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Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction
Chapters
Summary January 3rd, 2020
The robotic technique shown herein aims at faithfully reproducing the open procedure for radical treatment of cancer of the body-tail of the pancreas. The protocol also demonstrates the ability to master involvement of major peripancreatic vessels without conversion to open surgery.
Transcript
This video shows a robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the spleno-mesenteric junction. The procedure was performed to remove a cancer located in the body of the pancreas. Procedure shown in this video was conducted in compliance with the guidelines set out by the Ethics Committee of Pisa University Hospital for robotic operations, including regulations on research activity.
The CT scan demonstrates a hypo-enhancing pancreatic tumor, with upstream dilation of the main duct. The tumor is located in the proximal part of the body of the pancreas and appears to be strictly adherent to the splenic vein, in close proximity to the spleno-mesenteric junction. The robotic patient side cart can reach the patient from either side.
The robotic vision cart is conveniently placed at one side of the patient as to permit a clear view of the screen by the surgeon at the table. The robotic console is placed at the feet of the patient. The surgeon at the table stands between the patient's legs, while the operating surgeon sits at the console.
After induction of general anesthesia, the patient is placed supine with the legs parted. Intermittent pneumatic compression cuffs are placed around the legs for prophylaxis of deep vein thrombosis. The patient is safely secured to the operating table, and the abdomen is widely prepped.
Next, a pneumoperitoneum is established and maintained at approximately 10 mm of mercury. Four robotic ports and one laparoscopic port are required. The laparoscopic port has to be 12 mm in size and is used by the assistant at the table.
One of the robotic port is used for the endoscope, while the three remaining ports are used for the robotic instruments. The optic port is placed at the umbilicus. The endoscope is introduced, and the abdomen is explored, searching for occult tumor deposits.
Thereafter, the other ports are placed on either side along the transverse umbilical line, at the level of the perirectal line and the anterior axillary line. The assistant port is placed along the right perirectal line. Before docking the robotic system, the patient is placed in reverse Trendelenburg position, and the table is tilted to the right side.
After reaching the desired position, the laser light originating from the overhead boom is pointed to the site of the optic port. Next, the appropriate arm is docked to the optic port, and the endoscope is introduced. The scope is oriented towards the surgical site to permit the targeting process that is triggered by pressing the dedicated button on the camera head.
Targeting automatically adjusts the overhead boom. The robotic instruments are inserted under vision. The procedure begins by detaching the omentum from the colon without division of the gastrocolic ligament.
Dissection starts midway along the transverse mesocolon and extends to the right, until the hepatic flexure of the colon is reached, and to the left until the splenic flexure of the colon is fully mobilized. Once the lesser sac is fully opened, the pancreatic body and tail become clearly visible. Dissection begins with mobilization of the inferior margin of the pancreas.
Early identification of the superior mesenteric vein provides a key landmark to proceed safely with further dissections. In preparation for the creation of a tunnel behind the pancreatic neck, common hepatic artery and the portal vein above the pancreatic neck must be clearly identified. Lymph node number 8a is resected and bring the common hepatic artery into clear view.
Lymphatic vessels are sealed with either Hemo-o-lok clips or ligatures. Once the course of the common hepatic artery is clearly defined, dissection of lymphatic tissue lying between the artery and the superior margin of the pancreatic neck brings the portal vein into clear view. The common hepatic artery is looped to increase visibility and facilitate handling of the vessels during the procedure.
Dissection around major arteries is preferentially carried out using cold scissors, as the use of energy devices at this level may result in internal injury to the vessel walls, thus potentially increasing the risk of delayed bleeding. Proceeding along the periadventitial vein and from bottom to up, the celiac trunk is naked in surrounding tissues. Following identification of the celiac trunk, dissection proceeds along the origin of the splenic artery.
During this stage, the dorsal pancreatic artery was injured. The bleeding site was fixed with a 5-0 polypropylene suture. Ligature and division of the dorsal pancreatic artery would have been required anyway, as this maneuver improves exposure of the origin of the splenic artery and offers more room for safe ligature of this large artery.
With the splenic artery in clear view, the vessel can now be safely ligated and divided. Two ligatures are applied proximally and the vessel is eventually divided between two Hemo-o-lok clips. Whenever possible, division of the splenic artery should occur before division of the splenic vein, as this maneuver prevents the occurrence of sinistral portal hypertension, thus reducing blood pooling in the spleen and the amount of backward bleeding.
A tunnel behind the neck of the pancreas is developed at this stage, however, as suspected at preoperative imaging, the tumor was strictly adherent to the spleno-mesenteric junction, making it preferable further mobilize the specimen in order to achieve wider control of all vascular pedicles before proceeding with vein resection and reconstruction. The main trunk of the superior mesenteric artery is hence identified to the left side of the superior mesenteric vein. The inferior mesenteric vein is also identified and spared to be used as a vascular patch at the time of vein reconstruction.
During perivascular dissections, large lymphatics are clipped to reduce the amount of lymphatic leak. Dissection now proceeds medial to lateral in a posterior plane to remove en bloc with the specimen a large amount of retroperitoneal soft tissue. The left adrenal gland is identified during this stage.
Further to the left, the Gerota fascia hovering the upper pole of the left kidney is removed en bloc with the specimen, thus uncovering the anterior surface of the upper renal pole. The left renal vein and the left adrenal vein are also clearly identified. The inferior mesenteric vein is divided between clips.
A segment of the vein is spared for vascular reconstruction. The splenic vein is dissected freed proximal to the site of tumor adherence to achieve upstream vascular control. Before dividing the neck of the pancreas, a transfixed suture is placed at the inferior margin of the gland to occlude the transverse pancreatic artery.
Division of the pancreas is often performed using an endoscopic stapler, but in this patient, because of the limited space available, the gland was divided using Harmonic shears. The pancreatic duct was identified, dissected off, and selectively ligated. After completion of transsection, the pancreatic neck was closed with interrupted sutures of 4-0 ePTFE.
When possible, the neck margin is immediately sent for frozen section histology. In this patient, cause of the proximity of the tumor to the neck of the pancreas, the transsection margin was assessed after removal of the specimen. To proceed with vein resection, vascular pedicles are crossclamped.
First, the splenic vein is clipped upstream to the site of tumor involvement. Second, the superior mesenteric artery is crossclamped to reduce intestinal congestion during venous occlusion. Third, the superior mesenteric vein and the portal vein are crossclamped.
A sidewall resection of the portal mesenteric junction is carried out. The inferior mesenteric vein is harvested. An ePTFE suture is placed between the inferior mesenteric vein graft and the upper corner of the vein defect.
The graft is incised longitudinally to be used as a vascular patch. A stay suture is placed on the right margin of the vein defect to improve exposure. Two half-running sutures are used.
Before releasing the clamps, the vein is flushed with saline solution containing sodium heparin. Dissection now proceeds along the periadventitial plane of the superior mesenteric artery in a cephalad direction. Because of the central location of this tumor, also the right side of the superior mesenteric artery is skeletonized with removal of the right celiac ganglion.
Once the plane is reached, the same dissection is performed on the left side. When using Harmonic shears, attention is paid that the active bleed is opposite to the artery. When finer dissection is required, the use of cold scissors is preferred.
Also the left celiac ganglion is removed en bloc with the specimen. Dissection is now completed along the posterior surface and the upper margin of the pancreas. The spleen is also mobilized.
At the end, the superior mesenteric vein, the superior mesenteric artery, the left adrenal vein, and the left renal vein are clearly visible. Before completing the procedure, the round ligament is mobilized and is placed to protect the naked retroperitoneal vessels. The specimen is now placed in an endoscopic bag and retrieved through a suprapubic transverse incision.
The procedure was completed in 635 minutes, with an estimated blood loss of 150 mL and no need for blood transfusions. Final pathology demonstrated G2 ductal adenocarcinoma of the pancreas, with perineural invasion and involvement of the spleno-mesenteric junction. All the 56 resected lymph nodes were negative.
Circumferential tumor margins were also negative. Pathology stage of this tumor was T3 N0 R0.At the longest followup of 30 months, the patient is alive, well, and disease-free. In this video, we have shown the feasibility of robot-assisted radical antegrade modular pancreatosplenectomy.
En bloc resection and reconstruction of the spleno-mesenteric junction was also shown. Robotic assistance permits to perform oncologically correct dissections in the same planes followed during the open procedure. We wish to underscore that the enhanced dexterity offered by robotic assistance cannot surrogate surgical competence.
We also believe that advanced laparoscopic skills are required to fully exploit the potential of robotic assistance in complex pancreatic resections.
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