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Surgery for Cancers of the Gastrointestinal Tract pp 131–145Cite as

Robotic Technique for Pancreaticoduodenectomy

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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.

Keywords

  • Pancreatic cancer
  • Robotic pancreaticoduodenectomy
  • Robotic whipple

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References

  1. Whipple AO, Parsons WB, Mullins CR. Treatment of carcinoma of the Ampulla of Vater. Ann Surg. 1935;102(4):763–79.

    CAS  PubMed Central  PubMed  CrossRef  Google Scholar 

  2. Whipple AO. Observations on radical surgery for lesions of the pancreas. Surg Gynecol Obstet. 1946; 82:623–31.

    CAS  PubMed  Google Scholar 

  3. Gagner M, Pomp A. Laparoscopic pylorus-preserving pancreatoduodenectomy. Surg Endosc. 1994;8(5): 408–10.

    CAS  PubMed  CrossRef  Google Scholar 

  4. Kendrick ML, Cusati D. Total laparoscopic pancreaticoduodenectomy: feasibility and outcome in an early experience. Arch Surg. 2010;145(1):19–23. doi: 10.1001/archsurg.2009.243.

    PubMed  CrossRef  Google Scholar 

  5. Palanivelu C, Rajan PS, Rangarajan M, Vaithiswaran V, Senthilnathan P, Parthasarathi R, et al. Evolution in techniques of laparoscopic pancreaticoduodenectomy: a decade long experience from a tertiary center. J Hepato-Biliary-Pancreat Surg. 2009;16(6):731–40. doi:10.1007/s00534-009-0157-8.

    CAS  CrossRef  Google Scholar 

  6. Narula VK, Mikami DJ, Melvin WS. Robotic and laparoscopic pancreaticoduodenectomy: a hybrid approach. Pancreas. 2010;39(2):160–4. doi:10.1097/MPA.0b013e3181bd604e.

    PubMed  CrossRef  Google Scholar 

  7. Giulianotti PC, Sbrana F, Bianco FM, Elli EF, Shah G, Addeo P, et al. Robot-assisted laparoscopic pancreatic surgery: single-surgeon experience. Surg Endosc. 2010; 24(7):1646–57. doi:10.1007/s00464-009-0825-4.

    PubMed  CrossRef  Google Scholar 

  8. Gagner M, Gentileschi P. Hand-assisted laparoscopic pancreatic resection. Semin Laparosc Surg. 2001;8(2): 114–25.

    CAS  PubMed  CrossRef  Google Scholar 

  9. Gagner M, Pomp A. Laparoscopic pancreatic resection: Is it worthwhile? J Gastrointest Surg. 1997;1(1): 20–5; discussion 5–6.

    CAS  PubMed  CrossRef  Google Scholar 

  10. Hanly EJ, Talamini MA. Robotic abdominal surgery. Am J Surg. 2004;188(4A Suppl):19S–26S. doi: 10.1016/j.amjsurg.2004.08.020.

    PubMed  CrossRef  Google Scholar 

  11. Gagner M, Palermo M. Laparoscopic Whipple procedure: review of the literature. J Hepato-Biliary-Pancreat Surg. 2009;16(6):726–30. doi:10.1007/s00534-009-0142-2.

    CrossRef  Google Scholar 

  12. Zeh 3rd HJ, Bartlett DL, Moser AJ. Robotic-assisted major pancreatic resection. Adv Surg. 2011;45: 323–40.

    PubMed  CrossRef  Google Scholar 

  13. Zureikat AH, Nguyen KT, Bartlett DL, Zeh HJ, Moser AJ. Robotic-assisted major pancreatic resection and reconstruction. Arch Surg. 2011;146(3):256–61. doi:10.1001/archsurg.2010.246.

    PubMed  CrossRef  Google Scholar 

  14. Zureikat AH, Moser AJ, Boone BA, Bartlett DL, Zenati M, Zeh 3rd HJ. 250 robotic pancreatic resections: safety and feasibility. Ann Surg. 2013; 258(4):554–9. doi:10.1097/SLA.0b013e3182a4e87c; discussion 9–62.

    PubMed  Google Scholar 

  15. Callery MP, Chang KJ, Fishman EK, Talamonti MS, William Traverso L, Linehan DC. Pretreatment assessment of resectable and borderline resectable pancreatic cancer: expert consensus statement. Ann Surg Oncol. 2009;16(7):1727–33. doi:10.1245/s10434-009-0408-6.

    PubMed  CrossRef  Google Scholar 

  16. Abrams RA, Lowy AM, O’Reilly EM, Wolff RA, Picozzi VJ, Pisters PW. Combined modality treatment of resectable and borderline resectable pancreas cancer: expert consensus statement. Ann Surg Oncol. 2009;16(7):1751–6. doi:10.1245/s10434-009-0413-9.

    PubMed  CrossRef  Google Scholar 

  17. Varadhachary GR, Tamm EP, Abbruzzese JL, Xiong HQ, Crane CH, Wang H, et al. Borderline resectable pancreatic cancer: definitions, management, and role of preoperative therapy. Ann Surg Oncol. 2006;13(8): 1035–46. doi:10.1245/aso.2006.08.011.

    PubMed  CrossRef  Google Scholar 

  18. Bassi C, Molinari E, Malleo G, Crippa S, Butturini G, Salvia R, et al. Early versus late drain removal after standard pancreatic resections: results of a prospective randomized trial. Ann Surg. 2010;252(2):207–14. doi:10.1097/SLA.0b013e3181e61e88.

    PubMed  CrossRef  Google Scholar 

  19. Cameron JL, Riall TS, Coleman J, Belcher KA. One thousand consecutive pancreaticoduodenectomies. Ann Surg. 2006;244(1):10–5. doi:10.1097/01.sla.0000217673.04165.ea.

    PubMed Central  PubMed  CrossRef  Google Scholar 

  20. Hatzaras I, Schmidt C, Klemanski D, Muscarella P, Melvin WS, Ellison EC, et al. Pancreatic resection in the octogenarian: a safe option for pancreatic malignancy. J Am Coll Surg. 2011;212(3):373–7. doi: 10.1016/j.jamcollsurg.2010.10.015.

    PubMed Central  PubMed  CrossRef  Google Scholar 

  21. Makary MA, Winter JM, Cameron JL, Campbell KA, Chang D, Cunningham SC, et al. Pancreaticoduodenectomy in the very elderly. J Gastrointest Surg. 2006;10(3):347–56. doi:10.1016/j.gassur.2005.12.014.

    PubMed  CrossRef  Google Scholar 

  22. Lai EC, Yang GP, Tang CN. Robot-assisted laparoscopic pancreaticoduodenectomy versus open pancreaticoduodenectomy—a comparative study. Int J Surg. 2012;10(9):475–9. doi:10.1016/j.ijsu.2012.06.003.

    PubMed  CrossRef  Google Scholar 

  23. Chalikonda S, Aguilar-Saavedra JR, Walsh RM. Laparoscopic robotic-assisted pancreaticoduodenectomy: a case-matched comparison with open resection. Surg Endosc. 2012;26(9):2397–402. doi:10.1007/s00464-012-2207-6.

    CAS  PubMed  CrossRef  Google Scholar 

  24. Buchs NC, Addeo P, Bianco FM, Ayloo S, Benedetti E, Giulianotti PC. Robotic versus open pancreaticoduodenectomy: a comparative study at a single institution. World J Surg. 2011;35(12):2739–46. doi:10.1007/s00268-011-1276-3.

    PubMed  CrossRef  Google Scholar 

  25. Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138(1):8–13. doi:10.1016/j.surg.2005.05.001.

    PubMed  CrossRef  Google Scholar 

  26. Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery. 2007;142(1):20–5. doi:10.1016/j.surg.2007.02.001.

    PubMed  CrossRef  Google Scholar 

  27. Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2007;142(5):761–8. doi:10.1016/j.surg.2007.05.005.

    PubMed  CrossRef  Google Scholar 

  28. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13.

    PubMed Central  PubMed  CrossRef  Google Scholar 

  29. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187–96. doi:10.1097/SLA.0b013e3181b13ca2.

    PubMed  CrossRef  Google Scholar 

  30. Fang WL, Su CH, Shyr YM, Chen TH, Lee RC, Tai LC, et al. Functional and morphological changes in pancreatic remnant after pancreaticoduodenectomy. Pancreas. 2007;35(4):361–5. doi:10.1097/MPA. 0b013e3180d0a8d5.

    PubMed  CrossRef  Google Scholar 

  31. You DD, Choi SH, Choi DW, Heo JS, Ho CY, Kim WS. Long-term effects of pancreaticoduodenectomy on glucose metabolism. ANZ J Surg. 2012;82(6):447–51. doi:10.1111/j.1445-2197.2012.06080.x.

    PubMed  CrossRef  Google Scholar 

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Author information

Authors and Affiliations

  1. Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Bhavin C. Shah M.D., Amer H. Zureikat M.D., Herbert J. Zeh III M.D. & Melissa E. Hogg M.D.

Authors
  1. Bhavin C. Shah M.D.
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  2. Amer H. Zureikat M.D.
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  3. Herbert J. Zeh III M.D.
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  4. Melissa E. Hogg M.D.
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Corresponding author

Correspondence to Melissa E. Hogg M.D. .

Editor information

Editors and Affiliations

  1. Division of Surgical Oncology, City of Hope, Los Angeles, California, USA

    Joseph Kim

  2. Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA

    Julio Garcia-Aguilar

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

In this video, the surgeon demonstrates his approach to robotic pancreaticoduodenectomy. (WMV 236334 kb)

Key Operative Steps

Key Operative Steps

  1. 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. 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. 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. 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. 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. 6.

    Removal of Hepatic Artery Lymph Node (Robotic).

  7. 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. 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. 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. 10.

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

  11. 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. 12.

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

  13. 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. 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. 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.

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Shah, B.C., Zureikat, A.H., Zeh, H.J., Hogg, M.E. (2015). Robotic Technique for Pancreaticoduodenectomy. In: Kim, J., Garcia-Aguilar, J. (eds) Surgery for Cancers of the Gastrointestinal Tract. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-1893-5_12

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  • DOI: https://doi.org/10.1007/978-1-4939-1893-5_12

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