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Robot-assisted laparoscopic surgery: A safe, feasible extension of conventional laparoscopy

Stephen Padilla
06 Apr 2018

An initial single-institution experience in Singapore has validated the safety and feasibility of robot-assisted laparoscopic (RAL) hepatobiliary and pancreatic (HPB) surgery, reports a new study.

“[R]obot assistance is complementary, and not competitive, with conventional laparoscopy, especially when performing certain complex tasks that may often be required during laparoscopic HPB surgery,” researchers said. “Its application to laparoscopic HPB surgery may further expand minimally invasive indications to even more technically challenging operations.”

A total of 20 patients (median age 56 years; range, 22–75 years; median tumour size, 4.0 cm; range 1.2–7.5 cm) underwent RAL HPB surgery. The median operation time was 445 minutes (range, 80–825 minutes) and median blood loss was 350 mL (range, 0–1,200 mL). [Singapore Med J 2018;59:133-138]

The following surgeries were performed: left-sided pancreatectomies (n=10), hepatectomies (n=7), triple bypass with bile duct exploration for obstructing pancreatic head cancer with choledocholithiasis (n=1), cholecystectomy for Mirizzi’s syndrome (n=1) and gastric resection for gastrointestinal stromal tumour (n=1).

Only one (5 percent) open conversion occurred. There were no 30-day/in-hospital mortalities and two (10.0 percent) major morbidities (>grade II on the Clavien-Dindo classification) reported. No reoperation was performed for postoperative complications. The median postoperative stay was 5.5 days (range, 3–22 days).

The 5-percent open conversion rate is similar to outcomes from other highly experienced centres, and this can be attributed to the surgeons’ collective experience with open complex and conventional laparoscopic HPB surgery prior to robotic surgery and to appropriate patient selection. [Ann Surg 2013;258:554-559; Ann Surg 2014;259:549-555; Int J Med Robot 2013;9:152-159]

“In our opinion, RAL surgery is current not competitive but simply an extension of conventional laparoscopic surgery,” researchers said. “It is an extremely useful tool to add to the armamentarium of any surgeon practicing advanced laparoscopic surgery, such as major HPB surgeries.”

Using the robot has several advantages, including the high-quality three-dimensional magnified view, stabilized control of the robotic instruments allowing fine stable movements and superior dexterity from the 7° of freedom of movement due to the highly innovative Endowrist. These benefits result in superior steadiness, precision and dexterity, which allow fine accurate dissection and suturing tight spaces.

“The clinical applicability of this in HPB surgery is mainly for fine, stable dissection and for complex reconstruction of bilioenteric and pancreaticoenteric anastomoses,” researchers noted. [Arch Surg 2003;138:777-784; J Hepatobiliary Pancreat Sci 2011;18:471-480]

The current study is a retrospective review of the first 20 consecutive patients who underwent RAL HPB surgery at a single institution over a 34-month period from February 2013 to November 2015. Of the three surgeon who handled the 20 patients, one performed surgeries on 17 participants (85.0 percent).

“Further evaluation with clinical trials in larger patient cohorts is needed to determine whether it is superior and advantageous when compared to conventional laparoscopy and especially whether the increased cost justifies its routine application,” researchers said.

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