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