Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

The current state of robotic-assisted pancreatic surgery

Nature Reviews Gastroenterology & Hepatology volume 9, pages 468–476 (2012)Cite this article

Subjects

Abstract

Pancreatic surgery is challenging for both surgeon and patient. With the advent of minimally invasive surgical techniques, patient morbidity could be reduced. However, these techniques must conform to established principles of open pancreatic surgery with regards to meticulous dissection, haemostasis and oncologic results. The robotic platform is utilized in all facets of surgery, and is being increasingly applied in pancreatic surgery. As with the introduction of any new technology, this approach must undergo rigorous examination before widespread adoption of the technique. In this article, we review the techniques and outcomes of robotic-assisted pancreatic resections, focusing on robotic-assisted pancreaticoduodenectomy, robotic-assisted distal pancreatectomy and robotic-assisted central pancreatectomy. As the outcomes of robotic-assisted surgery have yet to be rigorously evaluated against the gold standard of open surgery, this Review also highlights major laparoscopic pancreatic series in an effort to summarize the available literature on minimally invasive pancreatic surgery.

Key Points

  • The techniques of robotic-assisted pancreatic surgery can replicate the outcomes of the open approach

  • Multiple initial reports confirm that robotic-assisted pancreatic surgery is safe

  • Short-term oncologic outcomes seem to be comparable to those of open surgery, but long-term reports are still lacking

  • Detailed assessment of the benefits, costs and scope of implementation of robotic-assisted pancreatic surgery need to be carried out

This is a preview of subscription content

Access options

Buy article

Get time limited or full article access on ReadCube.

$32.00

Buy

All prices are NET prices.

Figure 1: Port placement for robotic-assisted pancreaticoduodenectomy.
Figure 2: The creation of the tunnel under the pancreatic neck in robotic-assisted pancreaticoduodenectomy.
Figure 3: A completed portal dissection.
Figure 4: A completed pancreaticoduodenectomy dissection.
Figure 5: A pancreaticojejunostomy.
Figure 6: A hepaticojejunostomy.
Figure 7: A gastrojejunostomy.
Figure 8: The coeliac axis as seen during pancreatic neck dissection for robotic-assisted distal pancreatectomy for a pancreatic neck cancer.

References

  1. The Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N. Engl. J. Med. 350, 2050–2059 (2004).

  2. Jayne, D. G. et al. Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer. Br. J. Surg. 97, 1638–1645 (2010).

    CAS  Article  Google Scholar 

  3. Gagner, M. & Pomp, A. Laparoscopic pylorus-preserving pancreatoduodenectomy. Surg. Endosc. 8, 408–410 (1994).

    CAS  Article  Google Scholar 

  4. Gagner, M. & Palermo, M. Laparoscopic Whipple procedure: review of the literature. J. Hepatobiliary Pancreat. Surg. 16, 726–730 (2009).

    Article  Google Scholar 

  5. Gumbs, A. A., Rodriguez Rivera, A. M., Milone, L. & Hoffman, J. P. Laparoscopic pancreatoduodenectomy: a review of 285 published cases. Ann. Surg. Oncol. 18, 1335–1341 (2011).

    Article  Google Scholar 

  6. Barbash, G. I. & Glied, S. A. New technology and health care costs—the case of robot-assisted surgery. N. Engl. J. Med. 363, 701–704 (2010).

    CAS  Article  Google Scholar 

  7. Zeh, H. J., Bartlett, D. L. & Moser, A. J. Robotic-assisted major pancreatic resection. Adv. Surg. 45, 323–340 (2011).

    Article  Google Scholar 

  8. Melvin, W. S., Needleman, B. J., Krause, K. R. & Ellison, E. C. Robotic resection of pancreatic neuroendocrine tumor. J. Laparoendosc. Adv. Surg. Tech. A 13, 33–36 (2003).

    CAS  Article  Google Scholar 

  9. Whipple, A. O., Parsons, W. B. & Mullins, C. R. Treatment of carcinoma of the ampulla of Vater. Ann. Surg. 102, 763–779 (1935).

    CAS  Article  Google Scholar 

  10. Traverso, L. W. & Longmire, W. P. Jr. Preservation of the pylorus in pancreaticuoduodenectomy. Surg. Gynecol. Obstet. 146, 959–962 (1978).

    CAS  PubMed  Google Scholar 

  11. Winter, J. M. et al. 1423 pancreaticoduodenectomies for pancreatic cancer: a single institution experience. J. Gastrointest. Surg. 10, 1199–1210 (2006).

    Article  Google Scholar 

  12. Kendrick, M. L. & Cusati, D. Total laparoscopic pancreaticduodenectomy: feasibility and outcome in an early experience. Arch. Surg. 145, 19–23 (2010).

    Article  Google Scholar 

  13. Zureikat, A. H., Nguyen, K. T., Bartlett, D. L., Zeh, H. J. & Moser, A. J. Robotic-assisted major pancreatic resection and reconstruction. Arch. Surg. 146, 256–261 (2011).

    Article  Google Scholar 

  14. Zeh, H. J. et al. Outcomes after robot-assisted pancreaticoduodenectomy for periampullary lesions. Ann. Surg. Oncol. 19, 864–870 (2012).

    Article  Google Scholar 

  15. Brennan, M. in Surgery of the Liver and Biliary Tract 3rd edn (eds Blumgart, L. & Fong, Y.) 1073–1089 (Saunders Co Ltd, New York, NY, USA, 2000).

    Google Scholar 

  16. Zhou, N. X. et al. Outcomes of pancreatoduodenectomy with robotic surgery versus open surgery. Int. J. Med. Robot. 7, 131–137 (2011).

    Article  Google Scholar 

  17. Narula, V. K., Mikami, D. J. & Melvin, W. S. Robotic and laparoscopic pancreaticoduodenectomy. Pancreas 39, 160–164 (2010).

    Article  Google Scholar 

  18. Buchs, N. C. et al. Outcomes of robot-assisted pancreaticoduodenectomy in patients older than 70 years: a comparative study. World J. Surg. 34, 2109–2114 (2010).

    Article  Google Scholar 

  19. Buchs, N. C. et al. Robotic versus open pancreaticoduodenectomy: a comparative study at a single institution. World J. Surg. 35, 2739–2746 (2011).

    Article  Google Scholar 

  20. Giulianotti, P. C., Addeo, P., Buchs, N. C., Ayloo, S. M. & Bianco, F. M. Robotic extended pancreatectomy with vascular resection for locally advanced pancreatic tumors. Pancreas 40, 1264–1270 (2011).

    Article  Google Scholar 

  21. Giulianotti, P. C. et al. Robot-assisted laparoscopic pancreatic surgery: single-surgeon experience. Surg. Endosc. 24, 1646–1657 (2010).

    Article  Google Scholar 

  22. Nguyen, K. T. et al. Technical aspects of robotic-assisted pancreaticoduodenectomy (RAPD). J. Gastrointest. Surg. 15, 870–875 (2011).

    Article  Google Scholar 

  23. Bassi, C. et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138, 8–13 (2005).

    Article  Google Scholar 

  24. Cuschieri, A., Jakimowicz, J. J. & van Spreeuwel, J. Laparoscopic distal 70% pancreatectomy and splenectomy for chronic pancreatitis. Ann. Surg. 223, 280–285 (1996).

    CAS  Article  Google Scholar 

  25. Cuschieri, A. Laparoscopic surgery of the pancreas. J. R. Coll. Surg. Edinb. 39, 178–184 (1994).

    CAS  PubMed  Google Scholar 

  26. Gagner, M., Pomp, A. & Herrera, M. F. Early experience with laparscopic resections of islet cell tumor. Surgery 120, 1051–1054 (1996).

    CAS  Article  Google Scholar 

  27. Fernández-Cruz, L. et al. Curative laparoscopic resection for pancreatic neoplasms: a critical analysis from a single institution. J. Gastrointest. Surg. 11, 1607–1622 (2007).

    Article  Google Scholar 

  28. Kim, S. C. et al. Comparative analysis of clinical outcomes for laparoscopic distal pancreatic resection and open distal pancreatic resection at a single institution. Surg. Endosc. 22, 2261–2268 (2008).

    Article  Google Scholar 

  29. Merchant, N. B., Parikh, A. A. & Kooby, D. A. Should all distal pancreatectomies be performed laparoscopically. Adv. Surg. 43, 283–300 (2009).

    Article  Google Scholar 

  30. Kooby, D. A. et al. A multicenter analysis of distal pancreatectomy for adenocarcinoma: is laparoscopic resection appropriate? J. Am. Coll. Surg. 210, 779–787 (2010).

    Article  Google Scholar 

  31. Jayaraman, S. et al. Laparoscopic distal pancreatectomy: evolution of a technique at a single institution. J. Am. Coll. Surg. 211, 503–509 (2010).

    Article  Google Scholar 

  32. Nigri, G. R. et al. Metanalysis of trials comparing minimally invasive and open distal pancreatectomies. Surg. Endosc. 25, 1642–1651 (2011).

    Article  Google Scholar 

  33. Borja-Cacho, D., Al-Refai, W. B., Vickers, S. M., Tuttle, T. M. & Jensen, E. H. Laparoscopic distal pancreatectomy. J. Am. Coll. Surg. 209, 758–765 (2009).

    Article  Google Scholar 

  34. Kooby, D. A. et al. Left sided pancreatectomy: a multicenter comparison of laparoscopic and open approaches. Ann. Surg. 248, 438–436 (2008).

    PubMed  Google Scholar 

  35. Kang, C. M., Kim, D. H. & Lee, W. Ten years of experience with resection of left sided pancreatic ductal adenocarcinoma: evolution and initial experience to a laparoscopic approach. Surg. Endosc. 24, 1533–1541 (2010).

    Article  Google Scholar 

  36. Daouadi, M. et al. Robot assisted minimally invasive distal pancreatectomy is superior to the laparoscopic technique. Ann. Surg. (in press).

  37. Kim, D. H., Kang, C. M., Lee, W. J. & Chi, H. S. The first experience of robot assisted spleen-preserving laparoscopic distal pancreatectomy in Korea. Yonsei Med. J. 52, 539–542 (2011).

    Article  Google Scholar 

  38. Kang, C. M., Kim, D. H., Lee, W. J. & Chi, H. S. Conventional laparoscopic and robot-assisted spleen-preserving pancreatectomy: does da Vinci have clinical advantages? Surg. Endosc. 25, 2004–2009 (2011).

    Article  Google Scholar 

  39. Waters, J. A. et al. Robotic distal pancreatectomy: cost effective? Surgery 148, 814–823 (2010).

    Article  Google Scholar 

  40. Choi, S. H., Kang, C. M., Hwang, H. K., Lee, W. J. & Chi, H. S. Robotic anterior RAMPS in well-selected left-sided pancreatic cancer. J. Gastrointest. Surg. 16, 868–869 (2012).

    Article  Google Scholar 

  41. Machado, M. A., Makdissi, F. F., Surjan, R. C. & Abdalla, R. Z. Robotic resection of intraductal neoplasm of the pancreas. J. Laparoendosc. Adv. Surg. Tech. 19, 771–775 (2009).

    Article  Google Scholar 

  42. Ntourakis, D. et al. Robotic left pancreatectomy for pancreatic solid pseudopapillary tumor. Ann. Surg. Oncol. 18, 642–643 (2011).

    Article  Google Scholar 

  43. Lillemoe, K. et al. Distal pancreatectomy: indications and outcomes in 235 patients. Ann. Surg. 229, 693–698 (1999).

    CAS  Article  Google Scholar 

  44. Speicher, J. E. & Traverso, L. W. Pancreatic exocrine function is preserved after distal pancreatectomy. J. Gastrointest. Surg. 14, 1006–1011 (2010).

    Article  Google Scholar 

  45. Sa Cunha, A., Rault, A., Beau, C., Collet, D. & Moser, A. J. Laparoscopic central pancreatectomy: single institution experience of 6 patients. Surgery 142, 405–409 (2007).

    Article  Google Scholar 

  46. Rotellar, F. et al. Totally laparoscopic Roux-en-Y duct to mucosa pancreaticojejunostomy after middle pancreatectomy: a consectutive nine-case series at a single institution. Ann. Surg. 247, 938–944 (2008).

    Article  Google Scholar 

  47. Giulianotti, P. C., Sbrana, F., Bianco, F. M., Addeo, P. & Caravaglios, G. Robot-assisted laparoscopic middle pancreatectomy. J. Laparoendosc. Adv. Surg. Tech. 20, 135–139 (2010).

    Article  Google Scholar 

  48. Kang, C. M., Kim, D. H., Lee, W. J. & Chi, H. S. Initial experience using robot-assisted central pancreatectomy with pancreaticogastrostomy: a potential way to advanced laparoscopic pancreatectomy. Surg. Endosc. 25, 1101–1106 (2011).

    Article  Google Scholar 

  49. Giulianotti, P. C., Addeo, P., Buchs, N. C., Bianco, F. M. & Ayloo, S. M. Early experience with robotic total pancreatectomy. Pancreas 40, 311–313 (2011).

    Article  Google Scholar 

  50. Oberholzer, J., Tzvetanov, I., Mele, A. & Beneditti, E. Laparoscopic and robotic donor pancreatectomy for living donor. J. Hepatobiliary Pancreat. Sci. 17, 97–100 (2010).

    Article  Google Scholar 

  51. Horgan, S. et al. Robotic distal pancreatectomy and nephrectomy for living donor pancreas-kidney transplantation. Transplantation 84, 934–936 (2007).

    Article  Google Scholar 

  52. Dulucq, J. L., Wintringer, P. & Mahajna, A. Laparoscopic pancreaticoduodenectomy for benign and malignant diseases. Surg. Endosc. 20, 1045–1050 (2006).

    CAS  Article  Google Scholar 

  53. Gumbs, A. A. & Gayet, B. The laparoscopic duodenopancreatectomy: the posterior approach. Surg. Endosc. 22, 539–540 (2008).

    Article  Google Scholar 

  54. Palanivelu, C. et al. Evolution in techniques of laparoscopic pancreaticoduodenectomy: a decade long experience from a tertiary center. J. Hepatobiliary Pancreat. Surg. 16, 731–740 (2009).

    CAS  Article  Google Scholar 

Download references

Author information

Affiliations

  1. Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, 5150 Center Avenue, Pittsburgh, 15213, PA, USA

    Josh Winer, David L. Bartlett, Herbert J. Zeh & Amer H. Zureikat

  2. Division of Gastrointestinal Surgery, Gulhane Military Medical Academy, Etlik, 06018, Ankara, Turkey

    Mehmet F. Can

Authors
  1. Josh Winer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mehmet F. Can
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. David L. Bartlett
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Herbert J. Zeh
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Amer H. Zureikat
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

J. Winer, H. J. Zeh and A. H. Zureikat contributed equally to all aspects of the article. M. F. Can researched data for the article and reviewed and edited the manuscript before submission. D. L. Bartlett provided substantial contribution to discussion of the content and reviewed and edited the manuscript before submission.

Corresponding author

Correspondence to Amer H. Zureikat.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Winer, J., Can, M., Bartlett, D. et al. The current state of robotic-assisted pancreatic surgery. Nat Rev Gastroenterol Hepatol 9, 468–476 (2012). https://doi.org/10.1038/nrgastro.2012.120

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrgastro.2012.120

Further reading

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing