Ugo Boggi, MD, FEBS

u.boggi@med.unipi.it

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