Robotisch assistierte obere gastrointestinale und hepatopankreatobiliäre Chirurgie: Etablierung durch einen Stepwise Approach und eine Analyse der ersten 100 Operationen

Zusammenfassung

Einleitung Die robotisch assistierte Chirurgie ist eine vielversprechende Technik zur Überwindung der Grenzen der laparoskopischen Chirurgie – insbesondere bei komplexen chirurgischen Eingriffen in der Oberbauchchirurgie. Im Folgenden beschreiben wir die Etablierung komplexer robotisch assistierter Oberbauchchirurgie in unserem Zentrum für minimalinvasive Chirurgie und präsentieren die Ergebnisse aus den ersten 100 Eingriffen.

Material und Methoden Die robotisch assistierte Chirurgie wurde mit dem Da Vinci^® Xi Surgical System^™ durchgeführt. Die Eingriffe wurden von 2 Chirurgen durchgeführt, die Spezialisten auf dem Gebiet der minimalinvasiven Chirurgie sind. Die robotisch assistierte Oberbauchchirurgie wurde in 3 Schritten etabliert. Step 1: Zunächst wurden robotisch assistierte Eingriffe mit leichterem Schwierigkeitsgrad durchgeführt (Cholezystektomien, atypische Magenresektionen und Fundoplikationen). Step 2: Anschließend wurden linksseitige Pankreasresektionen, Adrenalektomien und Lebersegment- bzw. atypische Leberresektionen als Verfahren mit mittlerem Schwierigkeitsgrad durchgeführt. Step 3: Schließlich wurden fortgeschrittene und hochkomplexe Verfahren durchgeführt (Hemihepatektomien, komplexe Pankreasresektionen, Gastrektomien und Ösophagektomien). Die von Juli 2017 bis Oktober 2018 erhobenen Daten wurden retrospektiv hinsichtlich Konversionsrate, Morbidität (Clavien-Dindo > 2) und Mortalität analysiert.

Ergebnisse Der 1. Schritt der Etablierung unseres Roboterprogramms umfasste 26 Eingriffe. Hier betrugen die Konversionsrate, die Morbidität und die Mortalität jeweils 0%. Im 2. Schritt wurden 23 Eingriffe durchgeführt. Die Konversionsrate, Morbidität und Mortalität lagen bei 28, 8 und 0%. Der letzte Schritt umfasste 51 hochkomplexe operative Verfahren. Diese Verfahren hatten eine Konversionsrate 43%, eine Morbidität von 41% und eine Mortalität von 4%.

Schlussfolgerung Unser Stepwise Approach ermöglicht eine sichere Etablierung robotisch assistierter Oberbauchchirurgie mit vergleichbaren Morbiditäts- und Mortalitätsraten – auch bei hochkomplexen operativen Eingriffen. Hochkomplexe Eingriffe erforderten jedoch vergleichsweise häufig eine Konversion, was durch die geringen Erfahrungswerte und durch die Lernkurve beeinflusst sein könnte.

Abstract

Introduction Robot-assisted surgery is a promising technique for overcoming the limitations of laparoscopic surgery, especially for complex and advanced surgical procedures. We now describe the implementation of our robotic upper GI and HPB surgery program in our centre of excellence for minimally invasive surgery and the results of our first 100 surgical procedures.

Method Robot-assisted surgery was performed using the Da Vinci^® Xi Surgical System^™. Robot-assisted surgical procedures were performed by two surgeons specialising in minimally invasive surgery. Our robotic surgery program for upper GI and HPB surgery was established in three steps. Step 1: firstly, relatively easy surgical procedures were performed robotically, including cholecystectomies, minor gastric resections and fundoplications. Step 2: secondly, pancreatic left sided resections, adrenalectomies and small liver resection were performed, as procedures with moderate degree of difficulty. Step 3: finally, advanced and highly complex procedures were performed, including right hemihepatectomy, complex pancreatic resections, total gastrectomies and oesophagectomies. Data collected from July 2017 till October 2018 were analysed retrospectively with regard to conversion rate, morbidity (Clavien Dindo > 2) and 90-d-mortality.

Results The first step of establishing our robotic surgical program included 26 procedures. Here, conversion rate, morbidity and mortality were 0%. In the second step of implementation, 23 procedures were performed. Conversion rate, morbidity and mortality were 28, 8 and 0% respectively. The last step included 51 advanced and highly complex procedures. These procedures had a morbidity of 41%, a mortality of 4% and a conversion rate of 43%.

Conclusion Our stepwise approach enables safe implementation of a robotic surgical program for upper GI and HPB surgery with comparable morbidity and mortality even for highly complex procedures. However, highly complex procedures in the learning curve required a high conversion rate.

Schlüsselwörter

Da Vinci^® Xi Surgical System - Etablierung - minimalinvasive Pankreaschirurgie - minimalinvasive Oberbauchchirurgie - Robotik

Key words

Da Vinci^® Xi surgical system - minimally invasive upper GI surgery - implementation - minimally invasive pancreatic surgery - robotic surgery

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