Robotic single-site plus ONE port distal pancreatectomy

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Abstract
Laparoscopic distal pancreatectomy is regarded as safe and effective surgical approach in benign and low-grade malignant tumor of the pancreas. With the advances of laparoscopic techniques and instruments, many efforts to reduce the number of the trocar site has been made. There are a few available surgical techniques of laparoscopic single-site (single port or reduced port) distal pancreatectomy, suggesting its safety and feasibility. However, it is true that laparoscopic single-site distal pancreatectomy is difficult and technically quite demanding. Robotic surgical system was introduced to overcome the limitation of conventional laparoscopic surgery. Recently, we experienced robotic single-site plus ONE port distal pancreatectomy in benign and low-grade malignant tumor of the pancreas. A 45-year-old male patient was incidentally found to have pancreatic mass in tail of the pancreas. October 6th 2015, robotic distal pancreatectomy was performed using the Da Vinci single-site surgical platform (DVSSP) with one additional port. Additional robotic 12-mm-port was placed left side of DVSSP, and robotic 3rd arm was used through this site. Usual robotic instruments such as hook, bipolar, vessel sealer, and endo-GIA with endo-wrist function could be used to facilitate effective surgical procedure. The general operation procedure was based on modified Lasso technique (isolation and ligation of splenic artery prior to Lasso technique). Resected specimen was delivered through umbilicus and drains were inserted through additional port site. Five consecutive clinical experiences were reviewed. This study was approved by institutional review board. Two patients were male and three were female with median age, 38 years (range 21–56). The distribution of the pathological diagnosis was 2 solid pseudopapillary tumors, 1 serous cystic neoplasm, 1 chronic pancreatitis, and 1 neuroendocrine tumor. Median operation time was 165 min (range 120–270 min), and intraoperative-estimated blood loss were median 5 ml (range 0–50 ml). One patient could preserve spleen by Warshaw procedure. One patient converted to conventional multi-port robotic distal pancreatectomy due to inter-arms collisions. There was no clinically relevant postoperative pancreatic fistula. Length of hospital stay was median 6 days after surgery (range 5–8 days). Robotic single-site plus ONE port distal pancreatectomy is safe and feasible with acceptable perioperative outcomes. Although, certain patients such as those with a hard pancreas need an amount of care due to the features of robotic GIA, currently available robotic single-site plus ONE port surgical system was thought to have potential role to make laparoscopic single-site distal pancreatectomy much easier and ergonomics, providing some room to expand more minimally invasive surgery. Further experiences are mandatory.

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