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Chapter 24
Robotic-Assisted Approach toMinimally
Invasive Distal Pancreatectomy
ChelseaF.Cardell andGerardJ.Abood
Introduction
Robotic surgical platforms are rapidly gaining popularity across all avenues of surgery with improved visualization and enhanced dexterity. Complex pancreatic surgery is no exception to this evolution in surgical technique. Minimally invasive
pancreatic surgery, especially distal pancreatectomy, has helped decrease incision
size and hasten patient recovery, and the extension from laparoscopic to robotic
surgery is a natural progression. In this chapter, we will describe our technique to
robotic distal pancreatomy, as well as review existing literature evaluating the safety
and efcacy of a robotic approach.
Indications
Both benign and malignant pancreatic diseases are indications for robotic distal
pancreatectomy. Benign indications include cystic neoplasms, acute and chronic
pancreatitis, and trauma with pancreatic ductal disruption. Malignant etiologies
include adenocarcinoma, pancreatic neuroendocrine tumors, as well as malignant
disease from other primary cancers that have metastasized to the pancreas.
C. F. Cardell · G. J. Abood (*)
Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
e-mail: Chelsea.cardell@lumc.edu; Gabood@lumc.edu
Switzerland AG 2025
E. P. Ceppa et al. (eds.), The SAGES Manual of Evolving Techniques in
Pancreatic Surgery, https://doi.org/10.1007/978-3-031-78409-5_24
419© The Author(s), under exclusive license to Springer Nature
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C. F. Cardell and G. J. Abood
Preoperative Testing
Patients are initially evaluated with a detailed history and physical and pertinent lab
values, including tumor markers. High-quality cross-sectional imaging is utilized
for surgical planning, in our practice commonly a pancreatic protocol CT with triple
phase contrast and thin cuts. Additional imaging in the form of MRI/MRCP and
EUS is utilized where necessary and appropriate for diagnosis of pancreatic lesions.
Once diagnosis of a pancreatic lesion has been made and surgical resection
determined to be appropriate management, patients are assessed for tolerance of
general anesthesia needed for surgery. Focus is given to cardiopulmonary status and
assessment of tolerance to pneumoperitoneum. We frequently collaborate with
anesthesia colleagues in optimization of our patients prior to surgery. In the case of
adenocarcinomas of the pancreas and planned splenectomy, appropriate splenic
vaccines are administered in the preoperative setting.
Patient Positioning andPreparation
The patient is brought to the operating room and placed in supine position, with
extremities appropriately padded, secured, and a footboard added to allow steep
Trendelenburg positioning. Additional intravenous access and arterial lines are
placed at the discretion of anesthesia before padding and tucking both arms at the
sides. A urinary catheter is placed; central lines are inserted when determined necessary by the surgeon and anesthesia team. Upper and lower forced air warming
devices are placed over the patient to ensure normothermia throughout the procedure. The patient’s bed is rotated 45° to the patient right to allow for docking of the
robot (Fig.24.1). Preoperative antibiotics and DVT prophylaxis are administered,
and the patient is prepped and draped in the usual standard fashion.
Operative Approach
Peritoneal Access
The peritoneum is accessed using a 5mm optical port in the left upper quadrant
using a 0° laparoscopic camera. The abdomen is insufated to 15 mmHg. The
abdominal cavity is then inspected for injury and evidence of metastatic disease or
anatomic features that may alter operative approach. Three additional 8mm ports,
and one 12mm (to accommodate a stapler and intraoperative ultrasound) robotic
ports are inserted to triangulate on the dissection eld in the conguration shown in
Fig.24.2. An 8mm assistant port is placed in the right lower quadrant, and a 5mm
incision made to accommodate a liver retractor. The patient is placed in a steep
24 Robotic-Assisted Approach toMinimally Invasive Distal Pancreatectomy
421
Fig. 24.1 Robotic conguration and patient positioning
reverse Trendelenburg position and rotated to the patient’s right. A Nathanson liver
retractor is inserted to retract the left lateral lobe of the liver. At this point, the
DaVinci system is brought into the eld and docked. Arm 1 is docked to the right of
the camera, and arms 3 and 4 are docked to the left of the camera. A 30° robotic
camera is inserted into arm 2 with a 30° downward orientation. Instruments are
subsequently inserted under direct visualization, typically a fenestrated bipolar
grasper in arm 1, a vessel sealer into arm 3, and a Cadiere grasper in arm 4. A long
laparoscopic suction device is used in through the assistant port to assist with retraction and eld visualization.
422
Fig. 24.2 Port placement
C. F. Cardell and G. J. Abood
Access totheLesser Sac
The anterior surface of the pancreas is exposed by dividing the gastrocolic ligament
just outside of the gastroepiploic arcade using a robotic vessel sealer. Graspers in
arms 1 and 4 are used to facilitate retraction and identication of the dissection
plane. This dissection plane is carried up along the stomach, taking down the short
gastric vessels to the left crus of the diaphragm. With the stomach fully mobilized,
it is placed behind the Nathanson liver retractor with the left lobe of the liver to
maintain visualization of the retroperitoneum. Mobilization is continued medially
toward the neck and head of the pancreas until there is a clear view of the
retroperitoneum.
24 Robotic-Assisted Approach toMinimally Invasive Distal Pancreatectomy
423
Mobilization ofPancreatic Body andIsolation ofSplenic Artery
The robotic vessel sealer is exchanged for a monopolar hook cautery to continue the
dissection of the pancreatic body. The superior border of the pancreas is identied
and dissected. The proximal splenic artery, at its origin from the celiac trunk, is typically identied at this point in the dissection and carefully isolated with blunt dissection and use of the hook cautery. Additionally, a robotic Maryland dissector can
be useful to dissect circumferentially around the artery. It is then encircled with a
vessel loop to provide gentle traction and divided with a single re of a 45mm vascular load through the assistant port (Fig.24.3). Depending on the patient anatomy,
a vessel loop placed around the pancreatic body may aid in retraction and identication and dissection of the splenic artery on the superior edge of the pancreas. We
routinely use intraoperative pancreatic ultrasound, typically through the 12mm left
working port, to identify the resection margin. Pancreatic cancers are typically
divided at the neck to ensure adequate lymph node harvest; benign tumors can be
divided 1–2cm to the right of the lesion as determined by intraoperative ultrasound.
Isolation oftheSplenic Vein
After the resection point on the pancreatic body has been identied, attention is
turned to dissection of the inferior border of the pancreas. Dissection is typically
carried out using hook cautery and robotic vessel sealer, starting at the inferior border of the pancreas and extending posteriorly along the avascular plane between the
pancreas and retroperitoneum. The superior mesenteric vein (SMV) is identied
and marks the proximal extent of dissection. A vessel loop passed around the pancreatic body aids in retraction and identication of vessels. Care is also taken to
Fig. 24.3 Isolation and
division of splenic artery
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C. F. Cardell and G. J. Abood
identify the inferior mesenteric vein (IMV) at its insertion into the splenic vein or
SMV to avoid injury. Along the course of the dissection of pancreas, the splenic
vein is identied and isolated. The pancreatic body is then divided with a 60mm
stapler through the assistant port (Fig.24.4). We nd that a stapler is an effective
method to divide the gland in the majority of cases. Following division of the gland,
any remaining dissection of the splenic vein is completed, and the vessel divided
with a 45mm vascular staple load through the assistant port (Fig.24.5).
Fig. 24.4 Dissection of
pancreatic body and neck
just prior to gland division
Fig. 24.5 Isolation of
splenic vein
24 Robotic-Assisted Approach toMinimally Invasive Distal Pancreatectomy
425
Mobilization fromtheRetroperitoneum
andSplenic Mobilization
At this point, all major vascular tributaries to the spleen have been controlled. The
pancreas is gently retracted toward the anterior abdominal wall using arm 4 and dissected from the retroperitoneum using a combination of hook cautery and robotic
vessel sealer. The assistant uses suction to retract and keep the eld clear of blood
and smoke. Continuing this dissection plane laterally leads the surgeon to the spleen.
The interior, superior, and posterior splenic ligaments are divided using the robotic
vessel sealer for complete mobilization of the specimen.
Specimen Extraction
The specimen is placed en bloc in a retrieval bag and to be extracted through a small
upper midline incision. A drain is left in the resection bed only in the circumstances
of high intraoperative blood loss (>1L), prolonged operative time greater than 4h,
or a thick gland requiring oversewing of the pancreatic duct. At this point, the
robotic system is undocked and the patient returned to a supine position to allow for
incision closure.
Closure
The upper midline port is closed with 2-0 PDS sutures in a gure-of-eight fashion,
the 12mm left working port is closed with a gure-of-eight using a Vicryl suture on
a Carter-Thomason device. Skin incisions of all ports are closed with running subcuticular 4-0 Monocryl sutures and skin glue.
Clinical Outcomes
Introducing Robotic Technology toPancreatic Surgery
Although robotic surgery had gained traction in other surgical specialties after introduction of the DaVinci system, it was not widely applied to complex pancreatic
surgery. Initial reports regarding the use of the robotic platform to perform distal
pancreatectomy focused on establishing feasibility of the new technology.
Giulianotti etal. helped introduce robotic technology to complex pancreatic surgery
in a descriptive series. They described the use of robotics in a small series of pancreatic operations from 2007 to 2010, including one distal pancreatectomy, two
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C. F. Cardell and G. J. Abood
Appleby procedures, and two pancreatoduodenectomies with portal vein resection
[1]. No procedures required conversion to open, mean operative time was 392min,
and there were no mortalities [1]. This early description of robotic distal pancreatectomy was limited in number but allowed introduction of the technique to the surgical community.
This initial series was followed by multiple larger, single-institution studies
establishing the safety and feasibility of robotic distal pancreatectomy. Suman etal.
reported a series of 49 robotic distal pancreatectomies, including splenic preservation. In their patients, the rate of major morbidity (Clavien-Dindo grade III/IV) was
5%, with 5% of patients developing a grade B/C pancreatic stula. However, the
patients described in their series required a conversion to open in 18.4% of cases
[2]. Zureikat etal. published a slightly larger series of 250 robotic pancreatic resections, 83 of which were distal pancreatectomy [3]. They observed a 13% ClavienDindo grade III morbidity rate, a 17% rate of grade B/C pancreatic stula, and only
a 2% rate of conversion-to-open procedures [3]. Several other small, singleinstitution studies demonstrated similar rates of morbidity, pancreatic stula, and
conversion-to-open procedures [4, 5]. While still limited by small numbers and
lacking comparison control groups, these studies introduced cases to potentially
compare to historic controls and helped solidify the safety and feasibility of robotic
distal pancreatectomies.
Introduction of any new technology, even to familiar procedures, is associated
with a signicant operator learning curve. Shakir etal. examined this learning curve
using cumulative sum analysis (CUSUM) in 100 robotic distal pancreatectomies.
They noted signicant reductions in operative time after 20 and 40 cases to 266 and
210 min, respectively, from an initial average operative time of 331 min [6].
Reductions in readmissions (40–20%) and grade B/C stulas (27.5–11.7%) were
also noted after 40 cases [6]. Similar cumulative sum analysis in another 55 patients
found the learning curve to be only 10 cases to achieve similar operative times as
Shakir etal., although both studies were conducted at high volume institutions with
considerable support and mentorship from experienced robotic surgeons [7].
Comparison withOpen andLaparoscopic Approaches
After demonstration that the robotic approach is both a feasible and safe approach
to distal pancreatectomy, comparison to existing approaches is necessary prior to
justication of widespread adoption. Existing literature has compared clinical outcomes between both open and laparoscopic approaches to the robotic approach.
The largest study comparing operative approaches in distal pancreatectomy by
Lee et al. examined 805 distal pancreatectomies in a well-matched cohort: 37
robotic, 131 laparoscopic, and 637 open procedures. Compared to robotic and minimally invasive approaches, open procedures had a signicantly higher blood loss
(p<0.001) and trended toward a longer hospital stay [8]. Rates of R0 oncologic
resections were similar among all three groups. Clinical outcomes between
24 Robotic-Assisted Approach toMinimally Invasive Distal Pancreatectomy
427
laparoscopic and robotic approaches were comparable, with no clear advantage of
one over the other [8].
Much of the existing literature comparing robotic and laparoscopic distal pancreatectomy has been conducted in single-institution series. However, Guerrini etal.
conducted a systematic review and meta-analysis which included ten studies with
813 patients [9]. Among 267 robotic and 546 laparoscopic distal pancreatectomies,
pancreatic stula formation, bleeding rate, and Clavien-Dindo complications grade
III were equivalent between the groups. However, the robotic approach demonstrated lower rates of conversion-to-open (OR 0.33 95% CI 0.12–0.92) and shorter
hospital stay (mean difference−0.74 95% CI −1.31 to 0.15) [9].
A more contemporary propensity matched analysis compared 102 robotic distal pancreatectomies to 102 laparoscopic distal pancreatectomies and found that
there were no signicant differences in operative time, estimated blood loss, transfusion rate, pancreatic stula, and overall morbidity between the groups [10]. The
robotic approach reduced the conversion-to-open rate (2.9% vs 9.8%, p=0.045),
especially in large tumors and improved splenic preservation rates in patients
without malignancy (95.5% vs 52.4%, p=0.001). Decreased length of hospital
stay was also associated with the robotic approach (7.67 vs 8.58 days,
p=0.032) [10].
Cost may present a practical limitation to widespread adoption of the robotic
approach to distal pancreatectomy, especially as a robotic system requires signicant upfront investment from hospitals. Waters etal. explored this possible limitation by studying cost-effectiveness between robotic, laparoscopic, and open distal
pancreatectomy. In their series of 77 patients (32 open, 28 laparoscopic, and 17
robotic), ASA class and patient characteristics were similar, although both minimally invasive approaches were performed less frequently for malignancy than
open pancreatectomy in that era (29% vs 47%) [11]. Operative time was longer in
robotic cases, 298 min vs 245 in laparoscopic cases vs 222 min in open cases
(p<0.05) [11]. Length of stay was notably shorter in robotic cases (4 vs 8days
[open] vs 6days [laparoscopic]). Total cost was lowest among the robotic cases,
with an average total cost of $10,588 compared to $16,059 in open cases and
$12,986in laparoscopic cases, with total cost including operative time, supplies,
anesthesia, nursing, laboratory, and overall hospital costs as recording in hospital
accounting records [11].
Magge etal. also examined comparative cost data between robotic, laparoscopic,
and open distal pancreatectomy. In their cohort of 374 total patients, open surgery
included the most malignant pathologies (48% vs 20% in the laparoscopic group,
and 31% in the robotic group, p<0.0001) [12]. Analysis of postoperative outcomes
in multivariate analysis adjusting for patient factors demonstrated that the robotic
approach had statistically signicant lower rates of any Clavien complication
(p=0.012), 30-day mortality (0.016), and shorter length of stay (p=0.0001) compared to laparoscopic and open approaches [12]. The authors similarly found robotic
distal pancreatectomy to have the lowest total cost ($15,440, p=0.002), compared
to laparoscopic ($16,733) and open ($23,228). Cost in this study was dened as
direct costs of admission, including operating room time, instruments, medications,
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C. F. Cardell and G. J. Abood
tests, personnel, capital investments of operating room purchases with amortization
over time, and salaries of operating personnel [12].
While encouraging, it is important to interpret the existing literature with knowledge that much of the early described literature is lacking in rigorous methodology
such as randomized clinical trials. Some effort has been made to examine minimally
invasive techniques in a randomized fashion in the DIPLOMA trial, a trial which
demonstrated non-inferior oncologic outcomes of minimally invasive distal pancreatectomy compared to open surgery, but did not distinguish between laparoscopic
and robotic techniques [13]. The majority of the studies discussed here were carried
out in highly specialized tertiary referral centers with existing expertise in robotic
surgery and signicant resources. Additionally, none of the studies randomized
patients to operation approach, leaving the choice to surgeon discretion. As evidenced by several studies having higher proportions of benign disease in the robotic
group, it is likely that surgeons elected more straightforward cases to be performed
robotically, especially early on in their experience with the robotic approach to distal pancreatectomy. This has potential to underestimate rates of complications,
length of stay, and ultimately cost. It is critical to continue to evaluate the role of
emerging technology as it becomes more commonplace in complex surgery.
Conclusions
In this chapter, we present our approach utilizing a robotic platform to perform a
distal pancreatectomy. Our robotic approach maintains the same principles of dissection planes and careful vessel identication as in laparoscopic or open surgery,
yet, we feel the robotic platform offers superior visualization and versatility in dissection that cannot be as easily achieved in open or laparoscopic approaches.
Existing literature has established that use of a robotic platform is feasible, safe, and
results in non-inferior clinical outcomes compared to more traditional approaches.
Additionally, patients undergoing a robotic approach may benet from decreased
conversion rates and shorter hospital stays. Cost-effectiveness analysis suggests that
despite the common assumption that robotic surgery may be more expensive, it is
actually more cost effective than other surgical approaches. Although existing literature is lacking in randomized controlled trials and may be subject to selection
bias, we believe the benets of robotic distal pancreatectomy will continue to be
evident as more surgeons familiarize themselves with the technique and will be
applied to increasingly complex cases. Future efforts should focus on robotic training and proctoring to spread this technology outside of specialized centers.