REVO

HBP Surgery Week 2024 / Thursday, March 21, 2024 / Grand Walkerhill Seoul

Which one is better? Laparoscopic, Hybrid & Robotic (Professor Chang Moo Kang, Yonsei University College of Medicine)

I'm going to talk about the topic of today's session from the perspective of favoring hybrid and robotic surgery. At first, pancreaticoduodenectomy (PD) is an absolutely complicated and highly technical operation which involves two stages. That is organ resection and reconstruction of the remaining pancreas and bile ducts, duodenum, or stomach. Because of this, it was previously thought that it would be impossible to perform PD using a minimally invasive approach. In recent years, however, several references and cases from local and international surgeons indicate that reports of laparoscopic and robotic surgery are growing. The number of cases in which minimally invasive-based PD is being recommended to patients is gradually increasing in real-world clinical settings.

When performing PD, it is common to encounter two different clinical situations. In the case of periampullary cancer, potential vascular resection can be highly challenging due to pancreatitis and cholangitis. However, the reconstruction phase may be rather easy because the pancreas is relatively hard and the pancreatic ducts and bile ducts are large and thick.

Benign and borderline malignant tumors are the complete opposite of what I described earlier. While resection is relatively easy, reconstruction can be very challenging because you have to deal with a soft pancreas less than 2 millimeters thick and small, thin bile ducts.

Therefore, when considering minimally invasive-based PD, I believe that a hybrid approach, in which the resection is performed laparoscopically and reconstruction is performed robotically, is very effective and reasonable. Hybrid surgery minimizes the disadvantages of laparoscopic and robotic surgery while maximizing the benefits of each.

Most importantly, laparoscopic resections have a long history, and even complex PD (Whipple procedure) have a well-standardized surgical procedure, making them safe and effective. This is one of the benefits of laparoscopic surgery. There are many other benefits of laparoscopic resection.

First, during the resection phase, the surgeon must be able to react immediately to a variety of unexpected situations. In this respect, the laparoscopic approach is thought to have an advantage over the robotic approach. Also, if the surgical site needs to be reoriented during surgery, laparoscopic surgery is relatively easier to change direction than robotic surgery. A disadvantage of the laparoscopic approach is the limited instrumental movement, but this can be overcome by adjusting the position of the trocar to establish the proper direction of resection. In addition, it is easier for the surgeon to control the movements of the assistant during surgery, making the laparoscopic approach highly effective and safe for resection.

Also, in my opinion, one of the biggest advantages of the laparoscopic approach is that the cost of laparoscopic surgery in Korea is comparable to open surgery. Therefore, surgeons shouldn't hesitate to change the surgical approach to ensure patient safety. For these reasons, laparoscopic approaches for the resection stage are the majority in real-world clinical settings.

In the reconstructive phase, however, robotic surgery has significant advantages. Before we get into the details, I'd like to introduce you to Revo-i, a surgical robot system from South Korea. Currently, a variety of surgical robotic systems are being developed around the world. Among them, Revo-i, developed by Korean company meerecompany, was already introduced in general surgery in 2017, and in 2023, it was installed at Severance Hospital and used in hepatopancreatic surgery.

During Whipple procedure, there are few emergencies that require an immediate response after tissue is removed. Instead, the surgeon must focus on accurately and reliably reconstructing the remaining pancreas and bile ducts. At this point, robotic surgery, which offers wrist-like articulation and tremor reduction features, provides a significant advantage. The Korean surgical robot Revo-i enables safe and effective minimally invasive surgery.

This video is a pancreatic bile duct reconstruction using Revo-i, and you can see that it can be done safely. Even inexperienced surgeons can perform safe, effective, minimally invasive surgeries with the Revo-i surgical robotics system.

In 2018, Severance Hospital performed the first minimally invasive Whipple surgery using Revo-i and published a case report[i]. We also published a video paper on these first attempts to standardize difficult surgical procedures[ii].

Recently, we published a study comparing hybrid Whipple surgery with Revo-i to hybrid Whipple surgery with American surgical robotic system[iii]. We compared pre-, intra-, and post-operative outcomes and found no differences between the two groups. This confirmed that Revo-i is a safe and effective system for advanced pancreatic cancer surgery.

The minimally invasive Whipple procedure, shown in Figure 1, is currently followed at Severance Hospital, which performs laparoscopic PD as well as hybrid PD. Based on these considerations, we strive to apply minimally invasive surgery that is safe and effective. In addition, approximately 60 percent of patients at Severance now undergo laparoscopic or robotic Whipple procedures, typically for peri-nipple conditions.

Figure 1. How minimally invasive Whipple surgery is applied at Severance Hospital 

Finally, to answer the question of whether laparoscopic, hybrid, or robotic surgery is superior, a hybrid approach - laparoscopic resection and robotic reconstruction - appears to be the most effective alternative. This concludes the presentation.

Korean Article: https://www.whosaeng.com/152523

References

[i] Chang Moo Kang, et al. First experience of pancreaticoduodenectomy using Revo-i in a patient with insulinoma. Ann Hepatobiliary Pancreat Surg. 2020 Feb;24(1):104-108.

[ii] Chang Moo Kang, et al. Revo-i Assisted Minimally Invasive Pancreaticoduodenectomy: How I Do It. Ann Robot Innov Surg. 2021 May;2(1):7-14. English. Published online May 18, 2021.

[iii] Ji Su Kim, et al. The Revo-i Robotic Surgical System in Advanced Pancreatic Surgery: A Second Non-Randomized Clinical Trial and Comparative Analysis to the da Vinci™ System. Yonsei Med J

. 2024 Mar;65(3):148-155. doi: 10.3349/ymj.2023.0140.