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

This method can help answer key question about how to perform the robotic central pancreatectomy with an end-to-end anastomosis. The main advantages of this technique are that it simplifies the reconstruction approach after robotic central pancreatectomy, avoids pancreaticoenterostomy, and allows conservation of this anatomic continuity of the gastrointestinal tract. Demonstrating the procedure with me will be Gao Yuan-Xing and Xu Yong, associate senior doctors from my department.

Before beginning the procedure, place the patient supine at a 20-degree reverse Trendelenburg position with the legs split, and drap the patient in the standard sterile fashion for upper abdominal surgery. Position the surgeon console in the operating room, the patient cart over the patient's head and vision cart to the right of the patient. Then direct the assistant surgeon to stand between the patient's legs with the back table for the instruments and supplies at the left rear of the assistant.

When everything is in position, use a scalpel to make a one centimeter incision three centimeters inferior and right lateral to the umbilicus, and insert a veress needle through the incision into the abdominal cavity. Use the automatical insufflation instrument to establish a carbon dioxide pneumoperitoneum of 14 millimeters of mercury, and replace the veress needle with a 12 millimeter trocar as the camera port. Insert the robotic endoscope into the trocar, and perform a diagnostic laparascopy to confirm the abdominal adhesion status and operative feasibility.

Under the view of the endoscope, place an 8 millimeter trocar in the left anterior axillary line at the level of the umbilicus for the first robotic arm, and place a 12 millimeter trocar 2 centimeter inferior and left lateral to the umbilicus as the assistant port. Place a 12 millimeter trocar in the right mid-clavicular line at the level of the umbilicus, and insert an 8 millimeter trocar into the right mid-clavicular 12 millimeter trocar in a trocar in trocar fashion for the second robotic arm. Then, place an 8 millimeter trocar under the costal margin in the right middle axillary line for the third robotic arm.

Dock the robotic arm, and dock the robotic endoscope in the camera arm. To mobilize the pancreas neck and body, use the forceps on the third robotic arm to grasp and elevate the anterior wall of the the stomach to expose the gastrocolic ligament. Have the assistant apply tension in the gastrocolic ligament using the grasping forceps coupled with the bipolar forceps and the second robotic arm.

Divide the gastrocolic ligament to enter the lesser sac, and use the laparoscopic ultrasonic scalpel on the first robotic arm to expose the anterior surface of the pancreas. Then, use the bipolar forceps on the second robotic arm to perform hemostasis until the level of the right gastroepiploic vein is reached. Using the cautery hook, carefully dissect the pancreatic neck from the inferior to superior direction, dividing the posterior wall of the pancreatic neck from the portal superior mesenteric, inferior mesenteric, and splenic veins.

When the tissues have been divided, create a tunnel between the veins and the posterior wall of the pancreatic neck. Then use the cautery hook and ultrasonic scalpel to dissect the pancreatic body from the splenic vessels and connective tissues toward the pancreatic tail. To transect the pancreatic parenchyma, insert the laparoscopic ultrasound probe through the assistant trocar and perform ultrasonography on the pancreas to reconfirm the location and size of the lesion.

According to the results of the ultrasonography, use the cautery hook to mark two transection lines on the pancreatic surface about one centimeter away from the lesion. Insert the fenestrated bipolar forceps through the inferior margin of the pancreas to lift the pancreatic body and further detach the proximal part of pancreatic body from the splenic vessels and connective tissues. Then mobilize the pancreatic neck and proximal pancreatic body from the posterior vessels and tissues.

Using the ultrasonic scalpel, incise the pancreas parenchyma along the distal and proximal transection line and expose the pancreatic duct. Transect the pancreatic parenchyma around the pancreatic duct, and carefully protect and mobilize the pancreatic duct from the transected pancreatic parenchyma. Then use laparoscopic scissors from the assistant port to sharply transect the pancreatic duct about one centimeter away from the stump.

To reduce the tension of the anastomosis, use the cautery hook and bipolor forceps to further mobilize the pancreatic stump from the posterior vessels and connective tissues. Implant the stent into the abdominal cavity through the assistant port and use microforceps to hold the sidewall of pancreatic duct stump within the pancreatic body. Gently insert the stent into the distal pancreatic duct stump, and use 5-0 absorbable sutures to suture the pancreatic duct with the stent so that the stent is closely encircled by the duct.

Using a similar approach without a suture, insert the other end of the stent into the proximal pancreatic duct stump, followed by placement of a 4-0 nonabsorbable horizontal mattress suture around the proximal and distal pancreatic stumps. While pulling the two pancreatic stumps closer, continue to insert the proximal end of the stent into the proximal pancreatic duct stump. Next, perform an end-to-end anastomis of the pancreatic duct stumps using a 5-0 nonabsorbable suture with an interrupted stitch, and knot the remaining ties on the pancreatic stumps.

Then use a 4-0 nonabsorbable suture to make a continuous stitch to suture the anterior portion of the pancreatic stumps. When the stumps have been secured, carefully check for bleeding, and conduct a thorough hemostasis, encircling the anastomosis site with absorbable hemostatic gauze as necessary. Place the resected specimen into a plastic sample bag, and remove the bag through the enlarged incision of the camera port.

Place two drains along the superior and inferior borders of the anastomosis site, and extract the drains from the port for the third robotic arm. Then give the patient intravenous antibiotics, parenteral nutrition, analgesia, somatostatin, proton pump inhibitors, and other appropriate treatment according to conventional central pancreatectomy protocols. In this representative procedure, the resected pancreas was about 5.5 by 2.5 by 2.5 centimeters.

After a smooth discharge and recovery, the postoperative CT scan revealed a slight exudation around the pancreas with no dilation or stricture in the pancreatic duct. While attempting this procedure, it is important to remember to transect the pancreatic duct sharply, and to fully mobilize the pancreatic stumps, particularly the distal pancreatic stump, prior to the end-to-end anastomosis to achieve the tension-free"anastomosis. After its development, this technique paved the way for researchers in the field of minimally invasive HPB surgery to explore the optimization of the reconstruction approaches for pancreatic duct and parenchyma after pancreatectomy.

After watching the video, you should have to good understanding of how to use a robotic surgical system to perform the central pancreatectomy and to reconstruct the anatomic continuity of the pancreas by end-to-end anastomosis.