Development of an Innovative Parallel Robot Used in Laparoscopic Pancreatic Surgery

Background: In pancreatic cancer surgery, tumor violation of blood vessels is often considered a contraindication to surgery, especially laparoscopic surgery. We have completed 17 cases of major venous repair or reconstruction during laparoscopic pancreatic surgery, and we believe that this surgical method may be safe and feasible based on the skilled laparoscopic techniques. Materials and Methods: Between January 2014 and March 2022, a prospective cohort of 17 patients underwent major venous repair or reconstruction in our department. Among them, 15 cases underwent laparoscopic pancreaticoduodenectomy, 1 case underwent laparoscopic distal pancreatectomy, and 1 case underwent laparoscopic central pancreatectomy. In all of these cases, the pancreatic tumor invaded either portal veins (PV) or superior mesenteric veins. Given these clinical situations, 13 cases accepted laparoscopic venous resection and reconstruction, and 4 cases underwent venous repair. Results: Ten of 17 patients (58.8%) were male. The mean age was 67.1 (range 57-81). All patients' operations were successfully completed without transit to open. The average blocking time of venous resection and reconstruction was 30.1 (range 15-41) minutes and the average time of venous wedge resection and stitching was 24.0 (range 18-30) minutes. After surgeries, there were no complications such as PV stenosis, bleeding, thrombosis, and liver failure. Thirteen patients died within 2 years because of the tumor recurrence, and 4 patients are currently followed by outpatient visits, with no obvious signs of tumor recurrence. Conclusion: Studies have shown that the reconstruction or repair of the major veins under laparoscopic surgery is safe and effective. We recommended that surgeons need to have the basics of open surgery in case laparoscopic surgery cannot be continued, and have proficient laparoscopic surgery techniques combined with extensive training to achieve a learning curve for vascular anastomosis. Clinical Trial Registration number: KY2021SL152-01.

Laparoscopic pancreatic surgery: An overview of the literature and experiences of a single center

<sec><st>Methods</st> A retrospective 5 year review (2013–2017) of all pancreatic surgery for CHI in children performed in one surgical centre by one surgeon was undertaken. Data was collated on patient demographics including mode of surgery: open or laparoscopic. Pre-operative 18 F-DOPA PET scan results were used to differentiate between diffuse and focal CHI. The type and site of the CHI lesion was then correlated with the completion rate of the laparoscopic approach. </sec> <sec><st>Results</st> There were a total of 10 patients and 14 episodes of surgery. All patients had a confirmed diagnosis of CHI. The median age at surgery is 7 months (range 2–22). A laparoscopic approach was completed in 85% (11/13) of operations. One child had a planned open operation. Four patients (40%) had more than one operation for CHI. 80% (4/5) of those with diffuse CHI had laparoscopic operations. One required conversion to open as the pneumoperitoneum was not well tolerated in a 2 month old infant. 100% (5/5) of patients with focal CHI in the tail of the pancreas had completed laparoscopic operations. 50% (2/4) had laparoscopic surgery for focal head of pancreas CHI lesion. </sec> <sec><st>Conclusion</st> A planned laparoscopic approach is possible in the vast majority of cases of surgery for CHI. The completion laparoscopic rate is high (85%). Possible risk factors for open surgery including young age and focal lesion in the head of the pancreas. The rate of open surgical approach in view of the PET scan findings is important when counselling families pre-operatively. </sec>

Over the past decade, there has been increasing adoption of minimally invasive pancreatic surgery world-wide and this has naturally expanded to the management of pancreatic neuroendocrine neoplasms (PNENs). More recently, robotic pancreatic surgery (RPS) was introduced to overcome the limitations during laparoscopic pancreatic surgery (LPS). Due to the relative rarity of PNEN and the novelty of minimally invasive pancreatic surgery in particular RPS today, the evidence for robotic surgery in PNENs remains extremely limited. Presently, the available evidence is limited to a few low level retrospective case-control studies. These studies suggest that RPS may be associated with a higher splenic preservation rates and lower open conversion rates compared to conventional laparoscopic surgery. Ideally a prospective randomized trial should be performed but this would be extremely challenging due to the rarity of PNEN, making it almost impossible to conduct a sufficiently powered trial.

Minimally invasive pancreatic surgery, although known to be feasible and safe, is still not considered a standard procedure. We report our experience with laparoscopic pancreatic surgery in a retrospective case series. Fifteen consecutive patients (3 male, 12 female) underwent primarily laparoscopic pancreatic surgery from February 2000 to June 2005. Histologically confirmed diagnoses were: neuroendocrine pancreatic tumors (n = 11), adult nesidioblastosis (n = 1), serous cystadenoma (n = 1), and pseudocysts due to chronic pancreatitis (n = 2). Enucleation (n = 3) or left pancreatic resection with spleen preservation (n = 6) was performed laparoscopically in 9 patients. The mean (+/-standard deviation) operative time was 173 +/- 48 minutes (range, 120-250 minutes) and the mean postoperative hospital stay was 5.5 +/- 1.2 days (range, 5-8 days) for the laparoscopic cases. Conversion to open surgery was necessary in 6 patients because of: closeness of the lesion to the portal/mesenteric vein (n = 3), inadequate intraoperative tumor localization (n = 2), or stapler device dysfunction (n = 1). In these patients, open enucleation (n = 1), middle segment pancreatectomy (n = 2), left pancreatic resection (n = 2), and pylorus-preserving Whipple resection (n = 1) were performed. The mean operative time was 268 +/- 74 minutes (range, 150-360 minutes) with a mean postoperative hospital stay of 8 +/- 2 days (range, 6-10 days). Both operative time and hospital stay were significantly longer in patients with secondary open surgery compared to patients with successful laparoscopic operations. Laparoscopic enucleation or distal pancreatectomy with spleen preservation for benign lesions located in the body or tail of the pancreas can be performed safely, with all the potential benefits of minimally invasive surgery. Preoperative tumor localization is of utmost importance to limit pancreatic mobilization and to avoid blind pancreatic resection and conversion to open surgery.

The experience of laparoscopic pancreatic surgery

Pancreatic surgery is one of the most challenging fields in visceral surgery. However, laparoscopic pancreatic surgery has not become the standard of care as yet, especially because of the very demanding reconstruction of anastomoses in pancreaticoduodenectomy. Robotic surgery has been a recent advance in laparoscopy. Its benefits are a better 3D view, a greater degree of freedom corresponding to that of the human hand, and tremor elimination. These factors greatly facilitate the intracorporeal suturing and knot-tying, which offers a technical advantage in performing pancreaticojejunostomy as compared with laparoscopic resections. However, only a few centres are offering this procedure for pancreatic resections. Retrospective analyses show that robotic pancreatic resections are safe und oncologically adequate if performed by experienced surgeons. Prospective, randomised trials comparing laparoscopic and robotic pancreatic resection techniques are not available to date.

Indications in the field of pancreatic surgery should be limited considering the technical difficulties and the characteristics of pancreatic diseases. Benign or low-grade malignant tumors, including pseudocysts, islet tumors, and cystic tumors, are indications for distal pancreatectomy. Islet tumors such as insulinomas are good candidates for this procedure when they are located near splenic vessels or the main pancreatic duct and enucleation is considered inappropriate. Techniques of laparoscopic distal pancreatectomy with/without splenectomy and laparoscopy-assisted distal pancreatectomy indicated in low-grade malignant tumors such as mucinous cystadenoma are described. Insulinoma is one of the best candidates for enucleation because many of the cases are solitary and benign. The technique of enucleation is also described.

Background: The most common types of true epithelial exocrine pancreatic cystic neoplasms are serous cystic neoplasms (SCNs), mucinous cystic neoplasms (MCNs), intra-ductal papillary mucinous neoplasms (IPMNs), and solid pseudo-papillary neoplasms (SPPNs). Both open and laparoscopic pancreatic surgeries are major procedures with significant morbidity and mortality rates. This study aimed to determine the outcomes of laparoscopic pancreatic surgery in managing true exocrine epithelial pancreatic cystic neoplasms in terms of postoperative pancreatic fistula and recurrence rate and to identify associated risk factors.

Laparoscopic distal pancreatectomy has become the gold standard for benign tumors. As more surgeons have expertise in open and laparoscopic pancreatic surgery, increasing numbers of benign-appearing tumors are being removed via minimally invasive techniques and found to have malignancy on final pathology. Because of our growing experience in laparoscopic distal pancreatectomy, we have begun removing preoperatively suspected malignancies in the distal pancreas with minimally invasive techniques. All cases were collected prospectively in a database and analyzed retrospectively. All cases begun laparoscopically with the intention of performing the resection with minimally invasive techniques were considered even if the operation was ultimately converted to an open procedure. A total of 12 cases have been attempted of which four required hand assistance and one required conversion to an open approach due to delayed bleeding from a calcified splenic artery that had been transected with laparoscopic GIA stapler device. In total, eight (67%) patients had malignant disease and four (33%) were found to have benign tumors. The median lymph node retrieval is 8 (range 3-16) with no positive margins. The morbidity rate is 17% with one reoperation (8%) and one mortality (8%) at 30 and 90 days. The laparoscopic approach to malignant pancreatic tumors is feasible with similar morbidity and mortality rates to benign series. When tumors are next to the confluence of the splenic portal vein, a hand-assisted approach may be adviseable. Calcified splenic arteries should be sought on preoperative imaging and either transected in non-calcified segments or controlled via open techniques via the hand port.

Laparoscopic pancreatic surgery has gradually expanded to include pancreatoduodenectomy (PD). This study presents data regarding the efficacy of laparoscopic PD in a single center. This was a single-cohort, prospective observational study. From March 2012 to September 2015, 50 consecutive patients underwent laparoscopic PD using a five-trocar technique. Reconstruction of the digestive tract was performed with double jejunal loop technique whenever feasible. Patients with radiological signs of portal vein invasion were operated by open approach. Twenty-seven women and 23 men with a median age of 63 years (range 23-76) underwent laparoscopic PD. Five patients underwent total pancreatectomy. All, but 1 patient (previous bariatric operation), underwent pylorus-preserving resection. Reconstruction was performed with double jejunal loop in all cases except in 5 cases of total pancreatectomy. Conversion was required in 3 patients (6%) as a result of difficult dissection (two cases) and unsuspected portal vein invasion (1 patient). Median operative time was 420 minutes (range 360-660), and the 90-day mortality was nil. Pancreatic fistula occurred in 13 patients (26%). There was one grade C (reoperated), one grade B (percutaneous drainage), and all remaining were grade A (conservative treatment). Other complications included port site bleeding (n = 1), biliary fistula (n = 2), and delayed gastric emptying (n = 2). Mean hospital stay was 8.4 days (range 5-31). Laparoscopic PD is feasible and safe, but is technically demanding and may be reserved to highly skilled laparoscopic surgeons with proper training in high-volume centers. Isolated pancreatic anastomosis may be useful to decrease the severity of postoperative pancreatic fistulas. Therefore, it could be a good option in patients with a high risk for developing postoperative pancreatic, as well as by less-experienced surgeons.

The Role of Minimally Invasive Surgery for Pancreatic Pathology

Laparoscopic Surgery for Pancreatic Tumors

Background: Laparoscopic and Robotic approaches have become increasingly used for pancreatic surgery. The aim of this study is to evaluate compile and evaluate existing literature on the comparison of laparoscopic pancreatic surgery and robotic pancreatic surgery in the resection of Pancreatic neoplasms. The outcomes of each technique were quantified using meta-analysis.

Introduction: Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) with conservation of the splenic artery and vein (Kimura’ technique) is considered a technically challenging procedure that requires a high level of expertise in laparoscopic and pancreatic surgery. Methods: A prospective descriptive study on 18 patients with laparoscopic “antegrade” spleen-preserving distal pancreatectomy with Kimura’ technique from 2018 to 2023. The perioperative indications, clinical data, intraoperative index, pathological postoperative specimens, postoperative complications, and follow-up results were retrospectively evaluated. Results: The mean age was 39.4±13.3. Only 2 male patients accounted for 11.1%. The average operating time is 171±23 min. The average blood loss is 65.7±43 ml. The average tumor size is 4.1 cm. The average hospitalization is 9.4 days. The rate of pancreatic fistula is 66.7%. There is no case of transferring open surgery or blood transfusion during surgery. The results of pathological after surgery there were eight cases of solid pseudopapillary tumors, four cases of mucinous cystadenoma, six cases of neuroendocrine tumors. Conclusion: Kimura’s technique for laparoscopic spleen-preserving distal pancreatectomy is safe and feasible, which can be applied to benign tumors in the body and tail of the pancreas. However, this is a difficult technique in laparoscopic surgery that requires surgeons to have a lot of experience and equipment need to be adequate.