Ugo Boggi, MD, FEBS
UNIVERSITY OF PISA
Robotic-assisted surgery in
HPB malignancies
Disclosure
Da Vinci
Despite this …….
We know that in the hands of gifted, and well
trained, surgeons all HPB procedures (feasible
using MI techniques) can be performed
laparoscopically without robotic assistance.
But the real advantage of robotic surgery is …………….
Having placed a COMPUTER between the surgeon and the
patient
The global surgical robot market size was valued at USD 4.0 billion in 2015 and is
expected to grow at a compound annual growth rate of 20.03% over the next eight
years.
Commercially available surgical robots
da Vinci Surgical System
Telelap ALF-X
“Next generation” of surgical robots
Medtronic (“Einstein”)
Coming
soon
Verb Surgical (J&J and Google)
What is the current value of robotic assistance in HPB
surgery
Robotic assistance enhnaces surgical dexterity,
especially when fine dissection and intracorporeal
sutures are needed.1. Pancreatic surgery ★★★ liver surgery ★
2. Whipple ★★★★★ distal pancreatectomy
★3. Preservation of splenic vessels ★★★
4. Rare indications ★★★★★★
Our experience
321Robotic Pancreatic Resections
Enucleation
Central
DP(1 Appleby)
PD(15 vein resections)
Total(5 vein resections)
112
160
22 1215
Type of resection Robotic-assistance Laparoscopy
N. % N. %
Segment I 2 1.9% 0 -
Segment II, III, IVb, V, VI 12 11.5% 68 68.0%
Segment IVa, VII, VIII 52 50.0% 5 5.0%
Left lateral
segmentectomy
3 2.8% 26 25.0%
Right lateral
segmentectomy
1 0.9% 0 -
Left hepatectomy 11 10.5% 1 1.0%
Segm VI+VII+VIII 1 0.9% 0 -
Right hepatectomy (LDLT) 1 0.9% 0 -
Right hepatectomy 19 18.2% 0 -
Extended right
hepatectomy
2 1.9% 0 -
Total 104 100
204 MI
liver
resections
Type of resection Robotic-assistance Laparoscopy
N. % N. %
Segment I 2 1.9% 0 -
Segment II, III, IVb, V, VI 12 11.5% 68 68.0%
Segment IVa, VII, VIII 52 50.0% 5 5.0%
Left lateral
segmentectomy
3 2.8% 26 25.0%
Right lateral
segmentectomy
1 0.9% 0 -
Left hepatectomy 11 10.5% 1 1.0%
Segm VI+VII+VIII 1 0.9% 0 -
Right hepatectomy (LDLT) 1 0.9% 0 -
Right hepatectomy 19 18.2% 0 -
Extended right
hepatectomy
2 1.9% 0 -
Total 104 100
204 MI
liver
resections
Type of resection Robotic-assistance Laparoscopy
N. % N. %
Segment I 2 1.9% 0 -
Segment II, III, IVb, V, VI 12 11.5% 68 68.0%
Segment IVa, VII, VIII 52 50.0% 5 5.0%
Left lateral segmentectomy 3 2.8% 26 25.0%
Right lateral
segmentectomy
1 0.9% 0 -
Left hepatectomy 11 10.5% 1 1.0%
Segm VI+VII+VIII 1 0.9% 0 -
Right hepatectomy
(LDLT)
1 0.9% 0 -
Right hepatectomy 19 18.2% 0 -
Extended right
hepatectomy
2 1.9% 0 -
Total 104 100
204 MI
liver
resections
Major hepatectomies 34 32.6%
Major hepatectomies 34 32.6%
4b
56
4a8
7
2
3
Laparoscopic segments
Robotic segments
Training Practice
ROBOTIC VERSUS OPEN PANCREATODUODENECTOMY FOR
PANCREATIC CANCER: A propensity score-matched analysis based on
factors predictive of margin status.
Period: Feb 1, 2014 - Jan 31, 2017
Inclusion criteria: Pancreatic Cancer
LEEPP for specimen analysis
Primary endpoint: Rate of positive margins (≤ 1 mm)
Secondary endpoints: Examined lymph nodes
Perioperative transfusions
Patients receiving adjuvant therapy
Sample size calculation for RCTs
No Robotic PD was converted to Open PD, laparoscopy, or hand
assistance.
50PDs
24Robotic-PDs
26Open-PDs
Variable Chi squared p HR
Age 0.06 0.8 0.99 (0.94-1.05)
BMI 3.23 0.07 1.17 (0.98-1.44)
M/F 0.30 0.59 1.36 (0.45-4.16)
Ca19.9 0.61 0.43 1 (0.99-1.0006)
Cardiac disease 0.06 1 1.21 (0.27-5.50)
COPD 0.21 1.00 0.57 (0.04-6.70)
Hypertension 0.005 0.95 0.96 (0.31-2.95)
Diabetes 0.42 0.73 1.55 (0.4-5.96)
Neutrophil to lymphocyte ratio 0.13 0.71 1.05 (0.80-1.46)
Platelet to lymphocyte ratio 0.39 0.53 0.99 (0.98-1.006)
Preoperative albumin level 0.46 0.49 1.42 (0.51-4.17)
Tumor size Computed Tomography 13.26 0.0003 0.85 (0.77-0.94)
ASA class 0.84 0.36 0.66 (0.26-1.60)
Factors predictive of R1
Variable Chi squared p HR
Symptoms 0.21 1 1.76 (0.25-20.8)
Jaundice 1.71 0.22 0.43 (0.12-1.56)
Pain 0.04 0.85 1.12 (0.36-3.45)
Weight loss 0.44 0.65 1.88 (0.29-12.32)
Percutaneous biliary drainage 0.1 0.75 1.23 (0.33-4.53)
Endoscopic biliary drainage 0.4 0.52 1.68 (0.33-8.45)
Tumor size (pathology) 13.3 0.0003 0.18 (0.05-0.48)
Positive lymph nodes 3.81 0.05 0.9 (0.81-1)
Examined lymph nodes 0.38 0.53 1.01 (0.97-1.05)
Mean lymph node ratio 5.79 0.02 0.005 (0.000002-
0.42)
Mean LOODS 6.3 0.01 0.54 (0.31-0.88)
Perineural infiltration 0.08 0.77 1.31 (0.19-8.62)
Duodenal infiltration 7.78 0.005 5.35 (1.58-18.06)
Variable Robotic PD Open PD p
Number of patients 20 24 -
Age, years, median (IQR) 65 (58.5-
74.75)
72.5 (59.75-
78.75)
0.29
Gender, males (%) 10 (50%) 13 (54.1%) 0.78
Body Mass Index, Kg/m2, mean (±SD) 23.1±3.2 24.1±3.1 0.32
Time from C-ECT to surgery, days, mean
(±SD)
19.9±10.5 27.5±17.8 0.12
Preop. Ca 19.9 level, U/L, mean (±SD) 353.3±528.6 1362.7±4497 0.36
Neu to lymph ratio, %, mean (±SD) 3.2±1.4 3.5±2.9 0.70
Plat to lymph ratio, %, mean (±SD) 184.1±58.5 180.5±64.3 0.85
Tumor diameter (C-ECT), mm, mean
(±SD)
26.1±6.7 25.2±9.7 0.74
Tumor diameter (path), mm, mean (±SD) 27±6.3 26.5±8.5 0.79
Baseline characteristics matched cohorts
Variable Robotic PD Open PD
T stage, number (%): T1
T2
T3
2 (10%)
0 (0%)
18 (90%)
0 (%)
0 (%)
24 (100%)
0.20
-
0.20
N stage, number (%): N0
N1
2 (10%)
18 (90%)
4 (16.7)
20 (83.3%)
0.67
0.67
Positive lymph nodes, number, (%):
1
2-3
4-7
≥8
2 (10%)
5 (25%)
6 (30%)
5 (25%)
2 (8.3%)
11 (45.8%)
4 (16.7%)
3 (12.5%)
1
0.21
0.47
0.43
Lymph node ratio, mean (±SD) 0.11 ± 0.12 0.12 ± 0.13 0.92
Mean LOODS, (±SD) -2.33 ± 1.08 -2.39 ± 1.2 0.85
Perineural infiltration, number (%):Negative
Positive
1 (5%)
19 (95%)
4 (16.7%)
20 (83.3%)
0.35
0.35
Variable Robotic PD Open PD p
≤1 mm Direct ≤1 mm Direct ≤1 mm Direct
R1 resections, number, (%) 10
(41.7%)
0 (0%) 11(55.0
%)
0 (0%) 0.38 -
R1 margin, number, (%)
Anterior (%) 0 0 (0%) 4
(16.6%)
0 (0%) 0.11 -
Posterior (%) 6 (30.0%) 0 (0%) 4
(16.6%)
0 (0%) 0.29 -
Vein (%) 5 (25.0%) 0 (0%) 5
(20.8%)
0 (0%) 1 -
SMA (%) 4 (20.0%) 0 (0%) 2 (8.3%) 0 (0%) 0.38 -
Neck of the pancreas
(%)
0 0 0 0 - -
Common bile duct (%) 0 0 0 0 - -
Proximal duodenum (%) 0 0 0 0 - -
R1 resections in matched cohorts
Variable Robotic PD Open PD p
Examined lymph nodes, number, mean (±SD) 42±14 42±15 0.2
Pts receiving blood transfusions, number, (%)
Overall
Intraoperative
Postoperative
8 (40%)
1 (5%)
7 (35%)
19 (79.1%)
10 (41.6)
13 (54.1%)
0.07
0.06
0.2
Pts receiving adjuvant chemotherapy, number,
(%)
Overall
≥ 6 cicles
single agent
combination
chemotherapy
15 (75%)
10 (50%)
11 (55%)
4 (20%)
13 (56.5%)
7 (46.6%)
13 (56.5%)
0 (0%)
0.2
0.48
0.92
0.2
Variable Robotic PD Open PD p
n % n %
Local 3 15 2 8.6 1 Fisher
Liver metastasis 8 40 7 30.4 1 Fisher
Peritoneal
carcinomatosis3 15 4 17.4 1 Fisher
Lung metastasis 2 10 4 17.4 0.64 Fisher
Multiple metastatic sites 1 5 2 8.6 0.60 Fisher
Tumor recurrence in matched cohorts
(alfa 0.025, power=90%, non-inferiority margin of 10% corresponding to a value of
0.038).
Based on the results our study
A non-inferiority RCT comparing RPD and OPD having the rate of R1
resection as the primary study endpoint requires
3355 pairs
1. Because of the lack of sound evidence, we cannot make final
conclusions.
2. With this limitation:
a. Robotic HPB surgery is
promising
Conslusions
b. Robotic HPB surgeons should learn about this
techniquec. Programs for systematic training are very much
needed