Page 6 - World Association of Laparoscopic Surgeons - Journal

RJ Orti-Rodríguez

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of them nonlaparoscopic surgeons, as an experimental Europe and North America as Giulanotti et al expose in
procedure due to the associated morbidity and the very their article. The authors explain that the length of hospital
difficult surgical technique of this particular surgery. 9 stay of their series, divided in this article into two
In the open approach, when the procedure is performed independent series according to the institution where the
by significant expertise in pancreatic surgery, rates of procedure was performed, varied depending if the patient
morbidity and mortality are prone to decrease (morbidity = was operated in Europe or in America. In the Italian group
18-54%; mortality = 1-4%). From the first description of the mean hospital stay was 22 days and in the US group,
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the Whipple’s procedure, the technique has suffered some was 9 days. They stress that Europeans patients do not go
modifications and surgeons have to develope their surgical home if they have a drain in place but american patients
skills day by day until reach the morbidity and mortality were discharged at the 9th day (mean), with or without drain,
rates of this era. Whenever the minimal access approach to reduce the price of the procedure. We realized that this
(laparoscopic and robotic) was between certain security series is a large one which has a big influence in the final
limits, it must suffer a similar development as open analysis, so we also suggest this as the main reason why the
approach. WA of the hospital stay is higher in RG than in LG.
Robotic surgery improves many of the shortcomings of Rates of periopertive morbidity in laparoscopic PD in
laparoscopy. The dizzying development of the surgical series of high-volume range between 26 and 40%. In this
industry, makes possible in robotic surgery binocular review, we identified 69 morbidity cases (36%) in LG and
three-dimensional imaging, 360º movement of surgical 18 (21%) in RG, but these data are not very reliable because
instruments and a better comfort and precision, without the of two series of RG (60 patients; 55%) did not specifically
physiologic tremor, of the surgeon. These advances allow report this variable. Although we did not take in count this
to perform complex procedures with nearly identical cases for the final analysis we did not want to compare both
principles to open surgery making robotic surgery the groups due to the high difference in their sizes.
probable expected step in minimal access pancreatic surgery. PPF is the most frequent and one of the most dangerous
Gagner et al 11 described the first laparoscopic specific major complication after pancreatic resection. There
pancreaticoduodenectomy in 1994 and reported a large is a huge variation between series in the reported rates,
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series of 10 patients some years later with a mean operative probably because of the different definitions of PPF used.
time of 510 minutes. From this series to the most In spite of the robotic surgery allows a better freedom of
recent ones, there is a significant decrease in the operating movement to perform an anastomosis, we found a higher
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room time. Kendrick et al published in 2010 a series of percentage of fistula in RG (30%) than in LG (14.5%) when
54 patients with a mean operative time of 368 minutes and we compared both arms. Probably this finding could be
state that their initially long operation time decreased from caused because more than 50% of the patients of the Buchs
a mean of 7.7 hours in the first 10 patients to 5.3 hours in et al publication 17 had pancreatic stump sclerosis, where
the last 10; on the other hand, Ammori et al 14 recently small pancreatic leaks are common. The other article in
reported a small series of six patients with a mean which data showed a high incidence of pancreatic fistula
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operating room time of 628 minutes. Surprisingly, in RG, was the Giulanotti et al publication. They attribute this high
the WA was 394.77 minutes, practically the same as in LG incidence also to the subgroup of patient who followed
(388.8 mins), in spite operative times usually remain injection sclerosis of the duct but do not rule out a surgical
significantly longer in robotic surgery than in other technique fail. However, similar rates of bleeding (RG: 9%;
approaches. LG: 4%) and conversion (LG:8.3%; RG:12%) were found
Many publications report numerous potential benefits in both groups. Conversion rates was compared favorably
of robotic surgery over the traditional approach: Less pain, with that in the literature (11.5%).
less risk of infection, less blood loss and transfusions, less We can find similar rates of motality in high-volume
scarring, faster recovery and quicker return to normal centers for open PD (1 to 4%) and for minimal access PD
activities. 15,16 But, in this case, we found clear differences (0 to 5%). We found five cases in the whole series of LG
in mean estimated blood loss and mean hospital stay between (2.7%) and three in the RG (3%) which is in keeping with
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both groups in favor of LG. The WA of the estimated blood the literature reviewed. In the article of Buchs et al, there
loss was 178.7 ml for LG and 319.06 ml for RG. We can was one death as a result of a fatal cardiac arrhythmia in a
not explicate this difference and we would need a more patient over 70 years old. In spite of this death, the authors
thorough analysis to get conclusions. In the other hand the conclude that a totally robotic approach for PD can be
WA of the hospital stay was 9.9 days (LG) and 15.31 days performed safely in an elderly population, with similar
(RG). This variations in the length of hospital stay can be results compared with younger patients. The other two cases
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explained by the differences in the health systems between reported by Giulanotti et al were due to sepsis following
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