Application of End-to-end Anastomosis in Robotic Central Pancreatectomy

Summary

The robotic central pancreatectomy with end-to-end anastomosis is feasible and safe for tumor in the pancreatic neck and proximal portion of pancreatic body. The operative techniques of this operation are presented.

Abstract

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of pancreatic body. With technological development, the robotic surgical system has shown its advantage in minimally invasive surgery and been increasingly applied in central pancreatectomy. However, reconstruction of the continuity of pancreas with end-to-end anastomosis after robotic central pancreatectomy has not been applied. In this study, we report surgical techniques for robotic central pancreatectomy with end-to-end anastomosis. The pancreas is reconstructed by duct-to-duct anastomosis of the pancreatic duct with a pancreatic stent inserted in the two stumps of pancreatic duct, and by end-to-end anastomosis of the pancreatic parenchyma. Compared with traditional central pancreatectomy with pancreaticoenteric anastomosis, this approach decreases the operative injury to the patient, and also conserves the integrity and continuity of the digestive duct and pancreatic duct. The robotic surgical system integrated with multiple instruments with flexible and precise movement is particularly suitable for the dissection and reconstruction of the pancreatic duct. We found that robotic central pancreatectomy with end-to-end anastomosis is safe and feasible, and we need more experience to evaluate its best indications and long-term outcomes.

Introduction

Central pancreatectomy is increasingly performed for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of pancreatic body¹. Compared with the pancreaticoduodenectomy or distal pancreatectomy, central pancreatectomy resects less tissues and conserves more pancreatic parenchyma and function. Currently, the major approaches for the pancreas reconstruction are over-sewing the cephalic pancreatic stump and performing a pancreaticojejunostomy or pancreaticogastrostomy to the distal stump^2,3. These two approaches are widely used in the op....

Protocol

Written informed consent was obtained from the patient for the publication of this report and any accompanying videos and images.

1. Preoperative Preparation

1. Carefully evaluate the preoperative images of CT or MRI for the exact location of the tumor and its relation to the surrounding tissues.
2. Give the patient a soft diet one day before the operation and begin fasting at midnight before the operation.
3. Place the patient on the operating table. Then, place a peripheral venous catheter and induce general anesthesia using standard procedures. Introduce a central venous catheter through the right internal jugular ....

Results

The operation process was smooth. The operative time was 141 mins and the intraoperative blood loss was about 50 mL. The size of the resected pancreas was about 5.5 × 2.5 × 2.5 cm (Figure 4). The patient recovered smoothly after surgery and discharged on the 6^th postoperative day. When the patient was discharged, he had a normal diet and normal defecation, and had no fever, no abdominal pain or distension. The routine blood examination and blood bi.......

Discussion

Malignant tumors located in the pancreas neck and the proximal part of the pancreatic body are often treated with pancreaticoduodenectomy or distal pancreatectomy. However, for benign or low malignant potential tumors in those sites, the standard pancreaticoduodenectomy or distal pancreatectomy will remove excessive normal tissues and result in excessive injury. Therefore, the central pancreatectomy or pancreatic enucleation, known as "parenchyma-sparing pancreatectomy", becomes a preferable choice for the treatm.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
da Vinci Robotic Surgical System	Intuitive Surgical, USA	Si
EndoWrist Permanent Cautery Hook	Intuitive Surgical, USA	420183
Harmonic Ace Curved Shears	Ethicon, USA	420275
EndoWrist Large needle Driver	Intuitive Surgical, USA	420006
EndoWrist Cadiere Forceps	Intuitive Surgical, USA	420049
EndoWrist Black Diamond Micro Forceps	Intuitive Surgical, USA	420033
Lapro-Clip 8 mm Absorbable Clips	Covidien  , USA	8886848882
5-0 non-absorbable suture	Ethicon, USA	M8717
4-0 non-absorbable suture	Ethicon, USA	D9775
5-0 absorbable suture	Ethicon, USA	D9943
Absorbable hemostas	Ethicon, USA	W1912
Laparoscopic Ultrasound Probe	BK Ultrasound, Denmark	8666-RF	transducer contact surface: 30*5mm; Frequence: 4.3-10 MHz
Pancreatic stent	Yaxin Medical, Suzhou, China	1.2 mm
Antibiotics (ceftriaxone sodium for injection)	Roche, Shanghai, China	H10983036	ceftriaxone sodium (2g) adding to normal saline (100ml), once per day.
Proton pump inhibitors (lansoprazole injection)	Luoxin Pharmaceutical, Linyi, China	H20055118	lansoprazole injection (30 mg) adding to normal saline (100ml), twice per day.
Somatostatin (Somatostatin for injection)	Merck Serono, Germany	H20090929	Somatostatin for injection (6000ug) adding to nornal saline to a total of 48ml, 2 ml/h
Analgesic
Analgesic (sufentanil Citrate injection)	Humanwell Healthcare, Fuzhou, China	H20054171	sufentanil Citrate (200ug),  Ondansetron hyrochloride (20mg), adding to normal saline to a total of 80 ml, 1 ml/h
Analgesic (Ondansetron hyrochloride injection)	Qilu Pharmaceutical, Hainan, China	H10970065	sufentanil Citrate (200ug),  Ondansetron hyrochloride (20mg), adding to normal saline to a total of 80 ml, 2 ml/h
Parenteral nutrition
Parenteral nutrition(Compond vitamin injection)	Pude Pharmaceutical, Datong, China	H20093720	1 piece
Parenteral nutrition(Compond amino acid injection)	Kelun Pharmaceutical, Chengdu, China	H20066058	500 ml
Parenteral nutritionz(Fat emulsion injection)	Fresenius Kabi AB, Sweden	H20160019	250 ml
Parenteral nutrition(10%KCl injection)	Jinyao Pharmaceutical, Tianjin, China	H12020518	50 ml
Parenteral nutrition(10%NaCl injection)	CR, Double-Crane, Beijing, China	H11020865	50 ml
Parenteral nutrition(Insulin injection)	No.1 biochemical and pharmaceutical, Shanghai, China	H31020519	28 Unit