Stephanie Novak

Grading of Surgeon Technical Performance Predicts Postoperative Pancreatic Fistula for Pancreaticoduodenectomy Independent of Patient-related Variables.

Objective: To evaluate and quantify surgical skill by grading surgical performance of the pancreaticojejunostomy from robotic pancreaticoduodenectomies (RPDs). We hypothesized that video grading of surgical performance would contribute to estimating risk of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy. Background: POPF majorly contributes to pancreaticoduodenectomy morbidity. Risk scores [Fistula Risk Score (FRS) and Braga] derived from patient variables are validated for predicting POPF. Birkmeyer et al showed assessment of surgical proficiency is an important component of outcomes. Methods: POPF was diagnosed using International Study Group definition. Technical performance of robotic pancreaticojejunostomy video was graded by 2 blinded surgeons using: (1) pancreaticojejunostomy step-by-step variables [PJ-specific variables (PJVs); max = 115]; and (2) the Objective Structured Assessment of Technical Skills (OSATS) score. Results: One hundred thirty-three pancreaticojejunostomies were analyzed. POPF was 18%. Higher FRS (P = 0.011) and Braga (P = 0.041) scores predicted POPF. Graders’ subjective prediction did not correlate with FRS/Braga scores. Grader 1 scores (P = 0.043), but not grader 2 (P = 0.44), predicted POPF. PJV scores >105 were predictive of POPF (P = 0.039). Scoring only PJV duct-to-mucosa stitches (max = 50) was highly predictive of POPF (P = 0.0053). Higher OSATS scores were associated with a decreased rate of POPF (P = 0.022). On multivariate analysis, adding technical scoring to statistically significant patient variables (ie, gland texture) improves the model and can independently predict POPF. The strongest predictive model for POPF consisted of soft gland (odds ratio = 18.28, 95% confidence interval = 2.19–152.57) and low OSATS (odds ratio = 0.82, 95% confidence interval = 0.70–0.96). OSATS, modeled with FRS or Braga scores, independently predicted POPF. Conclusions: This is the first study to demonstrate that technical scoring of a surgeons performance independently predicts patient outcomes in pancreatic surgery. Future studies should consider how to validate and incorporate technical metrics.

Robotic central pancreatectomy

Central pancreatectomy (CP) is a parenchyma-sparing procedure that can be utilized in the resection of tumors of the neck or the proximal body of the pancreas. Among 872 open CP reported since 1993, the mean rate of morbidity was 43.2% and mean rate of mortality was 0.24%. The mean pancreatic fistula rate was 28%. The rate of clinically significant pancreatic fistulas with ISGPF Grades B and C was 19%. The rate of development of post-operative diabetes mellitus was at 2% and the average incidence of exocrine insufficiency experienced by patients undergoing open CP was 4.4%. Also, the mean length of hospital stay was around 15 days. In comparison, a total of 100 patients underwent either laparoscopic or robotic CP with a mean rate of morbidity of 37.3% and mean rate of mortality of 0%. Also, the mean rate of development of pancreatic fistula was 36.6%. The rate of clinically significant pancreatic fistulas with ISGPF Grades B and C was 17%. The rate of development of post-operative diabetes mellitus was at 1.5%. None of the patients included in these series developed any postoperative exocrine insufficiency. The mean length of hospital stay was around 13 days. Standard procedures such as DP and PD are associated with lower rates of short-term morbidity such as pancreatic fistula development but are also accompanied with a higher rate of long-term endocrine and exocrine insufficiency due to the significant loss of normal pancreatic parenchyma when compared to CP. It can be inferred, albeit from limited and small retrospective studies and case reports, that conventional and robotic-assisted laparoscopic approaches to CP are safe and feasible in highly specialized centers.

Robotic vascular resections during Whipple procedure

Indications for resection of pancreatic cancers have evolved to include selected patients with involvement of peri-pancreatic vascular structures. Open Whipple procedures have been the standard approach for patients requiring reconstruction of the portal vein (PV) or superior mesenteric vein (SMV). Recently, high-volume centers are performing minimally invasive Whipple procedures with portovenous resections. Our institution has performed seventy robotic Whipple procedures with concomitant vascular resections. This report outlines our technique.

Performing the Difficult Cholecystectomy Using Combined Endoscopic and Robotic Techniques: How I Do It

Laparoscopic cholecystectomy is the standard of care for cholelithiasis as well as cholecystitis. However, in the setting of Mirizzi syndrome or gangrenous cholecystitis where the critical view cannot be ascertained, subtotal cholecystectomy may be necessary. Using the robot-assisted approach, difficult cholecystectomies can be performed upfront without need for partial cholecystectomy. Even in the setting of Mirizzi syndrome where severe scarring and fibrosis are evident, definitive cholecystectomy and takedown of the cholechystocholedochal fistula can be performed in a safe and feasible fashion following successful endoscopic common bile duct stent placement. The purposes of this report are to review the history of Mirizzi syndrome as well as its traditional and novel treatment techniques and highlight technical pearls of the robotic approach to this diagnosis.