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PC Giulianotti, MD, FACS

Robotic Pancreatic Surgery. PC Giulianotti, MD, FACS. Professor and Chief Division of General, Minimally Invasive and Robotic Surgery University of Illinois Medical Center at Chicago. Laparoscopic Pancreatic Surgery. Robotic Liver Surgery: background. Robotic Biliary Surgery: background.

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PC Giulianotti, MD, FACS

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  1. Robotic Pancreatic Surgery PC Giulianotti, MD, FACS Professor and Chief Division of General, Minimally Invasive and Robotic Surgery University of Illinois Medical Center at Chicago

  2. Laparoscopic Pancreatic Surgery RoboticLiver Surgery: background Robotic Biliary Surgery: background Laparoscopic Pancreatic Surgery: Background Backgrounds 1994 Gagner M, Pomp A. Laparoscopic pylorus-preserving pancreatoduodenectomy Surg 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.

  3. Laparoscopic Pancreaticoduodenectomy RoboticLiver Surgery: background Robotic Biliary Surgery: background Laparoscopic Pancreatic Surgery: Background Laparoscopic Pancreaticoduodenectomy: Background Backgrounds 146 procedures reported between 1994 and 2009 146 procedures reported between 1994 and 2009 Morbidity: 16% Mortality: 1.3% Conversion Rate: 46% (12-100%) Fistula Rate: 7.5% Laparoscopic Whipple procedure is not only feasible but also safe, with low mortality and acceptable rates of complications. Laparoscopic Whipple procedure is not only feasible but also safe, with low mortality and acceptable rates of complications.

  4. Laparoscopic Pancreaticoduodenectomy RoboticLiver Surgery: background Robotic Biliary Surgery: background Laparoscopic Pancreatic Surgery: Background Laparoscopic Pancreaticoduodenectomy: Background Backgrounds Morbidity: 41.9% Mortality: 1.6% Conversion Rate: 4.6% Fistula Rate: 17.7% 54 totally laparoscopic procedures 8 robot-assisted procedures Laparoscopic pancreaticoduodenectomy is feasible, safe, effective, and holds promise for providing advantages seen with minimally invasive approaches in other procedures.

  5. Robotic Pancreaticoduodenectomy RoboticLiver Surgery: background Robotic Biliary Surgery: background Laparoscopic Pancreatic Surgery: Background Laparoscopic Pancreaticoduodenectomy: Background Backgrounds Pancreas. 2009 Nov 12. Robotic and Laparoscopic Pancreaticoduodenectomy: A Hybrid Approach. Narula VK et al. 5 patients Laparoscopic 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.

  6. Robotic Pancreaticoduodenectomy RoboticLiver Surgery: background Robotic Biliary Surgery: background Robotic Pancreaticoduodenectomy Laparoscopic Pancreatic Surgery: Background Laparoscopic Pancreaticoduodenectomy: Background Backgrounds 134 pancreatic procedures Morbidity: 26% Mortality: 2.2% Conversion Rate: 10.4% Fistula Rate: 20.9% 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.

  7. Robotic Pancreaticoduodenectomy Steps • Port setting - Diagnostic laparoscopy-Mobilization of right colon • Kocker maneuver • Hepatic hilum dissection • Doudeno-jejunal mobilization • Division of pancreas • Dissection of uncinate process • Reconstruction

  8. Robotic Pancreaticoduodenectomy Step 1 Port setting Reverse trendelemburg Slight left rotation Arms tucked to the side Parted legs

  9. Robotic Pancreaticoduodenectomy Step 1 Port setting 1 O A 3 2 Arm 1 8mm Assistant port 12mm Optic Port 12mm Arm 2 Arm 3

  10. Robotic Pancreaticoduodenectomy Step 2 Kocher Maneuver

  11. Robotic Pancreaticoduodenectomy Step 3 Hepatic Hilum

  12. Robotic Pancreaticoduodenectomy Step 4 Duodeno-jejunal flexure

  13. Robotic Pancreaticoduodenectomy Step 5 Pancreatic transection

  14. Robotic Pancreaticoduodenectomy RoboticLiver Surgery: background Robotic Biliary Surgery: background Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Laparoscopic Pancreatic Surgery: Background Laparoscopic Pancreaticoduodenectomy: Background Step 6 Uncinate process 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)

  15. Robotic Pancreaticoduodenectomy RoboticLiver Surgery: background Robotic Biliary Surgery: background Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Laparoscopic Pancreatic Surgery: Background Laparoscopic Pancreaticoduodenectomy: Background Step 7 Reconstruction Reconstruction • Challenging in laparoscopy • Surgeon fatigue • Inability to deal with fine • microsuturing (5/0 – 6/0) • Vision sometimes • inadequate

  16. Robotic Pancreaticoduodenectomy Step 7 Reconstruction Reconstruction: hepatico-jejunostomy

  17. Robotic Pancreaticoduodenectomy RoboticLiver Surgery: background Robotic Biliary Surgery: background Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Laparoscopic Pancreatic Surgery: Background Laparoscopic Pancreaticoduodenectomy: Background Lymphadenectomy • Extended lymphadenectomy for pancreatic cancer • has 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).

  18. Robotic Pancreaticoduodenectomy Celiac trunk Lymphadenectomy

  19. Robotic Pancreaticoduodenectomy 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.

  20. Robotic Pancreaticoduodenectomy RoboticLiver Surgery: background Robotic Biliary Surgery: background Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Laparoscopic Pancreatic Surgery: Background Laparoscopic Pancreaticoduodenectomy: Background 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 ml Length of Stay: 13 days

  21. Robotic Pancreaticoduodenectomy RoboticLiver Surgery: background Robotic Biliary Surgery: background Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Laparoscopic Pancreatic Surgery: Background Laparoscopic Pancreaticoduodenectomy: Background For cancer US experience: 36 cases of pancreatic malignancy (73.5%) R0 rate: 90.9% Lymph nodes harvested: 16.8 Median Follow Up: 12 months (range: 4-24) *: after a median survival of 13 months

  22. Distal Pancreatectomy RoboticLiver Surgery: background Robotic Biliary Surgery: background Laparoscopic Pancreatic Surgery: Background Laparoscopic distal pancreatectomy: Background Backgrounds By a laparoscopic approach 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.

  23. Robotic Distal Pancreatectomy RoboticLiver Surgery: background Robotic Biliary Surgery: background Robotic distal pancreatectomy Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Laparoscopic Pancreatic Surgery: Background Laparoscopic Pancreaticoduodenectomy: Background Backgrounds

  24. Robotic Distal Pancreatectomy RoboticLiver Surgery: background Robotic Biliary Surgery: background Robotic distal pancreatectomy Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Laparoscopic Pancreatic Surgery: Background Laparoscopic Pancreaticoduodenectomy: Background Backgrounds • 32 open vs. 28 laparoscopic vs. 17 robotic distal pancreatectomies • Similar cost • Shorter hospital stayfor the robotic group • Higher rate of spleen preservingcases in the robotic group • Increased operative time for the robotic approach

  25. Robotic Distal Pancreatectomy RoboticLiver Surgery: background Robotic Biliary Surgery: background Robotic distal pancreatectomy Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Laparoscopic Pancreatic Surgery: Background Laparoscopic Pancreaticoduodenectomy: Background 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 fistula Mortality: NO MORTALITY Blood loss: 240 ml (10-1000) Length of stay: 7 days (3-19)

  26. Robotic Distal Pancreatectomy RoboticLiver Surgery: background Robotic Biliary Surgery: background Robotic distal pancreatectomy Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy With spleen preservation Laparoscopic Pancreatic Surgery: Background Robotic distal pancreatectomy with spleen preservation Laparoscopic Pancreaticoduodenectomy: Background Personal experience 24 Spleen Preservingout of 55 distal pancreatectomies • ADVANTAGES of Robot • Splenic vessels dissection • Hemostasis • Spleen preserved PARAMETERS (US) Conv. rate:NO CONVERSION Mean op. time: 250 min (140-510) Transfusion: NO TRANSFUSION Morbidity:20%, 1 fistula Mortality: NO MORTALITY Blood loss: 115 ml (10-300) Length of stay: 6 days (3-13)

  27. Robotic Distal Pancreatectomy RoboticLiver Surgery: background Robotic Biliary Surgery: background Robotic distal pancreatectomy Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Laparoscopic Pancreatic Surgery: Background Robotic distal pancreatectomy with spleen preservation Laparoscopic Pancreaticoduodenectomy: Background For cancer pancreatic malignancy (39.7%) R0 rate: 87% Lymph nodes harvested: 16 Follow up 50% of patients are alive without recurrence at a mean FU of 51 months 33% are dead

  28. Robotic Total Pancreatectomy RoboticLiver Surgery: background Robotic Biliary Surgery: background Robotic distal pancreatectomy Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Robotic Pancreaticoduodenectomy Our experience Laparoscopic Pancreatic Surgery: Background Robotic distal pancreatectomy with spleen preservation Laparoscopic Pancreaticoduodenectomy: Background 7 robotic total pancreatectomies, 42.9% spleen preserving 3 patients with malignant disease PARAMETERS (US) Conv. rate:28.6% Mean op. time: 485 min (300-630) Transfusion: 28.6% Morbidity:28.5% Mortality: NO MORTALITY Blood loss: 450 ml (50-1200) Length of stay: 8.7 days (5-15) 1 associated with autologus islets transplantation

  29. Robotic Middle Pancreatectomy Personal experience 3 robotic middle pancreatectomies No Conversion No intra-operative transfusion No morbidity No mortality Mean operative time: 245 minutes (240-255) Pathology: 3 Cystadenomas Giulianotti PC et al. J Laparoendosc Adv Surg Techn. In press

  30. Robotic pancreatic surgery Extending the limits Vascular resection • 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 aminimally invasive vascular resection? Buchs NC et al. World J Gastroenterol 2010;16:818-31.

  31. Robotic vascular resection A technical challenge Our experience in robotic vascular resection associated with pancreatic resection: • 2 modified Appleby operations(splenopancreatectomy associated with celiac axis resection) • 2 portal vein resections associated with pancreaticoduodenectomy • 1 portal vein resection associated with distal splenopancreatectomy • 1 portal vein resection associated with a total pancreatectomy • Median age 60 years • Performed between May 2007 and December 2010

  32. Robotic vascular resection A technical challenge • 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

  33. Robotic vascular resection Robotic portal vein resection and reconstruction Associated with a robotic splenopancreatectomy

  34. Robotic pancreatic surgery CONCLUSIONS • ROBOTIC TECHNOLOGY ALLOWS: • Easiness dissection of the uncinate process • High quality of tissue manipulation • Safe reconstructive phase • Easier microdissection and spleen preservation

  35. Robotic 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.

  36. The Robotic Training Lab The Bruno and Tony Pasquinelli Lab Procedures performed at UIC and offered for training include: • Splenectomy • Total gastrectomy • Lung lobectomy • Colorectal surgery • Thyroidectomy • Adrenalectomy • Esophagectomy • Major hepatectomies • CBD Procedures • Whipple

  37. The Robotic Training Lab The Bruno and Tony Pasquinelli Lab Simulation Case observation Hands on

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