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

This video illustrates a robotic approach to two cases of spleen-preserving distal pancreatectomy. The first case involves a 36-year-old woman presenting with the typical abdominal symptoms. The CT scan reveal a round lesion in the pancreatic body suggestive of a neuroendocrine neoplasm.

Place the patient in a supine French position. Lower the right arm alongside the body on an arm support and abduct the left arm. Tilt the operating table 10 degrees in anti-Tredelenburg and 10 degrees to the right.

Introduce a Veress needle on Palmer's point to insufflate the abdomen. Introduce four eight-millimeter robot trocars. Start with introduction of the camera port in a line from the crossing of the left midclavicular line and the costal cartilage to the umbilicus, approximately 11 centimeters from the costal margin at the expected level of the pancreatic tail.

The trocars are placed in a semi-curved line above the umbilicus, with a distance of seven centimeters between them. Introduce one assistant trocar three centimeters below the middle of trocars three and four. Place one five-millimeter trocar from the right subcostal area for stomach and liver retraction.

Dock the robot from the right shoulder of the patient. Identify the gastrocolic ligament and divide it with a vessel sealing device, so that the lesser sac is open. Introduce the liver retractor from the patient's right side and retract both the liver and the stomach.

Create a retropancreatic tunnel by mobilizing the pancreas. Start the mobilization cranially by using a robotic forceps and the cautery hook, and dissect all the tissue around the pancreas. Then, mobilize caudally likewise.

Ensure that the tunnel is complete by placing the forceps caudally and advancing until it's visible cranially. Identify the splenic vein and the splenic artery. Place a vessel loop around the pancreas using a robotic forceps as means of retraction.

Pass the loops around the pancreas, around the transaxial line, through the tunnel, and hold the end of the loops together using metallic or Hem-o-lok clips. Dissect the pancreas using a linear stapler, performing gradual compression for four minutes. If the transection is not complete after that step, detach the specimen using a vessel sealing device, scissors, or the cautery hook.

Place a vessel loop around the vessels to facilitate retraction prior to the staplers entering. Dissect the splenic vessels using a linear stapler. In case of the Warshaw procedure, transect first the splenic artery, and then the splenic vein.

Mobilize the pancreas until the splenic hilum. In the Warshaw procedure, the splenic vessels are transected again using a stapler or Hem-o-lok clips as close as possible behind the pancreatic tail in order to preserve all collateral vessels between the gastroepiploic vessels and the spleen. Detach the pancreatic tail from the spleen hilum using the vessel sealing device or a stapler.

Place the specimen in an Endo bag and remove through Pfannenstiel incision. Assess the spleen's condition prior to pneumoperitoneum exsufflation. The operative time was 190 minutes with an estimated blood loss of 200 milliliters.

A postoperative collection was percutaneously drained, resulting in a grade B pancreatic fistula. The patient was discharged on postoperative day five, and the drain was removed on day 22. The pathology revealed a Grade 1 invasive NET, with one positive regional lymph node, classifying in it as T2N1R1.

The second patient is a 76-year-old male with chronic pancreatitis, presenting with lower left abdomen pain for the past 18 months. His CT scan revealed an image of chronic pancreatitis with a dilated pancreatic duct in the tail, up to seven millimeters, and multiple calcifications. As shown before, identify the gastrocolic ligament and divide it.

Then, introduce the liver retractor. After the mobilization phase, the endoscopic ultrasonography probe is introduced to identify the dilated pancreatic duct and assess the parenchymal transection. Create a retropancreatic tunnel by mobilizing the pancreas.

Start the mobilization by using a robotic forceps and dissect all tissue around the pancreas. Identify the splenic vessels. Mobilize the splenic vein and the splenic artery and preserve them.

Ensure that the tunnel is complete by placing the forceps caudally and advancing it until it's visible cranially. Place a vessel loop around the pancreas using a robotic forceps as means of retraction. Pass the loop to surround the pancreas around the resection line and hold the end of the loop together using metallic or Hem-o-lok clips.

Dissect the pancreas using a linear stapler, performing gradual compression for four minutes. If the transection is not complete after that step, detach the specimen using a vessel sealing device, scissors, or the cautery hook. After the transection of the pancreas, the small splenic branches posterior to the pancreas are carefully ligated using metallic or Hem-o-lok clips.

Mobilize the pancreas until the splenic hilum. Carefully dissect all tissue around the pancreas using the vessel sealing device until you reach the hilum of the spleen. Detach the pancreatic tail using the vessel sealing device or a stapler.

In this procedure, a robotic vessel sealer was used. Place the specimen in an Endo bag and remove. Introduce a drain from the left side of the patient and advance it next to the pancreatic stump.

Make sure the drain makes no direct contact with either the pancreas or vessel stumps. Total operation time was 180 minutes with an estimated blood loss of 50 milliliters. The patient was discharged on postoperative day seven.

On the 18th postoperative day, the patient presented to the outpatient clinic complaining about pain in the lower left abdomen. A CT scan reveal a fluid collection which was transgastrically drained. The histopathological examination revealed chronic atrophic pancreatitis with no sign of malignancy.

Modifications of the procedure include the use of a second assistant trocar, the introduction of the liver retractor from either left or right, and the use of the energy device by the table side surgeon or the robotic console surgeon. The robotic spleen-preserving distal pancreatectomy is a feasible and safe procedure in experienced hands. Patient's anatomy may be crucial in deciding the ideal surgical technique.

Regarding the comparison of the two techniques, further studies are needed.