The current protocol delineates the use of robot-assisted pancreaticobiliary junction resection for the surgical management of benign duodenal tumors. This approach provides an effective solution for treating these tumors while minimizing duodenal loss and reducing associated complications.
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Method Article
Application of Robot-assisted Pancreaticobiliary Junction Resection in Benign Duodenal Tumors
* These authors contributed equally
In This Article
Summary
Abstract
Robot-assisted pancreaticobiliary junction resection is a surgical technique employed to treat benign duodenal tumors. The procedure involves several key steps: making a longitudinal incision in the duodenum, excising the tumor at the pancreaticobiliary junction, inserting a biliary stent, connecting the biliary and duodenal mucosa, and suturing the duodenal incision during phase I. The robotic system enhances visibility, facilitates precise operations, minimizes duodenal traction injuries to the duodenum and surgical trauma, ensures accurate suture and fixation of bile duct stents, connects the bile duct and duodenal mucosa and reduces postoperative recovery time. Given the complexity of the operation and the associated risk of postoperative duodenal fistula, a thorough preoperative evaluation and meticulous perioperative preparation are crucial. Prior to the procedure, a comprehensive assessment was conducted, integrating the patient's medical history, family history, serological tests, and imaging studies. Special emphasis was placed on determining the benign or malignant nature of the tumor and evaluating the status of the duodenal artery blood supply network to ascertain the feasibility and efficacy of the surgery. During the operation, efforts were made to minimize duodenal trauma and avoid compromising the duodenal artery blood supply network. Additionally, the use of bile duct stents was considered essential to prevent biliary strictures, facilitate bile discharge, and mitigate biliary complications. Postoperatively, real-time monitoring of amylase and jaundice indicators in drainage fluid informed the timely removal of drainage tubes in accordance with the enhanced recovery after surgery (ERAS) protocol. Subsequent follow-up indicated a successful recovery, characterized by a notable reduction in preoperative abdominal pain, the absence of long-term complications, and no evidence of tumor recurrence. Consequently, robot-assisted pancreaticobiliary junction resection demonstrates a safe and effective surgical approach for the treatment of benign duodenal tumors.
Introduction
Duodenal tumors are relatively rare, exhibiting a low incidence, and can be classified as benign or malignant. Primary duodenal tumors (PTD) are the most common, while secondary tumors are less frequent1,2. Common benign tumors in the duodenum include adenoma, stromal cell tumor, lipoma, fibroma, and hemangioma, with adenoma being the most prevalent and possessing the potential for malignant transformation3,4,5. The disease typically presents insidiously, with early stages often being asymptomatic or displaying non-specific symptoms such as upper abdominal fullness, dull pain, and discomfort. As the disease progresses, symptoms may include anemia, jaundice, gastrointestinal bleeding, fever, abdominal mass, and intestinal obstruction, thus posing a significant threat to public health6. Surgical resection remains the preferred treatment for benign neoplasms in the duodenum7.
The generalized pancreaticobiliary junction encompasses the pancreatic head, the duodenal wall segment of the common bile duct, the pancreatic segment, the descending part of the duodenum, and the surrounding tissue of the pancreatic head. More specifically, it is defined as the point where the common bile duct terminates, the main pancreatic duct opens, and the area between the duodenal papilla anatomically referred to as the ampulla of Vater or the papilla8. Tumors at this junction can obstruct the outflow of fluids, leading to increased pressure within the ducts, dilation, stasis, and stone formation. Additionally, these tumors can disrupt fluid flow, leading to reflux, inflammation, and further tumor growth9,10. In recent years, laparoscopic biliary and pancreatic surgeries have gained popularity and success due to advancements in minimally invasive techniques. Traditional treatment methods for benign tumors of the duodenal papilla include endoscopic resection, local transduodenal resection, and pancreaticoduodenectomy11,12.
Although laparoscopy has been widely adopted in surgical practice, there have been few reports on the resection of benign duodenal tumors, particularly those involving the duodenal papilla11,13,14. In this study, an innovative treatment method was employed, involving robot-assisted pancreaticobiliary junction resection and duodenal anastomosis following biliary stent implantation. The overall goal of this approach is to restore bile duct patency while excising the tumor, preserving digestive system function, and minimizing the risk of complications. The rationale for this approach lies in its capacity to merge the precision of robotic surgery with the advantages of minimally invasive techniques. This method provides enhanced visualization, increased dexterity, and improved control during complex dissections, especially in delicate anatomical regions such as the pancreaticobiliary junction. By integrating an advanced robotic system, this approach not only facilitates lesion removal but also restores bile duct patency, preserves digestive system functionality, and minimizes complications such as bile leakage, pancreatic leakage, bleeding, and infection, ultimately demonstrating positive clinical outcomes.
CASE PRESENTATION:
This study presents a 66-year-old female patient who was admitted to the hospital due to abdominal pain persisting for over a month. A CT scan revealed a 13 mm x 13 mm mass in the duodenal papillary area, characterized by a distinct boundary (see Figure 1). Preoperative gastroscopy indicated an enlarged duodenal papilla with surface congestion and erosion (see Figure 2A-B). Additionally, ultrasound gastroscopy demonstrated an occupied duodenal papilla measuring approximately 19.1 mm x 15.4 mm, extending to the end of the main pancreatic duct (see Figure 2C-D). Pathological analysis using Hematoxylin and Eosin (HE) staining confirmed the presence of a duodenal papillary villous tubular adenoma (see Figure 3). The patient had no significant medical history, and her physical examination findings and laboratory results were unremarkable.
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Protocol
The operation is routine and has received ethical approval. The research content and methods meet the medical ethics norms and requirements. The Ethics Committee of the Six Affiliated Hospitals of Sun Yat-sen University approved this study. The patient provided written informed consent.
1. Patient selection
- Use the following inclusion criteria: benign duodenal tumors, including adenoma, stromal cell tumor, lipoma, fibroma, and hemangioma.
- Use the following exclusion criteria: malignant tumors of the duodenum, including adenocarcinoma, leiomyosarcoma, malignant lymphoma, carcinoid, etc. Additionally, patients with severe comorbidities such as heart disease and diabetes, coagulation disorders or predispositions to bleeding, severe systemic infections, or a poor overall health status that renders them unsuitable for surgery are excluded. Furthermore, patients who have personally declined the surgical procedure will also be excluded.
2. Preoperative preparation, operative position, and anesthesia
- Ask the patient to adhere to a low-fat, low-salt, and low-sugar diet the day before the surgical operation and to refrain from consuming food or water for at least 8 h prior to the surgery.
- Place the patient in a supine position with the head elevated and slightly tilted to the left.
- Administer general anesthesia using 1%-4% sevoflurane, cyclopofol (10 mg/mL), cisatracurium (2 mg/mL), and sufentanil (5 µg/mL). Perform endotracheal intubation. Evaluate the anesthetic effect based on the patient's post-anesthesia and intraoperative conditions, including the presence of a complete anesthesia block, the absence of additional drugs during the procedure, and the stability of vital signs.
3. Surgical procedure
- Make a vertical incision 1 cm below the navel and insufflate carbon dioxide using a Veress needle into the abdominal cavity to create a pneumoperitoneum. This causes the abdomen to inflate, providing a larger and clearer surgical field, which facilitates the procedure. Then, insert a 10 mm trocar and introduce the laparoscope (the third arm of the robot) after establishing the pneumoperitoneum.
- Explorate the intraperitoneal organs to observe that there were no ascites (identified as fluid visible inside the abdomen) and there were no signs of tumor implantation or metastasis. If there are signs of tumor implantation or metastasis, nodules or lesions will be visible in areas outside the primary tumor site on the camera.
- Place the other three trocars in the following positions: a 10 mm trocar in the right anterior axillary line level (the first arm of the robot), a 10 mm trocar in the medial to the intersection of the umbilical level and the midclavicular line (the second arm of the robot), a 10 mm trocar in the 5 cm above the umbilicus, at the left midclavicular line (the fourth arm of the robot). Additionally, prepare two 12 mm auxiliary ports located on the vertical line at the midpoint between trocars numbered 2 and 3 and medial to the left midclavicular line (see Figure 4).
- Connect to the robot operating lever and perform the laparoscopic operation with the robot's assistance (see Figure 5).
- Mobilize the descending and horizontal parts of the duodenum through a Kocher incision.
- Use an ultrasonic knife to dissect the descending part of the duodenum of about 8 cm (see Figure 6) and identify the duodenal papillary mass.
- Use an ultrasonic knife to incise the duodenal fold and muscle layer with a cut depth of 3-5 mm around the tumor. Fully excise the tumor and freeze the specimens immediately to examine. The results revealed no malignant evidence in the duodenal papillary adenoma.
- Use a 4-0 absorbable line to anastomose discontinuously the incised duodenal fold, muscle layer, and the stump of the confluent part of the biliary pancreatic duct.
- Place the stent tube to support them (see Figure 7). Use 4-0 priline to suture and place the stent into the distal part of the duodenum (see Figure 8).
NOTE: The diameter and length of the stent tube were 2.67 mm and 10 cm, respectively. (see Table of Materials). - Suture intermittently the mucosal layer of the duodenal incision and the plasma muscle layer to bury the wound using 3-0 putis (see Figure 9).
- Rinse the abdominal cavity with saline to check for any bleeding points and place a drain at Winslow foramena and para duodenum, respectively. Finally, use 4-0 silk to suture the incision, and the operation is concluded.
4. Postoperative nursing and monitoring
- Perform ECG monitoring and administer low-flow oxygen post-operation.
- Encourage the patient to consume a semi-liquid diet and engage in bed exercises on the 1st day after surgery.
- Administer anti-inflammatory, hemostatic, analgesic, albumin, and acid suppression treatments.
- Monitor changes in amylase and bilirubin levels in the drainage tube on the 1st, 2nd, 3rd, 5th, 7th, and 9th day post-operation.
NOTE: It is crucial to maintain the patency of the drainage tube and to ensure the early recovery of gastrointestinal function.
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Results
On January 14, 2024, a robot-assisted pancreaticobiliary junction resection was performed at the hospital, followed by biliary stent implantation and anastomosis of the bile duct and duodenum. Postoperative pathology results were consistent with the preoperative findings from other hospitals. Postoperative drainage amylase and bilirubin levels showed a significant decrease (see Table 1), and the patient experienced a smooth recovery following surgery. We have conducted follow-ups for over 6 months post-s...
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Discussion
Duodenal benign tumors are infrequent in clinical practice, yet they can lead to severe complications1,15,16. The choice of treatment depends on factors such as the size, location, and tissue type of the lesion. Given the relatively fixed position of the duodenum, which is often situated posterior to the peritoneum and closely associated with the head of the pancreas and the ampulla of the bile pancreatic duct, intraoperative bl...
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Disclosures
The authors have no conflicts of interest or financial ties to disclose.
Acknowledgements
This work was supported by grants from the Project of Guangdong Clinical Medical Research Center of Digestive Diseases (2020B1111170004), National Key Clinical Discipline, and the program of Guangdong Provincial Clinical Research Center for Digestive Diseases.
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Materials
| Name | Company | Catalog Number | Comments |
|---|---|---|---|
| Abdominal instrument button | Johnson & Johnson | / | / |
| Abdominal instrument cap | Johnson & Johnson | / | / |
| Abdominal instrument collar | Johnson & Johnson | / | / |
| Abdominal instrument connector | Johnson & Johnson | / | / |
| Barbs | Johnson & Johnson | / | / |
| Blade | Johnson & Johnson | / | / |
| Blood pad | Johnson & Johnson | / | / |
| Cloth towel forceps | Johnson & Johnson | / | / |
| Da Vinci robot (IV) | Intuitive Surgical, USA | / | / |
| Disposable drainage tube | Johnson & Johnson | 412280 | 10 cm x 2.67 mm |
| Electric knife head | Johnson & Johnson | / | / |
| Forceps | Johnson & Johnson | / | / |
| Hilt | Johnson & Johnson | / | / |
| Holding flask | Johnson & Johnson | / | / |
| Intestinal forceps | Johnson & Johnson | / | / |
| Laparoscope | Johnson & Johnson | / | / |
| Laparoscopic instruments | Johnson & Johnson | / | / |
| Long curved forceps | Johnson & Johnson | / | / |
| Medium curved forceps | Johnson & Johnson | / | / |
| Needle holders | Johnson & Johnson | / | / |
| Ovoid forceps | Johnson & Johnson | / | / |
| Paraffin oil | Johnson & Johnson | / | / |
| Purse string forceps | Johnson & Johnson | / | / |
| Right angled forceps | Johnson & Johnson | / | / |
| Right angled forceps | Johnson & Johnson | / | / |
| Scissors | Johnson & Johnson | / | / |
| Siphonhead | Johnson & Johnson | / | / |
| Small cup | Johnson & Johnson | / | / |
| Small curved forceps | Johnson & Johnson | / | / |
| Sonotome keyhole | Johnson & Johnson | / | / |
| Steel ruler | Johnson & Johnson | / | / |
| Straight forceps | Johnson & Johnson | / | / |
| Suction needle plate | Johnson & Johnson | / | / |
| Suture needle | Johnson & Johnson | Vcp397H | / |
| Syringe | Johnson & Johnson | / | / |
| Syringe needle | Johnson & Johnson | / | / |
| Tissue forceps | Johnson & Johnson | / | / |
| Trocar(XCEL) | Ethicon Endo-Surgery | 695C71 | / |
| Ultrasonic knife spacers | Johnson & Johnson | / | / |
| Ultrasound knife | Johnson & Johnson | / | / |
| Yarn ball | Johnson & Johnson | / | / |
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