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Main text History of pancreatic surgery Pancreatic surgery as we know it developed at the end of the nineteenth century. At that time, surgery for patients with obstructive jaundice was limited by coagulopathy, and palliative biliary bypass was developed to relieve obstruction caused by pancreatic malignancies [2]. These palliative by- passes originated in Russia and Switzerland, followed by Roux ’ s development of the Roux-en-Y bypass using a seg- ment of intestine near the turn of the century. The next landmark in pancreatic surgery was the distal pancreatic re- section. This portion of the gland was approached first be- cause patients with these lesions were not jaundiced and there was less concern for coagulopathy. In the early part of the twentieth century there were a number of surgeons who attempted and completed a variety of pancreatic resections but there was as yet no standardized approach to this organ. Surgeons per- formed isolated resection of carcinomas of the ampulla of Vater. Halstead did this in 1898 (a trans-duodenal ap- proach), and through World War I there were three more isolated case reports of similar resections. Until about 1930, these four isolated cases represented the scope of surgery for malignancies in this region. This was indeed a rich era in surgical history, and the inter- ested reader is invited to review the references used here and the references contained therein to obtain a detailed history of these procedures. Surgery for malignant lesions of the pancreas The modern era of pancreatic resections for malignan- cies started in 1933 when Dr. Allen Oldfather Whipple, Chairman of the Department of Surgery at Columbia University College of Physicians and Surgeons (New York NY) invited Dr. Hap Mullins, a resident in the de- partment, to develop the surgical technique for pancrea- toduodenectomy (PD), known in the United States as the Whipple Operation, and in Japan as “ PD ” . After spending time in the laboratory, they performed a two-stage ampullary resection. Unfortunately, the patient died, possibly due to the use of catgut sutures in the pancreatic anastomosis. Whipple and Mullins persisted, changed the sutures to silk, and the second and third pa- tients survived the surgery [2]. The pancreatic duct was ligated in these operations. Whipple ’ s first one stage re- section was actually performed because of an error in the preoperative diagnosis [3]. During his career, Whip- ple performed the operation 37 times, with a mortality rate of about 33%. Pyloric preservation was introduced in 1968 by Longmire and Traverso, but the basic princi- ples of the operation have not changed since its intro- duction by Whipple [2]. While some surgeons have attempted to modify the operation by performing more extensive resections such as total pancreatectomy, it is not clear that these operations resulted any survival ad- vantages. Perioperative mortality rates changed little until the late twentieth century. One of the major developments in the history of pan- creatic surgery is the concept of Centers of Excellence, which routinely report postoperative mortality rates of < 2% [2]. One of the leading forces behind this change in practice originated at Johns Hopkins Medical Center in Baltimore MD under the leadership of Dr. John L. Cam- eron. By centralizing pancreatic resections in Maryland, it was shown that for every 1% increase in market share of PDs, in-hospital mortality decreased by 5% [3]. An impressive growth in case volume from 1970 to 2006 was associated with a reduction in mortality from 30 to 1%. This remarkable change was due to many contribut- ing factors that came together to result in greatly im- proved patient outcomes. Minimally invasive surgery As we trace the history of robotic surgery for malignant lesions of the pancreas, the next major historical mile- stone is the remarkable growth of laparoscopic surgery, which is one type of minimally invasive surgery. While it became popular among general surgeons starting in 1989, laparoscopic surgery had a long history by that time but was somewhat limited, being performed mostly by gyne- cologists. In the late 1980s, there was growing interest in the use of right upper quadrant mini-laparotomies for cholecystectomy. Mouret performed the first laparoscopic cholecystectomy in 1987, in France [4]. The operation was soon performed in the United States and the interest that exploded in this procedure was mirrored by the activity in the display area of the Clinical Congress of the American College of Surgeons in October 1989. The majority of these early procedures were performed at non-University medical centers, and only later did this approach become common at universities. One of the first laparoscopic cholecystectomies performed at a University medical cen- ter in the United States was at the University of Maryland Medical Center (also the origin of the widely used “ Mary- land Dissector ” ) in November 1989 by Karl Zucker, Robert Bailey and John “ Jack ” Flowers. Early critics of the procedure suggested that it should be performed at specialized centers [5]. This was a true revolution in General Surgery and became unstoppable. One of the unique features of this revolution is that it did not start in academic laboratories. There was very little data to support or justify its use and the procedure rapidly spread throughout the world [5]. The financial benefits to the entire healthcare economy fueled the rapid growth of this entire field. Patients everywhere demanded that their operations were performed laparo- scopically. The tools to perform the procedure were fairly new in 1987, especially the video-laparoscope and Lefor BMC Biomedical Engineering (2019) 1:2 Page 2 of 15 | The Surgical Technologist | JULY 2021 304