Robotic Duodenum-preserving Total Pancreatic Head Resection for Intraductal Papillary Mucinous Neoplasms

Summary

This protocol presents robotic duodenum-preserving total pancreatic head resection (R-DPPHRt) for intraductal papillary mucinous neoplasms (IPMNs). A video demonstrates the technique in a patient with main duct-IPMN, highlighting its feasibility as a minimally invasive, organ-preserving alternative to pancreaticoduodenectomy.

Abstract

Robotic duodenum-preserving pancreatic head resection (R-DPPHR) is a technically feasible procedure for benign or borderline tumors of the pancreatic head. Among these, pancreatic cystic neoplasms (PCNs), particularly intraductal papillary mucinous neoplasms (IPMNs), are ideal candidates for this minimally invasive, organ-preserving approach. While numerous studies have demonstrated the short- and long-term advantages of DPPHR over conventional pancreaticoduodenectomy (PD), detailed video descriptions of the robotic-assisted procedure are scarce. This case report presents a step-by-step technical video of R-DPPHRt for a main duct-IPMN (MD-IPMN) in the pancreatic head. A 65-year-old male patient with upper abdominal discomfort was diagnosed with MD-IPMN, presenting as a 4.3 cm cystic-solid mass in the pancreatic head. R-DPPHRt was performed using the da Vinci Xi system, with an operation time of 350 minutes and an estimated blood loss of 150 mL. The patient had an uneventful postoperative course and was discharged on postoperative day 9. Pathology confirmed MD-IPMN with low-grade dysplasia. R-DPPHRt is an effective, function-preserving treatment for selected patients with pancreatic cystic neoplasms, particularly when performed by experienced surgeons in high-volume centers. While this single-case report limits generalizability, the article offers unique value by providing a clear procedural template.

Introduction

Duodenum-preserving pancreatic head resection (DPPHR) was first reported by Beger and colleagues in 1972 to treat chronic pancreatitis¹. To treat benign or low-grade malignant tumors of the pancreatic head, a more extensive procedure known as duodenum-preserving total pancreatic head resection (DPPHRt) was developed in 1988². This technique provides an alternative to conventional pancreaticoduodenectomy (PD) and may include segmental resection of the duodenum and common bile duct when necessary³.

Intraductal papillary mucinous neoplasm (IPMN) is a major subtype of pancreatic cystic neoplasms (PCNs) and is widely recognized as a precursor lesion to pancreatic cancer. Surgical resection remains one of the primary treatment strategies for IPMNs, with current guidelines recommending intervention based on the presence of high-risk stigmata or worrisome features⁴. However, for benign or low-grade malignant lesions restricted to the pancreatic head, with a diameter of no more than 5 cm, especially in patients under 70 years old, the optimal surgical procedure remains uncertain.

The advantages of DPPHR over conventional PD are evident not only in reduced early postoperative complications, but also in better long-term quality of life (QoL)^3,5,6,7. For long-term function, DPPHR has advantages over PD in terms of a lower incidence of metabolic dysfunctions^7,8. With the advancement of minimally invasive surgery, robotic surgical systems are increasingly adopted due to their enhanced dexterity, tremor filtration, high-definition visualization, reduced intraoperative bleeding, and faster postoperative recovery⁹. As indicated by recent research, robotic DPPHR (R-DPPHR) has strengths in conserving both exocrine and endocrine pancreatic functions, with the aid of intraoperative indocyanine green (ICG) fluorescence imaging^10,11.

In this report, we present a case of a 65-year-old male patient diagnosed with a main duct IPMN (MD-IPMN) of the pancreatic head. The patient underwent successful R-DPPHRt. This report aims to illustrate the feasibility and clinical advantages of R-DPPHRt in the management of pancreatic head IPMN, and to explore its potential indications in patients with benign or borderline tumors in the pancreatic head. Robotic duodenum-preserving total pancreatic head resection offers an organ-preserving alternative to pancreaticoduodenectomy, particularly for selected patients with IPMNs.

Protocol

The present protocol received approval from the Institutional Review Board of Peking Union Medical College Hospital (approval no: I-23ZM0030). Written informed consent was obtained from the patient for the publication of this case and the video.

1. Patient selection

1. Set the following inclusion criteria: IPMNs located in the pancreatic head; age younger than 70 years old; radiological findings indicating benign or low malignancy potential; maximum diameter < 5 cm.
2. Set the following exclusion criteria: Abrupt change in caliber of pancreatic duct with distal atrophy; elevation of serum tumor marker (especially CA19-9) levels; regional lymph node enlargement; malignancy confirmed by cytology; dilation of the entire pancreatic duct; involving the duodenum, with none/few of pancreatic parenchyma remaining; recurrence of IPMNs.

2. Surgical technique

1. Operative setting
   1. Position the anesthetized patient on the operating table compatible with the da Vinci robotic system in a supine 15° reverse Trendelenburg position, with 5° right-sided elevation and the legs abducted.
   2. Use povidone-iodine to finish sterile exposition; create a sufficient region for specimen extraction.
   3. After the pneumoperitoneum is created, follow the five-port technique to settle the trocars (Figure 1).
2. Exploration phase
   1. Thoroughly scan the intraperitoneal organs and peritoneal surfaces to identify any unexpected metastases.
   2. Equip the arm 3 with a laparoscope, then aim the laparoscope at the mid-right part of the hepatogastric ligament, fix the laparoscope port, and press the docking button to allow the other three robotic arms to dock according to the predefined procedure of the da Vinci robotic system. Equip arm 1 with cadiere forceps, arm 2 with bipolar forceps, and arm 4 with ultrasonic scalpel after docking.
   3. Elevate the greater omentum, incise the gastrocolic ligament inferior to the gastroepiploic vessels to open the lesser sac, and mobilize the stomach and pancreas.
   4. Re-evaluate the specific surgical procedure after the pancreatic head and uncinate process are fully exposed.
      NOTE: Confirm the suitability of DPPHRt or PD after gaining access to the lesser sac. Proceed with DPPHRt only if the tumor shows no significant malignant features and is confined to the pancreatic head.
3. Dissection phase
   1. Kocher maneuver: Mobilize the duodenum by incising along the lateral peritoneal reflection and dissecting through the anterior fascia of the right kidney, the second portion of the duodenum, and the posterior aspect of the pancreatic head.
      NOTE: Arm 1 retracts the entire stomach and small bowel to the patient's left; use arm 4 equipped with an ultrasonic scalpel to dissect instead of blunt dissection to prevent bleeding.
   2. SMV branches: Dissect along the inferior border of the pancreas to find SMV branches. Identify the trunk of Henle (gastrocolic trunk) along the SMV tributaries, and expose the superior mesenteric vein-portal vein axis (SMV-PV axis).
   3. Dissect the plane between the SMV-PV axis and the pancreatic neck. Dissect and divide the right gastroepiploic vein (RGEV).
   4. Dissect the hepatoduodenal ligament cranially to expose the common hepatic artery (CHA) and perform lymphadenectomy of the lymph node group 8.
   5. Assess the extent of resection based on the preoperative imaging results. Mark the area and transect the pancreas anterior to the PV.
   6. Resect the main pancreatic duct (MPD) at the pancreatic stump and perform intraoperative frozen section pathology.
      NOTE: Avoid using electrocautery instruments when handling the MPD to prevent damage to the ductal epithelium.
   7. Pass a vascular retraction tape behind the SMV. Pull the tape to elevate the SMV and expose the anterior-right border of the SMA and gastroduodenal artery (GDA) for dissection.
   8. Dissect along the right border of SMV and SMA, expose and shut down the branches entering the tumor from the inferior pancreaticoduodenal artery (IPDA).
      NOTE: If intraoperative vascular injury to the trunk of IPDA or GDA occurs during the procedure, use 5-0 Prolene vascular suture to fix the lesions.
   9. Preserve the anterior inferior pancreaticoduodenal artery (AIPDA) and posterior inferior pancreaticoduodenal artery (PIPDA).
      NOTE: Preserve the inferior pancreatic duodenal arterial arcade by dissecting the subcapsular pancreatic head parenchyma. Avoid intraoperative injury to the arterial arcade coursing through pancreatic parenchyma or mixed with yellow adipose tissue.
   10. Dissect distally along the gastroduodenal artery (GDA) to identify and suture-ligate tumor-feeding branches , including those arising from the anterior superior pancreaticoduodenal artery (ASPDA). Sacrifice the ASPDA if required to achieve adequate clearance.
       NOTE: Suture-ligate branches derived from IPDA or GDA as tumor-feeding vessels during dissection.Use electrosurgical instruments cautiously for hemostasis to avoid uncontrollable intraoperative bleeding.
   11. Preserve the branches of the posterior superior pancreaticoduodenal artery (PSPDA) supplying the duodenum maximally. Separate the cystic-solid tumor along the upper border of the pancreas.
       NOTE: Dissect along the GDA to expose the PSPDA, preserving its branches that feed the common bile duct (CBD) and duodenum.
   12. Activate the fluorescence lens to visualize the course of the common bile duct (CBD) using indocyanine green (ICG) during steps 2.3.8 to 2.3.11. Reassess the anatomy of the CBD as needed to prevent injury. Resect the pancreatic head parenchyma nearly completely along the CBD.
       NOTE: Due to the half-life of ICG and its hepatic metabolism, inject ICG intravenously 30 min before imaging to achieve optimal visualization of the bile duct. Do not administer ICG in patients with a known allergy. Omit fluorescence imaging in such cases.
   13. Expose the MPD on the lateral wall of the duodenum. Resect the margin for intraoperative frozen section pathology. Ligate the stump of the MPD.
       NOTE: Confirm that both the pancreatic duct margin at the stump and the lateral duodenal wall margin are negative. Proceed to radical resection (PD) if either margin is positive.
   14. Resect the pancreatic head and uncinate process containing the lesion completely. Remove the surgical specimen inside a retrieval bag, following the oncologic no-touch principle.
   15. Irrigate and clean the surgical field. Confirm that the vascular arcade of the posterior branch of the pancreatoduodenal artery is intact and that the blood supply to the duodenum is adequate (Figure 2).
   16. Reinforce the vascular stumps with sutures before proceeding with gastrointestinal reconstruction.
4. Reconstruction phase
   1. Incise the ligament of Treitz. Transect the jejunum 20 cm from the ligament of Treitz using a linear cutter stapler.
   2. Dissect a vessel-free area in the transverse mesocolon. Lift the distal jejunum posterior to the colon through the opening in the mesocolon.
   3. Tunnel the jejunal limb from the ventral to the dorsal aspect of the pancreas and anchor it to the seromuscular layer using 3-0 barbed sutures.
   4. Create a full-thickness opening in the jejunum using arm 4 equipped with monopolar scissors. Insert a 2 x 4 mm internal stent into the main pancreatic duct (MPD). Perform a duct-to-mucosa anastomosis using interrupted 5-0 PDS sutures.
   5. Suture the ventral seromuscular layer of the jejunum to the ventral side of the pancreas and complete the knotting with the dorsal side suture.
      NOTE: Based on our previous publication¹², barbed sutures are feasible for pancreaticojejunostomy during minimally invasive pancreatic surgery and may reduce rates of clinically relevant postoperative pancreatic fistula (CR-POPF) and severe complications.
   6. Perform a side-to-side enterostomy using an electric cutting stapler 40 cm distal to the prior anastomosis. Close the common enterotomy with 3-0 barbed sutures. Close the mesenteric defect.
   7. Reconfirm the duodenal vascular supply is adequate. Place two drains near the anastomosis and pancreatic stump through robot trocars 1 and 4.
   8. Complete the procedure and close the incisions according to standard robotic surgical technique.

Results

A 65-year-old male presented with upper abdominal discomfort that worsened after meals. A 3.0 cm x 1.6 cm cystic-solid lesion in the pancreatic head was identified by contrast-enhanced CT and endoscopic ultrasound (EUS). The patient initially opted for surveillance. During follow-up, the lesion enlarged rapidly to 4.3 cm x 1.9 cm and developed an enhancing mural nodule (Figure 3). He had a seven-year history of diabetes and a normal body mass index (19.9 kg/m²). No evidence of distant metast...

Discussion

This case illustrates the use of DPPHRt as a preferable alternative to PD for selected PCNs located in the pancreatic head. The dissection and preservation of the pancreaticoduodenal vascular arcades are key to the success of the procedure. R-DPPHRt combines the advantages of robot-assisted minimally invasive surgery with the benefits of an organ-preserving surgical procedure. With the assistance of the robotic system, surgeons have a clearer view and more operational angles when dealing with the complex anatomical struc...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Sutures:
Internal pancreatic duct stent, 2 × 4 mm
PDS, RB-2, 75 cm, 5-0; Z148: taper point. ½ circle 13 mm	Ethicon	Z148
Prolene, RB-1, 90 cm, 5-0; round bodied. ½ circle 17 mm	Ethicon	W8556
Stratafix, 20 cm, 3-0; MOD12: taper point, ½ circle 26 mm	Ethicon	MOD 12
Instruments robot:
Cadiere forceps	Intuitive Fosun	470049
Endoscope with camera, 8 mm, 30°	Intuitive Fosun	470027
Fenestrated bipolar forceps	Intuitive Fosun	470205
Harmonic ACE curved shears	Intuitive Fosun	480275
Monopolar curved scissors (Hot shears)	Intuitive Fosun	470179
Permanent cautery hook	Intuitive Fosun	470183
Other:
Echelon Flex 60 mm Stapler	Ethicon	PSEE60A
Hem-o-lok Clips ML	Weck Surgical Instuments	544230
Hem-o-lok Clips L	Weck Surgical Instuments	544240
Hem-o-lok Clip applier ML	Weck Surgical Instuments	544965
Hem-o-lok Clip applier L	Weck Surgical Instuments	544990
TKBAG 130 mm retrieval bag	G T.K Medical	HSD130
White filling 60 mm	Ethicon	GCFLGW