Background/Objectives: The IWATE criteria are well-established as a helpful tool to preoperatively estimate the difficulty and perioperative outcome of laparoscopic liver resections. We evaluated the relationship between the IWATE criteria and the perioperative outcomes in robotic-assisted liver resections (RARLs). Methods: We retrospectively analyzed the data of 58 patients who underwent robotic-assisted liver surgery at our center between July 2019 and April 2023. The operative difficulty of every patient was graded according to the IWATE criteria and compared to the perioperative outcome. Results: The median operation time was 236.5 min (range 37–671 min), and the median length of stay was 6 days (range 3–37 min). The majority had no complications (65.5%; n = 38), 18 (31.0%) patients suffered from mild complications (CD ≤ 3A) and 2 patients (3.4%) suffered from relevant complications (CD ≥ 3B). We observed no deaths within 30 postoperative days. The surgery time, postoperative ICU stay and perioperative blood transfusions increased significantly with a higher difficulty level (p = < 0.001; p < 0.001; p = 0.016). The length of stay, conversion to open surgery (n = 2) and complication rate were not significantly linked to the resulting IWATE group. Conclusions: The IWATE criteria can be implemented in robotic-assisted liver surgery and can be helpful in preoperatively estimating the difficulty of robotic liver resections. Whether there is a “robotic effect” in minimally invasive liver resections has to be further clarified. The IWATE criteria can help to develop curricula for robotic training.

Background: According to current guidelines, preoperative endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting (ERCP/stenting) is often necessary in patients with obstructive jaundice due to pancreatic ductal adenocarcinoma (PDAC), including severe jaundice (bilirubin > 250 umol/l), pruritus, cholangitis, cholestatic liver dysfunction, renal failure, severe malnutrition, or delayed surgery for tumors requiring neoadjuvant chemotherapy. We aimed to investigate the impact of preoperative ERCP/stenting on postoperative and long-term outcomes following pancreaticoduodenectomy (PD) for PDAC. Methods: Clinicopathological data of patients who underwent partial/total PD for PDAC between 2012 and 2019 in two hepato-pancreato-biliary centers in Germany and Switzerland were assessed. We compared patients treated with preoperative ERCP/stenting with those directly undergoing surgery according to postoperative morbidity, postoperative mortality, overall survival (OS) and disease-free survival (DFS). Results: During the study period, 192 patients underwent partial/total PD for PDAC. ERCP/stenting was performed in 105 patients, and 87 patients underwent resection without prior intervention. Postoperative 90-day overall morbidity rate (71% vs. 56%, p = 0.029) and superficial surgical site infection (SSI) rate (39% vs. 17%, p < 0.001) were significantly worse following preoperative ERCP/stenting. Major postoperative morbidity rate (18% vs. 21%, p = 0.650), organ/space SSI rate (7% vs. 14%, p = 0.100), and 90-day postoperative mortality rate (4% vs. 2%, p = 0.549) did not significantly differ between the two groups. After excluding 44 patients for whom the indication for ERCP/stenting was not consistent with current guidelines, ERCP/stenting was associated with a higher superficial SSI rate (36% vs. 17%, p = 0.009) and shorter length of stay (12 vs. 16 days, p = 0.004). Median OS (ERCP/stenting: 18 months vs. no ERCP/stenting: 23 months, p = 0.490) and median DFS (ERCP/stenting: 14 months vs. no ERCP/stenting: 18 months, p = 0.645) were independent from the utilization of ERCP/stenting. Conclusions: Preoperative ERCP/stenting in patients with PDAC can be performed without increasing organ/space SSI, major perioperative morbidity, and mortality rates and without worsening oncologic outcomes. However, it is associated with higher superficial SSI rates. If ERCP/stenting is not performed routinely but according to current guidelines, it is also associated with a shorter length of hospital stay. Further refinement of the indications for preoperative ERCP/stenting may reduce superficial SSI rates.

Robotic-assisted liver surgery (RALSs) has numerous advantages over laparoscopic and open procedures. However, prior abdominal surgeries (PAS) are frequently considered as constraints for RALSs. Our study evaluated the impact of PAS on the intraoperative course and postoperative outcomes after RALSs. For this retrospective cohort study, clinicopathological data were collected from all patients who underwent RALSs at the University Hospital Münster between December 2018 and March 2024. Patients were stratified based on whether they had undergone PAS or not (NPAS), the intraoperative course and postoperative outcomes after RALSs were analyzed. In total, 116 patients were identified, 79 patients had undergone PAS, and 37 patients had not. The mean surgery time, conversion rate, intraoperative complications, postoperative intensive care unit (ICU) admissions and length of hospital stay (LOS) were comparable between the two groups. Forty-three patients had postoperative complications, without significant difference (PAS: 34 patients, NPAS: 9 patients). No deaths were observed within 30 days of surgery. One PAS patient died within 90 days of surgery. Perioperative outcomes in patients undergoing RALSs were comparable in between PAS and NPAS patients and PAS was not associated with an increased risk of postoperative complications. PAS alone should not be considered as contraindication for RALSs.

Minimal-invasive techniques have been increasingly performed to treat pancreatic lesions. We evaluated the differences between open and robotic approach for distal pancreatectomy (DP) in terms of postoperative analgesic consumption and perioperative outcomes. Clinicopathological data of patients undergoing DP from 2012-2023 were evaluated. The study compared robotic (RDP) with open distal pancreatectomies (ODP) regarding total postoperative morphine consumption. Secondary endpoints included intensive care unit (ICU) stay and hospital stay. During the study period, 78 DP were performed, including, 24 RDP and 54 ODP. Multivisceral resections including DP and laparoscopic DP were excluded. Patients who underwent RDP required significantly less opioid analgesics compared to those after ODP (113.60 mg; 0,00-516,20 mg morphine milligram equivalents; median; minimum-maximum vs. 253.75 mg; 15,00-3519,45 mg; p<0.001). When adjusted for patient weight, the morphine equivalent dose also showed a significant difference between RDP and ODP (1.51; 0,00-6,53 mg/kg vs. 3.19; 0,24-62,85 mg/kg; p=0.004). Additionally, patients who underwent RDP had significantly shorter postoperative ICU stay compared to patients with ODP (0; 0-7 days vs. 4; 1-54 days; p<0.001) and shorter hospital stay compared to the open group (10.5; 6-33 days vs. 16; 9-92 days; p<0.001). Patients who underwent RDP required significantly lower amounts of opioid analgesics compared to ODP. Furthermore, RDP was associated with significantly shorter length of ICU and hospital stay.