We present our operative approach to robot assisted distal pancreatectomy, splenectomy, and celiac axis resection (DP-CAR), demonstrating that the procedure is safe and feasible with proper planning, patient selection, and surgeon experience.
Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), relying on collateral flow to the liver through the gastroduodenal artery (GDA). In the current manuscript, the technical conduct of robotic DP-CAR is outlined. The greater curve of the stomach is mobilized with care to avoid sacrificing the gastroepiploic vessels. The stomach and liver are retracted cephalad to facilitate dissection of the porta hepatis. The hepatic artery (HA) is dissected and encircled with a vessel loop. The gastroduodenal artery (GDA) is carefully preserved. The common HA is clamped and triphasic flow in the proper HA via the GDA is confirmed using intra-operative ultrasound. A retropancreatic tunnel is made over the superior mesenteric vein (SMV). The pancreas is divided with an endovascular stapler at the neck. The inferior mesenteric vein (IMV) and splenic vein are ligated. The HA is stapled proximal to the GDA. The entire specimen is retracted laterally with further dissection cephalad to expose the superior mesenteric artery (SMA). The SMA is then traced back to the aorta. The dissection continues cephalad along the aorta with the bipolar energy device used to divide the crural fibers and celiac nerve plexus. The specimen is mobilized from the patient’s right to left until the origin of the celiac axis is identified and oriented towards the left. The trunk is circumferentially dissected and stapled. Additional dissection with hook cautery and the bipolar energy device fully mobilizes the pancreatic tail and spleen. The specimen is removed from the left lower quadrant extraction site and one drain is left in the resection bed. A final intra-operative ultrasound of the proper HA confirms pulsatile, triphasic flow in the artery and liver parenchyma. The stomach is inspected for evidence of ischemia. Robotic DP-CAR is safe, feasible and when used in conjunction with multi-modality therapy, offers potential for long-term survival in selected patients.
Pancreatic cancers involving the body and tail of the pancreas are traditionally surgically managed with a distal pancreatectomy and splenectomy. Approximately 30% of pancreatic cancers present in a locally advanced stage with involvement of structures beyond the pancreas1. A subset of these patients present with involvement of the celiac axis or proximal hepatic artery without involvement of the aorta. In this circumstance, an aggressive pre-operative strategy involving neo-adjuvant chemotherapy of FOLFIRINOX2,3 or Gemcitabine-Abraxane4 with potential neoadjuvant radiation prior to surgical resection with a modified version of the original Appleby procedure is considered5. The procedure involves resecting the celiac axis at its origin and relying on collateral flow to hepatic artery proper through the GDA. While this aggressive approach for locally advanced pancreatic cancer is performed only in highly selected patients, there is suggestion of potential oncologic benefit in retrospective series6,7,8.
The robotic surgical platform offers numerous technical advantages compared with open and laparoscopic techniques, including enhanced three-dimensional visualization, instrument wrist articulation and the ability for the operating surgeon to control multiple instruments and the camera. Additionally, limited retrospective case series of patients undergoing robotic pancreatic surgery have suggested decreased intra-operative blood loss, decreased peri-operative pain, lower pancreatic fistula rates and improved recovery when compared with open pancreatic resections9,10,11,12,13,14. These technical and clinical benefits along with increased robotic training have led to an expansion of the robotic approach in pancreatic surgery, demonstrating the versatility of the platform to perform a variety of pancreatic resections and procedures, including pancreaticoduodenectomy and distal pancreatectomy with and without splenic preservation. Herein, we will provide the pre-surgical and surgical evaluation and decision making that is involved in proper selection of patients as well as detail the patient characteristics, pre-operative management, and a detailed review of the surgical technique of the DP-CAR performed with the robotic platform on a singular patient in our practice.
All aspects of this protocol fall within our institutions ethical guidelines of the human research ethics committee
1. Pre-operative planning
2. Initial Operative Steps: Diagnostic Laparoscopy and Robot Docking
3. Robot-Assisted Dissection
The duration of the procedure was 228 minutes with a blood loss of 50 mL. Post-treatment final pathology revealed a moderately differentiated (G2) ypT1c ductal adenocarcinoma. No nodal involvement was noted (0/21 total nodes). The circumferential resection margin was negative. The patient's post-operative course was uncomplicated. Her drain amylase levels post-operatively were in the normal range and the drain was removed on post-operative day 3. She was discharged home on post-operative day 4 tolerating a regular diet. Her follow appointments in clinic demonstrated that her recovery was progressing well.
Figure 1: Pre-treatment CT imaging demonstrating locally advanced body of pancreas mass involving celiac axis and splenic vein. Please click here to view a larger version of this figure.
Figure 2: Post-treatment CT imaging demonstrating locally advanced body of pancreas mass involving celiac axis and splenic vein with persistent soft tissue infiltration surrounding celiac cells. Please click here to view a larger version of this figure.
Figure 3: Opening of lesser sac and mobilization of greater curve. Short gastric vessels are ligated with care taken to preserve gastroepiploic vessels. Please click here to view a larger version of this figure.
Figure 4: Dissection of porta hepatis with identification of common and proper hepatic artery and gastroduodenal artery with triphasic ultrasound signal. Please click here to view a larger version of this figure.
Figure 5: Dissection of inferior border of pancreas with identification of superior mesenteric vein and creation of retropancreatic tunnel overlying vein. Please click here to view a larger version of this figure.
Figure 6: Final identification of arterial Following division landmarks and adequate flow prior to ligation of common hepatic artery. Please click here to view a larger version of this figure.
Figure 7: Following division of pancreas, the superior mesenteric artery is exposed and dissection proceeds cephalad to its root on the aorta. Please click here to view a larger version of this figure.
Figure 8: Celiac axis origin exposed and oriented to patient left by laterally retracting the specimen prior to division. Please click here to view a larger version of this figure.
Figure 9: Final resection bed anatomy highlight. Please click here to view a larger version of this figure.
With proper pre-operative planning, patient selection, and surgeon experience, it is clinically feasible and safe to approach locally advanced pancreatic tumors of the body/tail of the pancreas with celiac involvement with robot assisted distal pancreatectomy, splenectomy, and celiac axis resection. Proper patient selection requires comprehensive pre-operative planning with cross-sectional imaging to identify the tumor and its anatomical relationship to surrounding vascular structures. At this time, it is also imperative to identify any anomalous arterial or venous circulation that would imperil the attempted resection or make it infeasible.
Intra-operative findings may also shift our treatment approach in real time. Findings suggesting the continued involvement of the celiac root at the time of surgery would make resection infeasible. Therefore, high quality post-treatment imaging prior to surgery is also critically important to evaluate the degree of treatment response. Additionally, findings on inadequate retrograde arterial flow through the gastroduodenal artery to the proper hepatic artery or liver may require an arterial reconstruction, and pre-operative preparedness for this reconstruction is imperative. After resection, gastric ischemia or congestion due to division of major vascular structures is a potential and morbid sequela. However, despite division of the short gastric vessels and left gastric artery, the gastroepiploic circulation remains unviolated in the course of this dissection. These vessels are often adequate to ensure adequate perfusion of the stomach and therefore gastrectomy can be avoided. However, the stomach must be observed closely for ischemic changes prior to conclusion of this procedure.
The traditional operative approach to management of tumors involving the body and tail of the pancreas is a distal pancreatectomy. However, more recently, radical antegrade pancreaticosplenectomy (RAMPS) has been proposed as an alternative procedure that is increasingly utilized and has been suggested to offer an increased rate of negative tangential margins15. Despite these promising results, no large prospective studies yet exist that show a demonstrable improvement in overall survival or recurrence free survival when compared with traditional distal pancreatectomy. Additional prospective studies are needed to establish clear clinical guidelines for routine use of RAMPS during distal pancreactomy16.
The robot platform has seen ever increasing use in a variety of complex pancreatic resections. This protocol and video highlights one potential operative approach utilizing this platform for approaching a clinically challenging disease process.
The authors have nothing to disclose.
Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health under award number 5U54GM104942-04 (BAB).
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Da Vinci Robotic Platform XI | Intuitive Surgical | ||
Lightworks Video Editer | Lightworks | ||
Studio 3 Video logging platform | Stryker |