Name: application of end-to-end anastomosis in robotic central pancreatectomy
Uploaded: 2018-06-02T13:30:00
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 perip...

<ol>
	<li>Goudard, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reappraisal+of+central+pancreatectomy+a+12-year+single-center+experience.">Reappraisal of central pancreatectomy a 12-year single-center experience.</a> JAMA Surg. 149 (4), 356-363 (2014).</li><li>Iacono, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Systematic+review+of+central+pancreatectomy+and+meta-analysis+of+central+versus+distal+pancreatectomy.">Systematic review of central pancreatectomy and meta-analysis of central versus distal pancreatectomy.</a> Br J Surg. 100 (7), 873-885 (2013).</li><li>Sperti, C., Beltrame, V., Milanetto, A. C., Moro, M., Pedrazzoli, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Parenchyma-sparing+pancreatectomies+for+benign+or+border-line+tumors+of+the+pancreas.">Parenchyma-sparing pancreatectomies for benign or border-line tumors of the pancreas.</a> World Journal of Gastrointestinal Oncology. 2 (6), 272-281 (2010).</li><li>Kim, D. H., Kang, C. M., Lee, W. J., Chi, H. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+central+pancreatectomy+with+pancreaticogastrostomy+(transgastric+approach)+in+a+solid+pseudopapillary+tumor+of+the+pancreas.">Robotic central pancreatectomy with pancreaticogastrostomy (transgastric approach) in a solid pseudopapillary tumor of the pancreas.</a> Hepato-gastroenterology. 58 (110-111), 1805-1808 (2011).</li><li>Addeo, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+central+pancreatectomy+with+stented+pancreaticogastrostomy:+operative+details.">Robotic central pancreatectomy with stented pancreaticogastrostomy: operative details.</a> The international journal of medical robotics + computer assisted surgery: MRCAS. 7 (3), 293-297 (2011).</li><li>Abood, G. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+minimally+invasive+central+pancreatectomy:+technique+and+outcomes.">Robotic-assisted minimally invasive central pancreatectomy: technique and outcomes.</a> J Gastrointest Surg. 17 (5), 1002-1008 (2013).</li><li>Schwarz, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Total+Laparoscopic+Central+Pancreatectomy+with+Pancreaticogastrostomy+for+High-Risk+Cystic+Neoplasm.">Total Laparoscopic Central Pancreatectomy with Pancreaticogastrostomy for High-Risk Cystic Neoplasm.</a> Annals of surgical oncology. 23 (3), 1035 (2016).</li><li>Topal, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreaticojejunostomy+versus+pancreaticogastrostomy+reconstruction+after+pancreaticoduodenectomy+for+pancreatic+or+periampullary+tumours:+a+multicentre+randomised+trial.">Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours: a multicentre randomised trial.</a> The Lancet Oncology. 14 (7), 655-662 (2013).</li><li>Lemaire, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Functional+and+morphological+changes+in+the+pancreatic+remnant+following+pancreaticoduodenectomy+with+pancreaticogastric+anastomosis.">Functional and morphological changes in the pancreatic remnant following pancreaticoduodenectomy with pancreaticogastric anastomosis.</a> Br J Surg. 87 (4), 434-438 (2000).</li><li>Rault, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreaticojejunal+Anastomosis+Is+Preferable+to+Pancreaticogastrostomy+after+Pancreaticoduodenectomy+for+Longterm+Outcomes+of+Pancreatic+Exocrine+Function.">Pancreaticojejunal Anastomosis Is Preferable to Pancreaticogastrostomy after Pancreaticoduodenectomy for Longterm Outcomes of Pancreatic Exocrine Function.</a> Journal of the American College of Surgeons. 201 (2), 239-244 (2005).</li><li>Lai, E. C., Tang, C. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+distal+pancreatectomy+versus+conventional+laparoscopic+distal+pancreatectomy:+a+comparative+study+for+short-term+outcomes.">Robotic distal pancreatectomy versus conventional laparoscopic distal pancreatectomy: a comparative study for short-term outcomes.</a> Frontiers of medicine. 9 (3), 356-360 (2015).</li><li>Konstantinidis, I. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+total+pancreatectomy+with+splenectomy:+technique+and+outcomes.">Robotic total pancreatectomy with splenectomy: technique and outcomes.</a> Surg Endosc. , (2017).</li><li>Liu, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+surgical+outcomes+of+robot-assisted+laparoscopic+pancreaticoduodenectomy+versus+laparoscopic+pancreaticoduodenectomy+for+periampullary+neoplasms:+a+comparative+study+of+a+single+center.">The surgical outcomes of robot-assisted laparoscopic pancreaticoduodenectomy versus laparoscopic pancreaticoduodenectomy for periampullary neoplasms: a comparative study of a single center.</a> Surg Endosc. 31 (6), 2380-2386 (2017).</li><li>Lui, R., Zhao, G., Yin, Z., Zhao, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+enucleation+for+pancreatic+neoplasm+with+interposition+repair+of+the+main+pancreatic+duct:+a+case+report.">Robotic enucleation for pancreatic neoplasm with interposition repair of the main pancreatic duct: a case report.</a> Chinese Journal of Laparoscopic Surgery. 9 (6), 373-374 (2016).</li><li>Ehrhardt, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ueber+Resektionen+am+Pankreas1.">Ueber Resektionen am Pankreas1.</a> DMW-Deutsche Medizinische Wochenschrift. 34, 595-597 (1908).</li><li>Wolk, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+central+pancreatectomy+and+pancreatic+enucleation+as+pancreatic+resections--A+comparison.">Evaluation of central pancreatectomy and pancreatic enucleation as pancreatic resections--A comparison.</a> Int J Surg. 22, 118-124 (2015).</li><li>Ishii, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Remnant+pancreas+reconstruction+with+duct-to-duct+anastomosis+after+middle+pancreatectomy:+a+report+of+two+cases.">Remnant pancreas reconstruction with duct-to-duct anastomosis after middle pancreatectomy: a report of two cases.</a> Hepato-gastroenterology. 62 (137), 190-194 (2015).</li><li>Di Benedetto, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Meso-pancreatectomy:+new+surgical+technique+for+Wirsung+reconstruction.">Meso-pancreatectomy: new surgical technique for Wirsung reconstruction.</a> J Am Coll Surg. 214 (2), 1-4 (2012).</li><li>Oida, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=End-to-end+anastomosis+after+medial+pancreatectomy+for+tumor.">End-to-end anastomosis after medial pancreatectomy for tumor.</a> Hepato-gastroenterology. 54 (76), 1266-1268 (2007).</li><li>Ramesh, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=End-to-end+anastomosis+of+pancreas.">End-to-end anastomosis of pancreas.</a> Surgery. 131 (6), 691-693 (2002).</li><li>Kang, C. 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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 treatm...

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.

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	<tbody>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">da Vinci Robotic Surgical System</td>
			<td style="width:296px;">Intuitive&#160;Surgical, USA</td>
			<td style="width:113px;">Si</td>
			<td style="width:159px;"></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">EndoWrist Permanent Cautery Hook</td>
			<td>Intuitive&#160;Surgical, USA</td>
			<td style="width:113px;">420183</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:205px;">Harmonic Ace Curved Shears</td>
			<td>Ethicon, USA</td>
			<td style="width:113px;">420275</td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">EndoWrist Large needle Driver</td>
			<td>Intuitive&#160;Surgical, USA</td>
			<td style="width:113px;">420006</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:205px;">EndoWrist Cadiere Forceps</td>
			<td>Intuitive&#160;Surgical, USA</td>
			<td style="width:113px;">420049</td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">EndoWrist Black Diamond Micro Forceps</td>
			<td>Intuitive&#160;Surgical, USA</td>
			<td style="width:113px;">420033</td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Lapro-Clip 8 mm Absorbable Clips</td>
			<td>Covidien&#160; , USA</td>
			<td style="width:113px;">8886848882</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:205px;">5-0 non-absorbable suture</td>
			<td>Ethicon, USA</td>
			<td style="width:113px;">M8717</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:205px;">4-0 non-absorbable suture</td>
			<td>Ethicon, USA</td>
			<td style="width:113px;">D9775</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:205px;">5-0 absorbable suture</td>
			<td>Ethicon, USA</td>
			<td style="width:113px;">D9943</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:205px;">Absorbable hemostas</td>
			<td>Ethicon, USA</td>
			<td style="width:113px;">W1912</td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Laparoscopic Ultrasound Probe</td>
			<td>BK Ultrasound, Denmark</td>
			<td style="width:113px;">8666-RF</td>
			<td>transducer contact surface: 30*5mm; Frequence: 4.3-10 MHz</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:205px;">Pancreatic stent</td>
			<td>Yaxin Medical, Suzhou, China</td>
			<td style="width:113px;">1.2 mm&#160;</td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Antibiotics&#160;(ceftriaxone sodium for injection)</td>
			<td style="width:296px;">Roche, Shanghai, China</td>
			<td style="width:113px;">H10983036</td>
			<td>ceftriaxone sodium (2g) adding to normal saline (100ml), once per day.</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Proton pump inhibitors (lansoprazole injection)&#160;</td>
			<td style="width:296px;">Luoxin Pharmaceutical, Linyi, China</td>
			<td style="width:113px;">H20055118</td>
			<td>lansoprazole injection (30 mg) adding to normal saline (100ml), twice per day.</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Somatostatin (Somatostatin for injection)</td>
			<td style="width:296px;">Merck Serono, Germany</td>
			<td style="width:113px;">H20090929</td>
			<td>Somatostatin for injection (6000ug) adding to nornal saline to a total of 48ml, 2 ml/h</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:205px;">Analgesic</td>
			<td style="width:296px;"></td>
			<td style="width:113px;"></td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Analgesic (sufentanil Citrate injection)</td>
			<td style="width:296px;">Humanwell Healthcare, Fuzhou, China</td>
			<td style="width:113px;">H20054171</td>
			<td>sufentanil Citrate (200ug),&#160; Ondansetron hyrochloride (20mg), adding to normal saline to a total of 80 ml, 1 ml/h</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Analgesic (Ondansetron hyrochloride injection)</td>
			<td style="width:296px;">Qilu Pharmaceutical, Hainan, China</td>
			<td style="width:113px;">H10970065</td>
			<td>sufentanil Citrate (200ug),&#160; Ondansetron hyrochloride (20mg), adding to normal saline to a total of 80 ml, 2 ml/h</td>
		</tr>
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			<td height="21" style="height:21px;width:205px;">Parenteral nutrition&#160;</td>
			<td style="width:296px;"></td>
			<td style="width:113px;"></td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Parenteral nutrition(10% glucose injection)</td>
			<td style="width:296px;">Shijiazhuang No.4 Pharmaceutical&#65292;Shijiazhuang, China</td>
			<td style="width:113px;">H20133313</td>
			<td>1000 ml</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Parenteral nutrition(5% glucose&#160; injection)</td>
			<td style="width:296px;">Shijiazhuang No.4 Pharmaceutical&#65292;Shijiazhuang, China</td>
			<td style="width:113px;">H13022474</td>
			<td style="width:159px;">250 ml</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Parenteral nutrition(Compond vitamin injection)</td>
			<td style="width:296px;">Pude Pharmaceutical, Datong, China</td>
			<td style="width:113px;">H20093720</td>
			<td style="width:159px;">1 piece</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Parenteral nutrition(Compond amino acid injection)</td>
			<td style="width:296px;">Kelun Pharmaceutical, Chengdu, China</td>
			<td style="width:113px;">H20066058</td>
			<td style="width:159px;">500 ml</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Parenteral nutritionz(Fat emulsion injection)</td>
			<td style="width:296px;">Fresenius Kabi AB, Sweden</td>
			<td style="width:113px;">H20160019</td>
			<td style="width:159px;">250 ml</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Parenteral nutrition(10%KCl injection)</td>
			<td style="width:296px;">Jinyao Pharmaceutical, Tianjin, China</td>
			<td style="width:113px;">H12020518</td>
			<td style="width:159px;">50 ml</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Parenteral nutrition(10%NaCl injection)</td>
			<td style="width:296px;">CR, Double-Crane, Beijing, China</td>
			<td style="width:113px;">H11020865</td>
			<td style="width:159px;">50 ml</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Parenteral nutrition(Insulin injection)</td>
			<td style="width:296px;">No.1 biochemical and pharmaceutical, Shanghai, China</td>
			<td style="width:113px;">H31020519</td>
			<td style="width:159px;">28 Unit</td>
		</tr>
	</tbody>
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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 an...

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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 ...

This method can help answer key question about how to perform the robotic central pancreatectomy with an end-to-end anastomosis. The main advantages of this technique are that it simplifies the reconstruction approach after robotic central pancreatectomy, avoids pancreaticoenterostomy, and allows conservation of this anatomic continuity of the gastrointestinal tract. Demonstrating the procedure with me will be Gao Yuan-Xing and Xu Yong, associate senior doctors from my department.Before beginning the procedure, place the patient supine at a 20-degree reverse Trendelenburg position with the legs split, and drap the patient in the standard sterile fashion for upper abdominal surgery. Position the surgeon console in the operating room, the patient cart over the patient's head and vision cart to the right of the patient. Then direct the assistant surgeon to stand between the patient's legs with the back table for the instruments and supplies at the left rear of the assistant.When everything is in position, use a scalpel to make a one centimeter incision three centimeters inferior and right lateral to the umbilicus, and insert a veress needle through the incision into the abdominal cavity. Use the automatical insufflation instrument to establish a carbon dioxide pneumoperitoneum of 14 millimeters of mercury, and replace the veress needle with a 12 millimeter trocar as the camera port. Insert the robotic endoscope into the trocar, and perform a diagnostic laparascopy to confirm the abdominal adhesion status and operative feasibility.Under the view of the endoscope, place an 8 millimeter trocar in the left anterior axillary line at the level of the umbilicus for the first robotic arm, and place a 12 millimeter trocar 2 centimeter inferior and left lateral to the umbilicus as the assistant port. Place a 12 millimeter trocar in the right mid-clavicular line at the level of the umbilicus, and insert an 8 millimeter trocar into the right mid-clavicular 12 millimeter trocar in a trocar in trocar fashion for the second robotic arm. Then, place an 8 millimeter trocar under the costal margin in the right middle axillary line for the third robotic arm.Dock the robotic arm, and dock the robotic endoscope in the camera arm. To mobilize the pancreas neck and body, use the forceps on the third robotic arm to grasp and elevate the anterior wall of the the stomach to expose the gastrocolic ligament. Have the assistant apply tension in the gastrocolic ligament using the grasping forceps coupled with the bipolar forceps and the second robotic arm.Divide the gastrocolic ligament to enter the lesser sac, and use the laparoscopic ultrasonic scalpel on the first robotic arm to expose the anterior surface of the pancreas. Then, use the bipolar forceps on the second robotic arm to perform hemostasis until the level of the right gastroepiploic vein is reached. Using the cautery hook, carefully dissect the pancreatic neck from the inferior to superior direction, dividing the posterior wall of the pancreatic neck from the portal superior mesenteric, inferior mesenteric, and splenic veins.When the tissues have been divided, create a tunnel between the veins and the posterior wall of the pancreatic neck. Then use the cautery hook and ultrasonic scalpel to dissect the pancreatic body from the splenic vessels and connective tissues toward the pancreatic tail. To transect the pancreatic parenchyma, insert the laparoscopic ultrasound probe through the assistant trocar and perform ultrasonography on the pancreas to reconfirm the location and size of the lesion.According to the results of the ultrasonography, use the cautery hook to mark two transection lines on the pancreatic surface about one centimeter away from the lesion. Insert the fenestrated bipolar forceps through the inferior margin of the pancreas to lift the pancreatic body and further detach the proximal part of pancreatic body from the splenic vessels and connective tissues. Then mobilize the pancreatic neck and proximal pancreatic body from the posterior vessels and tissues.Using the ultrasonic scalpel, incise the pancreas parenchyma along the distal and proximal transection line and expose the pancreatic duct. Transect the pancreatic parenchyma around the pancreatic duct, and carefully protect and mobilize the pancreatic duct from the transected pancreatic parenchyma. Then use laparoscopic scissors from the assistant port to sharply transect the pancreatic duct about one centimeter away from the stump.To reduce the tension of the anastomosis, use the cautery hook and bipolor forceps to further mobilize the pancreatic stump from the posterior vessels and connective tissues. Implant the stent into the abdominal cavity through the assistant port and use microforceps to hold the sidewall of pancreatic duct stump within the pancreatic body. Gently insert the stent into the distal pancreatic duct stump, and use 5-0 absorbable sutures to suture the pancreatic duct with the stent so that the stent is closely encircled by the duct.Using a similar approach without a suture, insert the other end of the stent into the proximal pancreatic duct stump, followed by placement of a 4-0 nonabsorbable horizontal mattress suture around the proximal and distal pancreatic stumps. While pulling the two pancreatic stumps closer, continue to insert the proximal end of the stent into the proximal pancreatic duct stump. Next, perform an end-to-end anastomis of the pancreatic duct stumps using a 5-0 nonabsorbable suture with an interrupted stitch, and knot the remaining ties on the pancreatic stumps.Then use a 4-0 nonabsorbable suture to make a continuous stitch to suture the anterior portion of the pancreatic stumps. When the stumps have been secured, carefully check for bleeding, and conduct a thorough hemostasis, encircling the anastomosis site with absorbable hemostatic gauze as necessary. Place the resected specimen into a plastic sample bag, and remove the bag through the enlarged incision of the camera port.Place two drains along the superior and inferior borders of the anastomosis site, and extract the drains from the port for the third robotic arm. Then give the patient intravenous antibiotics, parenteral nutrition, analgesia, somatostatin, proton pump inhibitors, and other appropriate treatment according to conventional central pancreatectomy protocols. In this representative procedure, the resected pancreas was about 5.5 by 2.5 by 2.5 centimeters.After a smooth discharge and recovery, the postoperative CT scan revealed a slight exudation around the pancreas with no dilation or stricture in the pancreatic duct. While attempting this procedure, it is important to remember to transect the pancreatic duct sharply, and to fully mobilize the pancreatic stumps, particularly the distal pancreatic stump, prior to the end-to-end anastomosis to achieve the tension-free"anastomosis. After its development, this technique paved the way for researchers in the field of minimally invasive HPB surgery to explore the optimization of the reconstruction approaches for pancreatic duct and parenchyma after pancreatectomy.After watching the video, you should have to good understanding of how to use a robotic surgical system to perform the central pancreatectomy and to reconstruct the anatomic continuity of the pancreas by end-to-end anastomosis.

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Research

JoVE Journal

Medicine

Remote Magnetic Navigation for Accurate, Real-time Catheter Positioning and Ablation in Cardiac Electrophysiology Procedures

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac substrates such as left atrial flutter. This protocol describes all the clinical and invasive interventional steps performed during a human electrophysiological study and ablation to assess the accuracy, safety and real-time navigation of the Catheter Guidance, Control and Imaging (CGCI) system. Patients who underwent ablation of a right or left atrium flutter substrate were included. Specifically, data from three left atrial flutter and two counterclockwise right atrial flutter procedures are shown in this report. One representative left atrial flutter procedure is shown in the movie. This system is based on eight coil-core electromagnets, which generate a dynamic magnetic field focused on the heart. Remote navigation by rapid changes (msec) in the magnetic field magnitude and a very flexible magnetized catheter allow real-time closed-loop integration and accurate, stable positioning and ablation of the arrhythmogenic substrate.

This report provides a detailed description of a new remote navigation system based on magnetic driven forces, which has been recently introduced as a new robotic tool for human cardiac electrophysiology procedures.

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac ...

Murine Ileocolic Bowel Resection with Primary Anastomosis

Intestinal resections are frequently required for treatment of diseases involving the gastrointestinal tract, with Crohn&#8217;s disease and colon cancer being two common examples. Despite the frequency of these procedures, a significant knowledge gap remains in describing the inherent effects of intestinal resection on host physiology and disease pathophysiology. This article provides detailed instructions for an ileocolic resection with primary end-to-end anastomosis in mice, as well as essential aspects of peri-operative care to maximize post-operative success. When followed closely, this procedure yields a 95% long-term survival rate, no failure to thrive, and minimizes post-operative complications of bowel obstruction and anastomotic leak. The technical challenges of performing the procedure in mice are a barrier to its wide spread use in research. The skills described in this article can be acquired without previous surgical experience. Once mastered, the murine ileocolic resection procedure will provide a reproducible tool for studying the effects of intestinal resection in models of human disease.

Ileocolic resection is commonly performed in several human diseases; however, little is known regarding the impact of intestinal resection on surgical illnesses. This article provides instruction on executing the procedure in mice with high success, providing a means to study the effects of ileocolic resection in models of disease.

Intestinal resections are frequently required for treatment of diseases involving the gastrointestinal tract, with Crohn&#8217;s disease and colon cancer ...

Robotic Ablation of Atrial Fibrillation

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between pulmonary vein (PV) and left atrium (LA) is created. This conduction block prevents AF, which is triggered by irregular electric activity originating from the PV. However, transmural atrial lesions are required which can be challenging. Re-conduction and AF recurrence occur in 20 - 40% of the cases. Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new remote catheter system (RCS), is presented. Objective of this article is to show feasibility of robotic AF ablation with a novel system. Materials and Methods: After interatrial trans-septal puncture is performed using a long sheath and needle under fluoroscopic guidance. The needle is removed and a guide wire is placed in the left superior PV. Then an ablation catheter is positioned in the LA, using the sheath and wire as guide to the LA. LA angiography is performed over the sheath. A circular mapping catheter is positioned via the long sheath into the LA and a three-dimensional (3-D) anatomical reconstruction of the LA is performed. The handle of the ablation catheter is positioned in the robotic arm of the Amigo system and the ablation procedure begins. During the ablation procedure, the operator manipulates the ablation catheter via the robotic arm with the use of a remote control. The ablation is performed by creating point-by-point lesions around the left and right PV ostia. Contact force is measured at the catheter tip to provide feedback of catheter-tissue contact. Conduction block is confirmed by recording the PV potentials on the circular mapping catheter and by pacing maneuvers. The operator stays out of the radiationfield during ablation. Conclusion: The novel catheter system allows ablation with high stability on low operator fluoroscopy exposure.

Pulmonary vein isolation (PVI) with an ablation catheter is a curative treatment for atrial fibrillation (AF). Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new robotic catheter system is presented. The goal of the procedure is electrical block between pulmonary vein and left atrium.

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between ...

Emergency Undocking in Robotic Surgery: A Simulation Curriculum

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of a robotic system. In traditional robotic training for surgeons, a brief web based overview of performing an emergency undocking is provided during initial introductory training to the robotics system. During such a process, there is no training in delineation of interdisciplinary roles for operating room (OR) personnel. The training presented here uses formative simulation and debriefing followed by a lecture. For the simulation, a modified gynecologic simulator is draped in a steep trendelenburg position consistent with most gynecologic laparoscopic surgery. The training torso is modified using tubing hooked to pressure bags of red food colored IV fluid used to simulate a catastrophic vessel injury on demand. Positioned throughout the operating room setting is an interprofessional team consisting of embedded standardized persons (ESPs) to fulfill the roles of a circulating nurse, scrub nurse, anesthesiologist, and bedside assist surgeon. Robotic surgeons are presented a case scenario necessitating emergency undocking, and given control of the robotic instruments. The scenario is terminated following either successful completion of an emergency undock, or at five minutes due to the emergent nature of the case. A debriefing session with hands on training of the steps to emergency undocking, necessary equipment, troubleshooting techniques, and operating room personnel roles follows the simulation. The learners are presented with a short lecture reemphasizing the material presented in the debriefing for their own self-study. This training results in improved time accessing the patient, improved knowledge, confidence, and completion of critical actions, and can be replicated in most institutions. All robotic surgeons should be able to demonstrate competence in this crucial intervention. A limitation of the curriculum is ability to access the in-situ environment for training purposes.

This training platform is designed to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of the robotic system. Training includes the utilization of the technology and equipment to perform an emergency undocking, as well as delineation of roles for such a scenario.

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of ...

Vessel-sparing Excision and Primary Anastomosis

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short bulbar or posterior urethral strictures, urethroplasty by excision and primary anastomosis (EPA) is recommended. As EPA only requires the excision of the narrowed segment and the surrounding spongiofibrosis, a full-thickness transection of the corpus spongiosum, as performed in the traditional transecting EPA (tEPA), is usually unnecessary. Jordan et al. introduced the idea of a vessel-sparing approach in 2007, aiming to reduce surgical trauma, especially to the dual arterial blood supply of the urethra, and, thus, potentially reducing the risk of postoperative erectile dysfunction or glans ischemia. This approach could also be beneficial for subsequent urethral interventions such as redo urethroplasty using a free graft, in which a well-vascularized graft bed is imperative. Nevertheless, these potential benefits are only assumptions as prospective studies comparing the functional outcome of both techniques with validated questionnaires are currently lacking. Moreover, vessel-sparing EPA (vsEPA) should at least be able to provide similar surgical outcomes as tEPA. The aim of this paper is to give an elaborate, step-by-step overview of how to manage patients with isolated short bulbar or posterior urethral strictures with vsEPA. The main objective of this manuscript is to outline the surgical technique and to report the representative surgical outcome. A total of 117 patients were managed according to the described protocol. The analysis was performed on the entire patient cohort and on the bulbar (n = 91) and posterior (n = 26) vsEPA group separately. Success rates were 93.4% and 88.5% for the bulbar and posterior vsEPA, respectively. To conclude, vsEPA, as outlined in the protocol, provides excellent success rates with low complication rates for isolated short bulbar and posterior urethral strictures.

Here, we present an elaborate and efficient protocol to treat isolated short bulbar or posterior urethral strictures with vessel-sparing excision and primary anastomosis.

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short ...

Creation of Colonic Anastomosis in Mice

Intestinal anastomoses are commonly performed in both elective and emergent operations. Even so, anastomotic leaks are a highly feared complications of colonic surgeries and can occur in up to 26% of surgical anastomoses, with mortality being up to 39% for patients with such a leak. Currently, there remains a paucity of data detailing the cellular mechanisms of anastomotic healing. Devising preventative strategies and treatment modalities for anastomotic leak could be greatly potentiated by a better understanding of appropriate anastomotic healing.
A murine model is ideal as previous studies have shown that the murine anastomosis is the most clinically similar to the human case as compared with other animal models. We offer an easily reproducible murine model of colonic anastomosis in mice that will allow for further illustration of anastomotic healing.

Anastomotic leak or breakdown after surgery is a major cause of postoperative morbidity and mortality. Our surgery for creating a colonic anastomosis is a reliable and reproducible method for studying the healing mechanisms of anastomoses.

Intestinal anastomoses are commonly performed in both elective and emergent operations. Even so, anastomotic leaks are a highly feared complications of ...

One-anastomosis Gastric Bypass (OAGB) in Rats

The goal of this protocol is to set up a preclinical model of bariatric surgery and, more specifically, OAGB in obese rats. Based on this preclinical model, longitudinal studies can be carried out to provide an improved understanding of the mechanisms underlying the outcomes seen after bariatric surgery in humans. For this purpose, rats are operated on through a laparotomy under general anesthesia with isoflurane. First, the surgeon creates a long and tubular gastric pouch: after greater curve and hiatal dissection, the nonglandular stomach is stapled and removed. Then, the remaining stomach is also stapled in order to create a gastric tube and exclude the antrum of the stomach. After that, the surgeon performs a single end-to-side gastrojejunostomy 35 cm from the duodenojejunal angle. This limb length has been chosen in order to reproduce the same ratio between the biliopancreatic limb (BPL) and common limb (CL) length as in human bariatric surgery. The operation ends by aponeurotic and cutaneous closure. The early postoperative management consists of subcutaneous hydration, an intramuscular prophylactic antibiotic injection, a parietal injection of xylocaine, the administration of painkillers, and a progressive reintroduction of diet.

One-anastomosis Gastric Bypass OAGB in Rats

This protocol is for the performance of one-anastomosis gastric bypass (OAGB) on rat. The operator performs a long and tubular-stapled gastric pouch followed by hand-sewn anastomosis. For this model, the operator reproduces the same ratio between biliopancreatic and common limb in humans; therefore, the biliopancreatic limb measures 35 cm.

The goal of this protocol is to set up a preclinical model of bariatric surgery and, more specifically, OAGB in obese rats. Based on this preclinical ...

DIPLOMA Approach for Standardized Pathology Assessment of Distal Pancreatectomy Specimens

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignant cancers. A minority (20%) of PDACs are found in the pancreatic body and tail. Accurate pathology assessment of the pancreatic specimen is essential for providing prognostic information and it may guide further treatment strategies. The recent 8th edition of the American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) staging system for pancreatic tumors has incorporated significant changes to tumor (pT) stage, which is predominantly based on tumor size. This change emphasizes the importance of careful block selection. Owing to the greater prevalence of tumors in the head of the pancreas, efforts are made to standardize the assessment of pancreatoduodenectomy specimens. However, consensus regarding the macroscopic assessment of distal (i.e., left) pancreatectomy specimens is lacking. The DIPLOMA approach includes the standardized measurement of pancreas and other resected organs, inking of relevant surgical margins and anatomical surfaces without removing covering layers of fat, measurement of tumor size (for T-stage), together with assessment of splenic vessel involvement (and other organs if present). All relevant margins are assessed, and relevant blocks are selected to confirm these parameters microscopically. The current protocol describes a standardized approach to the macroscopic assessment of distal pancreatectomy specimens. This approach was developed during several meetings with pathologists and surgeons during the preparation phase for an international multicenter trial (DIPLOMA, ISRCTN44897265), which focuses on radicality of distal pancreatectomy for pancreatic ductal adenocarcinoma. This standardized approach can be instrumental in the design of studies and will uniform reporting on the outcomes of distal pancreatectomy. The described technique is used in the DIPLOMA trial for pancreatic ductal adenocarcinoma but may also be useful for other indications.

The current study highlights a standardized approach to the macroscopic assessment of distal pancreatectomy specimens for pancreatic ductal adenocarcinoma, with special emphasis on the measurement of pancreatic dimensions and those of other organs, inking of margins, measurement of tumor size and proximity to margins, lymph node sampling and block selection.

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignant cancers. A minority (20%) of PDACs are found in the pancreatic body and tail. ...

Application of Lucilia sericata Larvae in Debridement of Pressure Wounds in Outpatient Settings

Biological therapy using Lucilia sericata larvae has numerous advocates worldwide, yet it is still fairly unknown and not commonly applied in daily practice because of the limited awareness and insufficient experience of medical and nursing personnel. There are case reports suggesting that maggot therapy can be applied and supported by lay caregivers, provided they are supervised and informed by physicians/nurses. The foregoing observation suggests that the method should be considered for implementation by a wider group of caregivers if accepted and meticulously supervised by trained and experienced medical staff. The concerns related to the therapeutic use of maggots in certain regions seem understandable, but are not supported by scientific facts. It should be noted that many therapeutic agents (including brood) used in medicine are of natural origin, and are associated with low production costs and high possibilities of implementation in the course of therapy. By analyzing the literature and using our own clinical and research experience, we have come to conclusions related to using larvae therapy, as a quick and safe method providing cleaning and revitalization in the process of treating wounds of various etiologies, especially pressure ulcers. In the current study, medical-grade Lucilia sericata maggots were applied to remove necrotic tissue from deep pressure sores. The treatment is mostly accepted by both caregivers and patients. In most cases, it is conducted by trained and experienced medical personnel in home and outpatient settings. Over the course of the conducted analyzes involving the collected specimens, there were no statistically significant relationships (p&gt; 0.05) confirmed between the wound surface successfully cleared by brood and variables, such as time from wound formation, location, surface size, and the depth of damage to the tissue structure. The lack of statistical dependence may result from the small size of the studied group. Based on the current findings, we have formulated the following conclusions: Maggot Debridement Therapy (MDT) is a fast and effective method enabling the preparation of the wound bed. The use of MDT in outpatient settings is safe and acceptable for patients and their caregivers.

Application of Lucilia sericata Larvae in Debridement of Pressure Wounds in Outpatient Settings

Maggots of Lucilia sericata were used in the debridement of deep pressure sores in outpatient settings for the treatment of pressure sores involving the complete skin thickness. The technique presented in the article does not pose risks for the patient.

Biological therapy using Lucilia sericata larvae has numerous advocates worldwide, yet it is still fairly unknown and not commonly applied in daily ...

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 ...