How I Do It: Robotic Pancreaticoduodenectomy

Abstract

Beginning in 2008, our group embarked on a systematic approach to develop and modify the robotic pancreaticoduodenectomy (RPD). Since that time, over 600 RPDs have been performed at the University of Pittsburgh. Early studies (2008–2012) focused on safety and feasibility. This was followed by identification of the learning curve which is estimated at 80 cases for novice adopters (2012–2014). Once we established benchmarks of excellence, we proceeded with multi-institutional comparative effectiveness studies of RPD versus standard open pancreaticoduodenectomy (2014–2016); some of which have demonstrated beneficial outcomes to the robotic approach, such as reductions in blood loss and morbidity. 5 Finally, over the past few years (2016–present), we focused on implementing a dedicated training program to facilitate safe dissemination. Throughout this time period, various technical modifications have been incorporated into the procedure, with the overall aim of reducing operating time, curtailing morbidity, and improving oncologic outcomes. In this article, we review the technical aspects of RPD as it is performed by our group today. Although the principles of the operation are similar to OPD, the sequence of steps and the role of the assistant are radically different. Our aim here is to provide the reader with a detailed account of the technical steps of this complex operation, while emphasizing that keys to successful results are patient selection, team approach, and a fundamental understanding of the principles of open pancreatic surgery. Our indications for RPD are similar to those of open pancreaticoduodenectomy with a few important exceptions. Most RPDs are for periampullary malignancy, but it can be performed for premalignant cystic lesions as well as chronic pancreatitis—although the latter can be challenging. While there are no absolute contraindications for robotic pancreaticoduodenectomy in experienced hands beyond the learning curve, there are several relative contraindications, particularly for early adopters. The following are important considerations: