This document summarizes the author's decade of experience performing robotic Whipple procedures. It discusses the evolution of their surgical technique over time, including improvements to camera port positioning, the Kocher maneuver, uncinate process dissection, and pancreatic stump treatment. Results from over 95 robotic pancreatic anastomoses are presented, showing low conversion and morbidity rates. Recent developments including associated vascular resections, comparisons to open surgery, and the role of the patient side assistant are also reviewed. Finally, the need for further oncological outcome data from larger studies is acknowledged.

1. PC GIULIANOTTI, MD, FACS
A DECADE OF EXPERIENCE WITH THE ROBOTIC WHIPPLE,
EVOLUTION OF THE TECHNIQUE AND RESULTS

2. State of the art
Pancreatectomy*: 10351 results
Pancreatectomy AND laparoscopy*: 531
Pancreatectomy AND (robot or robotic)*: 36
Less than 250 pancreatic anastomoses after PD in minimally invasive surgery
published so far (laparoscopic and robotic, case reports excluded)
Only 97 Robotic assisted pancreatic anastomoses published
300
250
200
150
LAP
100
ROB
50
0
1994
1997
2003
2005
2006
2007
2008
2009
2010
2011
STANDING ON THE
SHOULDERS OF GIANTS
*[MESH TERMS] OR [ALL FIELDS] ON 11/01/2011

3. Our Experience

4. Our Experience
Epidemiologic data
Age: mean 62.15 ± 14.7 (range 28-86)
Male/Female = 1.02 (48/47)
ASA score: mean 2.45
100
90
80
70
60
50
Total (Cum)
40
30 Converted (Cum)
20
10
0
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2010

5. Evolution of Technique
FROM EXPERIENCE TO STANDARDIZATION:
₪ Camera port positioning
₪ Kocher maneuver
₪ Uncinate process dissection
₪ Pancreatic stump treatment

6. Camera Port Positioning
EVOLUTION OF TECHNIQUE

7. Camera Port Positioning
EVOLUTION OF TECHNIQUE

8. Camera Port Positioning
EVOLUTION OF TECHNIQUE

9. Kocher Maneuver
EVOLUTION OF TECHNIQUE
Safely performed under direct visual control of vascular structures

10. Uncinate Process Dissection
EVOLUTION OF TECHNIQUE
No major vascular injuries
No conversions related to technical difficulties during this step
First technical improvement: introduction of the fourth arm
Coming from the right side it is in the perfect direction to apply traction during the mesenteric vessels dissection
Second major progress: camera port positioning in the right side
Theoretically the laparoscopic technique could provide the same point of view, but without the flexibility of robotic
instruments moving the camera on the right could make the other phases of the PD extremely demanding

11. Pancreatic stump treatment
EVOLUTION OF TECHNIQUE
FOUR DIFFERENT OPTIONS:
₪ Glue injection
₪ Pancreatojejunostomy
₪ Pancreatogastrostomy with totally posterior approach
₪ Pancreatogastrostomy with anterior gastrotomy

12. Pancreatic stump treatment
1. GLUE INJENCTION

13. Pancreatic stump treatment
2. PANCREATO-JEJUNOSTOMY

14. Pancreatic stump treatment
3. PANCREATO-GASTROSTOMY, TOTALLY POSTERIOR APPROACH

15. Pancreatic stump treatment
4. PANCREATO-GASTROSTOMY WITH ANTERIOR GASTROTOMY

16. Pancreatic stump treatment
RESULTS (UIC patients*)
Glue injection (21 patients)
Fistula Rate: 28.6 %
Hemorrhage Rate: 4.8 %
Pancreato-jejunostomy (10 patients)
Fistula Rate: 0%
Hemorrhage Rate: 10 %
Pancreato-gastro posterior approach (13 patients)
Fistula Rate: 30.8 %
Hemorrhage Rate: 23.1 %
Pancreato-gastro anterior approach (11 patients)
Fistula Rate: 0 %
Hemorrhage Rate: 27.3 %
Total Fistula rate: previos publication (first 60 cases) 31.6%
present series 17.8%
* UNPUBLISHED DATA

17. Our experience - Results
OPERATIVE TIME
Mean 434 ± 103
Median 465 (240-720)
Whipple vs PPPD = 58/37
Mean estimated blood loss: median 225 cc, range 50 – 1500
Median Hospital stay : median 11, range 5-40
OPERATIVE TIME
100
80
60
40 Total (Cum)
Converted (Cum)
20
0
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2010

18. Our experience - Results
Mal/Ben = 63/32 = 1.96
Pathology
Adenoca. pancreas 38
Adenoca. papilla 13
IPMN 10
Chronic pancreatitis 9
Ampullary adenoma 5
Ademoca. choledochal duct 4
Adenoca. duodenum 2
Lymph nodes harvested: 18 ± 11.5
Staging*:
I 9
II A 21
II B 20
III 5
IV 2
* 6 MISSING VALUES

19. Our experience - Results
UIC Patients
Conversion rate: 3.4 %
Transfusions: 22.4%
Morbidity: 41.4% (only 27.1% Clavien III and IV)
Mortality: 3.1%
Fistula rate: 17.2% (A=3; B=3;C=4)
50% survival 21.8 months
Pancreatic
malignancy
(69.0%)
* 6 MISSING VALUES

20. Our experience - Results
*
* 1 Papillary
adenocarcinoma

21. What’s new in 2011
₪ Associate vascular resections
₪ Comparison with open PD
₪ Patient Side Assistant role in pancreatic surgery

22. Associate Vascular Resections
WHAT’S NEW IN 2011
2 left-sided splenopancreatectomy with celiac axis resection
1 left-sided splenopancreatectomy with portal vein resection
2 pancreaticoduodenectomy with portal vein resection
- No conversions occurred
- Overall mean operating time was 392 ± 66 minutes (range, 310 - 460 min)
- Overall mean blood loss was 200 ± 61 mL (range 150 - 300 mL)
- No transfusions
- No mortality
At a median follow-up of 6 months (range, 3-20 months), 4 patients were alive and
disease free

23. Open vs Robotic
WHAT’S NEW IN 2011
OPEN GROUP (N = 39) VS ROBOTIC GROUP (N = 44)
The robotic group had:
- Significantly shorter operative time (444 vs 559 min; p = 0.0001)
- Reduced blood loss (387 vs 827 ml; p = 0.0001)
- Higher number of lymph nodes harvested (16.8 vs 11.0; p = 0.02)
There was no significant difference between the two groups in terms of:
Complication rate
- Mortality rate
- Hospital stay

24. Patient Side Assistant
WHAT’S NEW IN 2011
Impact on the overall operative time (OT) of 11 different preoperative factors Using a
univariate t-student based analysis
Only the assistant (p=0.026) and the treatment of the pancreatic stump (p=0.001)
resulted significant in influencing the OT.
Factor N OT mean±SD p
The multivariate analysis demonstrated no significant
Benign/malign Ben 17 472.9±97.7 0.872
association of these factors, confirming their
ant Mal 39 478.1±136.7
independence. The Odds Ratio for the pancreatic
BMI +30 13 438.7±100.3 0.582
stump treatment is 3.5 (C.I.=1.8-5.2) and for the
-30 43 494.3±107
AGE + 70 15 435.1±85.0 0.170
assistant is 1.9 (C.I.=1.1-2.7).
-70 41 491.2±113.7
Preoperative -3.5 24 458.4±103.5 0.566 For the staging significance was found for stage 4
albmine +3.5 32 509.7±112.8 (p=0.008), but only 5 patients were included in this
ASA score 1-2 33 467.0±120.6 0.452 group and in this subpopulation the multivariate
3-4 23 484.2±101.0 analysis was not applicable
Haemoglobin +12 483.9±118.9 0.280
-12 479.3±100.5
Anastomosis Anast 486.6±130.2 0.001
vs glue Glue 457.5±56.2
Associate N 46 465.7±105.2 0.350
procedures Y 10 513.8±118.7
Assistant SF 429.2±73.8 0.026
AS 565.3±110.9
Stage 1-3 447.97±132.1 0.008
4 584.0±69.7
R 1 477.9±94.7 0.764
0 460.0±69.8

25. Oncological Outcome
Evidence based demonstration of favorable impact on oncological
outcomes is the following step
Difficult to evaluate: larger experience, standardization, randomized
trials…
DEVELOPING PROJECT:
To investigate possible benefits of minimally invasive
pancreatectomy and early start of adjuvant therapy.