Hybrid Pancreaticoduodenectomy for Pancreatic and Periampullary Cancer in the Robotic Era: The Tango, Slow and Rock And Roll

Introduction Despite the decrease in operative mortality of pancreaticoduodenectomy over last decades, operative morbidity remains high and overall survival is still poor. As such, minimally invasive surgery for periampullary malignancy is generally considered of limited value. We assessed the role of a hybrid minimally invasive approach in patients treated for early clinical stage pancreatic and periampullary cancer and analyzed operative and short-term surgical outcomes. Methods We conducted a retrospective analysis of a prospectively maintained hepatobiliary database under IRB approval. All patients who received robotic assisted pancreaticoduodenectomy for pancreatic or periampullary malignancies were included. The surgical approach consisted of a laparoscopic portion including exploration, cholecystectomy, kocherization of the duodenum, mobilization and division of the stomach and intestine. This was followed by robotic dissection of the hepatoduodenal ligament, pancreatic neck and peripancreatic lymph nodes. Finally a mini laparotomy was used to divide the pancreas and perform the reconstruction. Patients’ demographics, operative data, pathology results and short-term outcomes were analyzed. Results Eleven consecutive patients, underwent surgery for clinical stage I and II biopsy proven pancreatic head adenocarcinoma (n=8), neuroendocrine carcinoma (n=2) and duodenal gastrointestinal stromal tumor (n=1). Average operative time was 475 minutes. Average estimated blood loss was 375 mL; there was no perioperative or 90 days mortality. 27% of patients received perioperative blood transfusions. There were no grade B/C pancreatic fistulas. Mean hospital length of stay was seven days and readmission rate was 27%. Pathological examination of the specimen revealed 100% R0 resection with an average lymph node retrieval of 14. Conclusion The hybrid approach is safe and may be an acceptable introduction for a totally robotic pancreaticoduodenectomy. It offers the patients the advantages of a minimally invasive approach, maintains the classical surgical reconstruction phase and provides a flexible platform for the surgeon to gradually integrate the robotic technique.


Cherif Boutros, Lance Uradomo, Mukul Khandelwal, Harvinder Singh, Russell DeLuca, Yudhishtra Markan, Alan Morrison

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