Name: Robotic Duodenum-preserving Total Pancreatic Head Resection for Intraductal Papillary Mucinous Neoplasms (Video) | JoVE Journal
Uploaded: 2026-04-17T14:00:00.000+00:00
Duration: 10 min 10 s
Description: Learn robotic duodenum-preserving total pancreatic head resection for intraductal papillary mucinous neoplasms. This minimally invasive technique preserves the duodenum and offers an organ-sparing alternative to pancreaticoduodenectomy.

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5 minutes

This study is sponsored by the Peking Union Medical College Hospital Talent Cultivation Program (Category D, No. UHB12625)

The present protocol received approval from the Institutional Review Board of Peking Union Medical College Hospital (approval no: I-23ZM0030). Written informed consent was obtained from the patient for the publication of this case and the video.
1. Patient selection
<ol>
	<li>Set the following inclusion criteria: IPMNs located in the pancreatic head; age younger than 70 years old; radiological findings indicating benign or low malignancy potential; maximum diameter &#60; 5 cm.</li>
	<li>Set the following exclusion criteria: Abrupt change in caliber of pancreatic duct with distal atrophy; elevation of serum tumor marker (especially CA19-9) levels; regional lymph node enlargement; malignancy confirmed by cytology; dilation of the entire pancreatic duct; involving the duodenum, with none/few of pancreatic parenchyma remaining; recurrence of IPMNs.</li>
</ol>
2. Surgical technique
<ol>
	<li>Operative setting
	<ol>
		<li>Position the anesthetized patient on the operating table compatible with the da Vinci robotic system in a supine 15&#176; reverse Trendelenburg position, with 5&#176; right-sided elevation and the legs abducted.</li>
		<li>Use povidone-iodine to finish sterile exposition; create a sufficient region for specimen extraction.</li>
		<li>After the pneumoperitoneum is created, follow the five-port technique to settle the trocars (Figure 1).</li>
	</ol>
	</li>
	<li>Exploration phase
	<ol>
		<li>Thoroughly scan the intraperitoneal organs and peritoneal surfaces to identify any unexpected metastases.</li>
		<li>Equip the arm 3 with a laparoscope, then aim the laparoscope at the mid-right part of the hepatogastric ligament, fix the laparoscope port, and press the docking button to allow the other three robotic arms to dock according to the predefined procedure of the da Vinci robotic system. Equip arm 1 with cadiere forceps, arm 2 with bipolar forceps, and arm 4 with ultrasonic scalpel after docking.</li>
		<li>Elevate the greater omentum, incise the gastrocolic ligament inferior to the gastroepiploic vessels to open the lesser sac, and mobilize the stomach and pancreas.</li>
		<li>Re-evaluate the specific surgical procedure after the pancreatic head and uncinate process are fully exposed. 
		NOTE: Confirm the suitability of DPPHRt or PD after gaining access to the lesser sac. Proceed with DPPHRt only if the tumor shows no significant malignant features and is confined to the pancreatic head.</li>
	</ol>
	</li>
	<li>Dissection phase
	<ol>
		<li>Kocher maneuver: Mobilize the duodenum by incising along the lateral peritoneal reflection and dissecting through the anterior fascia of the right kidney, the second portion of the duodenum, and the posterior aspect of the pancreatic head. 
		NOTE: Arm 1 retracts the entire stomach and small bowel to the patient&#39;s left; use arm 4 equipped with an ultrasonic scalpel to dissect instead of blunt dissection to prevent bleeding.</li>
		<li>SMV branches: Dissect along the inferior border of the pancreas to find SMV branches. Identify the trunk of Henle (gastrocolic trunk) along the SMV tributaries, and expose the superior mesenteric vein-portal vein axis (SMV-PV axis).</li>
		<li>Dissect the plane between the SMV-PV axis and the pancreatic neck. Dissect and divide the right gastroepiploic vein (RGEV).</li>
		<li>Dissect the hepatoduodenal ligament cranially to expose the common hepatic artery (CHA) and perform lymphadenectomy of the lymph node group 8.</li>
		<li>Assess the extent of resection based on the preoperative imaging results. Mark the area and transect the pancreas anterior to the PV.</li>
		<li>Resect the main pancreatic duct (MPD) at the pancreatic stump and perform intraoperative frozen section pathology. 
		NOTE: Avoid using electrocautery instruments when handling the MPD to prevent damage to the ductal epithelium.</li>
		<li>Pass a vascular retraction tape behind the SMV. Pull the tape to elevate the SMV and expose the anterior-right&#160;border of the SMA and gastroduodenal artery (GDA) for dissection.</li>
		<li>Dissect along the right border of SMV and SMA, expose and shut down the branches entering the tumor from the inferior pancreaticoduodenal artery (IPDA). 
		NOTE: If intraoperative vascular injury to the trunk of IPDA or GDA occurs during the procedure, use 5-0 Prolene vascular suture to fix the lesions.</li>
		<li>Preserve the anterior inferior pancreaticoduodenal artery (AIPDA) and posterior inferior pancreaticoduodenal artery (PIPDA). 
		NOTE: Preserve the inferior pancreatic duodenal arterial arcade by dissecting the subcapsular pancreatic head parenchyma. Avoid intraoperative injury to the arterial arcade coursing through pancreatic parenchyma or mixed with yellow adipose tissue.</li>
		<li>Dissect distally along the gastroduodenal artery (GDA) to identify and suture-ligate tumor-feeding branches , including those arising from the anterior superior pancreaticoduodenal artery (ASPDA). Sacrifice the ASPDA if required to achieve adequate clearance. 
		NOTE: Suture-ligate branches derived from IPDA or GDA as tumor-feeding vessels during dissection.Use electrosurgical instruments cautiously for hemostasis to avoid uncontrollable intraoperative bleeding.</li>
		<li>Preserve the branches of the posterior superior pancreaticoduodenal artery (PSPDA) supplying the duodenum maximally. Separate the cystic-solid tumor along the upper border of the pancreas. 
		NOTE: Dissect along the GDA to expose the PSPDA, preserving its branches that feed the common bile duct (CBD) and duodenum.</li>
		<li>Activate the fluorescence lens to visualize the course of the common bile duct (CBD) using indocyanine green (ICG) during steps 2.3.8 to 2.3.11. Reassess the anatomy of the CBD as needed to prevent injury. Resect the pancreatic head parenchyma nearly completely along the CBD. 
		NOTE: Due to the half-life of ICG and its hepatic metabolism, inject ICG intravenously 30 min before imaging to achieve optimal visualization of the bile duct. Do not administer ICG in patients with a known allergy. Omit fluorescence imaging in such cases.</li>
		<li>Expose the MPD on the lateral wall of the duodenum. Resect the margin for intraoperative frozen section pathology. Ligate the stump of the MPD. 
		NOTE: Confirm that both the pancreatic duct margin at the stump and the lateral duodenal wall margin are negative. Proceed to radical resection (PD) if either margin is positive.</li>
		<li>Resect the pancreatic head and uncinate process containing the lesion completely. Remove the surgical specimen inside a retrieval bag, following the oncologic no-touch principle.</li>
		<li>Irrigate and clean the surgical field. Confirm that the vascular arcade of the posterior branch of the pancreatoduodenal artery is intact and that the blood supply to the duodenum is adequate (Figure 2).</li>
		<li>Reinforce the vascular stumps with sutures before proceeding with gastrointestinal reconstruction.</li>
	</ol>
	</li>
	<li>Reconstruction phase
	<ol>
		<li>Incise the ligament of Treitz. Transect the jejunum 20 cm from the ligament of Treitz using a linear cutter stapler.</li>
		<li>Dissect a vessel-free area in the transverse mesocolon. Lift the distal jejunum posterior to the colon through the opening in the mesocolon.</li>
		<li>Tunnel the jejunal limb from the ventral to the dorsal aspect of the pancreas and anchor it to the seromuscular layer using 3-0 barbed sutures.</li>
		<li>Create a full-thickness opening in the jejunum using arm 4 equipped with monopolar scissors. Insert a 2 x 4 mm internal stent into the main pancreatic duct (MPD). Perform a duct-to-mucosa anastomosis using interrupted 5-0 PDS sutures.</li>
		<li>Suture the ventral seromuscular layer of the jejunum to the ventral side of the pancreas and complete the knotting with the dorsal side suture. 
		NOTE: Based on our previous publication12, barbed sutures are feasible for pancreaticojejunostomy during minimally invasive pancreatic surgery and may reduce rates of clinically relevant postoperative pancreatic fistula (CR-POPF) and severe complications.</li>
		<li>Perform a side-to-side enterostomy using an electric cutting stapler 40 cm distal to the prior anastomosis. Close the common enterotomy with 3-0 barbed sutures. Close the mesenteric defect.</li>
		<li>Reconfirm the duodenal vascular supply is adequate. Place two drains near the anastomosis and pancreatic stump through robot trocars 1 and 4.</li>
		<li>Complete the procedure and close the incisions according to standard robotic surgical technique.</li>
	</ol>
	</li>
</ol>

<ol><li>Beger, H. G., Büchler, M., Bittner, R. R., Oettinger, W., Roscher, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Duodenum-preserving+resection+of+the+head+of+the+pancreas+in+severe+chronic+pancreatitis%3A+early+and+late+results%5BTitle%5D)+AND+%22Ann+Surg%22%5BJournal%5D)">Duodenum-preserving resection of the head of the pancreas in severe chronic pancreatitis: early and late results.</a> Ann Surg. 209 (3), 273-278 (1989).</li>
<li>Takada, T., Yasuda, H., Uchiyama, K., Hasegawa, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Duodenum-preserving+pancreatoduodenostomy%3A+a+new+technique+for+complete+excision+of+the+head+of+the+pancreas+with+preservation+of+biliary+and+alimentary+integrity%5BTitle%5D)+AND+%22Hepatogastroenterology%22%5BJournal%5D)">Duodenum-preserving pancreatoduodenostomy: a new technique for complete excision of the head of the pancreas with preservation of biliary and alimentary integrity.</a> Hepatogastroenterology. 40 (4), 356-359 (1993).</li>
<li>Beger, H. G., Poch, B., Vasilescu, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Benign+cystic+neoplasm+and+endocrine+tumours+of+the+pancreas-when+and+how+to+operate-an+overview%5BTitle%5D)+AND+%22Int+J+Surg%22%5BJournal%5D)">Benign cystic neoplasm and endocrine tumours of the pancreas-when and how to operate-an overview.</a> Int J Surg. 12 (6), 606-614 (2014).</li>
<li>Ohtsuka, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((International+evidence-based+Kyoto+guidelines+for+the+management+of+intraductal+papillary+mucinous+neoplasm+of+the+pancreas%5BTitle%5D)+AND+%22Pancreatology%22%5BJournal%5D)">International evidence-based Kyoto guidelines for the management of intraductal papillary mucinous neoplasm of the pancreas.</a> Pancreatology. 24 (2), 255-270 (2024).</li>
<li>Witzigmann, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Outcome+after+duodenum-preserving+pancreatic+head+resection+is+improved+compared+with+classic+Whipple+procedure+in+the+treatment+of+chronic+pancreatitis%5BTitle%5D)+AND+%22Surgery%22%5BJournal%5D)">Outcome after duodenum-preserving pancreatic head resection is improved compared with classic Whipple procedure in the treatment of chronic pancreatitis.</a> Surgery. 134 (1), 53-62 (2003).</li>
<li>Büchler, M. W., Friess, H., Müller, M. W., Wheatley, A. M., Beger, H. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Randomized+trial+of+duodenum-preserving+pancreatic+head+resection+versus+pylorus-preserving+Whipple+in+chronic+pancreatitis%5BTitle%5D)+AND+%22Am+J+Surg%22%5BJournal%5D)">Randomized trial of duodenum-preserving pancreatic head resection versus pylorus-preserving Whipple in chronic pancreatitis.</a> Am J Surg. 169 (1), 65-69 (1995).</li>
<li>Yin, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Long-term+quality+of+life+between+duodenum-preserving+pancreatic+head+resection+and+pancreatoduodenectomy%3A+a+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22Int+J+Surg%22%5BJournal%5D)">Long-term quality of life between duodenum-preserving pancreatic head resection and pancreatoduodenectomy: a systematic review and meta-analysis.</a> Int J Surg. 110 (2), 1139-1148 (2024).</li>
<li>Beger, H. G., Mayer, B., Vasilescu, C., Poch, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Long-term+metabolic+morbidity+and+steatohepatosis+following+standard+pancreatic+resections+and+parenchyma-sparing+local+extirpations+for+benign+tumor%3A+a+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22Ann+Surg%22%5BJournal%5D)">Long-term metabolic morbidity and steatohepatosis following standard pancreatic resections and parenchyma-sparing local extirpations for benign tumor: a systematic review and meta-analysis.</a> Ann Surg. 275 (1), 54-66 (2022).</li>
<li>Serra, F., Bonaduce, I., De Ruvo, N., Cautero, N., Gelmini, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Short-term+and+long-term+morbidity+in+robotic+pancreatic+surgery%3A+a+systematic+review%5BTitle%5D)+AND+%22Gland+Surg%22%5BJournal%5D)">Short-term and long-term morbidity in robotic pancreatic surgery: a systematic review.</a> Gland Surg. 10 (5), 1767-1779 (2021).</li>
<li>Li, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Video-based+indocyanine+green+fluorescence+applied+to+robotic+duodenum-preserving+pancreatic+head+resection%5BTitle%5D)+AND+%22Ann+Surg+Oncol%22%5BJournal%5D)">Video-based indocyanine green fluorescence applied to robotic duodenum-preserving pancreatic head resection.</a> Ann Surg Oncol. 31 (4), 2654-2655 (2024).</li>
<li>Jiang, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Robot-assisted+duodenum-preserving+pancreatic+head+resection+with+pancreaticogastrostomy+for+benign+or+premalignant+pancreatic+head+lesions%3A+a+single-centre+experience%5BTitle%5D)+AND+%22Int+J+Med+Robot%22%5BJournal%5D)">Robot-assisted duodenum-preserving pancreatic head resection with pancreaticogastrostomy for benign or premalignant pancreatic head lesions: a single-centre experience.</a> Int J Med Robot. 14 (4), e1903(2018).</li>
<li>Liu, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparisons+of+laparoscopic+and+robotic+pancreaticoduodenectomy+using+barbed+and+conventional+sutures+for+pancreaticojejunostomy%3A+a+propensity+score+matching+study%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Comparisons of laparoscopic and robotic pancreaticoduodenectomy using barbed and conventional sutures for pancreaticojejunostomy: a propensity score matching study.</a> Surg Endosc. 38 (10), 5858-5868 (2024).</li>
<li>Dai, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Early+drain+removal+is+safe+in+patients+with+low+or+intermediate+risk+of+pancreatic+fistula+after+pancreaticoduodenectomy%3A+a+multicenter+randomized+controlled+trial%5BTitle%5D)+AND+%22Ann+Surg%22%5BJournal%5D)">Early drain removal is safe in patients with low or intermediate risk of pancreatic fistula after pancreaticoduodenectomy: a multicenter randomized controlled trial.</a> Ann Surg. 275 (2), e307-e314 (2022).</li>
<li>Wilentz, R. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pathologic+examination+accurately+predicts+prognosis+in+mucinous+cystic+neoplasms+of+the+pancreas%5BTitle%5D)+AND+%22Am+J+Surg+Pathol%22%5BJournal%5D)">Pathologic examination accurately predicts prognosis in mucinous cystic neoplasms of the pancreas.</a> Am J Surg Pathol. 23 (11), 1320-1327 (1999).</li>
<li>Beger, H. G., Mayer, B., Poch, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Long-term+oncologic+outcome+following+duodenum-preserving+pancreatic+head+resection+for+benign+tumors%2C+cystic+neoplasms%2C+and+neuroendocrine+tumors%3A+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22Ann+Surg+Oncol%22%5BJournal%5D)">Long-term oncologic outcome following duodenum-preserving pancreatic head resection for benign tumors, cystic neoplasms, and neuroendocrine tumors: systematic review and meta-analysis.</a> Ann Surg Oncol. 31 (7), 4637-4653 (2024).</li>
<li>Lu, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+duodenum-preserving+pancreatic+head+resection+with+real-time+indocyanine+green+guidance+of+different+dosage+and+timing%3A+enhanced+safety+with+visualized+biliary+duct+and+its+long-term+metabolic+morbidity%5BTitle%5D)+AND+%22Langenbecks+Arch+Surg%22%5BJournal%5D)">Laparoscopic duodenum-preserving pancreatic head resection with real-time indocyanine green guidance of different dosage and timing: enhanced safety with visualized biliary duct and its long-term metabolic morbidity.</a> Langenbecks Arch Surg. 407 (7), 2823-2832 (2022).</li>
<li>Vege, S. S., Ziring, B., Jain, R., Moayyedi, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((American+gastroenterological+association+institute+guideline+on+the+diagnosis+and+management+of+asymptomatic+neoplastic+pancreatic+cysts%5BTitle%5D)+AND+%22Gastroenterology%22%5BJournal%5D)">American gastroenterological association institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts.</a> Gastroenterology. 148 (4), 819-822 (2015).</li>
<li>Vanden Bulcke, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Evaluating+the+accuracy+of+three+international+guidelines+in+identifying+the+risk+of+malignancy+in+pancreatic+cysts%3A+a+retrospective+analysis+of+a+surgically+treated+population%5BTitle%5D)+AND+%22Acta+Gastroenterol+Belg%22%5BJournal%5D)">Evaluating the accuracy of three international guidelines in identifying the risk of malignancy in pancreatic cysts: a retrospective analysis of a surgically treated population.</a> Acta Gastroenterol Belg. 84 (3), 443-450 (2021).</li>
</ol>

The authors have no conflicts of interest to declare.

This case illustrates the use of DPPHRt as a preferable alternative to PD for selected PCNs located in the pancreatic head. The dissection and preservation of the pancreaticoduodenal vascular arcades are key to the success of the procedure. R-DPPHRt combines the advantages of robot-assisted minimally invasive surgery with the benefits of an organ-preserving surgical procedure. With the assistance of the robotic system, surgeons have a clearer view and more operational angles when dealing with the complex anatomical struc...

Duodenum-preserving pancreatic head resection (DPPHR) was first reported by Beger and colleagues in 1972 to treat chronic pancreatitis1. To treat benign or low-grade malignant tumors of the pancreatic head, a more extensive procedure known as duodenum-preserving total pancreatic head resection (DPPHRt) was developed in 19882. This technique provides an alternative to conventional pancreaticoduodenectomy (PD) and may include segmental resection of the duodenum and common bile duct when necessary3.
Intraductal papillary mucinous neoplasm (IPMN) is a major subtype of pancreatic cystic neoplasms (PCNs) and is widely recognized as a precursor lesion to pancreatic cancer. Surgical resection remains one of the primary treatment strategies for IPMNs, with current guidelines recommending intervention based on the presence of high-risk stigmata or worrisome features4. However, for benign or low-grade malignant lesions restricted to the pancreatic head, with a diameter of no more than 5 cm, especially in patients under 70 years old, the optimal surgical procedure remains uncertain.
The advantages of DPPHR over conventional PD are evident not only in reduced early postoperative complications, but also in better long-term quality of life (QoL)3,5,6,7. For long-term function, DPPHR has advantages over PD in terms of a lower incidence of metabolic dysfunctions7,8. With the advancement of minimally invasive surgery, robotic surgical systems are increasingly adopted due to their enhanced dexterity, tremor filtration, high-definition visualization, reduced intraoperative bleeding, and faster postoperative recovery9. As indicated by recent research, robotic DPPHR (R-DPPHR) has strengths in conserving both exocrine and endocrine pancreatic functions, with the aid of intraoperative indocyanine green (ICG) fluorescence imaging10,11.
In this report, we present a case of a 65-year-old male patient diagnosed with a main duct IPMN (MD-IPMN) of the pancreatic head. The patient underwent successful R-DPPHRt. This report aims to illustrate the feasibility and clinical advantages of R-DPPHRt in the management of pancreatic head IPMN, and to explore its potential indications in patients with benign or borderline tumors in the pancreatic head. Robotic duodenum-preserving total pancreatic head resection offers an organ-preserving alternative to pancreaticoduodenectomy, particularly for selected patients with IPMNs.

<table><tbody><tr><td>&lt;strong&gt;Sutures:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Internal pancreatic duct stent, 2 &amp;times; 4 mm</td><td></td><td></td><td></td></tr><tr><td>PDS, RB-2, 75 cm, 5-0; Z148: taper point. &amp;frac12; circle 13 mm</td><td>Ethicon</td><td>Z148</td><td></td></tr><tr><td>Prolene, RB-1, 90 cm, 5-0; round bodied. &amp;frac12; circle 17 mm</td><td>Ethicon</td><td>W8556</td><td></td></tr><tr><td>Stratafix, 20 cm, 3-0; MOD12: taper point, &amp;frac12; circle 26 mm</td><td>Ethicon</td><td>MOD 12</td><td></td></tr><tr><td>&lt;strong&gt;Instruments robot:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Cadiere forceps</td><td>Intuitive Fosun</td><td>470049</td><td></td></tr><tr><td>Endoscope with camera, 8 mm, 30&amp;deg;</td><td>Intuitive Fosun</td><td>470027</td><td></td></tr><tr><td>Fenestrated bipolar forceps</td><td>Intuitive Fosun</td><td>470205</td><td></td></tr><tr><td>Harmonic ACE curved shears</td><td>Intuitive Fosun</td><td>480275</td><td></td></tr><tr><td>Monopolar curved scissors (Hot shears)</td><td>Intuitive Fosun</td><td>470179</td><td></td></tr><tr><td>Permanent cautery hook</td><td>Intuitive Fosun</td><td>470183</td><td></td></tr><tr><td>&lt;strong&gt;Other:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Echelon Flex 60 mm Stapler</td><td>Ethicon</td><td>PSEE60A</td><td></td></tr><tr><td>Hem-o-lok Clips ML</td><td>Weck Surgical Instuments</td><td>544230</td><td></td></tr><tr><td>Hem-o-lok Clips L</td><td>Weck Surgical Instuments</td><td>544240</td><td></td></tr><tr><td>Hem-o-lok Clip applier ML</td><td>Weck Surgical Instuments</td><td>544965</td><td></td></tr><tr><td>Hem-o-lok Clip applier L</td><td>Weck Surgical Instuments</td><td>544990</td><td></td></tr><tr><td>TKBAG 130 mm retrieval bag</td><td>G T.K Medical</td><td>HSD130</td><td></td></tr><tr><td>White filling 60 mm</td><td>Ethicon</td><td>GCFLGW</td><td></td></tr></tbody></table>

robotic duodenum-preserving total pancreatic head resection for intraductal papillary mucinous neoplasms

Robotic Duodenum-preserving Total Pancreatic Head Resection for Intraductal Papillary Mucinous Neoplasms

Robotic duodenum-preserving pancreatic head resection (R-DPPHR) is a technically feasible procedure for benign or borderline tumors of the pancreatic head. Among these, pancreatic cystic neoplasms (PCNs), particularly intraductal papillary mucinous neoplasms (IPMNs), are ideal candidates for this minimally invasive, organ-preserving approach. While numerous studies have demonstrated the short- and long-term advantages of DPPHR over conventional pancreaticoduodenectomy (PD), detailed video descriptions of the robotic-assisted procedure are scarce. This case report presents a step-by-step technical video of R-DPPHRt for a main duct-IPMN (MD-IPMN) in the pancreatic head. A 65-year-old male patient with upper abdominal discomfort was diagnosed with MD-IPMN, presenting as a 4.3 cm cystic-solid mass in the pancreatic head. R-DPPHRt was performed using the da Vinci Xi system, with an operation time of 350 minutes and an estimated blood loss of 150 mL. The patient had an uneventful postoperative course and was discharged on postoperative day 9. Pathology confirmed MD-IPMN with low-grade dysplasia. R-DPPHRt is an effective, function-preserving treatment for selected patients with pancreatic cystic neoplasms, particularly when performed by experienced surgeons in high-volume centers. While this single-case report limits generalizability, the article offers unique value by providing a clear procedural template.

A 65-year-old male presented with upper abdominal discomfort that worsened after meals. A 3.0 cm x 1.6 cm cystic-solid lesion in the pancreatic head was identified by contrast-enhanced CT and endoscopic ultrasound (EUS). The patient initially opted for surveillance. During follow-up, the lesion enlarged rapidly to 4.3 cm x 1.9 cm and developed an enhancing mural nodule (Figure 3). He had a seven-year history of diabetes and a normal body mass index (19.9 kg/m²). No evidence of distant metast...

This protocol presents robotic duodenum-preserving total pancreatic head resection (R-DPPHRt) for intraductal papillary mucinous neoplasms (IPMNs). A video demonstrates the technique in a patient with main duct-IPMN, highlighting its feasibility as a minimally invasive, organ-preserving alternative to pancreaticoduodenectomy.

Robotic duodenum-preserving pancreatic head resection (R-DPPHR) is a technically feasible procedure for benign or borderline tumors of the pancreatic ...

Introduction.Robotic duodenum-preserving total pancreatic head resection has many advantages over traditional pancreaticoduodenectomy in treating pancreatic cystic neoplasms, particularly intraductal papillary mucinous neoplasms.Protocol. Patient selection. Here we report a 65-year-old male patient diagnosed as intraductal papillary mucinous neoplasm by contrast enhanced computed tomography presenting as a 4.3 centimeter cystic solid mass with mural nodule in the pancreatic head.Operative setting. after the pneumoperitoneum is created following the five port technique to settle the trocars. Exploration phase.Incise the gastrocolic ligament inferior to the gastroepiploic vessels to open the lesser sac. Mobilize the stomach and pancreas. Reevaluate the lesion.Decide to conduct total duodenum-preserving pancreatic head resection. Dissection phase. Open the Kocher maneuver same as pancreaticoduodenectomy.Dissect along the inferior border of pancreas. Identify trunk of Henle along the superior mesenteric vein tributaries. Dissect and divide the right gastroepiploic vein.Lymphadenectomy of the lymph node group 8. Assess the extent of resection. Mark the border of transection.Transect the pancreas anterior to the portal vein. Avoid using electrocautery instruments to handle main pancreatic duct. Resect the margin of main pancreatic duct for frozen section pathology.Surround the superior mesenteric vein with a vascular retraction tape. Pull the tape to suspend superior mesenteric vein. Dissect along the superior mesenteric artery and the gastroduodenal artery on the anterior right border.Inject indocyanine green intravenously 30 minutes before imaging. Try to locate the common bile duct. Expose the inferior pancreaticoduodenal artery on the right side of superior mesenteric artery and superior mesenteric vein.Shut down the branches entering the tumor from inferior pancreaticoduodenal artery. Dissect distally along the gastroduodenal artery. Protect the common bile duct all the time.With help of indocyanine green imaging. Suture-ligate tumor-feeding vessels from the anterior superior pancreatic pancreaticoduodenal artery. Resect the margin of main pancreatic duct for frozen section pathology.Separate the tumor along the upper border of pancreas. Sacrifice the interior superior pancreaticoduodenal artery if necessary. Resect the pancreatic head and uncinate process, containing the lesion totally.Remove the surgical specimen inside a retrieval bag. Image with indocyanine green again to confirm the integrity of common bile duct. Reinforce the vascular stumps.Reconstruction phase. Incise the ligament of Treitz. Transect the jejunum 20 centimeters from the ligament of Treitz using linear cutter stapler.Lift the distal jejunum posterior to the colon. Pass through the pancreas from the ventral to the dorsal side. Suture to the seromuscular layer of the jejunum using 3-0 barbed sutures.Create a hole full-thickness through the jejunum. Perform a duct-to-mucosa anastomosis with interrupted 5-0 PDSs. Place a two times four millimeters internal stent into the main pancreatic duct.Suture the ventral seromuscular layer of the jejunum to the ventral side of the pancreas. Complete the knotting with the dorsal side suture. 40 centimeters distal to the previous anastomosis.Perform a side-to-side enterostomy using an electric cutting stapler. Close the common opening with 3-0 barbed sutures. Close the mesenteric defects.Place drains near the anastomosis and pancreatic stump. Complete the procedure and close the incisions.Results. Postoperative pathology revealed intraductal papillary mucinous neoplasm.Conclusion.Robotic total duodenum-preserving pancreatic head resection is a minimally invasive procedure for benign or low-grade malignant tumors of the pancreatic head. It can be an organ-preserving alternative to pancreaticoduodenectomy under specific conditions. This procedure should be performed by well-trained surgeons with extensive experience in robotic and pancreatic surgery.

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Research

JoVE Journal

Cancer Research

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Learn robotic duodenum-preserving total pancreatic head resection for intraductal papillary mucinous neoplasms. This minimally invasive technique preserves the duodenum and offers an organ-sparing alternative to pancreaticoduodenectomy.

Robotic Duodenum-preserving Total Pancreatic Head Resection for Intraductal Papillary Mucinous Neoplasms

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