Following laparoscopic staging, the right colon is mobilized and rotated medially to expose the root of the mesentery. A flexible liver retractor is used to retract segment 4 cranially. An extended Kocher maneuver is performed to release the proximal jejunum from the ligament of Treitz. The jejunum is transected with a 3.5-mm linear cutting stapler 10 cm distal to the former ligament of Treitz and marked with an Endo Stitch 50–60 cm downstream to mark the intended location of the duodenojejunostomy.

The gastrocolic omentum is divided with LigaSure. The groove between the gastroepiploic vascular pedicle and the duodenum is opened with the LigaSure. The right gastric artery is mobilized from the hepatic artery and divided to free the proximal duodenum. The duodenum is divided with a linear cutting stapler, after which the gastroepiploic pedicle is divided with a vascular stapler.

The robot is brought over the patient’s head with arms 2 and 3 on the patient’s right and the patient positioned right side up in steep reverse Trendelenburg (Fig. 13.2). The robotic surgeon operates the console while the laparoscopic surgeon sits between the patient’s legs.

The common hepatic artery (CHA) lymph node is resected and retrieved. The CHA is followed into the porta hepatis. The gastroduodenal artery (GDA) is temporarily occluded to confirm continued flow within the CHA and then ligated and divided with a vascular stapler. The PV is exposed and dissected into the hepatic hilum. The portal lymph nodes are swept into the specimen, searching for an aberrant right hepatic artery. The bile duct is divided with a stapler whenever possible to minimize contamination of the peritoneum with bile. The distal bile margin is resected and sent to pathology.

The origin of the right gastroepiploic vein is identified as it enters the SMV and divided. The SMV is dissected free from the pancreatic neck, and an articulated laparoscopic grasper is used to pass an umbilical tape beneath the pancreas. 2-0 silk sutures are placed to occlude the transverse pancreatic arteries at the inferior and superior borders of the pancreas. the gland is divided with cautery scissors in an attempt to identify and sharply transect the pancreatic duct.

The pancreas is elevated from the retroperitoneum using the third robotic arm. Venous tributaries on the lateral margin of the SMV-PV, superior pancreaticoduodenal vein, and tributaries from the first jejunal vein to the uncinate process are ligated with 3-0 silk ties and divided sharply. Arterial branches from the SMA are either divided with the LigaSure or controlled proximally with a silk tie and clip and transected distally with the LigaSure. The specimen is retrieved in a specimen bag and examined by frozen section. Gold fiducials are placed in cases of suspected malignancy. Lastly, antegrade cholecystectomy is performed.

A duct-to-mucosa pancreaticojejunostomy is performed using a modified Blumgart technique. Interrupted 5-0 Vicryl sutures are placed around the pancreatic duct to facilitate visualization. 2-0 silk horizontal mattress sutures are passed through the pancreas to anchor the seromuscular layer of the jejunum. A small enterotomy is made in the jejunum with robotic scissors, and an interrupted duct-to-mucosa anastomosis is completed (Fig. 13.3). The anastomosis is completed with an anterior layer of 2-0 silk sutures. A single-layer end-to-side hepaticojejunostomy is created with interrupted 5-0 Vicryl (Fig. 13.4). A running technique is used for ducts >5 mm in diameter when visualization is optimal. Finally, an antecolic, two-layer duodenojejunostomy is performed (Fig. 13.5). A posterior layer of interrupted seromuscular 2-0 silk sutures is placed, followed by full-thickness running 3-0 Vicryl after the duodenum and jejunum are opened. Two round 19 F surgical drains are placed: one anterior and one posterior to the biliary and pancreatic anastomoses. The robot is undocked, and the right lower quadrant incision and camera port are closed. The skin is closed with a monofilament subcuticular closure.