Laparobotic Duodenal Surgery: a Single Surgeon’s 9-year Experience

Jonas Mansson, MD, Anusak Yiengpruksawan, MD, Nino Carnevale, MD, Vikram Vattipally, MD. The Valley Hospital, Ridgewood, NJ

Background
Laparoscopic duodenal surgery has remained a challenge even among the experienced laparoscopic surgeons. This is due to disadvantages inherent to laparoscopic instruments that limit delicate maneuvers required in complex procedures. Application of the robotic surgical system with its unique endo-wrist instruments and 3-D high definition visual platform may allow these procedures to be done in a more efficient and safe manner. This report presents our 9-year experience with laparobotic (laparoscopic assisted robotic) duodenal surgery.

Methods
Patients undergoing duodenal procedures were identified from the Valley Hospital prospective Robotic Surgery database (July 2002 – 2011). A retrospective review of medical records was performed for demographics, procedure type, duodenal location, operative time, conversions, complications, pathology and length of hospital stay. Preoperative or intraoperative esophagogastroduodenoscopy was used in all cases to evaluate and localize the lesion. The da Vinci Robotic System (Intuitive Surgical Inc., Sunny Vale, Ca., USA) was used for all cases.

Results
Of the 600 cases performed over the nine year time period, 17 patients were identified (2.8%). The mean age was 65 (range 41-86) with 8 males and 9 females.
Indications for surgery included: benign polyps (n=6), malignancies (2 GIST, 1 carcinoid, 1 submucosal lipoma), diverticuli (n=3), strictures (n=2), duplication cyst (n=1), and annular pancreas(n=1). Distribution of lesion locations included D1 (n=3), D2 (n=10), D3 (n=3), and D4 (n=1). Operative procedures performed included: excision of polyp via duodenotomy (n=3), duodenotomy and intraluminal Endo-GIA stapler excision of tumor or polyp (n=3), tumor enucleation (n=2), excision and plication of diverticulum (n=1), Endo-GIA stapler excision of diverticulum (n=2), duodenoduodenostomy with or without stricturoplasty (n=3), excision of duodenal duplication cyst and suture closure (n=1). The mean operative time was 112 minutes (range 60-180 minutes). There were 2 conversions due to inability to localize the lesions. One patient (5.9%) developed postoperative c. difficile infection and duodenal stricture. There were no deaths. The mean hospital length of stay was 3 days (range 1-16 days).

Conclusions:
Laparobotic technique is safe and effective technique for duodenal surgery. The multiple degrees of freedom of the robotic endo-wrist instruments and 3D stereoscopic vision significantly contribute to the ability to mobilize and dissect the duodenum. Intraoperative endoscopy compensates for the lack of tactile feedback in tumor localization. Future large multi-institutional trials are needed to validate the use of laparobotics in duodenal surgery.
 

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