Robot-assisted pancreatic surgery—optimized operating procedures: set-up, port placement, surgical steps

Even in most challenging surgical interventions of the retroperitoneum, minimally invasive techniques are increasingly evaluated for their feasibility and efficacy. Indications for laparoscopic interventions have already demonstrated advantages over open pancreatic surgeries in some instances [1, 2]. Results of robotic-assisted interventions from high-volume centers suggest even broader application [3‐5]. Due to high costs, the application of these technologies is limited to a few large international centers, so that universally applied Standard Operating Procedures have not yet been established. Some studies also indicate that significant center-specific and time-dependent differences prevail, thus any benefits of robotic-assisted pancreatic surgery may develop only after extended learning curves [6‐9]. However, company marketing and the general popularity of such technologies increase daily. To minimize the rate of any serious complications, which may occur during the learning curve, standardization in experienced centers is extremely important. From our high-volume center-specific experiences, we present the following Optimized Operating Procedures, for the setting of robotic-assisted pancreatic surgery. This protocol should enable other centers to establish a robust-, time efficient- and safe robotic-assisted pancreatic surgery program.

Robot-assisted technology is novel, so that it is necessary to explain to the patient both the risks and advantages compared to conventional operating methods. We generally inform patients about current international opinions and studies to provide individual, evidence-based recommendations when considering this surgical technology's pros and cons.

This prospective post-marketing study (CARE study; E/A4/084/17) was conducted with IRB approval, which was necessary to collect data of a unique cohort receiving surgical treatment with the da Vinci Xi (Sunnyvale, USA) Surgical System (DRKS00017229).

Initial surgical assessment and indication for surgery is obtained at our Charité Pancreatic Outpatient Center. Specialized and experienced pancreatic surgeons inform and consent selected patients for robotic-assisted surgery. Anesthesiologists are consulted to thoroughly examine the patient before scheduling the operation. In the context of a professionalized ERAS (enhanced recovery after surgery) program, patients are surveilled before and after surgery by expertly skilled personnel. Patient admission to the hospital occurs one day prior to the operation for final clinical evaluation.

To avoid positioning and collision injuries, patients are placed on a soft vacuum mattress, and metal protectors are attached for safety and shield the surgical area. The left arm is positioned at the patient's side, while the right arm is stretched out to give anesthesiologists easy access (Fig. 1). The patient's legs are placed in French Position while their body remains in 12° reverse Trendelenburg inclination.

Irrespective of the pancreatic procedure, we set out all the robotic and assistant trocars prior to attachment of the robotic arms. Our center has established a "One Fits All” principle. When performing pancreatoduodenectomies (PD), total pancreatectomies (TP) and Appleby procedures (AP), four robotic trocars (8 mm) and two assistant trocars (15 mm/5 mm) are needed. For Distal Pancreatectomies (DP) however, we introduce a single assistant trocar (15 mm). Figure 2 indicates the exact port placement.

First, we place 8 mm trocar (R3) umbilical. After a pneumoperitoneum has been established, a diagnostic laparoscopy is then performed. If there is a good overview, other robotic trocars (R1, R2, R4) are placed in an imaginary horizontal line using standardized distances to avoid robotic arm collisions (see Fig. 2). During this process, any intra-abdominal adhesions are removed using laparoscopic instruments, before introducing the remaining assistant trocars (A1, A2).

The da Vinci Xi (Sunnyvale, USA) Patient Cart is aligned with the operating table on the left side (Fig. 1). The camera is now being introduced (R3). After the focal point has been adjusted intra-abdominally, the robotic system and arms are set up fully automatic. On demand, the required instruments are introduced into the patient and connected with the robotic arms (Fig. 3) (Table 1).

Operating procedures have now been significantly optimized and economized based on our center-specific experience. During the period of 2017–2021, we were able to conduct > 125 robotic-assisted pancreatic surgeries and > 70 PDs. We believe that this process optimization is particularly important in the robotic setting due to its limited spatial overview when compared to the open situs operations. For this reason, our team established a novel concept, named the “Reversed 6-to-6 Approach”:

The new standard for non-oncologic distal pancreatectomies is the minimally invasive resection of the pancreatic tail [11]. With this in view, we sought to establish standard, robotic-assisted distal pancreatectomies at our center. With respect to the individual surgical indication (benign versus malign), this procedure can be conducted with spleen preservation (Kimura Maneovre) or via complete oncologic clear-up [12]. As spleen-preserving procedures are rarely performed, we describe the individual steps of an oncologic distal pancreatectomy.

In the recent series of robotic-assisted pancreatectomies at our center, we were able to report good outcome parameters, after having implemented novel concepts, such as the “One Fits All” principle and “Reversed 6-to-6 Approach” [4]. Of particular relevance in the evaluation of this novel approach are the parameters, such as mean procedure time, in-hospital stay, complication rates and oncologic outcomes (Table 2). Like other large international centers, we present similar positive outcome parameters, while offering a standardized approach, feasible for majority of patients. There is also a measurable reduction in operating time compared to other centers, likely due to our steep learning curve (Fig. 4). Altogether, this indicates successful process optimization through standardization.

The rising popularity in the health care setting as well as intense marketing of robotic-assisted techniques warrants its broader application and distribution, particularly expected in pancreatic surgery. While the implementation of novel techniques is indispensable for innovation in the surgical field, it sometimes involves unforeseeable risks. Important studies from centers that have already established large programs for robotic-assisted pancreatic surgery have indicated that good performance and major benefits are only achieved after a long learning curve [6, 7]. At this point, professional training centers have been implemented to train international surgeons in conducting safe robotic-assisted pancreatic procedures [13]. They facilitate the acquisition of proficient skills at the robotic console, prior to their application on patients. However, they are not able to provide immediate surgical guidance on step-by-step operating procedures, necessary to acquire consistent outcome parameters in complex surgical settings. In this manuscript, we emphasize and were able to show that institutional process optimization and standardization, may shorten such learning curves. For this reason, we strongly propose to broadly implement standard operating procedures, which may facilitate intra- and inter-institutional process optimization as well as providing guidance for novel centers to establish a robust, time efficient- and safe robotic-assisted pancreatic surgical program.

Considering the continuous development of this technology, such recommendations need to be regularly discussed and re-evaluated to establish national and international consensus.