Technical Detail for Robot Assisted Pancreaticoduodenectomy

The manuscript describes a technique for robotic-assisted pancreaticoduodenectomy. The represented patient is a 42-year-old female with a prior history of IPMN, who presented with an acute onset of pancreatitis. Diagnostic imaging including CT scan, and endoscopic ultrasound revealed a complex septated heterogenous mass measuring 3.3 centimeters.

Biochemical workup was normal. She was recommended for robotic RAPD. Patient is positioned in a supine position on a split-leg table with right arm tucked, and pressure points padded.

The operating table is turned 45 degrees to accommodate for the Si robot. Xi robot can be docked from the side. The robotic and assistant ports are placed in correspondence with the figure.

The liver retractor is placed to the leftmost lateral port. The liver retractor works best if it retracts the gallbladder, and lifts the liver superiorly during the entirety of the resection. The resection phase is initiated with the entrance into the lesser sac.

The access into the lesser sac through the greater omentum below the gastroepiploic pedicle is performed. The assistant provides a gentle caudal counter-retraction. The dissection is carried along the greater curvature towards the pylorus.

The colon is fully mobilized off the duodenum. The gastroepiploic pedicle is preserved, and is not transected at this point. Kocherization of the duodenum is performed.

The lateral fibers of duodenum are grasped and transected. The bedside assistant provides a gentle medial counter-retraction of the duodenum. Mobilization of the duodenum including its third and fourth portion is carried to the ligament of Treitz.

Dynamic anterior and cranial retraction of the duodenum with A3 is key to an excellent exposure. Extensive kocherization allows for full visualization of the inferior vena cava, insertion of the left renal vein, and the aorta. The complete release of ligament of Treitz allows for exposure of proximal jejunum.

The jejunum is then extracted through the ligament of Treitz defect into the right superior colic upper quadrant. Next, the jejunum is measured out approximately 10 centimeters distal to the ligament of Treitz. The mesenteric vessels are taking with a vessel sealing device.

Utilizing a linear vascular stapler, the jejunum is transected. Linearization of the duodenum is performed in a sequential ligation of the mesenteric vessels of the proximal jejunum up to the uncinate process. The pars flaccida is open, and the care is taken not to enter the aberrant left hepatic artery.

The transection point of the stomach is taken approximately five centimeters proximal to the pylorus. The right gastroepiploic vessels are ligated utilizing the vessel sealer device. The stomach is then transected utilizing a thick linear stapler load.

The right gastric artery is ligated with laparoscopic titanium vascular 10 millimeter clips close to its takeoff from the proper hepatic artery. It is then ligated utilizing the blunt tip vessel sealing device. A3 grabs the distal gastric staple line, and retracts the specimen laterally and inferiorly putting the common hepatic artery, and the porta hepatis under tension.

The dissection continues through the superior border of the pancreas, and into the porta hepatis. The common hepatic artery lymph node is identified and resected. It is retrieved with a 10 millimeter laparoscopic specimen retrieval bag, hence, sent for permanent pathologic analysis.

This allows for full visualization of the gastroduodenal artery. The gastroduodenal artery is identified at the takeoff from the common hepatic artery. The robotic hook cautery is utilized to fully circumferentially dissect the gastroduodenal artery.

A vessel loop is passed around the GDA. The GDA is transected with a vascular stapler. The proximal stump is reinforced with a laparoscopic titanium vascular 10 millimeter clips.

The portal vein is dissected for a two-to-three centimeters in the cephalic direction. The plane between the common bile duct, and the portal vein is identified and developed posteriorly. The common bile duct is transected with a 60 millimeter curved tip vascular linear stapler above the level of the biliary stent.

The lateral border of the portal vein is further dissected utilizing the robotic hook cautery. The superior pancreaticoduodenal artery is often encountered, and is ligated utilizing the assistant's blunt tip vessel sealing device. The superior to inferior dissection of the portal vein continues to the superior border of the pancreas.

This dissection allows for exposure of the superior tunnel. A3 grabs and retracts the distal gastric staple line laterally and cephalic to put the gastroepiploic vein on a stretch as it enters the interior SMV. The fatty tissue near the pancreatic inferior border is opened utilizing the electric cautery.

The SMV is now visualized. The assistant provides gentle dissection to make the inferior tunnel. The right gastroepiploic vein is traced to its insertion in the SMV.

It is dissected, vessel loop is placed, and is ligated utilizing assistant's blunt tip vessel sealing device. A3 now retracts the specimen at the distal gastric staple line laterally to put the pancreatic neck on a stretch. The pancreatic parenchyma is transected utilizing the monopolar curved scissors with electric cautery.

Care is taken to identify the main duct. The assistant provides an anterior lift of the pancreas off the SMV during the parenchymal transection. The main pancreatic duct is transected utilizing scissors without electric cautery.

Four to five French pancreatic duct stent is placed into the main duct to ensure its identification. The remaining pancreatic parenchyma is transected utilizing electric cautery. This portion of the resection requires slow, meticulous dissection as significant hemorrhage may occur in the absence of operator precision.

The key to head an uncinate dissection during this phase is A3, which provides superior and lateral retraction of the specimen. A3 is dynamic during the resection, and requires frequent assessment of its placement. The uncinate process consists of three distinct layers.

The first layer consists of filamentous fibers between the SMV portal vein, and the pancreatic head, and uncinate process. A1 is replaced with hook cautery which is mainly utilized for its dissection. The second layer consists of first jejunal vein, the vein of Belcher, and the uncinate branches.

A1 and assistant blunt tip vessel sealing device is mainly utilized for dissection and ligation. The third layer is the SMA retroperitoneale margin. The SMV and portal vein is rotated immediately with A2 by the assistant.

The assistant's vessel sealing device is utilized for this ligation. Pancreaticojejunostomy is performed in a two-layer, end-to-side, duct to mucosa, in a modified Blumgart technique. A3 is often utilized to grab the previously placed sutures to provide cranial retraction and exposure.

Two all-silk trans-pancreatic horizontal mattress sutures are placed to secure the pancreatic parenchyma to the jejunum. Three sutures are placed, one above which is shown here, one below, and one straddling. All three sutures are tied, and the needles are kept on the suture.

Care is taken when tying the middle suture which straddles the main pancreatic duct to avoid accidental ductal ligation. The pancreatic duct stent is typically utilized to interrogate the patency of the duct. A1 is then switched to a monopolar scissors which is utilized to perform the enterotomy.

This is then replaced to the needle driver. Interrupted 5-0 PDS sutures are utilized to approximate the jejunum mucosa to the pancreatic duct. A minimum of six sutures can always be placed.

More sutures can be placed if the duct size is larger. The pancreatic duct stent is then fit through the enterotomy, prior to the placement of the anterior 5-0 PDS sutures. Once the anastomosis is complete, the same 3-0 silk sutures that were previously utilized to place the posterior layers are re-utilized for anterior layer of the pancreaticojejunostomy.

Hepaticojejunostomy is performed approximately 10 centimeters distal to the pancreaticojejunostomy. The anastomosis is performed in a single layer, either in interrupted or running fashion. A1 with monopolar curved scissors is used to transect a common bile duct staple line.

The bile grasping forceps are utilized to bring the jejunum closer to the common bile duct. A1 is re-armed with monopolar curved scissors, and is utilized to make the enterotomy. The anastomosis is performed using 5-0 PDS sutures in an interrupted fashion for ducts with diameter less than one centimeter.

For larger ducts, two running 4-0 barbed sutures are utilized in a single layer continuous fashion. For interrupted anastomosis, the posterior sutures are first placed and tied. For ducts less than one centimeter in size, we often employ a four-to-five French biliary stent to keep the patency of the anastomosis.

Next, additional 5-0 PDS sutures are placed to complete the anterior anastomosis. Once all the sutures are placed, the sutures are tied, and the anastomosis is complete. The gastrojejunostomy is a hand-sewn, anti-colic end-to-side isoperistaltic anastomosis.

Two, 3-0 silk marking stitches are placed on the jejunum approximately 40 to 60 centimeters distal to the hepaticojejunostomy. This marks the proximal and distal, denoting afferent and efferent limbs of the jejunum. A1 and A2 are replaced with bar grasping forceps.

The laparoscopic assistant reflects the omentum and the mesocolon cephalad which allows for the surgeon to locate the neoduodenum. The distal jejunum is then reduced, and placed back into infracolic compartment. The two marking stitches are identified, and the jejunum is brought in an anti-colic, isoperistaltic fashion up to the stomach.

The A1 and A2 are replaced with large dual-functioning needle drivers. An interrupted outer layer with two all-silk sutures are placed. The most cephalus suture is held by A3, and utilized as a retraction suture.

A1 is replaced with monopolar curved scissors. This is utilized to transect a gastric staple line. The scissors is also utilized to place the enterotomy in the jejunum.

The anastomosis is performed utilizing two, 3-0 barbed sutures in a running canal fashion. Interrupted outer layer with 2-0 silk sutures are placed to complete the gastrojejunostomy. Following the completion of the anastomosis, a 19-French round channel drain is placed anterior to the pancreaticojejunostomy and hepaticojejunostomy.

A false form ligament flap is utilized to cover the GDS stump. The instruments are removed and the robot is undocked. The fascia and incisions are closed in layers.

The total operative time was 225 minutes, estimated blood loss was 25 mLs, there was no post-operative complications. The final pathology revealed invasive moderately-differentiated adenocarcinoma arising from branch duct IPMN. The manuscript provides the detailed steps of a robotic-assisted pancreaticoduodenectomy, as performed at the University of Pittsburgh Medical Center.