Robot-assisted pancreaticoduodenectomy. Safety and feasibility

Background: The availability of robotic assistance could make laparoscopic pancreaticoduo- denectomy safely feasible. We herein provide a systematic review on laparoscopic robot-assisted pancreaticoduodenectomy (RAPD). Methods: Literature search was conducted on multiple databases considering articles published in English up to October 31, 2014, reporting on ten or more patients. Results: A total of 262 articles were identified. Excluding duplicates (n=172), studies not matching inclusion criteria (n=77), and studies not suitable for other reasons (n=6), a total of seven studies reporting on 312 RAPDs were eventually reviewed. These studies were either retrospective cohort studies (n=4) or case-matched studies (n=3). No randomized controlled trial was identified. Most patients undergoing RAPD were diagnosed with malignant tumors (224/312; 71.8%). RAPD was feasible in most patients. Conversion to open surgery was reported in 9.2% of the patients. A hybrid RAPD technique, employing standard laparoscopy or open surgery through a mini-incision, was adopted in most patients (178/312; 57.0%). Overall, there were six postoperative deaths at 30 days (6/312; 1.9%), including one intraoperative death caused by portal vein injury, while 137 out of 260 patients with complete information developed postoperative complications (52.7%). The mean length of hospital stay ranged from 10–29 days. Postoperative pancreatic fistula (POPF) occurred in 66 patients (66/312; 21.1%). Grade C POPF was reported in eight patients (8/312; 2.5%). The costs of RAPD were assessed in two studies, demonstrating additional costs ranging from 4,000–5,000 US dollars to 6,193 Euro. The mean number of examined lymph nodes and the rate of positive surgical margins indicate that RAPD could be an appropriate oncologic operation. Conclusion: RAPD is safely feasible. These results were obtained in selected patients and in specialized centers. RAPD should not be implemented in the occasional patient by surgeons without advanced laparoscopic skills and formal training in robotic surgery.