Pancreatic surgery is still the only curative treatment for the majority of pancreatic neoplasms.
Pancreatic carcinoma represents the fourth-leading cause of cancer-related death in the United States with 46,420 estimated new cases for 2014 and 35,590 deaths. In Europe, 103,773 new cases were estimated in 2012, and 8.15 deaths/100,000 in men and 5.62/100,000 in women. Adenocarcinoma of the pancreas is the most aggressive pancreatic neoplasm, with approximately 80 % of patients inoperable at the time of the diagnosis for locally advanced or metastatic disease. Pancreatic Neuroendocrine tumors (pNETs) represent about 7% of all NETs, 8.7% of gastroenteropancreatic NETs (GEP-NETs) and 1% to 2% of all pancreatic neoplasms. pNETs are further divided into functional and non-functional tumors, depending their secretive activity. Pancreatic robotic enucleation is a safe and feasible procedure with lower intraoperative blood loss, better perioperative outcomes, mortality rates less than 1% and shorter hospital stays compared with open surgery. The current literature is still lacking studies matching robotics, laparoscopic and open surgery. In our experience robotic enucleation is a safe procedure that allows sparing more parenchyma, reducing the risk of develop iatrogenic diabetes. Moreover, patients have a short hospital stay with a precocious return to every-day activities.
The indications for minimally-invasive enucleations are the same as for open pancreatic enucleations. However, the ongoing discussion is still focused on the survival benefits of surgery, the good long-term survivals and the risks of surgery itself. The advent of the minimally invasive technologies could have played a role in the increase of the number of surgical candidates. Very few comparative studies and no prospective randomized controlled trials are available in current literature matching laparoscopic, robotic and open pancreatic enucleation. However, minimally invasive approaches were proved to be feasible, reproducible, safe and effective, with lower blood loss and length of hospital stay compared to open surgery. The operating times are reported to be shorter compared to other laparoscopic resections. Conversion rates ranges from 20% to 33%. The rate of post-operative pancreatic fistulas (POPF) after laparoscopic enucleation (LEN) ranges from 13% to 38% and it was lower than that after open enucleation. The long-term results for laparoscopic enucleations are still lacking. In their systematic review, including 101 patients treated with a LEN, Briggs et al. reported a conversion rate ranging from 10% to 44% and a morbidity rate ranging from 22% to 67%, without significant differences in morbidity and mortality rates compared to open pancreatic surgery. Unfortunately, the experience with robotic enucleation (REN) is actually very small, mostly limited to single center case-series. The rationale for the development of a robotic program includes many interesting technical issues. First of all, the main advantages of the robotic system are represented by an optimal surgeon position, deeper high-definition 3D vision, endo-wrist arm technology (articulation of the instruments with 7 degrees of freedom), motion scaling and tremor filtration. Moreover, the use of an integrated ultrasound flexible probe moved by the surgeon from the robotic console mimics the movements of traditional open surgery. The ultrasound screen is seen in a picture-in-picture integrated mode. US probe is a powerful tool to exactly localize the lesion and its correlation with vessels and pancreatic duct overcoming the absence of tactile sense. Jin and colleagues recently reported a retrospective comparison between 25 open and 31robotic enucleations, mostly carried out for pNETs. The major peri-operative findings resulted to be highly comparable and favorable with both technique, with no significative differences in POPF development (10 vs. 7, p=0.6 respectively). Another paper published by Shi et al. in 2016, including 26 cases, reported a matching with17 open enucleations carried out during the same period. The crucial end-points of investigation, represented by the overall morbidity rate and incidence of pancreatic fistula were all similar, with REN showing shorter operative time. Our experience could represent the first European one reported in literature: therefore, it is of great interest at both local and national level.