Robotic Pancreatoduodenectomy for Pancreatic Head Cancer: a Case Report of a Standardized Technique

This video illustrates a robotic approach to a pancreatoduodenectomy for pancreatic cancer. Robotic pancreatoduodenectomy has been highly standardized in recent years and may be used in selected patients with pancreatic cancer, including those with a replaced right hepatic artery. This study describes and demonstrates robotics pylorus ring resecting pancreaticoduodenectomy in case of a replaced right hepatic artery.

A 58 year old woman presented with an incidental finding of a 1.7 centimeter periampullary mass suspect for malignancy. No distant metastases nor lymph node involvement was present on a preoperative CT scan. Preoperative work-up consists of evaluation of the CT scan and a check for relative contraindications, which can be expanded during the progression of experience.

This is the 3D reconstruction of hepatic vasculature, including the replaced right hepatic artery. In red is the arterial system. In yellow, the pancreatic duct.

In green, the biliary system. In blue, the portal system, and in white, the pancreatic tissue. Place the patient in a supine 20 to 30 degrees reverse Trendelenburg position with 20 to 30 degrees left tilt with the right arm lowered and the left arm abducted to lower limb are parted in the French position.

Place a Veress needle at the Palmer's point to induce a CO2 pneumoperitoneum pressure up to 10 to 12 millimeters of mercury. Place the vision port second 12 millimeter port and all four robotic ports under marked positions, then perform a full diagnostic laparoscopy for metastasis. Now, the resection phase is initiated with duodenal mobilization.

Dissect the left side of the ligament of Treitz to free the most distal part of the duodenum and the first part of the jejunum, then mobilize the ascending colon. Now we dock the robot to trocars. The stomach is retracted cranially to open omental bursa by dividing the gastrocolic ligament approximately 2 centimeters below the gastroepiploic pedicle.

Continue the mobilization towards the hepatic flexure. Arm 1 retracts the stomach and duodenum to the patient's left to facilitate the Kocher's maneuver. Hereafter, the proximal jejunum is retracted through the ligament of Treitz defect, where it is transacted with a linear stapler.

Hereafter, the duodenum is separated from the pancreatic hat with a blunt vessel sealing device. Now the right gastric artery is mobilized, clipped and transacted. Special care is taken to retract nasogastric tube before the stomach is transacted.

Now that the duodenum is mobilized, we initiate a portal dissection. The inflow station 8a is identified, mobilized, and extracted in an extraction bag. Then the replaced right hepatic artery and gastroduodenum artery are skeletonized.

Vessel loops are placed around all structures as means of retraction. The common hepatic duct is transacted. This can be done with either cold scissors or a vascular stapler.

Here, a vessel loop is placed around to replace right hepatic artery. In this case, a remnant cystic duct was transacted to provide better exposure. Now the arterial anatomy can be confirmed by clamp testing gastroduodenal artery.

Hereafter, transect the gastroduodenal artery with a vascular linear stapler and place two additional metal clips at proximal stump. The pancreatic neck can now be mobilized and transacted. First, the lower border of the pancreas is exposed.

This forms the beginning of a wide tunnel between the pancreas and the superior mesenteric vein. Through this tunnel, the pancreas is circled with a vessel loop and retracted cranially with arm 1. The pancreas is dissected with diathermic scissors, but care is taken not too close to pancreatic duct with diathermia.

After the transaction of the pancreatic neck, the uncinate process can be mobilized. Mobilize the entire central side of the superior mesenteric vein from the pancreatic neck down to the uncinate process using the dithermia hook. Take special care to identify the right gastro-epiploic vein and potentially the right colonic vein.

Now we start dissecting along the superior mesentery artery. Robotic arm 1 retracts the duodenum close to the uncinate process to the patient's right lower quadrant. Then we dissect between the pancreatic head and the superior mesenteric artery using a blunt tip vessel sealing device.

Here, we identify the origin of the replaced right hepatic artery. The lymph nodes behind a port vein and the right hepatic artery may have to be dissected separately. The specimen and the lymph nodes are placed in a large endobag, which is then positioned in the right lower quadrant of the abdomen.

Now that the specimen is freed, we initiate the reconstruction phase. Reposition the first vein with its tip through the foramen of Winslow. We are now set for the pancreatico-jejunostomy and hepatico-jejunostomy.

First, we position the jejunal loop. Then we perform pancreatico-jejunostomy in two layers end to side with a duct-to-mucosa method according to the modified Blumgart technique. Place three silk mattress sutures.

By holding both ends with the robotic arm, we can provide better exposure for the anastomosis. Now we insert a stent in the pancreatic duct and tie the mattress sutures down. We perform an enterotomy in preparation of the duct-to-mucosa sutures.

Now we place three to five sutures posteriorly and we retract both ends with arm 1. The pancreatic duct stent is repositioned to prevent accidental closing of the duct when the anterior sutures are placed. Now place three to five anterior sutures, tie them later to allow for optimal exposure.

Now take the three silk sutures previously used for the posterior mattress layer and use them for the anterior posterior layer of the pancreatico-jejunostomy. Aim to overlap the pancreas with jejunum. Drive the suture through the jejunum in an oblique direction in the corners and in the lateral direction in the middle and tie these to complete the anastomosis.

Now position 10 centimeters of jejunum between the pancreatico-jejunostomy and hepatico-jejunostomy. Use monopolar curved scissors to perform the enterotomy. Anchor the first barbed suture at the seven o'clock position.

Run the suture twice when anchoring, because of the lack of hooks in the first centimeter of the suture. Use this suture as a retraction suture in arm 1. Then run the other suture for the posterior row towards the three o'clock position.

Finally, run the suture for the anterior row towards the three o'clock position and tie the two barbed sutures to complete the anastomosis. We advised to use barbed sutures in thick bile duct wall only. The hooks on the barbed suture can damage and perforate a thin bile duct wall.

Place a gauze on the hepatico-jejunostomy anastomoses to check for a possible bowel leakage later. Now we prepare for the open gastrojejunostomy and extract the specimen. Introduce a 60 centimeter stitch and fixate it with arm 1 at the level of the hepatico-jejunostomy.

Use the other robotic arms to measure the 60 centimeters of bowel to determine the position of the gastrojejunostomy. Here, we place marking sutures. Reflect the mesocolon and locate the jejunal loop and marking sutures.

Fixate the bowel loop to the stomach in preparation of a bilo type two anastomosis. Remove robot arm 1 and extract the drain placed earlier. Now, mobilize and position round ligament on top of the portal vein between the gastroduodenal artery stump and pancreatico-jejunostomy.

Then hold and secure the endobag and the stay suture from the gastrojejunostomy with two laparoscopic graspers. Undock the robot and secure it from the patient. Then we make a muscle-sparing transverse incision in the left upper quadrant where we introduce medium hand port to extract the endobag and the remnant stomach.

Here we perform a single layer gastrojejunostomy. We make the enterotomy by removing the staple lines and we make an enterotomy on the jejunum. The anastomosis is then performed in a running fashion.

We inject two millimeters of blue dye in the afferent limb of the jejunum to facilitate endoscopic placement of a feeding tube. Finally, we close all incisions and fixate the drains. First, we close the extraction site fascia.

Then we insufflate the abdomen and place an additional drain to robot trocar 4. Hereafter, we close fascia of the 12 millimeter trocar sites and we close all cutaneous incisions. For postoperative management, we close the stomach pump on the nasogastric tube at six o'clock in the next morning.

Supervised walking is started on the first postoperative day. We perform a CT scan of the abdomen if the CRP does not decreased between day three and four. We then remove drains when amylase levels are less than three times the upper limit of normal serum amylase and the production of the drain is less than 250 CC per 24 hours.

In this case, the total operative time was 410 minutes. The estimated blood loss was 220 CC.There were no postoperative complications and the patient could be discharged at day five. Histology revealed erratically resected pancreatic ductal adenocarcinoma.

In conclusion, the described technique for robotic pancreatoduodenectomy is a feasible and safe procedure for high-volume centers which can perform at least 20 of these procedures per year, as advised by the 2020 Miami guidelines.