Robot Strong Procedure for Superior Mesenteric Artery (Wilkie) Syndrome

Summary

This protocol demonstrates the key technical steps of a Robot Strong procedure in a patient suspected of superior mesenteric artery (SMA) syndrome, also known as Wilkie syndrome.

Abstract

Superior mesenteric artery (SMA) syndrome is a rare cause of proximal intestinal obstruction resulting from compression of the third portion of the duodenum between the aorta and the superior mesenteric artery. The Strong procedure offers a physiological alternative to duodenojejunostomy by performing full duodenal mobilization, thereby omitting the need for an intestinal bypass (e.g., duodenojejunostomy). We present the case of a woman with chronic postprandial abdominal pain, nausea, and bloating, refractory to conservative management. When the patient positioned herself in a left lateral fetal position, the complaints resolved. Preoperative imaging demonstrated a reduced SMA-aorta distance (8.1 mm) with a normal aortomesenteric angle (52.1°), as well as signs of duodenal stasis, all potentially consistent with SMA syndrome. The patient underwent a Robot Strong procedure consisting of division of the ligament of Treitz and full duodenal mobilization, including Kocherization. The postoperative course was uneventful. At 6 weeks of follow-up, symptoms were resolved completely, with improved oral intake. At imaging follow-up, the duodenum was placed more caudally, fitting with the expected outcome. These findings confirm the feasibility and clinical effectiveness of the Robot Strong procedure in highly selected patients with SMA syndrome.

Introduction

Superior mesenteric artery (SMA) syndrome, also known as Wilkie syndrome, is a rare cause of proximal intestinal obstruction resulting from compression of the third portion of the duodenum between the aorta and the superior mesenteric artery^1,2. It is typically associated with a reduced aortomesenteric distance (<10 mm) and angle (<25°), often related to significant weight loss or anatomical predisposition³.

Patients usually present with postprandial abdominal pain, early satiety, nausea, and weight loss, frequently leading to delayed diagnosis d....

Protocol

The procedure was performed in accordance with the principles of the Declaration of Helsinki and the guidelines of the institutional human research ethics committee. The patient provided both written and oral informed consent for the use of her medical data and surgical video for educational and scientific purposes.

1. Setup

NOTE: The procedure is performed by two surgeons: a console surgeon and a tableside surgeon, who is positioned between the patient’s legs, allowing comfortable and close access to the surgical field.

1. Positioning
   1. Place the patient in the supine Fr....

Results

The operative time was 70 min, with negligible intraoperative blood loss. No intraoperative complications occurred. The postoperative course was uneventful, and the patient was discharged on postoperative day 3 in good clinical condition.

At the 6-week follow-up, the patient reported near complete resolution of postprandial abdominal pain. Oral intake significantly improved, allowing the patient to tolerate larger meal portions without discomfort. Occasional mild abdominal bloating was still r.......

Discussion

The SMA syndrome, also known as Wilkie syndrome, cast syndrome, or chronic duodenal ileus⁹, remains a rare and often underdiagnosed condition due to the nonspecific nature of its clinical presentation and the variability of radiological findings^1,4. In the present case, although the aortomesenteric angle was within normal limits, the reduced aortomesenteric distance and the patient’s symptoms were highly suggestive of SMA syndrome

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Assistant trocars	Applied	CTF73	L1 assistant port (https://pdf.medicalexpo.it/viewerCatalog-en/applied-medical/kii/74928-152615-_2.html#open)
Bipolar Forceps	Intuitive Surgical	470172	Robotic instrument R4 (https://www.intuitive.com/en-us/-/media/ISI/Intuitive/Pdf/da-vinci-x-xi-instruments-accessories-catalog.pdf)
Cadiere Forceps	Intuitive Surgical	471049	Robotic instrument R1 (https://www.intuitive.com/en-us/-/media/ISI/Intuitive/Pdf/da-vinci-x-xi-instruments-accessories-catalog.pdf)
da Vinci Surgical System	Intuitive Surgical	IS4000	Robotic platform (https://www.intuitive.com/)
Laparoscopic grasping forceps	Karl Storz	33310OD  https://www.lapspay.com/cps/rde/xbcr/karlstorz_assets/ASSETS/3641936.pdf?utm_source=chatgpt.com	Assistant instrument L1
LigaSure Maryland Device	Medtronic/Covidien	LF1937	Table-side energy device (L2) (sealing/laparoscopic-instruments/ligasure-maryland-jaw-sealer-divider-nano-coating.html or https://www.medtronic.com/en-us/healthcare-professionals/products/surgical-energy/vessel-sealing/ligasure-technology.html)
Monopolar Cautery Hook	Intuitive Surgical	470183	Robotic instrument R2 (https://www.intuitive.com/en-us/-/media/ISI/Intuitive/Pdf/da-vinci-x-xi-instruments-accessories-catalog.pdf)
Robotic camera 30°	Intuitive Surgical	470057	R3 camera arm ( https://www.intuitive.com/en-us/-/media/ISI/Intuitive/Pdf/da-vinci-x-xi-instruments-accessories-catalog.pdf)
Robotic trocars	Intuitive Surgical	470002	Four robotic ports (https://www.intuitive.com/en-us/-/media/ISI/Intuitive/Pdf/da-vinci-x-xi-instruments-accessories-catalog.pdf)
Veress Needle	ConMed	60-6050-002  https://www.kebomed.no/files/577/verres_needle_disposable_insufflation.pdf	Pneumoperitoneum at Palmer’s point