# Introduction of robotic pancreatoduodenectomy following phase 2a IDEAL guidelines

## TL;DR

This study evaluates the feasibility of robotic pancreatoduodenectomy using a structured framework and finds it feasible with experienced surgeons.

## Contribution

The study introduces a systematic assessment of robotic pancreatoduodenectomy using the IDEAL guidelines in its early phase.

## Key findings

- The median total operation time was 634 minutes with notable variation in resection and reconstruction times.
- Two cases were classified as fully successful, while two required additional laparotomy due to complications.
- Major postoperative complications occurred in two patients, highlighting the need for procedural refinement.

## Abstract

Robotic pancreatoduodenectomy (RPD) is a newly introduced procedure, which is still evolving and lacks standardization. An objective assessment is essential to investigate the feasibility of RPD. The current study aimed to assess our initial ten cases of RPD based on IDEAL (Idea, Development, Exploration, Assessment, and Long-term study) guidelines.

This was a prospective phase 2a study following the IDEAL framework. Ten consecutive cases of RPD performed by two surgeons with expertise in open procedures at a single center were assigned to the study. With objective evaluation, each case was classified into four grades according to the achievements of the procedures. Errors observed in the previous case were used to inform the procedure in the next case. The surgical outcomes of the ten cases were reviewed.

The median total operation time was 634 min (interquartile range [IQR], 594–668) with a median resection time of 363 min (IQR, 323–428) and reconstruction time of 123 min (IQR, 107–131). The achievement of the whole procedure was graded as A, “successful”, in two patients. In two patients, reconstruction was performed with a mini-laparotomy due to extensive pneumoperitoneum, probably caused by insertion of a liver retractor from the xyphoid. Major postoperative complications occurred in two patients. One patient, in whom the jejunal limb was elevated through the Treitz ligament, had a bowel obstruction and needed to undergo re-laparotomy.

RPD is feasible when performed by surgeons experienced in open procedures. Specific considerations are needed to safely introduce RPD.