Robotic pancreatoduodenectomy in the Netherlands: A multicenter analysis of the first 100 procedures

Background: Minimally invasive surgery is currently the gold standard for many surgical procedures. Most pancreatoduodenectomies, however, are still being performed through laparotomy. As conventional laparoscopy is limited by the rigid visual- and working axis, it might be less suited for complex procedures such as pancreatoduodenectomy. Robotic technology potentially offers a solution. The technically enhanced articulating instruments and 3D vision allow for optimal surgical dexterity, as needed during meticulous dissection and construction of the anastomoses in pancreatoduodenectomy. The aim of this study was to determine safety and feasibility of robotic pancreatoduodenectomy in the Netherlands. Materials and Methods: This is a multicenter post hoc analysis of prospective databases from three high volume Hepato-Pancreato-Biliary centers in the Netherlands. Outcomes were scored during index admission. The first 100 patients undergoing robotic pancreatoduodenectomy were included. Primary endpoint was severe complication, defined as occurrence of one or more of the following complications: post-pancreatectomy hemorrhage (ISGPS gr.B/C), pancreatic fistula (ISGPS gr.B/C), multi- or single organ failure or death. Results: In total, 100 consecutive patients underwent robotic pancreatoduodenectomy. Proven or suspected malignancy was the most frequent indication for resection (n=78). A total of 22 patients suffered from a severe complication. Delayed gastric emptying (ISGPS gr.B/C) occurred in 26 patients. Pancreatic fistula (ISGPS gr.B/C) occurred in 19 patients and 9 patients suffered from post-pancreatectomy hemorrhage (ISGPS gr.B/C). Severe bile leakages (ISGPS gr.B/C) occurred in 9 patients. A total of 7 patients underwent relaparotomy during index admission. Two patients developed multiple organ failure. In 8 patients the minimally invasive procedure was converted to open pancreatoduodenectomy. There was no postoperative in-hospital or 30-day mortality. Conclusion: These outcomes of the first 100 robotic pancreatoduodenectomies demonstrate that this procedure was introduced safely in three hospitals in the Netherlands without postoperative mortality and acceptable morbidity. Our results justify further expansion of robotic pancreatic surgery.