Multicenter outcomes of robotic reconstruction during the early learning curve for minimally-invasive pancreaticoduodenectomy

Background: Perceived excess morbidity during the early learning curve of minimally-invasive pancreaticoduodenectomy (MIPD) has limited widespread adoption. It was hypothesized that robotassisted reconstruction (RA) after MIPD allows anastomotic outcomes equivalent to open pancreaticoduodenectomy (PD). Methods: Intent to treat analysis of centrally audited data accrued during early adoption of RA-MIPD at five centers. Results: CUSUM analysis of operating times at each center identified 92 RA-MIPD during the early learning curve. Mean age was 65 +/- 12 years with body mass index 25.8 +/- 5.0. Surgical indications included malignant (60%) and premalignant (38%) lesions. Median operating time was 504 min (inter-quartile range 133) with 242 ml median estimated blood loss (IQR 398) and twelve (13%) conversions to open PD. Major complication rate (Clavien-Dindo III/IV) was 24% with 2 (2.2%) deaths and ten (10.9%) reoperations. Nine (9.9%) clinically significant pancreatic fistulae were observed (4 grade B; 5 grade C). Margin negative resection rate for malignancy was 90% (75% for PDA) with mean harvest of 16 +/- 8 lymph nodes. Conclusions: These multicenter data during the early learning curve for RA-MIPD do not demonstrate excess anastomotic morbidity compared to open. Further studies are required to determine whether surgeon proficiency and evolving technique improve anastomotic outcomes compared to open.