Introduction
Over the past three decades, the evolution of minimally invasive surgery has paved the way for performing complex abdominal operations. Although the implementation of laparoscopic surgery was incorporated in all fields of abdominal surgery, its limitations are becoming clearer in the field of hepatopancreatobiliary (HPB) surgery where two-dimensional (2D) vision, uncomfortable maneuverability, increased operative duration, and surgeon fatigue impede performing complex procedures such as pancreaticoduodenectomy. , The introduction of the robotic da Vinci system (Intuitive Surgical, Sunnyvale, CA) overcomes these flaws with its increased ergonomics and the ability to perform meticulous dissections and complex vascular, biliary, and alimentary tract reconstructions. ,
Pancreatic ductal adenocarcinoma is a lethal disease with a 5-year survival rate of 35% in patients with localized disease and a 12% rate for regional disease. Although pancreatic cancer carries a grim prognosis, surgical resection in the form of pancreaticoduodenectomy or distal pancreatectomy remains the mainstay of treatment for loco-regional disease. Several large studies that compared robotic pancreaticoduodenectomy to an “open” pancreaticoduodenectomy have shown several advantages of robotic pancreaticoduodenectomy in the form of decreased estimated blood loss (EBL) and decreased postoperative complications, without compromising resection margins. Robotic distal pancreatectomy is showing promising results compared to laparoscopic or “open” distal pancreatectomy with decreased EBL, lower conversion rates, and shorter hospital stay.
Mastering robotic HPB operations proved to be a skill that required as much agility and dedication as traditional “open” or laparoscopic operations, which is why its overall efficacy, outcomes, and costs are still far from reaching their full potential. Although robotic pancreaticoduodenectomy is considered one of the more technically demanding operations in general surgery, other robotic pancreatic resections such as distal pancreatectomy may also be challenging for experienced surgeons.
The purpose of this chapter is to describe the robotic approach to performing a pancreaticoduodenectomy, distal pancreatectomy with splenectomy, and extended distal pancreatectomy with splenectomy.
Preoperative assessment
Upon diagnosis of pancreatic ductal adenocarcinoma, the majority of patients have an advanced disease that negates upfront surgical resection and are therefore referred to an oncologist for neoadjuvant therapy before potentially undergoing resection. Hence, a multidisciplinary approach is advised to assess modifiable risk factors, radiologic/endoscopic interventions, clinical staging, and planning of neoadjuvant and adjuvant therapies. Distinguishing early-stage disease that is amenable to resection to borderline resectable from locally advanced disease is crucial for tailoring the multidisciplinary treatment strategy. ,
Imaging
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Triple phase IV-contrast abdominal computerized tomography (CT) with 1 mm cuts is widely available and used for diagnosis and staging. Besides identifying metastatic disease, triple phase CT allows evaluation of tumor location and size, tumor extension, vascular involvement, and biliary and pancreatic dilation ( Fig. 58.1 ). ,
Fig. 58.1
(A) Triple phase abdominal CT scan with 1 mm cuts—cross sectional. (B) Triple phase abdominal CT scan with 1 mm cuts—coronal.
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Magnetic resonance imaging (MRI)/MR cholangiopancreatography (MRCP) offers additional information from equivocal CT findings regarding localized disease description and provides additional information regarding hepatic lesions presumed to be metastatic disease. However, CT is more efficient in defining vascular involvement; thus, MR is not a prerequisite prior to resection ( Fig. 58.2 ).
Fig. 58.2
(A) Abdominal MRI showing common bile duct (CBD) dilation in the head of the pancreas (arrow) . (B) Abdominal magnetic resonance cholangiopancreatography showing CBD dilation in the head of the pancreas (arrow) .
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Endoscopic ultrasound (EUS) allows obtaining a histologic sample in the form of fine needle aspiration (FNA) and requires a definitive pathologic diagnosis prior to initiating treatment. While EUS is also not a requirement for pancreaticoduodenectomy or distal pancreatectomy, it may provide added value in the form of tumor staging, vessel involvement, and discovering uncommon histologic diagnoses.
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Routine endoscopic retrograde cholangiopancreatography (ERCP) with stenting for obstructing disease may increase postoperative complications. Thus, ERCP is recommended only when necessary—for instance, in patients suffering from cholangitis, patients undergoing neoadjuvant therapy, or in cases of biliary obstruction with a long interval to resection ( Fig. 58.3 ).
Fig. 58.3
Endoscopic Retrograde Cholangiopancreatography Showing Common Bile Duct Dilation.
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Positron emission tomography (PET)/CT is widely debated as a staging modality for pancreatic ductal adenocarcinoma, as large tumors may not be PET avid.
Our recommendation is a thorough review of all preoperative imaging studies available in order to plan a reconstructive strategy beforehand. Foreknowledge of any vascular aberration, such as a replaced right hepatic artery or a replaced common hepatic artery, is invaluable. Tumor involvement requiring vascular reconstruction may defer one from choosing a robotic approach for resection.
Systemic assessment
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Cardiac assessment is recommended for patients with a presumable higher risk for perioperative cardiac events.
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Age and frailty may anticipate a dreary postoperative course and should be considered preoperatively. ,
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Glycemic control—over 20% of patients with pancreatic cancer will present with hyperglycemia of some sort, from impaired fasting glucose to new-onset and long-lasting diabetes mellitus that should be corrected preoperatively.
Operative preparation
Patient preparation and anesthesia
Patients are positioned supine, with arms outstretched and with an endotracheally intubated nasograstric tube in place with intravenous antibiotics, arterial line, Foley catheter, and single shot intrathecal morphine sulfate injection prior to induction. Sequential compression devices are used as deep vein thrombosis prophylaxis.
Diagnostic laparoscopy
Following an 8 mm robotic trocar insertion at the umbilicus as a camera port (arm #2), a diagnostic laparoscopy with the robotic scope is ensued to exclude peritoneal carcinomatosis, liver metastasis, or other indicators of nonoperative disease. If the diagnostic laparoscopy shows localized disease without contraindications for resection, further trocars are inserted ( Fig. 58.4 ):
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Arm #1: 8 mm trocar lateral to the right midclavicular line at the level of the umbilicus a
a For distal pancreatectomy, arm #1 and the advanced access GelPort may be inserted 2 cm cephalad to current position.
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Arm #3: 12 mm at the left midclavicular line at the level of the umbilicus
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Arm #4: 8 mm left anterior axillary line cephalad to the level of the umbilicus
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5 mm AirSeal access port (CONMED Inc., Utica, NY) in the right anterior axillary line in the subcostal region for liver retraction
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An advanced access GelPort (Applied Medical, Rancho Santa Margarita, CA) is inserted between arms #1 and #2 caudal to the umbilicus
Bed position and docking
The bed is positioned 15 to 20 degrees reverse Trendelenburg 5 degrees tilt to the left. The da Vinci Xi is brought over the right of the patient’s shoulder with the scrub technician standing on the left and the assistant standing on the right of the patient ( Fig. 58.5 ).
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Arm #1: Fenestrated bipolar
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Arm #2: Camera
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Arm #3: Energy device
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Monopolar curved shears
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Hook cautery
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Vessel sealer
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EndoWrist staples
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Arm #4: Bowel grasper
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GelPort assistant:
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Atraumatic bowel grasper
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Suction/irrigator
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Robotic pancreaticoduodenectomy
Of the many ways to accomplish a pylorus-preserving pancreaticoduodenectomy safely, our proposed method relies on a sequence of diagnostic laparoscopy, duodenal mobilization, porta hepatis dissection, postpyloric duodenal division, and pancreatic resection and reconstruction ( 
). As the steps of pancreaticoduodenectomy occur in parallel and overlap each other, they may be interchangeable according to surgeon preference.
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Diagnostic laparoscopy, port placement, and docking
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Kocher maneuver
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Porta hepatis dissection
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Postpyloric duodenal transection
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Pancreatic transection
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Superior mesenteric vein dissection
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Hepaticojejunostomy
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Pancreaticojejunostomy
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Ligament of Treitz restoration
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Duodeno/gastrojejunostomy
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Da Vinci Xi (Intuitive Surgical)
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Da Vinci trocars
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8 mm × 3
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12 mm × 1
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Robotic fenestrated bipolar
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Robotic monopolar curved scissors
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Robotic vessel sealer
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Robotic bowel grasper
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Robotic needle drivers/Mega SutureCut needle driver
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EndoWrist stapler 45 with SmartClamp technology
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Robotic medium-large clip applier
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5 mm AirSeal access port (CONMED Inc.)
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Advanced access GelPort (Applied Medical)
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Laparoscopic suction/irrigator
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Laparoscopic atraumatic bowel graspers
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Laparoscopic liver retractor
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Laparoscopic EndoCatch bag (Applied Medical)
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Nonabsorbable V-Loc sutures (Medtronic)
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Prolene sutures (Johnson & Johnson)
Kocher maneuver
A laparoscopic liver retractor is placed through the 5 mm AirSeal access port to retract the left lobe of the liver in the cephalad direction. The hepatic flexure is mobilized sufficiently to gain full access to the duodenum. Next, medial rotation of the duodenum with the head of the pancreas is facilitated by freeing the lateral attachments of the duodenum with energized scissors or hook cautery starting at the foramen of Winslow and extending caudally around the duodenum and ventral to the inferior vena cava (IVC) ( Fig. 58.6 ). The bowel grasper in arm #4 is used to rotate the duodenum and expose the IVC, abdominal aorta, and left renal vein. Identifying the left renal vein and left lateral border of the aorta is a good confirmation that the Kocher maneuver is completed. The dissection progresses toward the ligament of Treitz, which is subsequently divided. The proximal jejunum is brought to the right upper quadrant and divided with a robotic blue load da Vinci Xi EndoWrist stapler 45 with SmartClamp technology (Intuitive Surgical) ( Fig. 58.7 ). Mobilizing the jejunum to the right side of the abdomen behind the mesenteric vessels should proceed without difficulty. We recommend against dividing the proximal duodenum before undertaking the Kocher maneuver, as this will make the dissection more difficult.
