The rebirth of pancreas transplantation: an innovative, fully robotic, reproducible surgical technique

Pancreas transplantation remains the only definitive therapy for restoring endogenous insulin secretion and physiologic glycemic control in patients with insulin-dependent diabetes mellitus. Utilization in the United States has declined, however, in part due to morbidity associated with open simultaneous pancreas-kidney transplantation (SPKT), secondary to the incision or bowel manipulation, and procedural concentration within high-volume centers. The dissemination of robotic kidney transplantation has demonstrated the feasibility of minimally invasive transplant surgery and provides a platform to reconsider pancreas transplantation using standardized robotic principles.

We describe a reproducible technique for robotic pancreas transplantation (RPT), applicable to SPKT, pancreas-after-kidney transplantation, and pancreas-transplant-alone. Patient selection follows established criteria with multidisciplinary evaluation and preoperative vascular imaging. The operative workflow includes back-table vascular construction, limited iliac vessel dissection, extraperitoneal graft placement in a head-down orientation on the left iliac fossa, tension-free portal vein anastomosis to the external iliac vein, arterial anastomosis to the external iliac artery, controlled reperfusion, and side-to-side duodeno-ileostomy. Port placement mirrors robotic kidney transplantation to promote procedural standardization.

Early experiences from high-volume centers demonstrate technical feasibility of RPT. Published series report successful implementation without routine need for hand assistance, and institutional experience supports reproducibility. Data remain limited, however, and are not powered to assess comparative outcomes or cost-effectiveness.

A standardized approach to RPT is technically feasible and may reduce the surgical burden associated with open SPKT. While larger multicenter studies are required to define safety, graft outcomes, and economic impact, dissemination of a reproducible operative framework represents an essential first step toward broader adoption.