1. Innovative Surgical Techniques
in Hepatobiliary and Pancreatic
Surgery
Iswanto Sucandy, MD
Sharona Ross, MD
Alexander Rosemurgy, MD
Advanced Foregut and HepatoPancreatoBiliary Surgery
Florida Hospital Tampa

2. Open versus Minimally Invasive Surgery

3. Minimally Invasive Surgery
 Laparoscopic Surgery
 Robotic Surgery
 Robotic Pancreatic Resection (Distal pancreatectomy and Whipple)
 Robotic Liver Resection (Major and Minor Hepatectomy)
 Robotic Biliary Tract Resection and Reconstruction

4. Minimally Invasive Surgery
 Started with laparoscopic cholecystectomy in 1990
 Surgery with “ small incisions “
 Advantages of minimally invasive surgery over traditional open surgery
 Faster postoperative recovery
 Shorter duration of hospital stay
 Less pain - > less narcotic use
 Less postoperative intestinal ileus
 Less surgical site infection
 Less postoperative hernia rate
 Better cosmesis
 Equal oncologic outcomes and survivals

5. Minimally Invasive Surgery
 Laparoscopic versus Robotic operation
 Robotic surgery is developed to overcome limitations of traditional laparoscopic
surgery
 Application of Robotic surgery in complex major operations is most suitable
 Hepatobiliary and Pancreatic surgery is the most technically complex/challenging
of all abdominal operations

6. Robotic Surgical System

7. Advantages of Robotic over Traditional
Laparoscopic Surgery
 7 degrees of wrist motion – lower conversion rate
 More precise dissections (key for complex Hepatobiliary and Pancreas operations)
 High definition robotic camera (superior 3D visualization)
 Tremor filtering
 3 working arms at once
 Elimination of excessive abdominal wall torque (especially in obese patients)
 More ergonomic for operating surgeon

8. Endowrist Movements

9. Robotic Pancreatic Surgery

10. Robotic Pancreatic Surgery
A. Robotic distal pancreatectomy - pancreatic tumor in neck/midbody/tail
B. Robotic Whipple (pancreaticoduodenectomy) - pancreatic head, distal bile duct, or
duodenal tumors
 Rapid recovery with shorter hospitals stay (average 5 days) especially with
enhanced recovery program after surgery
 Minimal postoperative pain and narcotic use

11. Robotic Pancreatic Surgery
(Distal Pancreatectomy)

12. Robotic Pancreatic Surgery
(Whipple Procedure)

13. Robotic Pancreatic Surgery
(Whipple Procedure)

14. Robotic Pancreatic Surgery
How about current surgical literature ?

15. A Multi-institutional Comparison of Perioperative Outcomes of
Robotic and Open Pancreaticoduodenectomy
Zureikat et al. Ann Surg. 2016 Oct;264(4):640-9
 1028 patients from 8 major HPB centers
 4.7 % conversion rate
Robotic Pancreaticoduodenectomy :
 Reduced blood loss ( - 181 ml )
 Reduced major complications (Odds ratio o.6)
 Similar 90-day mortality
 Similar oncologic outcomes R0 resection
 Similar postoperative pancreatic fistula rate
 Similar length of stay and readmission rate

16. Robotic Liver Surgery

17. Robotic Liver Surgery
 Most common indications : Primary and Metastatic Liver Tumors
 Most common procedures :
 Robotic non-anatomical liver resection - “wedges”
 Robotic Left or Right hemihepatectomy
 Robotic formal sectionectomy (removing 2 liver segments)
 Robotic cystic mass liver resection

18. Robotic Liver Surgery
Key Aspects :
 Tumor location (periphery versus central / high segment 7-8 lesions)
 Viccinity to the vital structures (inflow-outflow-biliary drainage)
 Tumor size
 Experience of robotic team (surgeon + OR team)
 Experience of anesthesia team (low CVP < 5mmhg)

19. Robotic Liver Surgery

20. Robotic Liver Surgery

21. Robotic Liver Surgery

22.  64 matched patients Robotic vs Open
 6% conversion rate, 3% 90-day mortality rate
Robotic Liver Resection :
 Shorter OR time (163 versus 210 minutes)
 Lower intraoperative blood loss (100 versus 300 ml)
 Lower intraoperative blood transfusion (1.6% versus 14.1%)
 Shorter duration of hospital stay (4 versus 7 days)
 Lower 30 day readmission rate (6.3% versus 12.5%)

23. Robotic Liver Surgery: Results for 70 Resections
Guilianotti et al. Surgery 2011;149:29-39.
 Mean operative time : 313 minutes
 Estimated blood loss : 150 mL
 Transfusion rate : 22%
 Open conversion rate : 3.7%
 Overall morbidity : 29.6%
 30-day mortality : 0%
 Resection margins (R0) : negative in all cases

24. Robotic Surgery
How about minimally invasive surgery of the biliary duct ?

25. Robotic Biliary Tract Resection

26. Robotic Biliary Tract Resection & Reconstruction
 First report of laparoscopic choledochal cyst excision 1995 by Farello et al.
 Technically difficult -- > slow adoption
 Robotic choledochal cyst excision and RY reconstruction – A case series of 27
patients in 2014.
 Robotic approach is gaining popularity due to technical ease of performing bilio-
enteric anastomosis

27. Robotic Biliary Tract Reconstruction

28. Innovative Surgical Techniques in Hepatobiliary
and Pancreatic Surgery
 Advanced Foregut and HepatoPancreatoBiliary Surgery
 Florida Hospital Tampa – Robotic HPB Program
 Referral : 3000 Medical Park Dr, Suite 500, Tampa, FL 33613
 Office Phone: (813) 615-7030
 Fax: (813) 615-8350