ROBOTIC PANCRETICODUODENECTOMY(PD) SINGLE INSTITUTE EXPERIENCE TECHNIQUE AND EARLY OUTCOMES Avlonitis S, Katopodi A, Geroukalis A, Kozadinos I 2nd Surgical Dpt, Minimally Invasive-Robotic General Surgery Iaso General Hospital, Athens

THE “WHIPPLE” OPERATION First described in 1898 by Alessandro Codvilla Refined in 1935 by Allen Whipple First laparoscοpic Whipple in 1992 by Gagner First fully robotic Whipple in 2003 by Giulianotti

Mean patient`s age was 57,8yrs (43-76) RETROSPECTIVE ANALYSIS OF 5 CASES OF PANCREATIC HEAD ADENOCARCINOMA TREATED WITH ROBOTIC PD 2 men and 3 women with diagnosis of adenocarcinoma of the pancreatic head underwent robotic PD, from February 2012 till June 2013 Mean patient`s age was 57,8yrs (43-76) Mean tumor size was 2,8cm (2,2-3,5) Ειχαμε σε ολους προεγχειρητικη ιστολογικη διαγνωση με EUS-FNA

Perioperative results Retrospective analysis of 5 cases of pancreatic head adenocarcinoma treated with robotic PD Perioperative results Mean operative time was 404min (300-520) Mean operative blood loss was 196ml (100-320) 24h ICU monitoring to all patients Mean hospital stay was 14 days (8-22)

Morbidity-Mortality and Radicality results Retrospective analysis of 5 cases of pancreatic head adenocarcinoma treated with robotic PD Morbidity-Mortality and Radicality results No mortality was seen in our patients Morbidity: 2 pancreatic fistulas, classified as Grade A and Grade B (according to the ISGPF definition) R0 resection was achieved in four patients. In one case the histopathology revealed R1 resection due to positive margins at the uncinate process ο ασθενης με το grade B παγκρεατικο συριγγιο είχε συγχρονο καρκινο εγκαρσιου για το οποιο υπεβληθη σε ταυτοχρονη εγκαρσιεκτομη.την τριτη μτχ ημερα εμφανισε διαφυγη από την εντερικη αναστομωση. Η αμυλαση από το υγρο της παροχετευσης ηταν 2700. αντιμετωπιστηκε με παρακεντηση-παροχετευση υπο αξονικο τομογραφο.

PATIENTS` SELECTION CRITERIA All our patients were selected based on tumor resectability defined as: No distant metastases No lymph node spread outside the resection field No vessel involvement. All patients were Grade 0 according to the 4 grade radiology classification system predicting vascular invasion (Lu DSK et al. AJR Am Roentgenol 1997; 168:1439) Αποκλειστηκαν τοσο οι απολυτες οσο και οι σχετικες αντενδειξεις για whipple. Για την εκτιμηση της αγγειακης συμμετοχης χρησιμοποιηθηκε το 5 grade radiology classsification system for prognosis of vessel involvment με τη βοηθεια MDCT.

PREOPERATIVE STAGING – RESECTABILITY EVALUATION Standard examinations to decide resectability: MDCT EUS CHEST CT MRI* PET scanning* Staging laparoscopy MRI and PET was used in cases of synchronous findings on CT, for example adrenal incidentaloma (PET) or hepatic hemangioma (MRI). Staging laparoscopy was routinely used at the begining of the robotic procedure ( one third it changes the stage and the resectability decision)

PORT PLACEMENT FOR ROBOTIC PD Camera Port (BLUE): 3 – 4 cm to the right and 1 – 2 cm inferior to the umbilicus. Instrument Arm  (YELLOW): Place 3-4 cm superior to the umbilicus on left midclavicular line (MCL) Instrument Arm  (GREEN): Place lateral to the umbilicus on the right MCL Instrument Arm  (RED): Place on the anterior axillary line and 1-2 cm superior to arm  12 mm Assistant Port (A1) (BLACK): Place 1-2 cm lateral to the umbilicus 12 mm Assistant Port (A2) (WHITE): (Optional) place ~5 cm inferior to the camera port half way between the camera port and instrument arm, connected with the AirSeal Device    (A1) (C) (A2)

OR SETTING Patient Positioning: Patient is placed on a split-leg table Supine position Position the patient on the table so that the umbilicus is located superior enough for the da Vinci camera arm to be docked at its "sweet spot". OR Tower Split leg table 9

INstrUMENTS USED FOR ROBOTIC PD Robotic fenestrated bipolar forceps Robotic Cadiere forceps Robotic hook with monopolar diathermy Robotic harmonic scalpel (Ultracision) Laparoscopic assistant scissors and forceps

ROBOTIC INSTRUMENTS USED FOR PD Fenestrated Bipolar Forceps Harmonic ACE® Curved Shears Cautery hook Cadiere Forceps

AirSeal System Constant smoke evacuation Stable pneumoperitoneum No scope smudging during the procedure

VIDEO

Is robotic pd superior to laparoscopic ? Robotic technology : improves our ability to precisely manipulate tissue minimize tissue trauma improve visibility reduce surgeon fatigue How do you put a value on these improvements? Dr. Talamini , Professor and Chairman of the Department of Surgery at the University of California, San Diego Dr. Talamini is Professor and Chairman of the Department of Surgery at the University of California, San Diego. He is a pioneer in minimally invasive abdominal surgery and specializes in robotic surgery

2nd SURGICAL DEPT MINIMALLY INVASIVE-ROBOTIC GENERAL SURGERY Director: Dr Ioannis K. Kozadinos Consultants: Dr Angeliki E. Katopodi Dr Spiridon G. Avlonitis Dr Andreas F.Geroukalis

OUR TEAM