Pancreaticoduodenectomy: Robotic-Assisted Resection

Pancreaticoduodenectomy: Robotic-Assisted Resection

Brian A. Boone

Herbert J. Zeh


  • The history and physical exam should focus on identifying evidence of metastatic disease, which would preclude resectability.

  • The robotic technique is routinely used for both benign and malignant disease.

  • Patients are not excluded from the robotic approach based on age, body mass index (BMI), or comorbidities.

  • Relative contraindications to robotic surgery are the anticipation of vascular resection and reconstruction and extensive prior abdominal surgery.


  • A primary goal of imaging modalities for pancreatic cancer is to determine resectability by excluding metastatic disease and involvement of the mesenteric vessels.

  • Based on consensus guidelines,1 resectable tumors are those that have no distant metastasis; have no radiographic evidence of abutment or distortion of the superior mesenteric vein (SMV) and portal vein (PV); and have clear fat planes surrounding the celiac axis, hepatic artery, and superior mesenteric artery (SMA) (FIG 1). Patients with tumor abutment of the SMV/PV, gastroduodenal artery (GDA) abutment or encasement up to the hepatic artery, or abutment of the SMA less than 180 degrees are considered to be borderline resectable and may benefit from neoadjuvant treatment.2

  • Computed tomography (CT) scan—A triphasic CT scan of the chest, abdomen, and pelvis with fine cuts through the pancreas is the mainstay of imaging for pancreatic pathology. CT allows for characterization of the pancreatic mass, identifies involvement of the mesenteric vessels, and evaluates for metastatic disease, particularly in the liver or lungs.

  • Endoscopic ultrasound (EUS)—This diagnostic modality, although not routinely performed at all institutions, should be considered standard of care in most cases. EUS allows for visualization and biopsy of the mass, particularly if a tissue diagnosis is required for treatment with neoadjuvant or adjuvant chemotherapy. Mesenteric vessel involvement can be evaluated. Additionally, suspicious lymph nodes can be identified and biopsied, which helps to accurately stage the patient.

  • Staging laparoscopy—The role of staging laparoscopy in the management of pancreatic cancer remains controversial and is not routinely performed at most institutions.3 For patients with large tumors, equivocal CT findings, or highly elevated carbohydrate antigen (CA 19-9), staging laparoscopy can be considered.

FIG 1 • A CT scan demonstrating the tumor relationship to the surrounding vasculature is required to determine resectability during the preoperative planning phase. A. CT scan of the abdomen with arterial contrast demonstrating clear fat planes around SMA in resectable pancreatic cancer (white arrow). B. Venous phase scan demonstrating clear fat planes around SMV (white arrow).


Preoperative Planning

  • Determining resectability based on high-quality diagnostic and imaging modalities is the key step in preoperative planning, particularly because the use of the robotic technique precludes the ability of the surgeon to palpate the tumor and readily identify vascular involvement intraoperatively.

  • Four units of crossmatched packed red blood cells should be prepared and available.

  • Preoperative antibiotics should be administered.


  • The general setup for the robotic operating room is depicted in FIG 2.

  • The patient is positioned supine on a split-leg table, which allows space for the assistant surgeon to have access to the abdomen. The right arm is tucked with protective foam padding.

  • Prior to the start of the procedure, central and arterial lines are inserted in addition to a nasogastric tube and Foley catheter. A convective warming blanket is used on the upper body.

FIG 2 • Setup of operating room for robotic pancreaticoduodenectomy. The robot is placed above the patient’s head. A split-leg table is used to allow the assistant access to the abdomen and robotic arms. The robotic console is placed to the side of the room to allow ample space for the circulator and scrub tech.