This is the largest series of robotic pancreatic surgery presented to date. Robotic surgery enables difficult technical maneuvers to be performed that facilitate the success of pancreatic minimally invasive surgery. The results in this series demonstrate that it is feasible and safe. Complication and mortality rates are comparable to those of open surgery but with the advantages of minimally invasive surgery.

Objective: The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019). Summary Background Data: MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking. Methods: The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology. Results: After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety. Conclusion: The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery.

Hypothesis: Robotic technology is the most advanced development of minimally invasive surgery, but there are still some unresolved issues concerning its use in a clinical setting.

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Obese patients with end-stage renal disease (ESRD) are often excluded from kidney transplantation due to concerns about surgical site infections. To reduce infections, we developed a robotic kidney transplantation method for obese recipients. From June 2009-December 2011, a prospective cohort of 39 obese patients underwent robotic kidney transplantation at a single center. The outcomes of patients with at least six months of follow-up (n=28) were compared to a frequency-matched retrospective cohort of obese patients who underwent open kidney transplantation from 2004-2009 (n=28). The 28 robotic patients were predominately African-American (46.4%) or Hispanic (35.7%), with a mean age of 47.9±10.7 years, similar to the control group. BMI in the robotic group was 42.6±7.8 kg/m2 compared to 38.1±5.4 kg/m2 in the control group (p=0.02). There were no surgical site infections in the robotic group (0/28), while 28.6% (8/28) in the control group developed an infection (p=0.004). Six-month creatinine (1.5±0.4 vs.1.6±0.6 mg/dL; p=0.47), and patient and graft survival (100%) were comparable between the two groups. Outcomes following robotic surgery compared favorably to conventional transplantation. Robotic surgery may therefore enable obese patients with ESRD to access kidney transplantation and may thereby reduce health disparities in groups with a high prevalence of obesity and ESRD.