Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

This video vignette demonstrates all steps of a robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy. The case involves a 16-year-old boy who was initially seen after a trauma accident. At imaging, the CT-scan revealed an incidental mass of 3.1 by 2 by 2.6 centimeters in the body of the pancreas.

The pre-operative diagnosis was a solid pseudopapillary Frantz tumor. Patient was considered eligible for robotic-assisted central pancreatectomy. Operative Setting.

After insufflation, a 12-millimeter Visiport trocar is placed to the right of the umbilicus where after four 8-millimeter robotic trocars are placed 11 to 12 centimeters from the pancreatic body. The trocar at the patient's right side, for row with arm one, is placed more cranial than the others. The second 12-millimeter table-side surgeon trocar is placed.

The distance between all these trocars is approximately seven centimeter. Finally, a five-millimeter trocar is placed in the left upper quadrant, which will hold the laparoscopic stomach/liver retractor. Pancreatic Identification and Mobilization.

The procedure starts with opening the lesser sack and transacting the gastrocolic ligaments, after which a liver retractor is installed in the left upper quadrant to retract the stomach and left side of the liver. To identify and locate the tumor, an intraoperative ultrasound is performed and the future resection margins are marked using the Kathari hook. Pancreas is first caudally and then cranially mobilized using the robotic Kathari hook, and the laparoscopic sealing device.

First, a vessel loop is placed at the left side of the tumor between the pancreas and the splenic vein. Then, the pancreas is clear to mobilize at the proximal side. A vessel loop is placed between the pancreas and the portomesenteric vein.

Mobile arm one moves the vessel loops cranially, so the mobilization of the pancreatic body can thoroughly be completed. Pancreatic transection. First, the pancreas is transected at the right side of the tumor, central from the superior mesenteric vein.

Closing off the stapler using the grated compression approach as described by Osborn may take up to five minutes. During the next step, there is taken care of venous mobilization. After careful venous mobilization, the pancreas is transacted at the left side of the tumor, using robotics scissors with diathermia.

Pancreatic duct is cut without diathermia. A stent is introduced to identify the pancreatic duct after a section. Window in the Mesocolon.

A window in the Mesocolon is created using the Kathari hook, while the colon is in caudal position. Here after, the mesocolon is placed in the cranial position and held with arm one. Then the window can be identified.

Creating the Roux-limb. Approximately 20 centimeters from the ligament of Treitz, a small opening in the proximal jejunum mesentery is created after it's divided with a powered endo-stapler with a vascular cartridge. Positioning the Roux-limb.

A Roux-limb is passed cranially through the window in the Mesocolon. A transverse colon is then placed back in the caudal position. The end of the Roux-limb and a 50 centimeter length suture are both held by arm one, while arm two and arm four are used to measure a 50-centimeter distance to the future Jejuno-Jejunostomy.

This location is marked with a clip.Jejuno-Jejunostomy. The small bowel at the location of the metal clip is sutured to the transacted proximal jejuno, to facilitate the anastomosis. Arm one retracts the suture cranially, while two small enterotomies are created, and a side-to-side Jejuno-Jejunostomy is made, using an endo stapler with fistular cartridge.

The remaining opening is closed with a 3.0 filo part suture.Pancreaticojejunostomy. The Roux-limb is positioned for the end-to-side pancreaticojejunostomy. A suture is placed to close the window in the transverse mesocolon and to fixate the jejunal mesentery.

The end-to-side pancreatico-jejunostomy is performed using the modified Blumgart technique. The anastomosis starts with three trans-pancreatic mattress sutures, using silk 2.0 sutures. The first suture is passed through the pancreas and jejunum from a cranial to a caudal position.

Then the suture is passed backwards, similarly, towards the interior side of the pancreas, and both ends are retracted by robot arm one. This step is repeated for the remaining two transpancreatic mattress sutures, centrally and caudally in the pancreas. A stent is placed in the pancreatic duct to avoid suturing the pancreatic duct.

Three transpancreatic sutures are tied without removing the needles, and the stent is removed afterwards. A small enterotomy is created in preparation for the future duct-to-mucosa sutures. The posterior duct-to-mucosa side is sutured with four to five PDs 5.0 sutures, in a clockwise way.

A pancreatic duct stent is placed to avoid suturing the pancreatic duct when suturing the anterior duct-to-mucosa side. Then the anterior duct-to-mucosa side is sutured with four to five PDs 5.0 sutures. The sutures are tied when the last suture has been performed, so optimal exposure could be created.

Three trans-pancreatic silk sutures from the mattress procedure are reused to perform anterior buttress layer of the pancreaticojejunostomy. For all the three sutures, the needle is passed through the jejunum and tied with the remaining end of its suture. Drain Placement.

A drain is introduced with arm one to a position cranial of the pancreaticojejunostomy.Results. Regarding the intraoperative outcomes, the operation time was 248 minutes. Intraoperative blood loss was 20 milliliters.

Post operative course was uneventful, except short-term medical treatment, with octreotide and antibiotics for a grade B pancreatic fistula. Drain emulates levels is normalized on post-operative day seven, or after the drain was removed. The patient was discharged on post-operative day eight.

This pathological assessment revealed a 2.2 centimeter solid, pseudopapillary tumor, and thus confirming the pre-operative diagnosis. Microscopically, an error zero resection was confirmed.Conclusion. Ladies and gentlemen, I hope that you enjoyed this video.

We feel that it illustrates that Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy is a feasible procedure in experienced hands. Robotic Central Pancreatectomy serves as a minimally invasive alternative to open central Pancreatectomy, but also as an alternative to open and minimally invasive distal pancreatectomy for central lesions. Clearly, further perspective and preferably randomized studies, are needed to confirm the safety and efficacy of this approach, and compare these with the open approach.

Thank you.