Case Report

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Journal of Minimally Invasive Surgery 2022; 25(2): 73-76

Published online June 15, 2022

https://doi.org/10.7602/jmis.2022.25.2.73

© The Korean Society of Endo-Laparoscopic & Robotic Surgery

Which one will you choose; open, laparoscopic, or robotic transduodenal ampullectomy?: a case report

Dawn Jung1,2 , Ji Eun Jung1 , Chang Moo Kang1,2

1Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
2Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea

Correspondence to : Chang Moo Kang
Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea
Tel: +82-2-2228-1004
Fax: +82-2-313-8289
E-mail: cmkang@yuhs.ac
ORCID:
https://orcid.org/0000-0002-5382-4658

Received: March 21, 2022; Revised: May 2, 2022; Accepted: May 12, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Transduodenal ampullectomy (TDA) is the treatment of choice for large premalignant lesions of the ampulla of Vater (AoV). With the development of surgical techniques, various methods, including the open, laparoscopic, and robotic approaches, for performing TDA have emerged. Herein, we report four consecutive cases treated with open, laparoscopic, and robotic TDA, with technical pitfalls and future perspectives of TDA in treating premalignant lesions of the AoV. The surgical techniques and principles for TDA were the same regardless of the surgical approaches. After surgery, none of the patients showed any abnormal findings or complications, except for digestive problems. All these surgical approaches are appropriate for patients requiring TDA; however, minimally invasive TDA, particularly the robotic approach is ideal. Considering the surgical complexity of TDA, the robotic approach is considered to be effective.

Keywords Ampulla of Vater, Duodenal neoplasms, Laparoscopy, Robotic surgical procedures

Pancreatoduodenectomy (PD) is the treatment of choice for ampulla of Vater (AoV) cancer. Although the incidence of lymph node metastasis is approximately 47% [1], and it is associated with poor prognostic biologic behavior, the curative resection of AoV cancer shows the most favorable long-term oncologic outcome by radical pancreatectomy among periampullary cancers [2,3].

What about premalignant lesions of the AoV? With the advancement in experiences and technologies of endoscopy, endoscopic papillectomy (EP) is a safe treatment modality for premalignant lesions of the AoV area. EP is usually attempted for tumors with no malignancy potential and has been confirmed benign by prior biopsy of tumors (<4.5 cm in diameter). The success rate of EP in the AoV area is 61% to 92%, and the recurrence rate is 0% to 33%. Complications of EP include pancreatitis in approximately 8% to 12% of cases and bleeding in 2% to 7% of cases. Perforation occurs in approximately 2% to 4% of cases, and in rare cases, mortality (0.3%–7%) may also occur [4]. In clinical practice, patients with potentially residual ampullary lesions after EP are common. Transduodenal ampullectomy (TDA) was reserved for such patients.

Generally, TDA is thought to be less aggressive and function-preserving surgery compared with PD; however, it still involves complex surgical processes, such as septoplasty for common channel formation between the bile and pancreatic ducts and common channel duodenal implantation. Therefore, it is typically performed using an open procedure. In theory, patients with potential indications for TDA are expected to have long-term survival, and a minimally invasive approach would be ideal, as long as the appropriate surgical technique and skills are available. Herein, we report four consecutive cases treated with open, laparoscopic, and robotic approaches of TDA with its technical pitfalls and future perspectives for treating premalignant lesions of AoV.

The surgical techniques and principles of TDA are the same, regardless of the surgical approaches. After exposure of the pancreaticoduodenal unit from the retroperitoneum, identification of AoV lesions is necessary because the duodenostomy site should be determined for an appropriate surgical approach to the AoV area. In the open approach (Fig. 1A), a small catheter was introduced into the AoV through the cystic duct, which could be easily identified by palpating the tip of the catheter on the duodenal wall. In contrast, in the laparoscopic (Fig. 1B) and robotic approaches (Fig. 1C), the effectiveness of palpation was limited, and intraoperative ultrasound to detect the previous endoscopic retrograde biliary drainage catheter or preoperatively placed endoscopic clips near the AoV could be applied to define the exact duodenal opening site. After identifying the AoV lesions, several stay sutures (4–0 absorbable) with sufficient healthy mucosal margins were placed for effective traction of the ampullary lesion. In procedure, we did not inject saline into the mucosa, and electrocautery was applied to resect the AoV for identifying the bile and pancreatic ducts to resect the whole layer of lesion. After complete resection of the AoV with the bile and pancreatic ducts, several sutures (6–0 absorbable) were placed for a septoplasty to allow the separate bile and pancreatic ducts into a common channel. And mount the stent by fixing it to the bile and pancreatic ducts. Finally, the duodenal mucosa was approximated to the common channel to complete the duodenal implantation of the common channel. After repairing the duodenostomy site, two silastic drains were placed before the external wound closure. Lymph node dissection was not performed because the risk of morbidity increased due to a larger dissection in TDA. None of the patients showed abnormal postoperative findings (Table 1). In the laparoscopic case, the hospital stay was prolonged due to vomiting, but in other cases, there were no other special complications. The pain index appeared to be better for the robot cases (Table 2); however, it was difficult to compare it as a subjective index for each patient.

Compared with PD, the surgical extent of TDA is limited; hence, it is thought to be an appropriate surgical option for treating premalignant lesions of AoV. Therefore, preoperative endoscopic ultrasonography and intraoperative frozen section test should be routinely performed to confirm the diagnosis and depth of lesion invasion before performing TDA. All four patients performed this study and had reported premalignancy pathology in postoperative pathologic diagnosis, indicating that accurate patient selection is important for TDA.

Fortunately, there are no advanced T stage cases. But even in advanced cases, according to a Korean multicenter study, there was no difference in prognosis between PD and TDA when Tis and T1 stages were reported [5]. With advances in laparoscopic skills and experience, several reports have demonstrated the technical feasibility and safety of TDA [6,7]. However, TDA usually requires an open approach due to complicated surgical procedures; consequently, minimally invasive approaches to TDA are rarely reported.

Several rationales exist for minimally invasive TDA for premalignant lesions of the AoV. First, the surgical extent of TDA is limited compared to the external wound for the open approach. It can benefit from a minimally invasive approach because the dissection-induced injury is smaller than access-induced injury. Second, long-term survival is expected for these patients. Quality of life should be considered to minimize cosmetic complications.

As shown in the present cases, an accurate suturing technique not only for creating a common channel between the small bile and pancreatic ducts but also for its implantation surrounding the folded duodenal mucosa is critical to complete the TDA. The laparoscopic approach is appropriate yet difficult for this surgical procedure. Based on three consecutive experiences of TDA for premalignant lesions of AoV, we believe that the robotic approach makes it much easier to complete these complicated and delicate surgical procedures. The wrist-like function of the surgical instruments and the stable three-dimensional magnified operation field provided by the robotic surgical system are thought to be useful. In the present cases, the operation time of the robot cases is longer than other approaches, which can be explained by the existence of docking time and the learning curve, and there is a sufficient possibility that the operation time will be shorter.

However, applying the robotic surgical system as a routine practice is difficult because of the high cost of robotic surgery. Recently, the Ministry of Food and Drug Safety in Korea approved the clinical use of Revo-i (the Korean robotic surgical system; Meerecompany Inc., Seoul, Korea) in minimally invasive surgery [8,9]. In addition, several international companies are actively involved in robotic surgical system development [10]. A day where patients would take advantage of robotic TDA with much available cost is believed to arrive soon.

In summary, we are living in an era intermingled with different surgical TDA approaches, including open, laparoscopic, and robotic systems. Currently, these surgical approaches are appropriate for patients requiring TDA; however, minimally invasive TDA, particularly using the robotic approach, is ideal. Considering the surgical complexity of TDA, robotic TDA is considered to be effective. Further clinical applications of robotic TDA are expected to increase in the near future.

Ethical statements

This study was approved by Institutional Review Board of Yonsei University College of Medicine with a waiver of informed consent (No. 4-2022-0102).

Authors’ contributions

Conceptualization: CMK

Formal analysis: JEJ

Investigation: JEJ

Methodology: DJ

Project administration: CMK

Writing–original draft: DJ

Writing–review & editing: All authors

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding/support

None.

Fig. 1. Site of incision while performing transduodenal ampullectomy. (A) Open approach, (B) laparoscopic approach, and (C) robotic approach.
Table. 1.

Summary of the four consecutive cases of transduodenal ampullectomy

ParametersTransduodenal ampullectomy case

OpenLaparoscopicRobotic 1Robotic 2
Age (yr)70606459
SexMaleFemaleMaleMale
DiagnosisAoV adenomaAoV carcinoma in situAoV carcinoma in situAoV tubular adenoma
Tumor size (cm)3.01.41.02.5
Previous procedureNoneERBD insertionNoneNone
Determining duodenostomy site, localization of AoVCatheter insertion through cystic duct and palpationPrevious ERBD catheter indentationPreoperative endoscopic clipping around AoV and IOUS detectionPreoperative endoscopic clipping around AoV and IOUS detection
Operation time (min)166296346311
Estimated blood loss (mL)7010050100
ComplicationNoneVomitingVomitingNone
Length of hospital stay (day)101589

AoV, ampulla of Vater; ERBD, endoscopic retrograde biliary drainage; IOUS, intraoperative ultrasonography.


Table. 2.

Postoperative pain score according to the time period

Postoperative dayPain scorea)

OpenLaparoscopicRobotic 1Robotic 2
18877
27755
39655
57635
75533
9333
1133

a)Numerical Pain Intensity Scale.


  1. Sierzega M, Nowak K, Kulig J, Matyja A, Nowak W, Popiela T. Lymph node involvement in ampullary cancer: the importance of the number, ratio, and location of metastatic nodes. J Surg Oncol 2009;100:19-24.
    Pubmed CrossRef
  2. Yeo CJ, Sohn TA, Cameron JL, Hruban RH, Lillemoe KD, Pitt HA. Periampullary adenocarcinoma: analysis of 5-year survivors. Ann Surg 1998;227:821-831.
    Pubmed KoreaMed CrossRef
  3. Howe JR, Klimstra DS, Moccia RD, Conlon KC, Brennan MF. Factors predictive of survival in ampullary carcinoma. Ann Surg 1998;228:87-94.
    Pubmed KoreaMed CrossRef
  4. Cheng CL, Sherman S, Fogel EL, et al. Endoscopic snare papillectomy for tumors of the duodenal papillae. Gastrointest Endosc 2004;60:757-764.
    Pubmed CrossRef
  5. Hong SS, Han SS, Kwon W, et al. Comparison of oncologic outcomes between transduodenal ampullectomy and pancreatoduodenectomy in ampulla of vater cancer: Korean multicenter study. Cancers (Basel) 2021;13:2038.
    Pubmed KoreaMed CrossRef
  6. Downs-Canner S, Van der Vliet WJ, Thoolen SJ, et al. Robotic surgery for benign duodenal tumors. J Gastrointest Surg 2015;19:306-312.
    Pubmed KoreaMed CrossRef
  7. Ahn KS, Han HS, Yoon YS, Cho JY, Khalikulov K. Laparoscopic transduodenal ampullectomy for benign ampullary tumors. J Laparoendosc Adv Surg Tech A 2010;20:59-63.
    Pubmed CrossRef
  8. Kang I, Hwang HK, Lee WJ, Kang CM. First experience of pancreaticoduodenectomy using Revo-i in a patient with insulinoma. Ann Hepatobiliary Pancreat Surg 2020;24:104-108.
    Pubmed KoreaMed CrossRef
  9. Lim JH, Lee WJ, Choi SH, Kang CM. Cholecystectomy using the Revo-i robotic surgical system from Korea: the first clinical study. Updates Surg 2021;73:1029-1035.
    Pubmed CrossRef
  10. Peters BS, Armijo PR, Krause C, Choudhury SA, Oleynikov D. Review of emerging surgical robotic technology. Surg Endosc 2018;32:1636-1655.
    Pubmed CrossRef

Article

Case Report

Journal of Minimally Invasive Surgery 2022; 25(2): 73-76

Published online June 15, 2022 https://doi.org/10.7602/jmis.2022.25.2.73

Copyright © The Korean Society of Endo-Laparoscopic & Robotic Surgery.

Which one will you choose; open, laparoscopic, or robotic transduodenal ampullectomy?: a case report

Dawn Jung1,2 , Ji Eun Jung1 , Chang Moo Kang1,2

1Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
2Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea

Correspondence to:Chang Moo Kang
Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea
Tel: +82-2-2228-1004
Fax: +82-2-313-8289
E-mail: cmkang@yuhs.ac
ORCID:
https://orcid.org/0000-0002-5382-4658

Received: March 21, 2022; Revised: May 2, 2022; Accepted: May 12, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Transduodenal ampullectomy (TDA) is the treatment of choice for large premalignant lesions of the ampulla of Vater (AoV). With the development of surgical techniques, various methods, including the open, laparoscopic, and robotic approaches, for performing TDA have emerged. Herein, we report four consecutive cases treated with open, laparoscopic, and robotic TDA, with technical pitfalls and future perspectives of TDA in treating premalignant lesions of the AoV. The surgical techniques and principles for TDA were the same regardless of the surgical approaches. After surgery, none of the patients showed any abnormal findings or complications, except for digestive problems. All these surgical approaches are appropriate for patients requiring TDA; however, minimally invasive TDA, particularly the robotic approach is ideal. Considering the surgical complexity of TDA, the robotic approach is considered to be effective.

Keywords: Ampulla of Vater, Duodenal neoplasms, Laparoscopy, Robotic surgical procedures

INTRODUCTION

Pancreatoduodenectomy (PD) is the treatment of choice for ampulla of Vater (AoV) cancer. Although the incidence of lymph node metastasis is approximately 47% [1], and it is associated with poor prognostic biologic behavior, the curative resection of AoV cancer shows the most favorable long-term oncologic outcome by radical pancreatectomy among periampullary cancers [2,3].

What about premalignant lesions of the AoV? With the advancement in experiences and technologies of endoscopy, endoscopic papillectomy (EP) is a safe treatment modality for premalignant lesions of the AoV area. EP is usually attempted for tumors with no malignancy potential and has been confirmed benign by prior biopsy of tumors (<4.5 cm in diameter). The success rate of EP in the AoV area is 61% to 92%, and the recurrence rate is 0% to 33%. Complications of EP include pancreatitis in approximately 8% to 12% of cases and bleeding in 2% to 7% of cases. Perforation occurs in approximately 2% to 4% of cases, and in rare cases, mortality (0.3%–7%) may also occur [4]. In clinical practice, patients with potentially residual ampullary lesions after EP are common. Transduodenal ampullectomy (TDA) was reserved for such patients.

Generally, TDA is thought to be less aggressive and function-preserving surgery compared with PD; however, it still involves complex surgical processes, such as septoplasty for common channel formation between the bile and pancreatic ducts and common channel duodenal implantation. Therefore, it is typically performed using an open procedure. In theory, patients with potential indications for TDA are expected to have long-term survival, and a minimally invasive approach would be ideal, as long as the appropriate surgical technique and skills are available. Herein, we report four consecutive cases treated with open, laparoscopic, and robotic approaches of TDA with its technical pitfalls and future perspectives for treating premalignant lesions of AoV.

CASE REPORT

The surgical techniques and principles of TDA are the same, regardless of the surgical approaches. After exposure of the pancreaticoduodenal unit from the retroperitoneum, identification of AoV lesions is necessary because the duodenostomy site should be determined for an appropriate surgical approach to the AoV area. In the open approach (Fig. 1A), a small catheter was introduced into the AoV through the cystic duct, which could be easily identified by palpating the tip of the catheter on the duodenal wall. In contrast, in the laparoscopic (Fig. 1B) and robotic approaches (Fig. 1C), the effectiveness of palpation was limited, and intraoperative ultrasound to detect the previous endoscopic retrograde biliary drainage catheter or preoperatively placed endoscopic clips near the AoV could be applied to define the exact duodenal opening site. After identifying the AoV lesions, several stay sutures (4–0 absorbable) with sufficient healthy mucosal margins were placed for effective traction of the ampullary lesion. In procedure, we did not inject saline into the mucosa, and electrocautery was applied to resect the AoV for identifying the bile and pancreatic ducts to resect the whole layer of lesion. After complete resection of the AoV with the bile and pancreatic ducts, several sutures (6–0 absorbable) were placed for a septoplasty to allow the separate bile and pancreatic ducts into a common channel. And mount the stent by fixing it to the bile and pancreatic ducts. Finally, the duodenal mucosa was approximated to the common channel to complete the duodenal implantation of the common channel. After repairing the duodenostomy site, two silastic drains were placed before the external wound closure. Lymph node dissection was not performed because the risk of morbidity increased due to a larger dissection in TDA. None of the patients showed abnormal postoperative findings (Table 1). In the laparoscopic case, the hospital stay was prolonged due to vomiting, but in other cases, there were no other special complications. The pain index appeared to be better for the robot cases (Table 2); however, it was difficult to compare it as a subjective index for each patient.

DISCUSSION

Compared with PD, the surgical extent of TDA is limited; hence, it is thought to be an appropriate surgical option for treating premalignant lesions of AoV. Therefore, preoperative endoscopic ultrasonography and intraoperative frozen section test should be routinely performed to confirm the diagnosis and depth of lesion invasion before performing TDA. All four patients performed this study and had reported premalignancy pathology in postoperative pathologic diagnosis, indicating that accurate patient selection is important for TDA.

Fortunately, there are no advanced T stage cases. But even in advanced cases, according to a Korean multicenter study, there was no difference in prognosis between PD and TDA when Tis and T1 stages were reported [5]. With advances in laparoscopic skills and experience, several reports have demonstrated the technical feasibility and safety of TDA [6,7]. However, TDA usually requires an open approach due to complicated surgical procedures; consequently, minimally invasive approaches to TDA are rarely reported.

Several rationales exist for minimally invasive TDA for premalignant lesions of the AoV. First, the surgical extent of TDA is limited compared to the external wound for the open approach. It can benefit from a minimally invasive approach because the dissection-induced injury is smaller than access-induced injury. Second, long-term survival is expected for these patients. Quality of life should be considered to minimize cosmetic complications.

As shown in the present cases, an accurate suturing technique not only for creating a common channel between the small bile and pancreatic ducts but also for its implantation surrounding the folded duodenal mucosa is critical to complete the TDA. The laparoscopic approach is appropriate yet difficult for this surgical procedure. Based on three consecutive experiences of TDA for premalignant lesions of AoV, we believe that the robotic approach makes it much easier to complete these complicated and delicate surgical procedures. The wrist-like function of the surgical instruments and the stable three-dimensional magnified operation field provided by the robotic surgical system are thought to be useful. In the present cases, the operation time of the robot cases is longer than other approaches, which can be explained by the existence of docking time and the learning curve, and there is a sufficient possibility that the operation time will be shorter.

However, applying the robotic surgical system as a routine practice is difficult because of the high cost of robotic surgery. Recently, the Ministry of Food and Drug Safety in Korea approved the clinical use of Revo-i (the Korean robotic surgical system; Meerecompany Inc., Seoul, Korea) in minimally invasive surgery [8,9]. In addition, several international companies are actively involved in robotic surgical system development [10]. A day where patients would take advantage of robotic TDA with much available cost is believed to arrive soon.

In summary, we are living in an era intermingled with different surgical TDA approaches, including open, laparoscopic, and robotic systems. Currently, these surgical approaches are appropriate for patients requiring TDA; however, minimally invasive TDA, particularly using the robotic approach, is ideal. Considering the surgical complexity of TDA, robotic TDA is considered to be effective. Further clinical applications of robotic TDA are expected to increase in the near future.

NOTES

Ethical statements

This study was approved by Institutional Review Board of Yonsei University College of Medicine with a waiver of informed consent (No. 4-2022-0102).

Authors’ contributions

Conceptualization: CMK

Formal analysis: JEJ

Investigation: JEJ

Methodology: DJ

Project administration: CMK

Writing–original draft: DJ

Writing–review & editing: All authors

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding/support

None.

Fig 1.

Figure 1.Site of incision while performing transduodenal ampullectomy. (A) Open approach, (B) laparoscopic approach, and (C) robotic approach.
Journal of Minimally Invasive Surgery 2022; 25: 73-76https://doi.org/10.7602/jmis.2022.25.2.73

Table 1 .. Summary of the four consecutive cases of transduodenal ampullectomy.

ParametersTransduodenal ampullectomy case

OpenLaparoscopicRobotic 1Robotic 2
Age (yr)70606459
SexMaleFemaleMaleMale
DiagnosisAoV adenomaAoV carcinoma in situAoV carcinoma in situAoV tubular adenoma
Tumor size (cm)3.01.41.02.5
Previous procedureNoneERBD insertionNoneNone
Determining duodenostomy site, localization of AoVCatheter insertion through cystic duct and palpationPrevious ERBD catheter indentationPreoperative endoscopic clipping around AoV and IOUS detectionPreoperative endoscopic clipping around AoV and IOUS detection
Operation time (min)166296346311
Estimated blood loss (mL)7010050100
ComplicationNoneVomitingVomitingNone
Length of hospital stay (day)101589

AoV, ampulla of Vater; ERBD, endoscopic retrograde biliary drainage; IOUS, intraoperative ultrasonography..


Table 2 .. Postoperative pain score according to the time period.

Postoperative dayPain scorea)

OpenLaparoscopicRobotic 1Robotic 2
18877
27755
39655
57635
75533
9333
1133

a)Numerical Pain Intensity Scale..


References

  1. Sierzega M, Nowak K, Kulig J, Matyja A, Nowak W, Popiela T. Lymph node involvement in ampullary cancer: the importance of the number, ratio, and location of metastatic nodes. J Surg Oncol 2009;100:19-24.
    Pubmed CrossRef
  2. Yeo CJ, Sohn TA, Cameron JL, Hruban RH, Lillemoe KD, Pitt HA. Periampullary adenocarcinoma: analysis of 5-year survivors. Ann Surg 1998;227:821-831.
    Pubmed KoreaMed CrossRef
  3. Howe JR, Klimstra DS, Moccia RD, Conlon KC, Brennan MF. Factors predictive of survival in ampullary carcinoma. Ann Surg 1998;228:87-94.
    Pubmed KoreaMed CrossRef
  4. Cheng CL, Sherman S, Fogel EL, et al. Endoscopic snare papillectomy for tumors of the duodenal papillae. Gastrointest Endosc 2004;60:757-764.
    Pubmed CrossRef
  5. Hong SS, Han SS, Kwon W, et al. Comparison of oncologic outcomes between transduodenal ampullectomy and pancreatoduodenectomy in ampulla of vater cancer: Korean multicenter study. Cancers (Basel) 2021;13:2038.
    Pubmed KoreaMed CrossRef
  6. Downs-Canner S, Van der Vliet WJ, Thoolen SJ, et al. Robotic surgery for benign duodenal tumors. J Gastrointest Surg 2015;19:306-312.
    Pubmed KoreaMed CrossRef
  7. Ahn KS, Han HS, Yoon YS, Cho JY, Khalikulov K. Laparoscopic transduodenal ampullectomy for benign ampullary tumors. J Laparoendosc Adv Surg Tech A 2010;20:59-63.
    Pubmed CrossRef
  8. Kang I, Hwang HK, Lee WJ, Kang CM. First experience of pancreaticoduodenectomy using Revo-i in a patient with insulinoma. Ann Hepatobiliary Pancreat Surg 2020;24:104-108.
    Pubmed KoreaMed CrossRef
  9. Lim JH, Lee WJ, Choi SH, Kang CM. Cholecystectomy using the Revo-i robotic surgical system from Korea: the first clinical study. Updates Surg 2021;73:1029-1035.
    Pubmed CrossRef
  10. Peters BS, Armijo PR, Krause C, Choudhury SA, Oleynikov D. Review of emerging surgical robotic technology. Surg Endosc 2018;32:1636-1655.
    Pubmed CrossRef

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