Robotic Technique for Pancreaticoduodenectomy

Abstract

While the robotic approach to pancreaticodudenectom is relatively new, this approach is not limited by many of the issues faced with the laparoscopic technique. There are better optics and imcreased maneverability, dexterity, abd precision with difficult tasks. Intial studies have confirmed the safety and feasibility of robotic pancreatocduodenectomy (RPD) and early reports have shown that outcomes are comparable to the open approach. At our institution, we frequently use laparoscopy for the intial mobilization steps, but complete the ajority of the resection and all of the reconstruction robotically. In this chapter, we describe our approach to RPD in detail with the necessary considerations for each step.

Key Operative Steps

• 1. “The Trick Move” (Laparoscopic): This is when the lesser sac is exposed and dissection proceeds in the avascular plane that separates the transverse mesocolon from the right gastroepiploic pedicle and then continues laterally to separate the hepatic flexure mesocolon from Gerota’s fascia. This step begins the exposure to the head of the pancreas.

• 2. “The ‘A-Ha’ Moment” (Laparoscopic): This occurs when the last fibers of the ligament of Treitz are divided and the jejunum comes into view. This allows mobilization of the jejunum into the RUQ.

• 3. “Doing Our Homework” (Laparoscopic): When the jejunum is stapled and the mesentery of the small bowel is divided, this dissection extends from the mesentery caudally to the duodenal attachments and pancreas cephalad. These maneuvers facilitate the subsequent robotic dissection of the SMV and uncinate.

• 4. “Confirming Our Orientation” (Laparoscopic): Endo Stitch is used to place sutures to orient the jejunum and secure the bowel to the stomach. This is a critical time saving maneuver to ensure an isoperistaltic orientation of the bowel for the gastrojejunal anastomosis.

• 5. “Graduation” (Laparoscopic): This step is the closure of the 12-mm camera port with a figure-of-eight Carter Thomason 0-polysorb suture. This step will eliminate the need to reinsert a laparoscope at the end of the robot procedure to close this port site.

• 6. Removal of Hepatic Artery Lymph Node (Robotic).

• 7. Robotic Dissection of Porta Hepatis (Robotic): These steps allow for identification of a replaced right hepatic artery, initiation of portal lymph node dissection, identification of the right lateral aspect of the portal vein, and creation of a “landing zone” for subsequent common bile duct isolation.

• 8. Identifying the Proximal and Distal SMV (Robotic): Prior to ligating the right gastroepiploic vein or any other major vein, it is of critical importance to make sure the superior mesenteric vein is safe by visualizing it above and below the gastroepiploic vein.

• 9. Umbilical Tape Around Pancreatic Neck (Robotic): R3 is used to lift the pancreas and retract it up and to the right, which allows for optimal exposure of the pancreatic neck.

• 10. “The First Jejunal” (Robotic): This vein is saved whenever possible, but its tributaries that course back and enter the uncinate are divided.

• 11. “Up and Out” (Robotic): R3 is used to lift the specimen up and out like the left hand of the surgeon during an open case. This is a critical step to provide optimal exposure during the uncinate dissection. R3 may need to be continuously adjusted as the dissection progresses from the inferior to superior.

• 12. Pancreaticojejunostomy (Robotic): Keeping the needles of the three 2–0 silk stitches on for the final buttress layer.

• 13. Hepaticojejunostomy (Robotic): The v-lock suture has barbs that do not catch the tissue on the first pass. When this suture is used, the second stitch needs to be placed very close to the first stitch so the barb catches and there is not a gap.

• 14. Gastrojejunostomy (Robotic): When the corners are sewn using the v-lock, it is important to take full-thickness bites; however, extreme caution must be used to take small bites to avoid kinking or narrowing the efferent or afferent limbs.

• 15. Teamwork (Robotic): The true key to this technique is a combined understanding, effort, and teamwork between two experienced robotic pancreatic surgeons. To expose key anatomic structures and perform a delicate, vascular dissection requires great coordination between the laparoscopic assistant and robotic surgeon.