Name: application of end-to-end anastomosis in robotic central pancreatectomy
Uploaded: 2018-06-02T13:30:00.000+00:00
Duration: 10 min 58 s
Description: Watch this Scientific Journal Video about Application of End-to-end Anastomosis in Robotic Central Pancreatectomy at JoVE.com

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从病人那里获得书面知情同意, 以便发表本报告以及随附的视频和图像。
1. 术前准备
<ol><li>仔细评估 CT 或 MRI 对肿瘤的确切位置及其与周围组织的关系的术前图像。</li>
	<li>在手术前一天给病人一个软饮食, 在手术前的午夜开始禁食。</li>
	<li>把病人放在手术台上。然后, 放置一个外周静脉导管, 并通过标准程序诱发全身麻醉。介绍一种中心静脉导管, 通过右颈内静脉的药物治疗液和外周动脉导管的血压监测。</li>
</ol>2. 病人的位置和口岸安置
<ol><li>将病人置于仰卧位, 向健与腿分开。上腹部手术的正常不育时尚的悬垂。</li>
	<li>将外科医生控制台放在病人的左侧。将病人推车放在病人头上, 并分别放在病人右侧的视车上。让助理外科医生站在病人的腿之间进行手术。在助手的左后方, 定位仪器和耗材的后表 (请参阅材料表)。</li>
	<li>做一个1厘米切口与手术刀3厘米下位和右侧的脐。通过本切口将 Veress 针插入腹腔内, 并用自动喷洒仪建立 CO2气腹 14 mmHg。</li>
	<li>取出 Veress 针, 然后插入一个12毫米套管针通过1厘米的切口作为相机端口。插入机器人内窥镜, 并进行诊断腹腔镜检查 (有助理外科医生持有机器人内窥镜), 以确认腹部粘连状态和手术可行性。在内窥镜的视野下插入余下的4套管针。</li>
	<li>将8毫米的套管针放在左前腋窝线 (图 2) 中, 用于第一个机械手的脐层。放置一个12毫米套管针2厘米下位和左侧的脐 (图 2) 作为辅助端口。</li>
	<li>将12毫米的套管针放在脐层的右锁骨中线线 (图2) 中。将8毫米套管针插入这个12毫米套管针, 用 "套管套管针" 的方式为第二个机械手。为第三个机械手 (图 2) 放置一个8毫米的套管针, 位于右侧腋窝线的肋边。机器人部队对接后, 将机器人内窥镜停靠在相机臂中。</li>
</ol>3. 胰腺颈部和身体的动员
<ol><li>在第三个机械手上抓住并继续用镊子把胃前壁抬高, 露出 gastrocolic 韧带。</li>
	<li>将 gastrocolic 韧带与第二臂机械手中的双极钳和助手手中的抓钳拉紧。将 gastrocolic 韧带分成小囊, 用腹腔镜超声刀将胰腺前表面暴露在第一个机械手上。在第二个机械手上进行双极钳止血, 直至达到右胃网膜静脉的水平。</li>
	<li>用烧灼钩仔细解剖胰颈的上、下方向。从下等向上级方向, 从门静脉 (PV)、肠系膜上静脉 (SMV)、下肠系膜静脉 (IMV)、脾静脉 (SV) 与烧灼钩分离出胰颈后壁。之后, 在 SMV-IMV-SV 和胰颈后壁之间建立一个隧道。</li>
	<li>用烧灼钩和超声刀解剖胰体从脾脏血管和结缔组织向胰尾。</li>
</ol>4. 胰腺实质的横断
<ol><li>通过辅助套管插入腹腔镜超声探头, 对胰腺进行超声检查, 确认病灶的位置和大小。根据超声检查结果, 将两条横断线从病变处的1厘米处标记, 在胰腺表面用烧灼钩。</li>
	<li>用钳插入胰腺的下缘, 用烧灼钩或超声波手术刀将胰体的近端从脾血管和结缔组织中分离出来。</li>
	<li>将胰颈和近端胰腺体形成后血管和组织后, 用超声刀切开远端和近端横断线的胰腺实质, 并暴露胰管。然后对胰管周围的软组织进行横断面。</li>
	<li>小心保护和动员胰管从横断的胰腺实质。然后, 用腹腔镜剪刀从辅助口, 将胰管从树桩上尖锐地横断面1厘米远。</li>
</ol>5. 胰腺连续性的重建
<ol><li>为了减少吻合的张力, 用烧灼钩和双极钳进一步调动后血管和结缔组织的胰残端。</li>
	<li>根据胰管树桩的大小, 选择一个直径为10厘米的塑料胰腺支架 (直径为1.2 毫米)。将支架的两端切向斜面, 并进行多侧穿孔。通过辅助端口将支架植入腹腔。</li>
	<li>用微钳将胰管残端的侧壁放在胰体中, 并轻轻地将针驱动器夹住的支架插入远端胰管残端。用5-0 可吸收缝线缝合胰管, 使支架紧密包围胰管。</li>
	<li>使用类似的方法, 但不缝合, 将支架的另一端插入到近端胰管残端。</li>
	<li>用水平床垫缝合 (4-0 不可吸收缝合) 缝合近端和远端胰树桩。</li>
	<li>将两个胰树桩拉近, 继续将支架的近端插入近端胰管树桩。最后, 将整个支架放在胰管内, 不要将其带入十二指肠腔内。</li>
	<li>用5-0 不可吸收缝线进行间断缝合, 对胰管树桩端到端吻合。</li>
	<li>把剩下的领带结在胰树桩上。</li>
	<li>用4-0 不可吸收缝线缝合连续缝合胰树桩的前部 (图 3)。</li>
</ol>6. 止血和引流
<ol><li>仔细检查出血部位并进行彻底止血。用可吸收止血纱布包围吻合部位。</li>
	<li>将切除后的标本放在塑料袋中, 从照相机端口的扩大切口取出袋子。</li>
	<li>将两个排水管沿吻合部位的上、下边界放置, 并从该端口提取出第三个机械手臂的排水管。</li>
</ol>7. Posteoperative 护理
<ol><li>术后, 给予患者静脉注射抗生素 (头孢曲松钠), 肠外营养 (葡萄糖, 复方维生素, 复方氨基酸, 脂肪乳剂, 胰岛素, 氯化钾, 氯化钠), 镇痛 (舒芬太尼, 恩丹西酮), 生长抑素, 质子泵抑制剂 (兰索拉唑) 和其他治疗一样的常规中央 pancreaticectomy。保持患者禁食, 然后取出胃管, 并在 2nd术后一天喂清楚的液体饮食。如果病人能忍受的话, 逐渐过渡到正常饮食。</li>
	<li>在 3rd术后一天测试淀粉酶和细菌培养的排泄液。如果没有胰腺瘘和感染的证据, 并且排泄量小于10毫升/天, 则清除排水管。</li>
</ol>

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没有竞争的金融利益存在。

恶性肿瘤位于胰颈和胰体近端, 常以胰十二指肠切除或远端胰腺治疗。然而, 对于良性或低恶性潜在肿瘤的那些部位, 标准的胰十二指肠切除术或远端胰腺将清除过多的正常组织, 并导致过度的伤害。因此, 中央胰腺或胰腺摘除, 称为 "实质保留胰腺", 成为治疗良性和低恶性潜在肿瘤的胰腺颈部和身体的首选选择。
早在 1908, Ehrhardt 报告了中央胰腺15。目前, 最常用的重建胰肠连续性后, 中央胰腺如下: (1) 过度缝合的近端胰腺残余和执行 pancreaticojejunostomy 的远端胰腺残余;(2) 过度缝合胰腺的近端残留物, 并对远端胰腺残余物执行 pancreaticogastrostomy。这两种重建方法确保了吻合的适当张力。然而, 它们扰乱了消化道的解剖连续性, 改变了胰腺的外分泌通路。由于 pancreaticojejunostomy 的肠道果汁可以激活胰腺酶, 所以在中枢胰腺中, C 型胰腺瘘的可能性相对较高, 因此短期并发症如出血也增加8,16。此外, 由于胰残端直接接触 pancreaticogastrostomy 中的胃液, 酶可以被灭活, 从而在理论上改善吻合的侵蚀。但它也可能导致胰腺外分泌不足, 并长期危害患者的营养状况9,10。
作为一种很少使用的方法, 端到端吻合的胰树桩可能解决上述重建方法的缺点;它不需要 pancreaticoenteric 吻合, 并能保持消化道的完整性和连续性。它还可以保持胰腺汁分泌的原始生理结构。然而, 可能是由于其技术复杂性, 报告只有少数开放的中央胰腺与端到端吻合的情况, 并且此方法未连续应用17,18,19, 20。
作为微创外科最先进的代表, 机器人手术系统已应用于中央胰腺, 目前的重建方法是过度缝合的近端胰腺残余和执行pancreaticojejunostomy 或 pancreaticogastrostomy 为远端胰腺残端6,21,22,23。我们的外科团队在机器人胰十二指肠切除, 中央胰腺和远端胰腺13,24有丰富的经验。我们还进行了机械胰腺摘除术与主要胰管侵袭和伤害。在该手术中, 我们通过插入胰腺支架和使用端到端吻合14来修复胰管损伤。根据我们在机器人胰腺手术方面的经验, 我们改进了传统的机器人中心胰腺端到端吻合术, 以最大限度地利用残余的胰腺实质和 minimalize 对患者的伤害。
目前, 我们使用机器人手术系统执行中央胰腺和重建胰腺的连续性通过胰管成形术和端到端胰腺吻合。我们发现, 短期的结果是有利的。由于机器人手术系统具有放大的3维视图, 多自由度运动的仪器, 消除生理颤动等特点, 这一手术系统显示的内在优势, 在解剖,胰管的整形和吻合术。与常规重建方法相比, 该方法避免了胰远端 pancreaticoenteric 吻合, 缩短了手术时间, 减少了损伤。两个胰树桩的直接吻合避免了胰残端与消化液接触, 理论上可以降低胰瘘和出血的风险。支架的放置也使胰管的吻合更加安全和快速。此外, 支架的持续支持也有助于预防胰管术后狭窄。另一方面, 即使胰腺瘘发生, 胰腺液可以通过支架进入十二指肠, 而不是在胰腺外流动, 从而减少胰腺瘘对周围器官的损伤。由于支架被缝合到胰管与可吸收缝合, 支架将自发脱落在几个月内。
手术的关键步骤是胰管与软组织吻合, 无张力。为实现无张力吻合, 应充分调动胰树桩的后血管和组织, 特别是远端残端。应注意的是, 胰管的横断是用剪刀代替能量仪器来完成的, 这样可以减少胰管的损伤, 并有助于更好的导管与导管吻合。另外, 胰管的树桩应该尽可能地从切除的胰腺中解剖。对于胰腺支架, 我们通常通过手术中心对不同直径和长度的塑料管进行消毒, 并在手术过程中选择正确的尺寸。
我们发现, 在某些患者中, 端到端吻合的机器人中心胰腺是安全可行的。该手术方法降低了中心胰腺的范围, 保持了生理学和解剖学的完整性和连续性, 反映了胰腺外科机器人手术系统的微创特征。由于该手术处于初期阶段, 许多问题尚不清楚, 如如何合理使用生长抑素术后;对于胰管长缺损的患者, 是否应选择中心胰腺;如果支架不自发脱落, 什么是副作用,等等它的技术修改和长期功效还有待探讨。

中央胰腺正在越来越多地进行治疗的良性或低恶性潜在肿瘤位于胰腺颈部或近端的胰腺体1。与胰十二指肠切除或远端胰腺相比, 中枢胰腺切除掉组织少, 保存胰腺实质和功能。目前, 胰腺重建的主要方法是过度缝合头胰残端, 并执行 pancreaticojejunostomy 或 pancreaticogastrostomy 到远端残端2,3。这两种方法广泛应用于开放, 腹腔镜和机器人中心 pancreatectomies4,5,6,7。然而, 上述两种重建方法打破了消化道的解剖连续性和胰腺液排泄的途径。胰残端与肠道果汁直接接触可能增加出血和瘘管的可能性8。虽然胃液可以不活跃的胰腺酶, 以避免吻合的侵蚀, 它可能导致胰腺外分泌不足, 并长期危害患者的营养状况9,10。
随着微创手术的发展, 机器人手术在其3维放大视图、稳定性和运动灵活性、等等方面显示了巨大的优势, 为吻合术提供了增强的解剖缝合能力和止血11,12。根据我们在机器人胰腺和修复受伤的胰管的经验13,14, 我们已经执行了一系列的机器人中心胰腺端到端吻合, 看到良好的结果。与 pancreaticojejunostomy 或 pancreaticogastrostomy 相比, 端到端胰腺吻合避免了消化道损伤;因此, 理论上减少了 pancreaticoenteric 瘘的可能性。但另一方面, 端到端的胰腺吻合造成了更大的技术困难。作为常规中央胰腺的更新, 常规中央胰腺的候选者也有资格参加这项手术。在此, 我们介绍了在本视频案例演示中, 在第三个 hepatopancreatobiliary 中心进行端到端吻合的机器人中心胰腺的操作技术。
迹象:
(1) 位于胰颈及近体的良、低恶性电位肿瘤适用于本手术。 (2) 主胰管的缺损在中央胰腺后应小于5厘米, 肿瘤大小不是重建的主要关注。
案例演示:
病人是一名31岁的男子。2年前在一次体检中无意中发现了胰腺颈部的病变。他进行了定期复查, 发现病灶最近 asymptomatically 扩大。他以前没有做过腹部手术的病史。在体检中, 没有积极的迹象存在。胰腺 MRI 表现为大约14毫米的胰腺颈部的准圆形病变;这被推定为神经内分泌肿瘤。在 T1 和 T2-weighted 成像方面, 病灶分别显示 hypointense 和 hyperintense 信号。在扩散加权成像中, 病灶显示 hyperintense 信号。病变在动脉期略有增强, 在实质阶段和延迟阶段显示了渐进增强模式 (图 1)。重度脂肪肝也由 MRI 诊断。胰管未发现扩张或狭窄。常规血液检查、IgG 异构体试验、肿瘤生物标志物、心电图和胸部 x 线均正常。生化试验显示, 在 53.9U/l 的 147.3 U/升和 AST (天门冬氨酸转氨酶) 轻微升高, 可能是由脂肪肝引起。

<table><tbody><tr><td>da Vinci Robotic Surgical System</td><td>Intuitive&amp;nbsp;Surgical, USA</td><td>Si</td><td></td></tr><tr><td>EndoWrist Permanent Cautery Hook</td><td>Intuitive&amp;nbsp;Surgical, USA</td><td>420183</td><td></td></tr><tr><td>Harmonic Ace Curved Shears</td><td>Ethicon, USA</td><td>420275</td><td></td></tr><tr><td>EndoWrist Large needle Driver</td><td>Intuitive&amp;nbsp;Surgical, USA</td><td>420006</td><td></td></tr><tr><td>EndoWrist Cadiere Forceps</td><td>Intuitive&amp;nbsp;Surgical, USA</td><td>420049</td><td></td></tr><tr><td>EndoWrist Black Diamond Micro Forceps</td><td>Intuitive&amp;nbsp;Surgical, USA</td><td>420033</td><td></td></tr><tr><td>Lapro-Clip 8 mm Absorbable Clips</td><td>Covidien&amp;nbsp; , USA</td><td>8886848882</td><td></td></tr><tr><td>5-0 non-absorbable suture</td><td>Ethicon, USA</td><td>M8717</td><td></td></tr><tr><td>4-0 non-absorbable suture</td><td>Ethicon, USA</td><td>D9775</td><td></td></tr><tr><td>5-0 absorbable suture</td><td>Ethicon, USA</td><td>D9943</td><td></td></tr><tr><td>Absorbable hemostas</td><td>Ethicon, USA</td><td>W1912</td><td></td></tr><tr><td>Laparoscopic Ultrasound Probe</td><td>BK Ultrasound, Denmark</td><td>8666-RF</td><td>transducer contact surface: 30*5mm; Frequence: 4.3-10 MHz</td></tr><tr><td>Pancreatic stent</td><td>Yaxin Medical, Suzhou, China</td><td>1.2 mm&amp;nbsp;</td><td></td></tr><tr><td>Antibiotics&amp;nbsp;(ceftriaxone sodium for injection)</td><td>Roche, Shanghai, China</td><td>H10983036</td><td>ceftriaxone sodium (2g) adding to normal saline (100ml), once per day.</td></tr><tr><td>Proton pump inhibitors (lansoprazole injection)&amp;nbsp;</td><td>Luoxin Pharmaceutical, Linyi, China</td><td>H20055118</td><td>lansoprazole injection (30 mg) adding to normal saline (100ml), twice per day.</td></tr><tr><td>Somatostatin (Somatostatin for injection)</td><td>Merck Serono, Germany</td><td>H20090929</td><td>Somatostatin for injection (6000ug) adding to nornal saline to a total of 48ml, 2 ml/h</td></tr><tr><td>&lt;strong&gt;Analgesic&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Analgesic (sufentanil Citrate injection)</td><td>Humanwell Healthcare, Fuzhou, China</td><td>H20054171</td><td>sufentanil Citrate (200ug),&amp;nbsp; Ondansetron hyrochloride (20mg), adding to normal saline to a total of 80 ml, 1 ml/h</td></tr><tr><td>Analgesic (Ondansetron hyrochloride injection)</td><td>Qilu Pharmaceutical, Hainan, China</td><td>H10970065</td><td>sufentanil Citrate (200ug),&amp;nbsp; Ondansetron hyrochloride (20mg), adding to normal saline to a total of 80 ml, 2 ml/h</td></tr><tr><td>&lt;strong&gt;Parenteral nutrition&amp;nbsp;&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Parenteral nutrition(Compond vitamin injection)</td><td>Pude Pharmaceutical, Datong, China</td><td>H20093720</td><td>1 piece</td></tr><tr><td>Parenteral nutrition(Compond amino acid injection)</td><td>Kelun Pharmaceutical, Chengdu, China</td><td>H20066058</td><td>500 ml</td></tr><tr><td>Parenteral nutritionz(Fat emulsion injection)</td><td>Fresenius Kabi AB, Sweden</td><td>H20160019</td><td>250 ml</td></tr><tr><td>Parenteral nutrition(10%KCl injection)</td><td>Jinyao Pharmaceutical, Tianjin, China</td><td>H12020518</td><td>50 ml</td></tr><tr><td>Parenteral nutrition(10%NaCl injection)</td><td>CR, Double-Crane, Beijing, China</td><td>H11020865</td><td>50 ml</td></tr><tr><td>Parenteral nutrition(Insulin injection)</td><td>No.1 biochemical and pharmaceutical, Shanghai, China</td><td>H31020519</td><td>28 Unit</td></tr></tbody></table>

application of end-to-end anastomosis in robotic central pancreatectomy

中心胰腺进行治疗的良性或低恶性潜在肿瘤位于胰腺颈部或近端的胰腺体。随着技术的发展, 机器人手术系统在微创手术中显示出了优势, 并越来越多地应用于中心胰腺。然而, 在机器人中心胰腺后, 用端到端吻合术重建胰腺的连续性尚未得到应用。在本研究中, 我们报告的手术技术的机器人中心胰腺与端到端吻合。胰管经导管与导管吻合术重建胰腺, 胰管置入胰管内两树桩, 胰实质端到端吻合。与传统的中央胰腺 pancreaticoenteric 吻合术相比, 该方法降低了患者的手术损伤, 同时也能有效的维持消化道和胰管的完整性和连续性。机器人手术系统结合多器械灵活、精确的运动, 特别适用于胰管的解剖和重建。我们发现, 机器人中心胰腺端到端吻合是安全可行的, 我们需要更多的经验来评估其最佳适应症和远期结果。

操作过程顺利。手术时间为141分钟, 术中失血约50毫升。切除的胰腺的大小约为 5.5 x 2.5 x 2.5 厘米 (图 4)。病人在手术后顺利康复, 并于 6th术后出院。当病人出院时, 他有正常的饮食和正常的排便, 没有发烧, 没有腹痛或腹胀。常规血液检查和血液生化检查无明显异常。Postopertative CT 扫描显示胰腺周围有轻微渗出, 胰管没有扩张或狭窄 (图 5)。腹部排泄量约为100毫升/天。病理检查证实有阴性 pseudopapillary 肿瘤, 免疫组化试验表明肿瘤为 B 连环 (细胞核和胶囊 +), PR (升 60%), 波形 (+), CD10 (-), (+), syn (+), CK (焦距 +), CD56 (+),ki-67 (2%)。在 20th的术后一天内清除了排水管。
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/57495/57495fig1.jpg"> 图 1: 患者的术前 MRI.红色箭头表示胰腺颈部的准圆形病变。<a href="/files/ftp_upload/57495/57495fig1large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/57495/57495fig2.jpg"> 图 2: 端口放置.使用了五个端口。1: 口岸为第一个机器胳膊;2: 端口为第二机械手 ("套管套管针" 时尚);3: 端口为第三个机械手;C: 摄像头端口;A: 助理港口;红圈:12 毫米套管针;蓝色圆环: 8 毫米套管针;RMAL: 右中腋线;RMCL: 右锁骨中线线;LAAL: 左前腋线。<a href="/files/ftp_upload/57495/57495fig2large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/57495/57495fig3.jpg"> 图 3: 胰腺连续性的重建.(A) 切除胰中段, 并解剖胰管树桩。(B) 胰腺支架插入胰管。(C) 胰管的导管与导管吻合是在缝合和拉合两个胰树桩的过程中完成的。(D) 胰腺的端到端吻合完成。黄色破折号线: 胰管的树桩;青色破折号线: 胰的切口边缘。<a href="/files/ftp_upload/57495/57495fig3large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/57495/57495fig4.jpg"> 图 4: 切除中心胰腺的总形态学.<a href="/files/ftp_upload/57495/57495fig4large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/57495/57495fig5.jpg"> 图 5: 病人的术后 ct 扫描.胰腺周围轻微渗出, 胰管无扩张或狭窄。白色箭头表示胰腺内的支架。<a href="/files/ftp_upload/57495/57495fig5large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>

Watch this Scientific Journal Video about Application of End-to-end Anastomosis in Robotic Central Pancreatectomy at JoVE.com

Application of End-to-end Anastomosis in Robotic Central Pancreatectomy

端到端吻合技术在机器人中心胰腺中的应用

端到端吻合的机器人中心胰腺在胰腺颈部和胰腺体近端肿瘤中是可行的、安全的。介绍了该手术的手术技术。

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of ...

application-end-to-end-anastomosis-robotic-central

Universidad San Sebastian

Research

JoVE Journal

Medicine

7.9K 次观看.  Chinese People's Liberation Army (PLA) General Hospital. 端到端吻合的机器人中心胰腺在胰腺颈部和胰腺体近端肿瘤中是可行的、安全的。介绍了该手术的手术技术。

视频: Application of End-to-end Anastomosis in Robotic Central Pancreatectomy

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer: Surgical Planning and Technique

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), relying on collateral flow to the liver through the gastroduodenal artery (GDA). In the current manuscript, the technical conduct of robotic DP-CAR is outlined. The greater curve of the stomach is mobilized with care to avoid sacrificing the gastroepiploic vessels. The stomach and liver are retracted cephalad to facilitate dissection of the porta hepatis. The hepatic artery (HA) is dissected and encircled with a vessel loop. The gastroduodenal artery (GDA) is carefully preserved. The common HA is clamped and triphasic flow in the proper HA via the GDA is confirmed using intra-operative ultrasound. A retropancreatic tunnel is made over the superior mesenteric vein (SMV). The pancreas is divided with an endovascular stapler at the neck. The inferior mesenteric vein (IMV) and splenic vein are ligated. The HA is stapled proximal to the GDA. The entire specimen is retracted laterally with further dissection cephalad to expose the superior mesenteric artery (SMA). The SMA is then traced back to the aorta. The dissection continues cephalad along the aorta with the bipolar energy device used to divide the crural fibers and celiac nerve plexus. The specimen is mobilized from the patient's right to left until the origin of the celiac axis is identified and oriented towards the left. The trunk is circumferentially dissected and stapled. Additional dissection with hook cautery and the bipolar energy device fully mobilizes the pancreatic tail and spleen. The specimen is removed from the left lower quadrant extraction site and one drain is left in the resection bed. A final intra-operative ultrasound of the proper HA confirms pulsatile, triphasic flow in the artery and liver parenchyma. The stomach is inspected for evidence of ischemia. Robotic DP-CAR is safe, feasible and when used in conjunction with multi-modality therapy, offers potential for long-term survival in selected patients.

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection DP-CAR for Pancreatic Cancer: Surgical Planning and Technique

We present our operative approach to robot assisted distal pancreatectomy, splenectomy, and celiac axis resection (DP-CAR), demonstrating that the procedure is safe and feasible with proper planning, patient selection, and surgeon experience.

机器人协助切除腹腔轴切除术 （DP-CAR） 胰腺癌:手术规划和技术

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), ...

科研

癌症研究

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

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several studies have described the safety of RPD in case of a replaced or aberrant right hepatic artery, but detailed video descriptions of the approach are lacking. This case report describes a step-&#173;by-&#173;step technical video in case of a replaced right hepatic artery. A 58-year-old woman presented with an incidental finding of a 1.7 cm pancreatic head mass. RPD was performed using the da Vinci Xi system and involves a robotic-assisted pancreatico- and hepatico-jejunostomy and open gastro-jejunostomy at the specimen extraction site. The operation time was 410 min with 220 mL of blood loss. The patient had an uncomplicated postoperative course and was discharged after 5 days. Pathology revealed a pancreatic head cancer. RPD is a feasible and safe procedure in case of a replaced hepatic artery when performed in selected patients in high-volume centers by experienced surgeons.

Robotic pancreatoduodenctomy (RPD) has been highly standardized in recent years and may be used in selected patients with pancreatic head cancer, including those with a replaced right hepatic artery. This case report describes a standardized and reproducible technique for RPD, which includes the approach of the Dutch LAELAPS-3 training program to an aberrant vasculature.

胰腺头癌机器人胰十二指肠切除术:标准化技术的病例报告

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several ...

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic platform, including three-dimensional vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate the principles of open pancreatoduodenectomy allowing safe oncologic dissection, hemostasis, and meticulous reconstruction. Over the course of the past decade, significant strides have been achieved in outlining the safety, feasibility, and learning curve of the robotic Whipple. When performed by high volume pancreatic surgeons experienced in RPD, recent comparative effectiveness studies show potential advantages compared to the open technique, including reductions in hospital stay and morbidity. National data also show reductions in conversion rates compared to its laparoscopic counterpart. Although long-term oncologic data are still needed, short-term oncologic surrogates of margin resection and lymph node harvest suggest no compromise in oncologic outcomes. As pancreatic surgeons increasingly integrate robotics into their practice, proficiency-based training and credentialing will be necessary for the safe application and dissemination of RPD. Here, we provide the detailed steps of a robotic pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.&#160;

The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

机器人辅助胰腺切除术的技术细节

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic ...

医学

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The recent rise of robotic and laparoscopic pancreatic surgery has found benefits such as reduced time to functional recovery. Few studies have reported on the feasibility, technique and outcome of robotic LPJ, especially including transection of the gastroduodenal artery. The present study describes the main steps for robotic LPJ in a patient with painful chronic pancreatitis with a dilated main pancreatic duct. The patient underwent robotic LPJ. The LPJ anastomosis is performed using a running suture technique in a longitudinal side-to-side manner. Routinely, the gastroduodenal artery is transected to drain the entire length of the main pancreatic duct. The patient is in French position; 7 trocars are placed (4 robotic, 2 laparoscopic assistants, 1 liver-retractor). After docking of the robot system, the omental bursa is opened, and the right gastroepiploic artery and vein are ligated at their base at the lower border of the pancreas. Intraoperative ultrasonography is performed in order to determine trajectory of the dilated main pancreatic duct which is opened for its entire length after the gastroduodenal artery has been suture ligated both cranially and caudally from the main pancreatic duct. A Roux limb is created, and a latero-lateral PJ is fashioned using several 3-0 barbed sutures. A stapled jejuno-jejunostomy is created at sufficient distance from the pancreatic anastomosis, aided by a 50 cm suture. The described technique for robotic LPJ is a complex but feasible operation for patients with treatment refractory CP and a dilated main pancreatic duct. Due to its complexity, implementation in high volume centers with extensive experience with CP surgery may improve outcomes.

Robotic lateral pancreaticojejunostomy (RLPJ) may be used in patients with painful, morphine dependent, chronic pancreatitis and a dilated main pancreatic duct. We describe a standardized and reproducible technique for RLPJ, which includes transection of the gastroduodenal artery.

慢性胰腺炎的机器人侧胰腺肌切除术

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The ...

Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the spleno-mesenteric junction, for cancer of the body-tail of the pancreas. The patient is placed supine with the legs parted and a pneumoperitoneum is established and maintained at 10 mmHg. To use the surgical system, four 8 mm ports and one 12 mm port are required. The optic port is placed at the umbilicus. The other ports are placed, on either side, along the pararectal line and the anterior axillary line at the level of the umbilical line. The assistant port (12 mm) is placed along the right pararectal line. Dissection begins by detaching the gastrocolic ligament, thus opening the lesser sac, and by a wide mobilization of the splenic flexure of the colon. The superior mesenteric vein is identified along the inferior border of the pancreas. Lymph node number 8a is removed to permit clear visualization of the common hepatic artery. A tunnel is then created behind the neck of the pancreas. To permit safe resection and reconstruction of the spleno-mesenteric junction, further preemptive dissection is required before dividing the pancreatic neck to bring in clear view all relevant vascular pedicles. Next, the splenic artery is ligated and divided, and the pancreatic neck is divided, with selective ligature of the pancreatic duct. After vein resection and reconstruction, dissection proceeds to complete the clearance of peripancreatic arteries that are peeled off from all lympho-neural tissues. Both celiac ganglia are removed en-bloc with the specimen. The Gerota fascia covering the upper pole of the left kidney is also removed en-bloc with the specimen. Division of short gastric vessels and splenectomy complete the procedure. A drain is left near the pancreatic stump. The round ligament of the liver is mobilized to protect the vessels.

The robotic technique shown herein aims at faithfully reproducing the open procedure for radical treatment of cancer of the body-tail of the pancreas. The protocol also demonstrates the ability to master involvement of major peripancreatic vessels without conversion to open surgery.

机器人辅助基质前体模块化胰腺切除术，包括切除和重建的斯普尔诺-梅森特克结

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the ...

Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of the pancreas. The aim of central pancreatectomy is to prevent postoperative life-long endocrine and exocrine insufficiency. The downside of central pancreatectomy is the high rate of postoperative pancreatic fistula, which is the main reason that many surgeons do not routinely use central pancreatectomy in eligible patients. Most studies report open or laparoscopic central pancreatectomy with a pancreatico-gastrostomy anastomosis in adults. This is the first description of a standardized approach to robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy reconstruction in an adolescent (16-year-old boy) with a pseudopapillary tumor in the body of the pancreas. The operation time was 248 min with 20 mL of blood loss. The postoperative course was uneventful except for the short-term medical treatment for a grade B pancreatic fistula. Robotic central pancreatectomy can be safely applied in selected patients in experienced centers.

Robotic central pancreatectomy may be used in selected patients in experienced centers. This protocol presents all steps and the feasibility of a robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy in a 16-year-old adolescent patient.

机器人中央胰腺切除术与鲁恩-Y胰腺切除术

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of ...

Robotic D3 Partial Duodenal Resection with Primary Side-to-Side Anastomosis

Duodenal stenosis is a condition that can be related to several diseases, being either intrinsic, such as neoplasm and inflammatory stenosis, or extrinsic, such as pancreatic pseudocyst, superior mesenteric artery syndrome, and foreign bodies. Current treatments range from endoscopic approaches, such as endoscopic resection and stent placement, to surgical approaches, including duodenal resection, pancreaticoduodenectomy, and gastrointestinal bypass. Minimally invasive robot-assisted surgery is gaining importance due to its potential to decrease surgical stress, intraoperative blood loss, and postoperative pain, while its instruments and 3D-vision facilitate fine dissection and intra-abdominal suturing, all leading to a reduced time to functional recovery and shorter hospital stay. We present a case of a 75-year-old female who underwent robotic D3 partial duodenal resection with primary side-to-side duodeno-jejunal anastomosis for a 5 cm adenoma with focal high-grade dysplasia.

This protocol presents a case of a robotic partial duodenal resection with primary side-to-side duodeno-jejunal reconstruction in a patient with a 5 cm duodenal stenosis. This is done at the third duodenal segment (D3) after an endoscopic mucosal resection (EMR) for a duodenal polyp.

机器人 D3 十二指肠部分切除术与初级侧对侧吻合术

Duodenal stenosis is a condition that can be related to several diseases, being either intrinsic, such as neoplasm and inflammatory stenosis, or ...

Application of Mid-Pancreatectomy with End-to-End Anastomosis in Pancreatic Benign Tumors

Mid-pancreatectomy combined with end-to-end anastomosis is a surgical procedure used to treat benign pancreatic tumors. It involves removing the tumor from the middle section of the pancreas and connecting the proximal and distal ends through an anastomosis. The traditional surgical approach for resecting the middle segment of the pancreas involves closing the proximal pancreas and creating a Roux-en-Y anastomosis with the jejunum. However, this approach carries a double risk of pancreatic stump fistula and pancreatico enteric anastomotic leak postoperatively. In this paper, a new procedure is described where stent tubes were placed into the proximal and distal sides of the pancreatic ducts after ensuring sufficient freedom from the proximal distal pancreas. The pancreatic parenchyma was then sutured continuously under direct vision to achieve pancreatic end-to-end anastomosis. This procedure helps preserve pancreatic function, reducing the risk of postoperative pancreatic insufficiency. However, due to the complexity and risks involved, thorough evaluation and preparation are necessary before surgery. We carefully assess the patient's history, serology, and imaging results to determine the feasibility and effectiveness of the procedure. During surgery, we consider the use of a suitable pancreatic duct stent to ensure the flow of pancreatic juice into the intestine through physiological pathways. Our goal is to remove the tumor while preserving as much normal pancreatic tissue as possible for the anastomosis. After the operation, it is crucial to monitor the patient's pancreatic function, paying close attention to blood glucose levels, drainage fluid volume, and amylase value of the pancreatic anastomosis. During the postoperative follow-up visit, the patient's pancreatic function was assessed, and there was no significant change in quality of life compared to before the surgery. This indicates that mid-pancreatectomy combined with end-to-end anastomosis is a safe and effective procedure for treating pancreatic benign neoplasms.

The present protocol describes the application of mid-pancreatectomy combined with end-to-end anastomosis in the surgical treatment of pancreatic benign tumors, which presents a feasible solution for managing such tumors while concurrently preserving pancreatic function.

胰腺中段切除术联合端对端吻合术在胰腺良性肿瘤中的应用

Mid-pancreatectomy combined with end-to-end anastomosis is a surgical procedure used to treat benign pancreatic tumors. It involves removing the tumor ...

Robotic Spleen-Preserving Distal Pancreatectomy: The Warshaw and Kimura Techniques

Spleen-preserving distal pancreatectomy offers an alternative surgical approach to the traditional distal pancreatectomy combined with splenectomy for removing benign and low-grade malignant lesions in the distal pancreas, avoiding complications associated with splenectomy. This procedure can be accomplished either by resecting and ligating the splenic vessels (Warshaw technique) or by preserving them (Kimura technique). Currently, the widespread use of minimally invasive surgery has established laparoscopic and robotic approaches for spleen-preserving distal pancreatectomy as valid and safe options for treating such conditions. Our protocol aims to describe how the Warshaw and Kimura techniques of spleen-preserving distal pancreatectomy can be performed robotically. The first patient is a 36-year-old female with a neuroendocrine tumor (NET) in the pancreatic body who underwent a spleen-preserving distal pancreatectomy with the ligation of the splenic vessels (WT). The second patient is a 76-year-old male with chronic pancreatitis presenting with a dilated main pancreatic duct in the tail of the pancreas who underwent a spleen-preserving distal pancreatectomy with a vessel-preserving approach (KT).

Here, we present a step-by-step protocol of robotic spleen preserving distal pancreatectomy, with and without preserving the splenic vessels (i.e., the Kimura and Warshaw techniques, respectively).

机器人保留脾脏远端胰腺切除术:Warshaw 和 Kimura 技术

Spleen-preserving distal pancreatectomy offers an alternative surgical approach to the traditional distal pancreatectomy combined with splenectomy for ...

Application of Robot-assisted Pancreaticobiliary Junction Resection in Benign Duodenal Tumors

Robot-assisted pancreaticobiliary junction resection is a surgical technique employed to treat benign duodenal tumors. The procedure involves several key steps: making a longitudinal incision in the duodenum, excising the tumor at the pancreaticobiliary junction, inserting a biliary stent, connecting the biliary and duodenal mucosa, and suturing the duodenal incision during phase I. The robotic system enhances visibility, facilitates precise operations, minimizes duodenal traction injuries to the duodenum and surgical trauma, ensures accurate suture and fixation of bile duct stents, connects the bile duct and duodenal mucosa and reduces postoperative recovery time. Given the complexity of the operation and the associated risk of postoperative duodenal fistula, a thorough preoperative evaluation and meticulous perioperative preparation are crucial. Prior to the procedure, a comprehensive assessment was conducted, integrating the patient's medical history, family history, serological tests, and imaging studies. Special emphasis was placed on determining the benign or malignant nature of the tumor and evaluating the status of the duodenal artery blood supply network to ascertain the feasibility and efficacy of the surgery. During the operation, efforts were made to minimize duodenal trauma and avoid compromising the duodenal artery blood supply network. Additionally, the use of bile duct stents was considered essential to prevent biliary strictures, facilitate bile discharge, and mitigate biliary complications. Postoperatively, real-time monitoring of amylase and jaundice indicators in drainage fluid informed the timely removal of drainage tubes in accordance with the enhanced recovery after surgery (ERAS) protocol. Subsequent follow-up indicated a successful recovery, characterized by a notable reduction in preoperative abdominal pain, the absence of long-term complications, and no evidence of tumor recurrence. Consequently, robot-assisted pancreaticobiliary junction resection demonstrates a safe and effective surgical approach for the treatment of benign duodenal tumors.

The current protocol delineates the use of robot-assisted pancreaticobiliary junction resection for the surgical management of benign duodenal tumors. This approach provides an effective solution for treating these tumors while minimizing duodenal loss and reducing associated complications.

机器人辅助胰胆结合部切除术在良性十二指肠肿瘤中的应用

Robot-assisted pancreaticobiliary junction resection is a surgical technique employed to treat benign duodenal tumors. The procedure involves several key ...

端到端吻合技术在机器人中心胰腺中的应用

摘要

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机器人协助切除腹腔轴切除术（DP-CAR）胰腺癌:手术规划和技术

胰腺头癌机器人胰十二指肠切除术:标准化技术的病例报告

机器人辅助胰腺切除术的技术细节

慢性胰腺炎的机器人侧胰腺肌切除术

机器人辅助基质前体模块化胰腺切除术，包括切除和重建的斯普尔诺-梅森特克结

机器人中央胰腺切除术与鲁恩-Y胰腺切除术

机器人 D3 十二指肠部分切除术与初级侧对侧吻合术

胰腺中段切除术联合端对端吻合术在胰腺良性肿瘤中的应用

机器人保留脾脏远端胰腺切除术:Warshaw 和 Kimura 技术

机器人辅助胰胆结合部切除术在良性十二指肠肿瘤中的应用

端到端吻合技术在机器人中心胰腺中的应用

摘要

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此视频中的章节

机器人协助切除腹腔轴切除术 （DP-CAR） 胰腺癌:手术规划和技术

胰腺头癌机器人胰十二指肠切除术:标准化技术的病例报告

机器人辅助胰腺切除术的技术细节

慢性胰腺炎的机器人侧胰腺肌切除术

机器人辅助基质前体模块化胰腺切除术，包括切除和重建的斯普尔诺-梅森特克结

机器人中央胰腺切除术与鲁恩-Y胰腺切除术

机器人 D3 十二指肠部分切除术与初级侧对侧吻合术

胰腺中段切除术联合端对端吻合术在胰腺良性肿瘤中的应用

机器人保留脾脏远端胰腺切除术:Warshaw 和 Kimura 技术

机器人辅助胰胆结合部切除术在良性十二指肠肿瘤中的应用

机器人协助切除腹腔轴切除术（DP-CAR）胰腺癌:手术规划和技术