Name: technical detail for robot assisted pancreaticoduodenectomy
Uploaded: 2019-09-28T14:45:00
Description: Watch this Scientific Journal Video about Technical Detail for Robot Assisted Pancreaticoduodenectomy at JoVE.com

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This protocol follows the guidelines of the University of Pittsburg Medical Center human research ethics comittee (Institutional Review Board: PRO15040497)
1. Preoperative workup and selection
<ol>
	<li>Check the triphasic CT scan (i.e., chest, abdomen, and pelvis with the primary imaging modality) to evaluate the extent of disease, rule out metastasis, and delineate aberrant or anomalous arterial vasculature.&#160;</li>
	<li>Perform EUS and endoscopic retrograde cholangiopancreatography (ER...

<ol>
	<li>Tseng, J. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+learning+curve+in+pancreatic+surgery.">The learning curve in pancreatic surgery.</a> Surgery. 141, 456-463 (2007).</li><li>Cameron, J. L., He, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Two+Thousand+Consecutive+Pancreaticoduodenectomies.">Two Thousand Consecutive Pancreaticoduodenectomies.</a> Journal of the American College of Surgeons. 220, 530-536 (2015).</li><li>Birkmeyer, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+hospital+volume+on+in-hospital+mortality+with+pancreaticoduodenectomy.">Effect of hospital volume on in-hospital mortality with pancreaticoduodenectomy.</a> Surgery. 125, 250-256 (1999).</li><li>Cirocchi, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+systematic+review+on+robotic+pancreaticoduodenectomy.">A systematic review on robotic pancreaticoduodenectomy.</a> Surgical Oncology. 22, 238-246 (2013).</li><li>Giulianotti, P. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotics+in+general+surgery:+personal+experience+in+a+large+community+hospital.">Robotics in general surgery: personal experience in a large community hospital.</a> Archives of surgery. 138, 777-784 (2003).</li><li>Wang, S. -. E., Shyr, B. -. U., Chen, S. -. C., Shyr, Y. -. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+between+robotic+and+open+pancreaticoduodenectomy+with+modified+Blumgart+pancreaticojejunostomy:+A+propensity+score-matched+study.">Comparison between robotic and open pancreaticoduodenectomy with modified Blumgart pancreaticojejunostomy: A propensity score-matched study.</a> Surgery. 164 (6), 1162-1167 (2018).</li><li>Magge, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+pancreatoduodenectomy+at+an+experienced+institution+is+not+associated+with+an+increased+risk+of+post-pancreatic+hemorrhage.">Robotic pancreatoduodenectomy at an experienced institution is not associated with an increased risk of post-pancreatic hemorrhage.</a> HPB. 20, 448-455 (2018).</li><li>Zureikat, A. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+hepatopancreatobiliary+surgery+in+North+America:+an+ACS-NSQIP+analysis+of+predictors+of+conversion+for+laparoscopic+and+robotic+pancreatectomy+and+hepatectomy.">Minimally invasive hepatopancreatobiliary surgery in North America: an ACS-NSQIP analysis of predictors of conversion for laparoscopic and robotic pancreatectomy and hepatectomy.</a> The official journal of Hepato-Pancreato-Billiary Association. 19, 595-602 (2017).</li><li>Zureikat, A. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+Multi-institutional+Comparison+of+Perioperative+Outcomes+of+Robotic+and+Open+Pancreaticoduodenectomy.">A Multi-institutional Comparison of Perioperative Outcomes of Robotic and Open Pancreaticoduodenectomy.</a> Annals of Surgery. 264, 640-649 (2016).</li><li>McMillan, M. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+Propensity+Score-Matched+Analysis+of+Robotic+vs+Open+Pancreatoduodenectomy+on+Incidence+of+Pancreatic+Fistula.">A Propensity Score-Matched Analysis of Robotic vs Open Pancreatoduodenectomy on Incidence of Pancreatic Fistula.</a> JAMA Surgery. 152 (4), 327-335 (2016).</li><li>Nguyen, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technical+Aspects+of+Robotic-Assisted+Pancreaticoduodenectomy+(RAPD).">Technical Aspects of Robotic-Assisted Pancreaticoduodenectomy (RAPD).</a> Journal of Gastrointestinal Surgery. 15, 870-875 (2011).</li><li>Zureikat, A. H., Nguyen, K. T., Bartlett, D. L., Zeh, H. J., Moser, J. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-Assisted+Major+Pancreatic+Resection+and+Reconstruction.">Robotic-Assisted Major Pancreatic Resection and Reconstruction.</a> Archives of Surgery. 146, 256-261 (2011).</li><li>Knab, M. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evolution+of+a+Novel+Robotic+Training+Curriculum+in+a+Complex+General+Surgical+Oncology+Fellowship.">Evolution of a Novel Robotic Training Curriculum in a Complex General Surgical Oncology Fellowship.</a> Annals in Surgical Oncology. 25 (12), 3445-3452 (2018).</li><li>Wu, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Recurrent+GNAS+mutations+define+an+unexpected+pathway+for+pancreatic+cyst+development.">Recurrent GNAS mutations define an unexpected pathway for pancreatic cyst development.</a> Science Translational Medicine. 3, 92 (2011).</li><li>Singhi, A. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=American+Gastroenterological+Association+guidelines+are+inaccurate+in+detecting+pancreatic+cysts+with+advanced+neoplasia:+a+clinicopathologic+study+of+225+patients+with+supporting+molecular+data.">American Gastroenterological Association guidelines are inaccurate in detecting pancreatic cysts with advanced neoplasia: a clinicopathologic study of 225 patients with supporting molecular data.</a> Gastrointestinal Endoscopy. 83, 1107-1117 (2016).</li><li>Tanaka, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Revisions+of+international+consensus+Fukuoka+guidelines+for+the+management+of+IPMN+of+the+pancreas.">Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas.</a> Pancreatology. 17, 738-753 (2017).</li><li>Malka, D., Castan, F., Conroy, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=FOLFIRINOX+Adjuvant+Therapy+for+Pancreatic+Cancer.">FOLFIRINOX Adjuvant Therapy for Pancreatic Cancer.</a> New England Journal of Medicine. 380, 1187-1189 (2019).</li><li>Nassour, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+Versus+Laparoscopic+Pancreaticoduodenectomy:+a+NSQIP+Analysis.">Robotic Versus Laparoscopic Pancreaticoduodenectomy: a NSQIP Analysis.</a> Journal of Gastrointestinal Surgery Official Journal of the Society for Surgery of the Alimentary Tract. 21, 1784-1792 (2017).</li><li>Gabriel, E., Thirunavukarasu, P., Attwood, K., Nurkin, S. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=National+disparities+in+minimally+invasive+surgery+for+pancreatic+tumors.">National disparities in minimally invasive surgery for pancreatic tumors.</a> Surgical Endoscopy. 31, 398-409 (2017).</li><li>Konstantinidis, I. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+total+pancreatectomy+with+splenectomy:+technique+and+outcomes.">Robotic total pancreatectomy with splenectomy: technique and outcomes.</a> Surgical Endoscopy. 32, 3691-3696 (2018).</li><li>Kornaropoulos, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Total+robotic+pancreaticoduodenectomy:+a+systematic+review+of+the+literature.">Total robotic pancreaticoduodenectomy: a systematic review of the literature.</a> Surgical Endoscopy. 31, 4382-4392 (2017).</li><li>Boone, B. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Assessment+of+Quality+Outcomes+for+Robotic+Pancreaticoduodenectomy:+Identification+of+the+Learning+Curve.">Assessment of Quality Outcomes for Robotic Pancreaticoduodenectomy: Identification of the Learning Curve.</a> JAMA Surgery. 150, 416-422 (2015).</li><li>Fisher, W. E., Hodges, S. E., Wu, M. -. F. F., Hilsenbeck, S. G., Brunicardi, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Assessment+of+the+learning+curve+for+pancreaticoduodenectomy.">Assessment of the learning curve for pancreaticoduodenectomy.</a> American Journal of Surgery. 203, 684-690 (2012).</li><li>Hmidt, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+hospital+volume,+surgeon+experience,+and+surgeon+volume+on+patient+outcomes+after+pancreaticoduodenectomy:+a+single-institution+experience.">Effect of hospital volume, surgeon experience, and surgeon volume on patient outcomes after pancreaticoduodenectomy: a single-institution experience.</a> Archives of Surgery. 145, 634-640 (2010).</li><li>Zureikat, A. H., Hogg, M. E., Zeh, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Utility+of+the+Robot+in+Pancreatic+Resections.">The Utility of the Robot in Pancreatic Resections.</a> Advances in Surgery. 48, 77-95 (2014).</li></ol>

With advances in the surgical technology, laparoscopic and robot-assisted surgeries are being increasingly used in gastrointestinal and hepatobiliary procedures. Conventional laparoscopy is associated with benefits over open surgery for many procedures. However, inherent limitations such as decreased surgical dexterity, suboptimal ergonomics, lack of wristed instruments, and 2-D visualization, have limited its dissemination to complex gastrointestinal operations such as PD.&#160;
Contrary to l...

Pancreaticoduodenectomy (PD) is a complex operation that combines a challenging resection and a meticolous reconstruction. During its early inception, the traditional open approach was frought with high complication rates and a mortality rate approaching 25%. In the last three decades, improvements in the surgical technique and perioperative care led to corresponding improvements in outcomes, with a reduction in mortality to less than 5%, especially at high volume centers1,2,3. Despite this, morbidity remains substantial. With advancements in surgical technology, minimally invasive surgical approaches through laparoscopy or robot-assisted surgery have emerged in an effort to curb this morbidity. Since its first report in 2003, interest in robotic pancreaticoduodenectomy (RPD) has grown by pancreatic surgeons4,5. Inherent advantages of the robotic platform, including three-dimensional (3D) vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate principles of open PD (OPD) in a minimally invasive manner, including safe oncologic dissection, hemostasis, and meticulous reconstruction4,6,7,8,9,10. The goal of this manuscript is to provide the detailed steps of an RPD performed at the University of Pittsburgh Medical Center (UPMC)11,12,13.
In the presented case study, a 42-year-old female with a previous history of intraductal papillary mucinous neoplasm (IPMN), initially presented with acute pancreatitis. Computed tomography (CT) of the abdomen revealed a 3.3 cm pancreatic head lesion with associated dilatation of the main pancreatic duct (Figure 1A,B), with a mixed type IPMN. Endoscopic ultrasound (EUS) confirmed the existence of an irregular, heterogenous cyst measuring 3.1 x 2.0 cm in the pancreatic head with mixed solid and cystic components and main PD duct dilation (Figure 1C). EUS cytology revealed the presence of atypical cells with no high-risk molecular mutations14,15. Biochemical workup including serum tumor markers were normal, with CA19-9 12 U/mL. Based on the Fukuoka criteria, this patient was recommended to have a PD and was deemed a suitable candidate for the robotic approach16.

<table border="0" cellpadding="0" cellspacing="0" style="width:973px;" width="972">
	<colgroup>
		<col span="2" />
		<col />
		<col />
	</colgroup>
	<tbody>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">3-0 V-Loc sutures</td>
			<td style="width:291px;">Medtronic (Minneapolis, MN)</td>
			<td style="width:119px;">VLOCMo614</td>
			<td style="width:273px;">Barbed Absorable Suture</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">4-5 Fr Freeman Pancreatic Flexi-Stent</td>
			<td style="width:291px;">Hobbs Medical (Stafford Springs, CT)</td>
			<td style="width:119px;">6542, 6552</td>
			<td>Pancreatic Duct Stent</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">5-0 PDS (polydiosxanone)</td>
			<td style="width:291px;">Ethicon (Somerville, NJ)</td>
			<td style="width:119px;">D10063</td>
			<td>Synthetic Absorbable Suture</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Cad&#237;ere forceps</td>
			<td style="width:291px;">Intuitive (Sunnyvale, CA)</td>
			<td style="width:119px;">470049</td>
			<td>Surgical Robot Instrument</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Da Vinci Si</td>
			<td style="width:291px;">Intuitive (Sunnyvale, CA)</td>
			<td style="width:119px;"></td>
			<td>Surgical Robot</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Da Vinci Xi</td>
			<td style="width:291px;">Intuitive (Sunnyvale, CA)</td>
			<td style="width:119px;"></td>
			<td>Surgical Robot</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Endo Clip 10 mm Applier</td>
			<td style="width:291px;">Covidien (Dublin, Ireland)</td>
			<td style="width:119px;">176619</td>
			<td>Laparoscopic Titanium Clip Applier</td>
		</tr>
		<tr height="63">
			<td height="63" style="height:63px;width:291px;">Endo GIA 45 mm Curved Tip Articulating Vascular Stapler with Tri-Stapler Technology</td>
			<td style="width:291px;">Covidien (Dublin, Ireland)</td>
			<td style="width:119px;">EGIA45CTAVM</td>
			<td>Laparoscopic Surgical Stapler</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:291px;">Endo GIA 60 mm Articulating Stapler with Tri-Stapler Technology</td>
			<td style="width:291px;">Covidien (Dublin, Ireland)</td>
			<td style="width:119px;">EGIA60AMT</td>
			<td>Laparoscopic Surgical Stapler</td>
		</tr>
		<tr height="63">
			<td height="63" style="height:63px;width:291px;">Endo GIA 60 mm Curved Tip Articulating Vascular Stapler with Tri-Stapler Technology</td>
			<td style="width:291px;">Covidien (Dublin, Ireland)</td>
			<td style="width:119px;">EGIA60CTAVM</td>
			<td>Laparoscopic Surgical Stapler</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">EndoCatch Gold 10 mm Specimen Pouch</td>
			<td style="width:291px;">Medtronic (Minneapolis, MN)</td>
			<td style="width:119px;">173050G</td>
			<td>Specimen Extraction Bag</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">EndoCatch II 15 mm Specimen Pouch</td>
			<td style="width:291px;">Medtronic (Minneapolis, MN)</td>
			<td style="width:119px;">173049</td>
			<td>Specimen Extraction Bag</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Fenestrated bipolar forceps</td>
			<td style="width:291px;">Intuitive (Sunnyvale, CA)</td>
			<td style="width:119px;">470205</td>
			<td>Surgical Robot Instrument</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">GelPOINT Mini Advanced Access Platform</td>
			<td>Applied Medical (Rancho Santa Margarita, CA)</td>
			<td style="width:119px;">CNGL3</td>
			<td>Laparoscopic Abdominal Access Platform</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Large needle driver</td>
			<td style="width:291px;">Intuitive (Sunnyvale, CA)</td>
			<td style="width:119px;">470006</td>
			<td>Surgical Robot Instrument</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Large SutureCut needle driver</td>
			<td style="width:291px;">Intuitive (Sunnyvale, CA)</td>
			<td style="width:119px;">470296</td>
			<td>Surgical Robot Instrument</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:291px;">LigaSure Blunt Tip Laparoscopic Sealer/Divider</td>
			<td style="width:291px;">Medtronic (Minneapolis, MN)</td>
			<td style="width:119px;">LF1844</td>
			<td>Laparoscopic Bioplar Device</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Mediflex liver retractor</td>
			<td style="width:291px;">Mediflex (Islandia NY)</td>
			<td style="width:119px;"></td>
			<td>Laparoscopic Liver Retractor</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Monopolar curved scissors</td>
			<td style="width:291px;">Intuitive (Sunnyvale, CA)</td>
			<td style="width:119px;">470179</td>
			<td>Surgical Robot Instrument</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Permanent cautery hook</td>
			<td style="width:291px;">Intuitive (Sunnyvale, CA)</td>
			<td style="width:119px;">470183</td>
			<td>Surgical Robot Instrument</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">ProGrasp forceps</td>
			<td style="width:291px;">Intuitive (Sunnyvale, CA)</td>
			<td style="width:119px;">470093</td>
			<td>Surgical Robot Instrument</td>
		</tr>
	</tbody>
</table>

technical detail for robot assisted pancreaticoduodenectomy

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic platform, including three-dimensional vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate the principles of open pancreatoduodenectomy allowing safe oncologic dissection, hemostasis, and meticulous reconstruction. Over the course of the past decade, significant strides have been achieved in outlining the safety, feasibility, and learning curve of the robotic Whipple. When performed by high volume pancreatic surgeons experienced in RPD, recent comparative effectiveness studies show potential advantages compared to the open technique, including reductions in hospital stay and morbidity. National data also show reductions in conversion rates compared to its laparoscopic counterpart. Although long-term oncologic data are still needed, short-term oncologic surrogates of margin resection and lymph node harvest suggest no compromise in oncologic outcomes. As pancreatic surgeons increasingly integrate robotics into their practice, proficiency-based training and credentialing will be necessary for the safe application and dissemination of RPD. Here, we provide the detailed steps of a robotic pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.&#160;

In the representative case, the total operative time was 225 min with an estimated blood loss (EBL) of 50 mL (Table 1). The patient was admitted to the surgical ward. Her postoperative course followed the UPMC institutional ERAS pathway. We routinely assess JP amylase at POD#1 and #3 to assess for pancreatic fistula and practice early drain removal on POD 3-5 when possible. The patient&#8217;s JP amylase levels were 403 U/L and 68 U/L, respectively. Therefore, the drain was removed on POD#3. The patient ...

Watch this Scientific Journal Video about Technical Detail for Robot Assisted Pancreaticoduodenectomy at JoVE.com

Technical Detail for Robot Assisted Pancreaticoduodenectomy

The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic ...

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