Standardization of robotic pancreaticoduodenectomy

Background: Robotic pancreaticoduodenectomy (RPD) has been reimbursed since April 2020, and the number of operations is increasing. We present our standardized RPD with the transition of its surgical techniques through the experience of 43 cases.
Surgical techniques: First, mobilization of the right colon and Kocher's maneuver. Next, lymph node dissection around hepatoduodenal ligament. Third, lymph node dissection along the superior mesenteric artery. Regarding device selection, we’ve been using dual bipolar techniques for dissection around arteries since August 2020. Reconstruction is performed by modified Child method. Pancreaticojejunostomy is performed with modified Blumgart technique and 8 stiches of duct-to-mucosa anastomosis. Choledochojejunostomy is performed with a continuous suturing technique.
Result: Of the 43 cases, 27 were bile duct or ampullary cancers, 6 IPMNs, 4 PDACs, 3 NETs, and 3 others. Mean operation time and blood loss were 654 min and 156 ml, respectively. Conversion was observed in 1 case (2.3%), pancreatic fistula in 3 (7.0%), and delayed gastric emptying in 2 (4.7%). Comparing cases before and after April 2020, both operation time and postoperative hospital stay have been significantly improved (569 vs 801 min; 12 vs 18 d).
Discussion: RPD has many advantages such as its articulated function and magnified view effects. The key points of RPD are standardization of each procedure and the collaborative work between the console surgeon and patient-side surgeons.