Innovative Surgical Techiniques in Hepatobiliary and Pancreatic Surgery
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Transcript of Innovative Surgical Techiniques in Hepatobiliary and Pancreatic Surgery
Innovative Surgical Techniques in Hepatobiliary and Pancreatic Surgery
Iswanto Sucandy, MD
Sharona Ross, MD
Alexander Rosemurgy, MD
Advanced Foregut and HepatoPancreatoBiliary Surgery
Florida Hospital Tampa
Open versus Minimally Invasive Surgery
Minimally Invasive Surgery
Laparoscopic Surgery
Robotic Surgery
Robotic Pancreatic Resection (Distal pancreatectomy and Whipple)
Robotic Liver Resection (Major and Minor Hepatectomy)
Robotic Biliary Tract Resection and Reconstruction
Minimally Invasive Surgery
Started with laparoscopic cholecystectomy in 1990
Surgery with “ small incisions “
Advantages of minimally invasive surgery over traditional open surgery
Faster postoperative recovery
Shorter duration of hospital stay
Less pain - > less narcotic use
Less postoperative intestinal ileus
Less surgical site infection
Less postoperative hernia rate
Better cosmesis
Equal oncologic outcomes and survivals
Minimally Invasive Surgery
Laparoscopic versus Robotic operation
Robotic surgery is developed to overcome limitations of traditional laparoscopic surgery
Application of Robotic surgery in complex major operations is most suitable
Hepatobiliary and Pancreatic surgery is the most technically complex/challenging of all abdominal operations
Robotic Surgical System
Advantages of Robotic over Traditional Laparoscopic Surgery
7 degrees of wrist motion – lower conversion rate
More precise dissections (key for complex Hepatobiliary and Pancreas operations)
High definition robotic camera (superior 3D visualization)
Tremor filtering
3 working arms at once
Elimination of excessive abdominal wall torque (especially in obese patients)
More ergonomic for operating surgeon
Endowrist Movements
Robotic Pancreatic Surgery
Robotic Pancreatic Surgery
A. Robotic distal pancreatectomy - pancreatic tumor in neck/midbody/tail
B. Robotic Whipple (pancreaticoduodenectomy) - pancreatic head, distal bile duct, or duodenal tumors
Rapid recovery with shorter hospitals stay (average 5 days) especially with enhanced recovery program after surgery
Minimal postoperative pain and narcotic use
Robotic Pancreatic Surgery(Distal Pancreatectomy)
Robotic Pancreatic Surgery(Whipple Procedure)
Robotic Pancreatic Surgery(Whipple Procedure)
Robotic Pancreatic Surgery
How about current surgical literature ?
A Multi-institutional Comparison of Perioperative Outcomes of Robotic and Open Pancreaticoduodenectomy
Zureikat et al. Ann Surg. 2016 Oct;264(4):640-9
1028 patients from 8 major HPB centers
4.7 % conversion rate
Robotic Pancreaticoduodenectomy :
Reduced blood loss ( - 181 ml )
Reduced major complications (Odds ratio o.6)
Similar 90-day mortality
Similar oncologic outcomes R0 resection
Similar postoperative pancreatic fistula rate
Similar length of stay and readmission rate
Robotic Liver Surgery
Robotic Liver Surgery
Most common indications : Primary and Metastatic Liver Tumors
Most common procedures :
Robotic non-anatomical liver resection - “wedges”
Robotic Left or Right hemihepatectomy
Robotic formal sectionectomy (removing 2 liver segments)
Robotic cystic mass liver resection
Robotic Liver Surgery
Key Aspects :
Tumor location (periphery versus central / high segment 7-8 lesions)
Viccinity to the vital structures (inflow-outflow-biliary drainage)
Tumor size
Experience of robotic team (surgeon + OR team)
Experience of anesthesia team (low CVP < 5mmhg)
Robotic Liver Surgery
Robotic Liver Surgery
Robotic Liver Surgery
64 matched patients Robotic vs Open
6% conversion rate, 3% 90-day mortality rate
Robotic Liver Resection :
Shorter OR time (163 versus 210 minutes)
Lower intraoperative blood loss (100 versus 300 ml)
Lower intraoperative blood transfusion (1.6% versus 14.1%)
Shorter duration of hospital stay (4 versus 7 days)
Lower 30 day readmission rate (6.3% versus 12.5%)
Robotic Liver Surgery: Results for 70 Resections
Guilianotti et al. Surgery 2011;149:29-39.
Mean operative time : 313 minutes
Estimated blood loss : 150 mL
Transfusion rate : 22%
Open conversion rate : 3.7%
Overall morbidity : 29.6%
30-day mortality : 0%
Resection margins (R0) : negative in all cases
Robotic Surgery
How about minimally invasive surgery of the biliary duct ?
Robotic Biliary Tract Resection
Robotic Biliary Tract Resection & Reconstruction
First report of laparoscopic choledochal cyst excision 1995 by Farello et al.
Technically difficult -- > slow adoption
Robotic choledochal cyst excision and RY reconstruction – A case series of 27 patients in 2014.
Robotic approach is gaining popularity due to technical ease of performing bilio-enteric anastomosis
Robotic Biliary Tract Reconstruction
Innovative Surgical Techniques in Hepatobiliary and Pancreatic Surgery
Advanced Foregut and HepatoPancreatoBiliary Surgery
Florida Hospital Tampa – Robotic HPB Program
Referral : 3000 Medical Park Dr, Suite 500, Tampa, FL 33613
Office Phone: (813) 615-7030
Fax: (813) 615-8350