Laparoscopic Robotic Assisted Whipple: Early Results of a Novel Technique and Comparison with the Standard Open Procedure

Matthew Walsh, MD, Sri Chalikonda, MD, Juan Ramon Aguilar Saavedra, MD, Gregory Lentz, PhD, John Fung, MD. Cleveland Clinic Fundation

Background: Since the introduction of minimally invasive surgery, surgeons have sought to optimize the efficiency and safety of these techniques. Recently, robotic assistance devices have been employed in conjunction with standard laparoscopic techniques to further refine minimally invasive surgery. The advantages of the laparoscopic and robotic approach to Whipple procedure are well documented, but any added safety or efficacy of laparoscopic robotic assisted surgery has not been demonstrated in the literature. In this series we compare the outcomes of Whipple procedure utilizing the laparoscopic robotic-assisted approach with its conventional open counterpart.
Methods: From March 2009 to August 2010, 25 minimally invasive Whipple resections were performed by a two pancreaticobiliary trained surgeons, compared with 25 open Whipples performed at the Cleveland Clinic Fundation. All resections were performed either using standard laparoscopic robotic-assisted approach using the da Vinci Robotic Surgical system (Intuitive Surgical, Sunnyvale, CA) or open classic Whipple. Retrospective statistical analysis of a prospectively collected group of patients was performed.
Results: Twenty five patients underwent Whipple procedure using a novel laparoscopic robotic-assisted approach and twenty five patients underwent open classical Whipple. Average age was 63 and 62 years in laparoscopic robotic assisted and open groups (p=0.33). Average BMI was (24 vs 26 p=0.19), Symtoms were present in (60% vs 64% p=0.38), and ASA score was (ASA 2 50%, ASA 3 45%, ASA 4 5% vs ASA 2 31%, ASA 3 69%) for the laparoscopic robotic assisted and open group respectively.. Indications included, adenocarcinoma (44% and 44%), IPMN (16% and 16%), and other (40% and 40%) in the laparoscopic robotic assisted and the open groups respectively. There was one perioperative death in the laparoscopic robotic assisted group . Overall morbidity, including wound infection, was 32% in laparoscopic robotic assisted group and 44%% in the open group (p=0.19) . Intraoperative factors including blood loss (537 vs 840 ml p=0.16), operative time (488 vs 364 min p=0.0009), in laparoscopic robotic assisted and open groups respectively. Conversion rate was 12% (3) in laparoscopic robotic assisted group. Reinterventions were performed in 8% and 24% in the laparoscopic robotic assisted and open groups respectively (p=0.064). Length of hospital stay was 10 days in the laparoscopic robotic assisted versus 14 days in the open group (p=0.031). Median tumor size was (3.33 vs 3.18 p=0.40), nodes examined (13 vs 12.6 p=0.44), positive margins (0% vs 12% p=0.041) in the laparoscopic robotic assisted and open groups respectively.
Conclusions: This is the only comparison of a novel laparoscopic robotic-assisted approach with the gold standard conventional open approach for Classic Whipple to date in the literature. Our data indicates a significant reduction in length of hospital stay in those patients undergoing laparoscopic robotic-assisted resection versus a conventional open approach. These data suggest equivalent intraoperative factors such as blood loss, and morbidity to open laparotomy. In summary, we find that this laparoscopic robotic-assisted Whipple is a safe and efficacious alternative to the conventional open approach.


Session: SS18
Program Number: S108

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