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

The authors have no acknowledgments.

Written informed consent was obtained from the patient for the publication of this report and any accompanying videos and images.
1. Preoperative Preparation
<ol>
	<li>Carefully evaluate the preoperative images of CT or MRI for the exact location of the tumor and its relation to the surrounding tissues.</li>
	<li>Give the patient a soft diet one day before the operation and begin fasting at midnight before the operation.</li>
	<li>Place the patient on the operating table. Then, place a peripheral venous catheter and induce general anesthesia using standard procedures. Introduce a central venous catheter through the right internal jugular vein for medication fluids and a peripheral arterial catheter for blood pressure monitor.</li>
</ol>
2. Patient&#39;s Position and Port Placement
<ol>
	<li>Place the patient in supine and 20&#176; reverse Trendelenburg position with the legs split. Drape in normal sterile fashion for upper abdominal surgery.</li>
	<li>Position the surgeon console at the left side of patient. Place the patient cart over the patient&#39;s head and the vision cart at the right side of the patient, respectively. Have the assistant surgeon stand between the patient&#39;s legs to perform the procedures. Position the back table for the instruments and supplies (see Table of Materials) at the left rear of the assistant.</li>
	<li>Make a 1-cm incision with the scalpel 3 cm inferior and right lateral to the umbilicus. Insert a Veress needle into the abdominal cavity through this incision, and establish a CO2 pneumoperitoneum of 14 mmHg with the automatic insufflation instrument.</li>
	<li>Remove the Veress needle and then insert a 12-mm trocar through the 1-cm incision as the camera port. Insert the robotic endoscope and perform a diagnostic laparoscopy (have the assistant surgeon hold the robotic endoscope) to confirm the abdominal adhesion status and operative feasibility. Insert the remaining 4 trocars as follows under the view of the endoscope.</li>
	<li>Place an 8-mm trocar in the left anterior axillary line (Figure 2) at the level of the umbilicus for the first robotic arm. Place a 12-mm trocar 2 cm inferior and left lateral to the umbilicus (Figure 2) as the assistant port.</li>
	<li>Place a 12-mm trocar in the right midclavicular line (Figure 2) at the level of the umbilicus. Insert an 8-mm trocar into this 12-mm trocar in a &#34;trocar in trocar&#34; fashion for the second robotic arm. Place an 8-mm trocar under the costal margin in the right middle axillary line for the third robotic arm (Figure 2). After the docking of robotic army, dock the robotic endoscope in the camera arm.</li>
</ol>
3. Mobilization of the Pancreas Neck and Body
<ol>
	<li>Grasp and keep elevating the anterior wall of the stomach by forceps on the third robotic arm to expose the gastrocolic ligament.</li>
	<li>Tension the gastrocolic ligament with the bipolar forceps in the second robotic arm and the grasping forceps in the assistant&#39;s hand. Divide the gastrocolic ligament to enter the lesser sac and expose the anterior surface of the pancreas with the laparoscopic ultrasonic scalpel on the first robotic arm. Perform hemostasis with bipolar forceps on the second robotic arm, until reaching the level of the right gastroepiploic vein.</li>
	<li>Carefully dissect the pancreatic neck from the superior and inferior direction with the cautery hook. Proceeding from the inferior to superior direction, divide the posterior wall of the pancreatic neck from the portal vein (PV), superior mesenteric vein (SMV), inferior mesenteric vein (IMV), and splenic vein (SV) with the cautery hook. Afterwards, create a tunnel between the PV-SMV-IMV-SV and posterior wall of the pancreatic neck.</li>
	<li>Dissect the pancreatic body from the splenic vessels and connective tissues towards the pancreatic tail with the cautery hook and ultrasonic scalpel.</li>
</ol>
4. Transection of the Pancreatic Parenchyma
<ol>
	<li>Insert the laparoscopic ultrasound probe through the assistant trocar and perform the ultrasonography on the pancreas to reconfirm the location and size of the lesion. According to the result of the ultrasonography, mark two transection lines at about 1 cm away from the lesion, on the pancreatic surface with the cautery hook.</li>
	<li>Lift the pancreatic body with the forceps inserting through the inferior margin of the pancreas and further detach the proximal part of pancreatic body from the splenic vessels and connective tissues with the cautery hook or ultrasonic scalpel.</li>
	<li>After mobilizing the pancreatic neck and proximal pancreatic body form the posterior vessels and tissues, incise the pancreas parenchyma along the distal and proximal transection line with the ultrasonic scalpel and expose the pancreatic duct. Then transect the parenchyma around the pancreatic duct.</li>
	<li>Carefully protect and mobilize the pancreatic duct from the transected pancreatic parenchyma. Then sharply transect the pancreatic duct about 1 cm away from the stump, using laparoscopic scissors from the assistant port.</li>
</ol>
5. Reconstruction of the Pancreatic Continuity
<ol>
	<li>To reduce the tension of anastomosis, further mobilize the pancreatic stump from the posterior vessels and connective tissues, using the cautery hook and bipolar forceps.</li>
	<li>Based on the size of the pancreatic duct stumps, choose a 10-cm plastic pancreatic stent with a proper diameter (1.2 mm in diameter in this case). Cut both ends of the stent to oblique planes and make several side perforations. Implant the stent into the abdominal cavity through the assistant port.</li>
	<li>Hold the side wall of pancreatic duct stump in the pancreatic body with micro forceps, and insert the stent caught by the needle driver into the distal pancreatic duct stump gently. Suture the pancreatic duct with the stent by using 5-0 absorbable suture, so that the stent is closely encircled by the pancreatic duct.</li>
	<li>Insert the other end of the stent into the proximal pancreatic duct stump using a similar approach but without suture.</li>
	<li>Suture the proximal and distal pancreatic stumps using the horizontal mattress suture (4-0 non-absorbable suture).</li>
	<li>Pull the two pancreatic stumps closer, and continue to insert the proximal end of stent into the proximal pancreatic duct stump. Finally, keep the whole stent within the pancreatic duct and do not bring it into the duodenum lumen.</li>
	<li>Perform the end-to-end anastomosis of the pancreatic duct stumps using interrupted suture with 5-0 non-absorbable suture.</li>
	<li>Knot the remaining ties on the pancreatic stumps.</li>
	<li>Suture the anterior portion of the pancreatic stumps using continuous suture with 4-0 non-absorbable suture (Figure 3).</li>
</ol>
6. Hemostasis and Drainage
<ol>
	<li>Carefully check for bleeding sites and conduct thorough hemostasis. Encircle the anastomosis site with absorbable hemostatic gauze.</li>
	<li>Put the resected specimen in the plastic bag and remove the bag from an enlarged incision in the camera port.</li>
	<li>Place two drains along the superior and inferior border of the anastomosis site and extract the drains from the port for the third robotic arm.</li>
</ol>
7. Posteoperative Care
<ol>
	<li>After surgery, give the patient intravenous antibiotics (ceftriaxone sodium), parenteral nutrition (glucose, compound vitamin, compound amino acid, fat emulsion, insulin, KCl, and NaCl), analgesic (sufentanil, ondansetron), somatostatin, proton pump inhibitors (lansoprazole) and other treatment as the same as that of conventional central pancreaticectomy. Keep the patient fasting, then remove the nasogastric tube and feed a clear fluid diet on the 2nd postoperative day. Gradually transition to normal diet if the patient can tolerate it.</li>
	<li>Test the drain fluid for the amylase and bacterial culture after the 3rd postoperative day. When there is no evidence of pancreatic fistula and infection, and the drain volume is less than 10 mL/day, remove the drains.</li>
</ol>

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No competing financial interests exist.

Malignant tumors located in the pancreas neck and the proximal part of the pancreatic body are often treated with pancreaticoduodenectomy or distal pancreatectomy. However, for benign or low malignant potential tumors in those sites, the standard pancreaticoduodenectomy or distal pancreatectomy will remove excessive normal tissues and result in excessive injury. Therefore, the central pancreatectomy or pancreatic enucleation, known as &#34;parenchyma-sparing pancreatectomy&#34;, becomes a preferable choice for the treatment of benign and low malignant potential tumors in the pancreatic neck and body.
As early as 1908, Ehrhardt had reported the central pancreatectomy15. Currently, the most commonly used reconstructions for pancreatico-intestinal continuity after central pancreatectomy are as follows: (1) over-sewing the proximal pancreatic remnant and performing pancreaticojejunostomy for the distal pancreatic remnant; (2) over-sewing the proximal pancreatic remnant and performing pancreaticogastrostomy for the distal pancreatic remnant. These two reconstruction approaches ensure an appropriate tension for anastomosis. However, they disrupt the anatomic continuity of digestive tracts and changes the exocrine pathway of the pancreas. Because the pancreatic enzymes could be activated by intestinal juice in the pancreaticojejunostomy, the possibility of Grade C pancreatic fistula is relatively higher in central pancreatectomy, so that the short-term complications such as bleeding also increase8,16. Moreover, as the pancreatic stump directly contacts gastric juice in the pancreaticogastrostomy, enzymes could be inactivated, thus, theoretically ameliorating the erosion of anastomosis. But it might also lead to pancreatic exocrine insufficiency, and in the long term jeopardize the patient&#39;s nutritional status9,10.
As a rarely utilized approach, the end-to-end anastomosis of pancreatic stumps might resolve the drawbacks of the aforementioned reconstruction approach; it does not need the pancreaticoenteric anastomosis and could maintain the integrity and continuity of the digestive tract. It could also keep the pancreatic juice secreting from its original physiological structure. However, perhaps because of its technical complexity, only a few cases of open central pancreatectomy with end-to-end anastomosis are reported, and this approach was not applied consecutively17,18,19,20.
As the most advanced representative of minimally invasive surgery, the robotic surgical system has been applied in the central pancreatectomy, and the current reconstruction approaches are over-sewing the proximal pancreatic remnant and performing pancreaticojejunostomy or pancreaticogastrostomy for the distal pancreatic remnant6,21,22,23. Our surgical team has rich experience in robotic pancreaticoduodenectomy, central pancreatectomy, and distal pancreatectomy13,24. We have also performed robotic pancreatic enucleation with main pancreatic duct invasion and injury. In that surgery, we repaired the pancreatic duct injury by inserting a pancreatic stent and using end-to-end anastomosis14. Based on our experience in robotic pancreatic surgery, we have modified the traditional robotic central pancreatectomy with end-to-end anastomosis, to maximize the residual pancreatic parenchyma and minimalize the injury to patients.
Currently, we used the robotic surgical system to perform the central pancreatectomy and reconstruct the pancreatic continuity through the pancreatic duct plasty and end-to-end pancreatic anastomosis. We found that the short-time outcomes were favorable. As the robotic surgical system has a magnifying 3-D view, multi-degree of freedom for the movement of instruments, the elimination of physiological fibrillation, and other characteristics, this surgical system shows inherent advantages in the dissection, plasty, and anastomosis of the pancreatic duct. Compared with conventional reconstruction approaches, this approach avoids the pancreaticoenteric anastomosis of the distal pancreatic stump, shortens the operation time, and reduces the injury. The direct anastomosis of the two pancreatic stumps avoids the pancreatic stump to contact with digestive fluids, which theoretically could reduce the risk of pancreatic fistula and bleeding. The placement of the stent also enables the anastomosis of the pancreatic duct to be more secure and rapid. In addition, continuous support by the stent also helps to prevent the postoperative stricture of the pancreatic duct. On the other hand, even if pancreatic fistula occurred, the pancreatic fluid could flow into the duodenum through the stent instead of flowing outside the pancreas, thereby reducing the damage of pancreatic fistula to the surrounding organs. Because the stent is sutured to the pancreatic duct with absorbable suture, the stent will spontaneously fall off within a few months.
The critical step of the procedure is the anastomosis of the pancreatic duct and parenchyma without tension. To achieve a tension-free anastomosis, the pancreatic stumps should be sufficiently mobilized from their posterior vessels and tissues, especially the distal stump. It should be noted that the transection of the pancreatic duct was performed by scissor instead of energy instruments, which could reduce the damage of the pancreatic duct and facilitate a better duct-to-duct anastomosis. Additionally, the stumps of the pancreatic duct should be dissected from the resected pancreas as much as possible for plasty. For the pancreatic stent, we usually sterilize plastic tubes with different diameters and lengths by the operation center and choose the correct size during the operation.
We found that in selected patients, the robotic central pancreatectomy with end-to-end anastomosis is safe and feasible. This surgical approach reduces the extent of the central pancreatectomy and maintains the integrity and continuity of physiology and anatomy, which reflects the minimally invasive characteristics of the robotic surgical system in pancreatic surgery. As this operation is at an initial phase, many issues are still unclear, such as how to rationally use somatostatin postoperatively; for patients with long defect of pancreatic duct, whether we should choose central pancreatectomy; if the stent does not fall off spontaneously, what is the side-effect, etc. Its technical modification and long-term efficacy also remain to be explored.

Central pancreatectomy is increasingly performed for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of pancreatic body1. Compared with the pancreaticoduodenectomy or distal pancreatectomy, central pancreatectomy resects less tissues and conserves more pancreatic parenchyma and function. Currently, the major approaches for the pancreas reconstruction are over-sewing the cephalic pancreatic stump and performing a pancreaticojejunostomy or pancreaticogastrostomy to the distal stump2,3. These two approaches are widely used in the open, laparoscopic and robotic central pancreatectomies4,5,6,7. However, the aforementioned two reconstruction approaches break the anatomic continuity of digestive tracts and the pathway for the excretion of pancreatic fluid. The directly contact of pancreatic stump with intestinal juice might increase the possibility of bleeding and fistula8. Although the gastric juice could inactive pancreatic enzymes to avoid the erosion of anastomosis, it might lead to pancreatic exocrine insufficiency, and in the long term jeopardize the patient&#39;s nutritional status9,10.
With the development of minimally invasive surgery, robotic surgery has shown great advantages in its 3-D magnifying view, stability, and flexibility of movements, etc., which provides enhanced dissecting and suturing capacity for anastomosis and hemostasis11,12. Based on our experience in robotic pancreatectomy and repair for injured pancreatic duct13,14, we have performed a series of robotic central pancreatectomy with end-to-end anastomosis and seen favorable outcomes. Compared with pancreaticojejunostomy or pancreaticogastrostomy, end-to-end pancreas anastomosis avoids the damage to digestive tracts; thus, theoretically reducing the possibility of pancreaticoenteric fistula. But on the other hand, the end-to-end pancreas anastomosis poses greater technical difficulties. As an update of conventional central pancreatectomy, the candidates for conventional central pancreatectomy are also eligible for this surgery. Here, we present operative techniques for robotic central pancreatectomy with end-to-end anastomosis in a tertiary hepatopancreatobiliary center in this video case presentation.
Indications:
(1) Benign and low-malignant potential tumors located in the pancreatic neck and proximal body are suitable for this operation. 
(2) The defect of the main pancreatic duct should be less than 5 cm after the central pancreatectomy, and the size of tumor is not the main concern for reconstruction.
Case Presentation:
The patient is a 31-year-old man. A lesion in the pancreatic neck was found accidently in a medical examination 2 years ago. He underwent regular re-examination and the lesion was found to be asymptomatically enlarged recently. He had no history of previous abdominal surgery. On physical examination, no positive sign existed. The pancreatic MRI showed a quasi-circular lesion approximately 14-mm in the pancreatic neck; this was presumed as a neuroendocrine tumor. On T1- and T2-weighted imaging, the lesion showed hypointense and hyperintense signal, respectively. On diffusion-weighted imaging, the lesion showed hyperintense signal. The lesion was slightly enhanced in the arterial phase and showed a progressive enhancement pattern in the parenchyma phase and delay phase (Figure 1). Severe fatty liver was also diagnosed by the MRI. No dilation or stricture was detected in the pancreatic duct. Routine blood examination, IgG isoform test, tumor biomarkers, electrocardiogram, and chest X-ray were normal. The biochemical test showed slightly elevated ALT (Alanine aminotransferase) at 147.3 U/L and AST (Aspartate aminotransferase) at 53.9U/L, which may be caused by fatty liver.

<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

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of pancreatic body. With technological development, the robotic surgical system has shown its advantage in minimally invasive surgery and been increasingly applied in central pancreatectomy. However, reconstruction of the continuity of pancreas with end-to-end anastomosis after robotic central pancreatectomy has not been applied. In this study, we report surgical techniques for robotic central pancreatectomy with end-to-end anastomosis. The pancreas is reconstructed by duct-to-duct anastomosis of the pancreatic duct with a pancreatic stent inserted in the two stumps of pancreatic duct, and by end-to-end anastomosis of the pancreatic parenchyma. Compared with traditional central pancreatectomy with pancreaticoenteric anastomosis, this approach decreases the operative injury to the patient, and also conserves the integrity and continuity of the digestive duct and pancreatic duct. The robotic surgical system integrated with multiple instruments with flexible and precise movement is particularly suitable for the dissection and reconstruction of the pancreatic duct. We found that robotic central pancreatectomy with end-to-end anastomosis is safe and feasible, and we need more experience to evaluate its best indications and long-term outcomes.

The operation process was smooth. The operative time was 141 mins and the intraoperative blood loss was about 50 mL. The size of the resected pancreas was about 5.5 &#215; 2.5 &#215; 2.5 cm (Figure 4). The patient recovered smoothly after surgery and discharged on the 6th postoperative day. When the patient was discharged, he had a normal diet and normal defecation, and had no fever, no abdominal pain or distension. The routine blood examination and blood biochemical test had no obvious abnormality. Postopertative CT scan showed slight exudation around the pancreas and no dilation or stricture in the pancreatic duct (Figure 5). The abdominal drain volume was about 100 mL/day. The pathological examination confirmed a solid pseudopapillary tumor with negative margin and the immunohistochemistry test showed that the tumor was B-catenin (nucleus and capsule +), PR (+60%), Vimentin (+), Cga (-), CD10 (+), syn (+), CK (focal+), CD56 (+), ki-67 (+ 2%). The drains were removed on the 20th postoperative day.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/57495/57495fig1.jpg" /> 
Figure 1: Preoperative MRI of the patient. Red arrow indicates a quasi-circular lesion in the pancreatic neck. <a href="/files/ftp_upload/57495/57495fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/57495/57495fig2.jpg" /> 
Figure 2: Port placement. Five ports were used. 1: port for the first robotic arm; 2: port for the second robotic arm (&#34;trocar in trocar&#34; fashion); 3: port for the third robotic arm; C: camera port; A: assistant port; red circle: 12-mm trocar; blue circle: 8-mm trocar; RMAL: right middle axillary line; RMCL: right midclavicular line; LAAL: left anterior axillary line. <a href="/files/ftp_upload/57495/57495fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/57495/57495fig3.jpg" /> 
Figure 3: Reconstruction of the pancreatic continuity. (A) The middle portion of the pancreas was resected and the stumps of pancreatic duct were dissected. (B) The pancreatic stent was inserted into the pancreatic duct. (C) The duct-to-duct anastomosis of the pancreatic duct was completed during suturing and pulling together two stumps of the pancreas. (D) The end-to-end anastomosis of the pancreas was completed. Yellow dash line: stumps of the pancreatic duct; Cyan dash line: cutting margin of the pancreas. <a href="/files/ftp_upload/57495/57495fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/57495/57495fig4.jpg" /> 
Figure 4: Gross morphology of the resected central pancreas. <a href="/files/ftp_upload/57495/57495fig4large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/57495/57495fig5.jpg" /> 
Figure 5: Postoperative CT scan of the patient. Slight exudation around the pancreas and no dilation or stricture in the pancreatic duct. White arrow indicates the stent in the pancreas. <a href="/files/ftp_upload/57495/57495fig5large.jpg" target="_blank">Please click here to view a larger version of this figure.</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

The robotic central pancreatectomy with end-to-end anastomosis is feasible and safe for tumor in the pancreatic neck and proximal portion of pancreatic body. The operative techniques of this operation are presented.

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 Views.  Chinese People's Liberation Army (PLA) General Hospital. The robotic central pancreatectomy with end-to-end anastomosis is feasible and safe for tumor in the pancreatic neck and proximal portion of pancreatic body. The operative techniques of this operation are presented.

Video: 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.

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

Cancer Research

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.

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.

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

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.

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.

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.

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.

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.

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).

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.

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