTIC TECHNOLOGY ALLOWS:

• Easiness dissection of the uncinate process

• High quality of tissue manipulation

• Safe reconstructive phase

• Easier microdissection and spleen preservation

Robotic pancreatic surgeryRobotic pancreatic surgery

CONCLUSIONS

• Minimally invasive pancreatic surgery still remains a big challenge.

• Robotic assistance overcome the limits of laparoscopy and is associated with lower blood losses and transfusion rate.

• Morbidity seems acceptable and lower than laparoscopy.

• Further randomized trials and longer follow up will be necessary to validate these results.

Robotic pancreatic surgeryRobotic pancreatic surgery

The Robotic Training LabThe Robotic Training LabThe Bruno and Tony Pasquinelli

Lab

Procedures performed at Procedures performed at UIC and offered for training UIC and offered for training include:include:• Splenectomy• Total gastrectomy• Lung lobectomy• Colorectal surgery• Thyroidectomy

• Adrenalectomy• Esophagectomy• Major hepatectomies• CBD Procedures• Whipple

The Robotic Training LabThe Robotic Training LabThe Bruno and Tony Pasquinelli

Lab

SimulationSimulation

Case observationCase observation

Hands onHands on

pc giulianotti, md, facs robotic pancreatic surgery professor and chief division of general,...

Documents

laparoscopic procedures

invasive surgery

background pancreas

laparoscopic pylorus

robotic instrumentation

success of pancreatic

fistula rate

conversion rate