The robotic central pancreatectomy: surgical technique, and literature review

Abstract

Central pancreatectomy (CP) is an infrequently performed procedure indicated for benign or low-grade pancreatic neck tumours. This parenchyma preserving operation is associated with favourable long term exocrine and endocrine function compared to its traditional alternative, the distal pancreatectomy (DP). Minimally invasive laparoscopic and robotic approaches to the CP confer the benefits of reduced trauma, reduced postoperative pain and better cosmesis. The aim of this paper is to demonstrate a reproducible method of performing the robotic CP (RCP) with pancreatogastrostomy, and then discuss the current literature surrounding this infrequently performed surgery, with the view that despite limited indications, the procedure has a role to play in the management of a subset of pancreatic pathologies. We demonstrate a safe and reproducible RCP method through the case of an otherwise well 20-year-old lady who was diagnosed with a 65mm solid pseudopapillary tumour of the pancreas. We then discuss the available literature supporting the safety and feasibility of the RCP. Compared to DP, the main drawback of RCP is the increased risk of pancreatic fistula (PF), due to the presence of two section planes of the pancreas, the soft remnant pancreas and the small main pancreatic duct. Other surgical complications associated with CP include intrabdominal abscess and fluid collection, pancreatitis, delayed gastric emptying, and splenic vessel injury. However, there is evidence that postoperative endocrine insufficiency is worse with DP compared to CP. Thirteen studies were identified that report on outcomes following RCP. Overall, most studies show no difference in rate of complications, or mortality. Robotic surgery offers numerous technical advantages, including superior three-dimensional visualization, magnification, articulation and dexterity, and longer operating times can be expected to reduce as surgeons gain more experience. We believe that the robotic method described in this paper is relatively safe, and reproducible. Multi-centre large volume trials are needed to further determine safety and efficacy of RCP, and to determine optimal reconstruction type.