Patient Choice
The study included patients who underwent RPD at 7 surgical institutes between January 2012 and October 2023, and data were collected at our institute; 74 cases later, the learning curve for the RPD was surmounted. The first RPD was completed in January 2012.
The patients were divided into two categories based on age: young (less than 50 years) and old (> 50 years). Any patient with a history of surgery and marked adhesion > 2 cm, especially in the upper part of the abdomen, was excluded from our study.
Data gathering
All data related to patient characteristics and tumor features were collected, and patients were classified physically by the American Society of Anesthesiologists (ASA). All Preoperative, intraoperative, and post operative morbidities were evaluated. The likelihood associated with surgery, such as fatality and different postoperative difficulties, was also evaluated. Incidence of periampullary adenocarcinoma death has also been reported.
Aim of Study Outcomes :
The primary aim of this study was to compare the safety and risks of our case categories. The secondary study goal was to compare survival between the two groups.
Method procedures
A brief internal stent was inserted for a small pancreatic duct measuring less than 3 mm, although pancreatic duct stents are not commonly employed. The same jejunal limb was then used for hepaticojejunostomy without stenting, with either continuous (for dilated) or interrupted (for non dilated ducts) sutures. By carefully lowering the stomach, an extracorporeal technique was used to perform a hand-sewn gastrojejunostomy. The gastrojejunostomy was placed in framesocolic, antecolic, and antiperistaltic positions close to the umbilical region. When feasible, a restricted antrectomy was performed following right gastric artery bifurcation in patients with an ischemic pylorus, instead of attempting pylorus-preserving pancreaticoduodenectomy. Oral liquid after 24 h and soft diet after 3 days, with no need for NGT feeding.
The Clavien-Dindo classification was used to categorize surgical complications [14]. According to the 2016 International Study Group for Pancreatic Fistula revised grading system [15], clinically meaningful grade B or C pancreatic leakage constitutes the definition of postoperative pancreatic fistula (POPF). The International Study Group of Pancreatic Surgery (ISGPS) established classification criteria for delayed gastric emptying (DGE), post-pancreatectomy hemorrhage (PPH), and chyle leak [16–18].
Based on the state of the resection margin, complete radical resection was performed in three cases: if there was no microscopic evidence of cancer at a resection margin of less than 1 mm, the resection was classified as R0; if there was microscopic evidence of cancer at a resection margin of less than 1 mm, it was classified as R1; and if there was a strong positive margin, it was classified as R2. Mortality that occurs within three months of surgery, involving the hospitalization period after surgery, is referred to as surgical mortality.
The clinicopathological features of the patients’ retrospective data on the preoperative, perioperative, and postoperative features were gathered. Some of the most common factors that were known about patients before and after surgery were age, sex, body mass index (BMI), comorbidities, ASHA score, obstructive jaundice, preoperative percutaneous transhepatic cholangial drainage (PTCD), tumor location, pathological type, largest tumor diameter, number of lymph nodes harvested, operation duration, estimated blood loss (EBL), and blood transfusion. Postoperative complications and the duration of hospital stay (LOS) were among the postoperative features. Intra-abdominal bleeding, chyle leakage, delayed gastric emptying (DGE), and clinically relevant postoperative pancreatic fistula (CR-POPF) are terms used by the International Study Group on Pancreatic Surgery (ISGPS) (9–12).
Positioning the patient, placing the trocar, and docking
The Da Vinci Si Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) was used to carry out the robotic procedures. The patients were placed in a supine 20 °reverse Trendelenburg position with their legs spread apart and a small inclination to the left. The assisting surgeon was positioned between the patient's legs. A 12-mm camera port was positioned below the umbilicus (Figure 1). Before docking, the scope was introduced to examine the abdominal cavity and rule out distant metastases after pneumoperitoneum induction. Subsequently, the robotic system was connected to the head of the patient. For R1 (the first robotic arm), an 8-mm trocar was positioned at the intersection of the left mid-clavicular line and the horizontal line of the umbilicus. The second robotic arm, R2, was positioned 2-3 cm below the ribs at the right anterior axillary line. R3 (the third robotic arm) and a 12-mm assistance trocar were positioned on the contralateral side, opposite to R1 and R2. Maintaining a spacing of 10–15 cm between neighboring robotic arms minimized the interference.
To perform a preliminary pancreatic examination, the gastrocolic ligament was opened. The right transverse colon, mesocolon, and hepatic colonic flexure were moved downward so that the duodenum and pancreatic head could be clearly seen. After dividing the retropancreatic region, the superior mesenteric vein (SMV) was visible. The GCT or gastrocolic trunk was later ligated. A portion of the distal stomach was removed with the aid of 60-mm linear cutter staplers (Echelon, Johnson & Johnson, USA). The common hepatic artery (CHA) was visualized by dissecting the top margin of the pancreas. After ligating the gastroduodenal artery (GDA) and right gastric artery (RGA) at their roots, the portal vein (PV) was visible. After the gallbladder was removed, the hepatoduodenal ligament was skeletonized and the common hepatic duct was separated. The superior mesenteric artery (SMA) was exposed using the right posterior "artery-first" technique. To view the aorta (AA) and left renal vein (LRC), an extended Kocher maneuver was used to dissect, retract, and then reposition the duodenum and the pancreatic head medially. The dissection of the SMA was approximately 1 cm superior to the LRC. We decided to cut the inferior pancreaticoduodenal artery (IPDA) and separate the adhesion between the pancreatic uncinate process and SMA at the back. Subsequently, the pancreas was split cranially in the neck. Using a 60-mm linear cutter stapler, the proximal jejunum was separated and dragged into the right upper quadrant. The uncinate process was separated from the SMV and SMA during the last stage of the resection. The right posterior "SMA-first" dissection method resulted in a thinner uncinate process. To improve visualization during dissection of the uncinate process, the pancreatic head, duodenum, and SMV were retracted laterally with a 45–60° anticlockwise rotation and medially. The uncinate process was then divided cranially and longitudinally along the right aspect of the SMA. En bloc resection of the specimen was used to clear the right 180° of the SMA,with stenting of the pancreatic duct. The specimen was removed by a 5-cm curved periumbilical incision, and the robotic system was then redocked.
A modified version of Child's approach was used to perform digestive repair. Our center performed a modified double-layer pancreaticojejunostomy using a duct-to-mucosa approach. The pancreatic remnant is 0.5 cm from the edge of the anastomosis and is a continuous suture with 4-0 prolene between the seromuscular layer of the jejunum. It can partially wrap the pancreatic stump after anastomosis. The inner layer is a duct-to-mucosa anastomosis that is sewn from the pancreatic stump edge to the major pancreatic duct (MPD) and jejunum's equivalent point. This technique removes any possible space between the pancreatic remnant and jejunum with improved attachment, preventing tears in the pancreatic duct and parenchyma. Duct-to-mucosa anastomosis frequently required six–eight stitches, and a trans-anastomotic stent was frequently inserted (as shown in figure 2). The common hepatic duct's width determined whether continuous or interrupted sutures were used during an end-to-side hepaticojejunostomy. Using a 60-mm linear cutter stapler (Echelon, Johnson & Johnson), gastrojejunostomy was performed using a side-to-side anastomosis approach between the posterior wall of the stomach and jejunum.
Data statestics
The Statistical Product and Service Solutions version 26 program was used to perform statistical analyses. Continuous variables were compared using a two-tailed Student's t-test and expressed as the mean ± standard deviation. Wilcoxon rank-sum test was used for continuous variables that were not normally distributed. Categorical variables are represented as numbers (percentages), and Pearson's χ2 test or Fisher's exact test contingency tables were used for comparison. The overall survival between the young and old groups was compared using Kaplan-Meier survival curves, and significance was assessed using the log-rank test. Cox proportional hazards regression and binary logistic regression were used for multivariate analysis. Statistical significance was set at P <0.05.