We would like to acknowledge Melissa Hogg, MD who supported and trained us in robotic pancreatic surgery.

The present protocol follows the ethics guidelines of the Amsterdam UMC.
1. Operative setting and trocar placement
<ol>
	<li>Place the patient in French position with a heating device, laying on a short grain mattress with the right arm tucked in and slightly lowered, and the left arm abducted to 90&#176;.</li>
	<li>After all safety procedures (hood, sterile glove and sterile scrub) are ascertained, create a sterile exposition. Have the first surgeon at the robot console and the table-side surgeon between the patient's legs. Perform the procedure using a 7-port technique.</li>
	<li>Create pneumoperitoneum by placing a Veress needle in the left hypochondrium, then place seven trocars as shown in Figure 2 (4 robotic, 2 laparoscopic assistants, and 1 trocar for the liver snake-retractor). 
	NOTE: The sequence of instruments (Table of Materials) during each operative step is seen in Table 1.</li>
	<li>Place the robot on the right side next to the patient and dock the arms to the previously placed trocars.</li>
	<li>Retract the falciform ligament ventrally using a percutaneous suture by using a straight needle.</li>
</ol>
2. Surgical technique
<ol>
	<li>Mobilization of the stomach
	<ol>
		<li>Open the greater omentum 2 cm distal from the gastroepiploic vessels using a sealing device by the table-side surgeon.</li>
		<li>Use the snake-retractor to retract the stomach and the left liver ventrally and cranially. Expose the anterior surface of the pancreas by dissecting the adhesions between the pancreas and the stomach and duodenum.</li>
		<li>Identify the right gastroepiploic vein and artery at the lower border of the pancreas and transect these using either a sealing device, clips or an endo-stapler using a vascular cartridge.</li>
	</ol>
	</li>
	<li>Ultrasound of the pancreas 
	NOTE: Now, the entire pancreas can be exposed.
	<ol>
		<li>Perform an intraoperative ultra-sound to locate the MPD. 
		NOTE: The ultrasound is integrated in the robotic console and controlled trough a grabbing point intended for a fenestrated robotic grasper.</li>
	</ol>
	</li>
	<li>Opening the MPD, ligation of the gastroduodenal artery
	<ol>
		<li>Determine the trajectory of the MPD and open the pancreas with the robotic monopolar diathermia hook. Insert a 5&#8722;7 Fr, 10 cm stent in the duct which prevents cautery damage to the dorsal surface of the MPD during dissection.</li>
		<li>Start the pancreatic duct incision at the pancreatic neck or body; then follow the duct towards the pancreatic tail.</li>
		<li>Finalize by proceeding from the pancreatic body to the pancreatic head which includes crossing the gastroduodenal artery. Expose and ligate the gastroduodenal artery on both sides, just below and above the pancreatic duct with stitches and subsequently transected.</li>
	</ol>
	</li>
	<li>Identification of the Roux limb 
	NOTE: Pulling up the small bowel to identify the Roux limb.
	<ol>
		<li>Reflect the transverse colon cranially to identify the ligament of Treitz and open the mesocolon in the avascular plane to the (patient's) left of the middle mesocolonic vessels.</li>
		<li>Approximately 30 cm from Treitz ligament, divide the jejunum using an endo-stapler. Mark the proximal end using a long suture which is retained. Pass the Roux limb through the defect and placed in close proximity to the MPD. Place the stapled end/stump of the bowel towards the splenic hilum.</li>
		<li>Mark the future lateral jejuno-jejunostomy site by a single suture after measuring a distance of 50 cm between the pancreatic anastomosis and the lateral jejuno-jejunostomy site.</li>
	</ol>
	</li>
	<li>Pancreaticojejunostomy anastomosis 
	NOTE: The Roux limb is opened with monopolar electrocautery.
	<ol>
		<li>First, complete the caudal part of the anastomosis ('inferior border') with a single row running suture until the medial end is reached, then complete the anterior or cranial wall in the same fashion with a new running suture. 
		NOTE: Both the layers are made using a 3-0 barbed suture (9'' 23 cm, V-20, &#189; circle 26 mm needle).</li>
		<li>Examine the lateral pancreatojejunostomy for leaks. 
		NOTE: A single stitch with a monofilament 5-0 suture (5'' 13 cm, RB, &#189; circle 17-26 mm needle), can be placed over any suspected wall defects. If one single barbed suture is not enough, use a second which can be tied to the first suture.</li>
	</ol>
	</li>
	<li>Jejunojejunostomy anastomosis
	<ol>
		<li>Aid the side-to-side lateral, isoperistaltic jejuno-jejunostomy anastomosis by measuring 60 cm between the pancreatic anastomosis and the site of this anastomosis.</li>
		<li>Align both small bowel loops and perform the enterotomies with monopolar electrocautery in each loop.</li>
		<li>Then, create an anastomosis using an endo-stapler. Close the remaining opening using a 3-0 barbed suture (9'' 23 cm, V-20, &#189; 22-26 mm needle) single layer.</li>
	</ol>
	</li>
	<li>Drain placement
	<ol>
		<li>Place a single tubular drain next to the LPJ site through the right trocar opening at the anterior axillary line and fix it with a single stitch to the external abdominal wall.</li>
	</ol>
	</li>
</ol>

<ol>
	<li>Van Der Gaag, N. 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=Functional+and+medical+outcomes+after+tailored+surgery+for+pain+due+to+chronic+pancreatitis.">Functional and medical outcomes after tailored surgery for pain due to chronic pancreatitis.</a> Annals of Surgery. 255 (4), 763-770 (2012).</li><li>Cahen, D. 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=Long-term+outcomes+of+endoscopic+vs+surgical+drainage+of+the+pancreatic+duct+in+patients+with+chronic+pancreatitis.">Long-term outcomes of endoscopic vs surgical drainage of the pancreatic duct in patients with chronic pancreatitis.</a> Gastroenterology. 141 (5), 1690-1695 (2011).</li><li>Cahen, D. 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=Endoscopic+versus+surgical+drainage+of+the+pancreatic+duct+in+chronic+pancreatitis.">Endoscopic versus surgical drainage of the pancreatic duct in chronic pancreatitis.</a> New England Journal of Medicine. 356, 676-684 (2007).</li><li>Zhao, X., Cui, N., Wang, X., Cui, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+strategies+in+the+treatment+of+chronic+pancreatitis:+An+updated+systematic+review+and+meta-analysis+of+randomized+controlled+trials.">Surgical strategies in the treatment of chronic pancreatitis: An updated systematic review and meta-analysis of randomized controlled trials.</a> Medicine (United States). 96 (9), 6220 (2017).</li><li>Meehan, J. J., Sawin, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+lateral+pancreaticojejunostomy+(Puestow).">Robotic lateral pancreaticojejunostomy (Puestow).</a> Journal of Pediatric Surgery. 46 (6), 5-8 (2011).</li><li>Kempeneers, M. 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=Multidisciplinary+treatment+of+chronic+pancreatitis:+an+overview+of+current+step-up+approach+and+new+options.">Multidisciplinary treatment of chronic pancreatitis: an overview of current step-up approach and new options.</a> Nederlands Tijdschrift voor Geneeskunde. 161, (2017).</li><li>Kim, E. Y., Hong, T. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+Longitudinal+Pancreaticojejunostomy+Using+Barbed+Sutures:+an+Efficient+and+Secure+Solution+for+Pancreatic+Duct+Obstructions+in+Patients+with+Chronic+Pancreatitis.">Laparoscopic Longitudinal Pancreaticojejunostomy Using Barbed Sutures: an Efficient and Secure Solution for Pancreatic Duct Obstructions in Patients with Chronic Pancreatitis.</a> Journal of Gastrointestinal Surgery. 20 (4), 861-866 (2016).</li><li>Khan, A. S., Siddiqui, I., Vrochides, D., Martinie, J. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+pancreas+drainage+procedure+for+chronic+pancreatitis:+robotic+lateral+pancreaticojejunostomy+(Puestow+procedure).">Robotic pancreas drainage procedure for chronic pancreatitis: robotic lateral pancreaticojejunostomy (Puestow procedure).</a> Journal of Visceral Surgery. 4 (4), 72 (2018).</li><li>Khaled, Y. S., Ammori, M. B., Ammori, B. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+lateral+pancreaticojejunostomy+for+chronic+pancreatitis:+A+case+report+and+review+of+the+literature.">Laparoscopic lateral pancreaticojejunostomy for chronic pancreatitis: A case report and review of the literature.</a> Surgical Laparoscopy Endoscopy &amp; Percutaneous Techniques. 21 (1), 36-40 (2011).</li><li>Puestow, C. B., Gillesby, W. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Retrograde+Surgical+Drainage+of+Pancreas+for+Chronic+Relapsing+Pancreatitis.">Retrograde Surgical Drainage of Pancreas for Chronic Relapsing Pancreatitis.</a> A.M.A Archives of Surgery. 76 (6), 898-907 (1958).</li><li>Adams, D. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Puestow+Procedure:+How+I+Do+It.">The Puestow Procedure: How I Do It.</a> Journal of Gastrointestinal Surgery. 17 (6), 1138-1142 (2013).</li><li>Eid, G. M., Entabi, F., Watson, A. R., Zuckerbraun, B. S., Wilson, M. A. <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+Laparoscopic+Side-to-Side+Lateral+Pancreaticojejunostomy.">Robotic-Assisted Laparoscopic Side-to-Side Lateral Pancreaticojejunostomy.</a> Journal of Gastrointestinal Surgery. 15, 1243 (2011).</li><li>Wright, G. P., Zureikat, A. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+of+Minimally+Invasive+Pancreatic+Surgery:+an+Evidence-Based+Systematic+Review+of+Laparoscopic+Versus+Robotic+Approaches.">Development of Minimally Invasive Pancreatic Surgery: an Evidence-Based Systematic Review of Laparoscopic Versus Robotic Approaches.</a> Journal of Gastrointestinal Surgery. 20 (9), 1658-1665 (2016).</li><li>D'Haese, J. G., Ceyhan, G. O., Demir, I. E., Tieftrunk, E., Friess, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+options+in+painful+chronic+pancreatitis:+A+systematic+review.">Treatment options in painful chronic pancreatitis: A systematic review.</a> HPB. 16 (6), 512-521 (2014).</li><li>Bachmann, K., Izbicki, J. R., Yekebas, E. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Chronic+pancreatitis:+Modern+surgical+management.">Chronic pancreatitis: Modern surgical management.</a> Langenbeck's Archives of Surgery. 396, 139-149 (2011).</li><li>Khaled, Y., Ammori, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+lateral+pancreaticojejunostomy+and+laparoscopic+berne+modification+of+beger+procedure+for+the+treatment+of+chronic+pancreatitis:+The+first+UK+experience.">Laparoscopic lateral pancreaticojejunostomy and laparoscopic berne modification of beger procedure for the treatment of chronic pancreatitis: The first UK experience.</a> Surgical Laparoscopy Endoscopy &amp; Percutaneous Techniques. 24 (5), 178-182 (2014).</li><li>Palanivelu, 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=Laparoscopic+lateral+pancreaticojejunostomy:+A+new+remedy+for+an+old+ailment.">Laparoscopic lateral pancreaticojejunostomy: A new remedy for an old ailment.</a> Surgical Endoscopy and other Interventional Techniques. 20 (3), 458-461 (2006).</li><li>Tantia, O., Jindal, M. K., Khanna, S., Sen, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+lateral+pancreaticojejunostomy:+Our+experience+of+17+cases.">Laparoscopic lateral pancreaticojejunostomy: Our experience of 17 cases.</a> Surgical Endoscopy and Other Interventional Techiques. 18 (7), 1054-1057 (2004).</li><li>Eid, G. M., Entabi, F., Watson, A. R., Zuckerbraun, B. S., Wilson, M. A. <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+Laparoscopic+Side-to-Side+Lateral+Pancreaticojejunostomy.">Robotic-Assisted Laparoscopic Side-to-Side Lateral Pancreaticojejunostomy.</a> Journal of Gastrointestinal Surgery. 15 (7), 1243-1243 (2011).</li><li>Hamad, A., Zureikat, A. H., Zeh, H. J., Boggi, U. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+Invasive+Drainage+Procedures+for+Chronic+Pancreatitis.">Minimally Invasive Drainage Procedures for Chronic Pancreatitis.</a> Minimally Invasive Surgery of the Pancreas. , 115-121 (2018).</li><li>Wright, G. P., Zureikat, A. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+of+Minimally+Invasive+Pancreatic+Surgery:+an+Evidence-Based+Systematic+Review+of+Laparoscopic+Versus+Robotic+Approaches.">Development of Minimally Invasive Pancreatic Surgery: an Evidence-Based Systematic Review of Laparoscopic Versus Robotic Approaches.</a> Journal of Gastrointestinal Surgery. 20, 1658-1665 (2016).</li></ol>

The authors have nothing to disclose.

Robotic LPJ can be used in selected patients with painful chronic pancreatitis and a dilated MPD. Robotic LPJ combines the advantages of the minimally invasive approach and the freedom of articulating wrists as known from open surgery. Generally, a minimally invasive approach offers enhanced postoperative recovery, a lower postoperative pain, and a shorter length of hospital stay9,16,17,18. The robotic approach has benefits over the standard laparoscopic approach. First, enhanced vision owing to the three-dimensional, high definition imaging allows for better visualization of anatomical structures for the surgeon during both the dissection and the reconstruction phase5,13,19. Secondly, the needle drivers augmented with wristed articulation allow for easy suturing to control bleeding while opening of the MPD. Thirdly, opening of the MPD is not limited by the direction of the laparoscopic instruments, since the monopolar diathermia has wristed articulation.
As observed by Khan et al.8, the intraoperative ultrasound is a useful tool to identify the MPD. Adding the color Doppler, ultrasound may also be very useful in identifying the trajectory of the gastroduodenal artery. Measuring the length of the Roux-loop using a long suture is important. Determining the length of a bowel loop using the robotic view can be particularly challenging. This may be relevant in case of a pancreatic fistula with risk of reflux of bowel content in case of a short Roux loop.
The robotic procedure is a lengthier, more costly, and more challenging procedure than the open approach13. Moreover, the use of this technology requires high experienced surgeons both in open and laparoscopic surgery, especially because tactile feedback is lacking20. The RLPJ is challenging and encompasses many critical steps during the dissection and the reconstruction phases.
The robotic LPJ with double transection of gastroduodenal artery is a complex but feasible operation for patients with painful CP and a dilated MPD unresponsive to conservative treatments. Due to the possible complication of this procedure and concerns on the threshold for annual case volume for minimally invasive pancreatic surgery, we believe it should be performed only in high-volume centers by surgeons with extensive experience in both open and minimally invasive pancreatic surgery21.
Due to the limited indications for surgery, currently, all published series are based on a low number of patients, varying from 6 to 17 inclusions7,16,17,18. Further studies should investigate the long-term outcomes for patients undergoing robotic LPJ to affirm the robotic approach as beneficial and safe.

Surgery is highly effective in selected patients with painful chronic pancreatitis1,2,3. Surgical intervention for chronic pancreatitis (CP) carries high postoperative risks4. Yet, in selected patients it might be the only available treatment, especially for painful CP that is non-responsive to medical therapy5,6. Pain and impaired quality of life are the most common indications for surgery in patients affected by CP3,7. The extension of pancreatic gland involvement and the location of the disease are the main preoperative parameters necessary to assess the best surgical strategy. Both resectional and decompressive techniques have proven to be successful for the treatment of this condition8. Decompressive techniques are preferred since they allow to preserve the pancreatic parenchyma, hence they lower the risk of postoperative endocrine and exocrine insufficiency9. Longitudinal pancreatojejunostomy was fist described in 1958 by Puestow and Gilesby10 and is nowadays one of the most common surgical techniques to treat CP11.
The debate of the best surgical technique and surgical approach, i.e., open or minimally invasive, is unresolved. In the few reported series in literature, laparoscopic LPJ shows advantages regarding postoperative pain and length of hospital stay9. Additionally, robotic surgery augments the minimally invasive approach with enhanced optics (three-dimensional vision) and extended degrees of freedom in the articulated instruments. This allows for very precise movements during suturing for pancreatic bleeding and the reconstruction phase of the operation5,7,9,12,13.
Here, we describe our robotic technique of LPJ which involves transection of the gastroduodenal artery. Patients are selected on the basis of symptoms related to CP (mostly continuous pain), and dilatation of main pancreatic duct (MPD) on preoperative imaging of at least 5 mm. A contrast-enhanced computed tomography (CT) scan is obtained to confirm the diagnosis and to exclude any neoplastic disease, distal biliary duct strictures, the presence of active acute pancreatitis (peripancreatic fluid and alteration in pancreatic parenchyma texture), and to measure the dilatation and the extension of the MPD dilatation. After these considerations, if the patient is deemed suitable for robotic LPJ, schedule a preoperative anesthesiology evaluation14,15.
A 45-year-old male presented with refractory CP non-responsive to conservative (pain) management for three years on the basis of episodes of heavy alcohol consumption. The patient ceased smoking (60-pack year) and drinking prior to surgery, and underwent endoscopic treatment (a 10 Fr, 7 cm stent was positioned in the MPD). Preoperative bilirubin- and lipase level were in the normal range. There was no pancreatic endocrine and exocrine insufficiency. The preoperative CT scan showed a dilated MPD in the body and tail of the pancreas (Figure 1).

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Systems</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Arietta Ultrasound</td>
			<td>Hitachi</td>
			<td>L43K / arietta v70</td>
			<td>Used for intraoperative laparoscopic ultrasonography.</td>
		</tr>
		<tr>
			<td>da Vinci Surgeon Console</td>
			<td>IS</td>
			<td>SS999</td>
			<td>Used to control the surgical robot.</td>
		</tr>
		<tr>
			<td>da Vinci Vision Cart</td>
			<td>IS</td>
			<td>VS999</td>
			<td>The vision cart houses advanced vision and energy technologies and provides communications across da Vinci system components.</td>
		</tr>
		<tr>
			<td>da Vinci Xi</td>
			<td>IS</td>
			<td>K131861</td>
			<td>The surgical robot: 'patient side-cart'</td>
		</tr>
		<tr>
			<td>Instruments</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Cobra Liver Retractor Diamond-Flex</td>
			<td>CareFusion</td>
			<td>89-6216</td>
			<td>Retracting the liver for optimal exposure of the surgical site.</td>
		</tr>
		<tr>
			<td>da Vinci Xi Endoscope with Camera, 8 mm, 30&#176;</td>
			<td>IS</td>
			<td>470027</td>
			<td>The camera of the da Vinci robot.</td>
		</tr>
		<tr>
			<td>ENDOEYE Rigid Video Laparoscope, 10 mm, 30&#176;</td>
			<td>Olympus</td>
			<td>WA50042A</td>
			<td>To see within the intra-abdominal cavity.</td>
		</tr>
		<tr>
			<td>ENDOWRIST Fenestrated Bipolar Forceps</td>
			<td>IS</td>
			<td>470205</td>
			<td>Used for dissection and coagulation.</td>
		</tr>
		<tr>
			<td>ENDOWRIST HOT SHEARS</td>
			<td>IS</td>
			<td>470179</td>
			<td>Used for cutting and coagulation.</td>
		</tr>
		<tr>
			<td>ENDOWRIST Mega SutureCut Needle Driver</td>
			<td>IS</td>
			<td>470309</td>
			<td>Used as a needle driver.</td>
		</tr>
		<tr>
			<td>ENDOWRIST Permanent Cautery Hook</td>
			<td>IS</td>
			<td>470183</td>
			<td>Used for coagulation.</td>
		</tr>
		<tr>
			<td>ENDOWRIST PROGrasp Forceps</td>
			<td>IS</td>
			<td>470093</td>
			<td>Used for dissection.</td>
		</tr>
		<tr>
			<td>LigaSure Dolphin Tip 37cm</td>
			<td>Medtronic</td>
			<td>LS1500</td>
			<td>Used for vessel sealing and dividing.</td>
		</tr>
	</tbody>
</table>

robotic lateral pancreaticojejunostomy for chronic pancreatitis

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The recent rise of robotic and laparoscopic pancreatic surgery has found benefits such as reduced time to functional recovery. Few studies have reported on the feasibility, technique and outcome of robotic LPJ, especially including transection of the gastroduodenal artery. The present study describes the main steps for robotic LPJ in a patient with painful chronic pancreatitis with a dilated main pancreatic duct. The patient underwent robotic LPJ. The LPJ anastomosis is performed using a running suture technique in a longitudinal side-to-side manner. Routinely, the gastroduodenal artery is transected to drain the entire length of the main pancreatic duct. The patient is in French position; 7 trocars are placed (4 robotic, 2 laparoscopic assistants, 1 liver-retractor). After docking of the robot system, the omental bursa is opened, and the right gastroepiploic artery and vein are ligated at their base at the lower border of the pancreas. Intraoperative ultrasonography is performed in order to determine trajectory of the dilated main pancreatic duct which is opened for its entire length after the gastroduodenal artery has been suture ligated both cranially and caudally from the main pancreatic duct. A Roux limb is created, and a latero-lateral PJ is fashioned using several 3-0 barbed sutures. A stapled jejuno-jejunostomy is created at sufficient distance from the pancreatic anastomosis, aided by a 50 cm suture. The described technique for robotic LPJ is a complex but feasible operation for patients with treatment refractory CP and a dilated main pancreatic duct. Due to its complexity, implementation in high volume centers with extensive experience with CP surgery may improve outcomes.

Representative results are shown in Table 2. The operative time was 388 min with 200 mL estimated intraoperative blood loss. The postoperative course was uncomplicated, thus no postoperative pancreatic fistula (POPF) was detected; on postoperative 3, the drain fluid amylase level measured was low and the drain was removed that day. The patient was discharged the next day. Pathology assessment confirmed the preoperative diagnosis of CP without malignancy.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/60301/60301fig1a.jpg" /> 
Figure 1: The appearance of the main pancreatic duct on CT scan. Diameter of the main pancreatic duct: 8.4 mm. <a href="https://www.jove.com/files/ftp_upload/60301/60301fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/60301/60301fig2a.jpg" /> 
Figure 2: Trocar placement. R1: placed at the right anterior axillary line; R2: placed at the right mid-clavicular line; R3: placed on, or just right of, the midline; R4: placed at the left mid-clavicular line. L1: placed at a distance of 8 cm caudally from R2 and R3; L2: placed at a distance of 8 cm caudally from R3 and R4; Arrow: Stomach retractor, placed at the left anterior axillary line. <a href="https://www.jove.com/files/ftp_upload/60301/60301fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1">
	<tbody>
		<tr>
			<td colspan="2"></td>
			<td colspan="5">Instruments Used</td>
		</tr>
		<tr>
			<td colspan="2" rowspan="2"></td>
			<td colspan="3">Robotic</td>
			<td colspan="2">Laparoscopic</td>
		</tr>
		<tr>
			<td colspan="3">(Console surgeon)</td>
			<td colspan="2">(Table-side surgeon)</td>
		</tr>
		<tr>
			<td colspan="2">Operative steps</td>
			<td>Dominant</td>
			<td>Non-dominant</td>
			<td>3rd arm</td>
			<td>L</td>
			<td>R</td>
		</tr>
		<tr>
			<td colspan="2">2.1. Mobilize stomach</td>
			<td>Permanent cautery hook</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Prograsp forceps or cadiere forceps</td>
			<td colspan="2">Sealing device, suction, curved scissors, clip-applier</td>
		</tr>
		<tr>
			<td colspan="2">2.2. US pancreas</td>
			<td>Permanent cautery hook</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Prograsp forceps or cadiere forceps</td>
			<td colspan="2">Suction, endo-echo device</td>
		</tr>
		<tr>
			<td colspan="2">2.3. Open pancreas</td>
			<td>Permanent cautery hook</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Prograsp forceps or cadiere forceps</td>
			<td colspan="2">Sealing device, suction, curved scissors, clip-applier</td>
		</tr>
		<tr>
			<td colspan="2">2.4. Roux limb</td>
			<td>Prograsp forceps or cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td>-</td>
			<td>Sealing device, stapler</td>
			<td>Suction</td>
		</tr>
		<tr>
			<td colspan="2">2.5. LPJ</td>
			<td>Large needle driver</td>
			<td>Cadiere forceps</td>
			<td>Prograsp forceps</td>
			<td colspan="2">Fenestrated grasper, suction, clip-applier, curved scissors</td>
		</tr>
		<tr>
			<td>2.6. JJ</td>
			<td>Positioning anastomosis site</td>
			<td>Prograsp forceps</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td colspan="2">Fenestrated graspers</td>
		</tr>
		<tr>
			<td></td>
			<td>Enterotomies for stapler</td>
			<td>Permanent cautery hook</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td colspan="2">Fenestrated grasper</td>
		</tr>
		<tr>
			<td></td>
			<td>Stapling</td>
			<td>Prograsp forceps</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Stapler</td>
			<td>Fenestrated grasper</td>
		</tr>
		<tr>
			<td></td>
			<td>Closing enterotomies</td>
			<td>Large needle driver</td>
			<td>Cadiere forceps</td>
			<td>Prograsp forceps</td>
			<td colspan="2">Fenestrated grasper, suction, clip-applier, curved scissors</td>
		</tr>
		<tr>
			<td></td>
			<td>Positioning anastomosis site</td>
			<td>Prograsp forceps</td>
			<td>cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Fenestrated grasper</td>
			<td>Prograsp forceps</td>
		</tr>
		<tr>
			<td rowspan="2"></td>
			<td rowspan="2">Fixating roux-loop to the mesentery</td>
			<td rowspan="2">Large needle driver</td>
			<td rowspan="2">Cadiere forceps</td>
			<td rowspan="2">Prograsp forceps</td>
			<td>Fenestrated, grasper, Suction</td>
			<td rowspan="2">Large needle driver</td>
		</tr>
		<tr>
			<td>clip-applier, curved scissors</td>
		</tr>
		<tr>
			<td colspan="8">The configuration for instrument arms is so that the 3rd arm is on the most lateral port controlled by the robotic (console) surgeon.</td>
		</tr>
	</tbody>
</table>
Table 1: Sequence of instruments during each operative step.
<table border="1" fo:keep-together.within-page="1">
	<tbody>
		<tr>
			<td>Variable</td>
			<td>Outcome</td>
		</tr>
		<tr>
			<td colspan="2">Intraoperative</td>
		</tr>
		<tr>
			<td>Operative time (min)</td>
			<td>388</td>
		</tr>
		<tr>
			<td>Dissection (min)</td>
			<td>161</td>
		</tr>
		<tr>
			<td>Reconstruction (min)</td>
			<td>113</td>
		</tr>
		<tr>
			<td>Estimated intraoperative blood loss (mL)</td>
			<td>200</td>
		</tr>
		<tr>
			<td colspan="2">Postoperative</td>
		</tr>
		<tr>
			<td>Clavien/Dindo complication grade</td>
			<td>0</td>
		</tr>
		<tr>
			<td>Drain removal, postoperative day</td>
			<td>3</td>
		</tr>
		<tr>
			<td>Postoperative hospital stay, days</td>
			<td>4</td>
		</tr>
		<tr>
			<td>Pathological diagnosis</td>
			<td>Chronic pancreatitis without malignancy</td>
		</tr>
		<tr>
			<td colspan="2">Operative time comprises of steps 1.3&#8722;2.7.1, dissection comprises of steps 2.1&#8722;2.4.2, reconstruction comprises of steps 2.5&#8722;2.6.3.</td>
		</tr>
	</tbody>
</table>
Table 2: Representative results of the surgery.

Watch this Scientific Journal Video about Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis at JoVE.com

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

Robotic lateral pancreaticojejunostomy (RLPJ) may be used in patients with painful, morphine dependent, chronic pancreatitis and a dilated main pancreatic duct. We describe a standardized and reproducible technique for RLPJ, which includes transection of the gastroduodenal artery.

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The ...

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10.6K vistas.  University of Amsterdam. Pancreaticojunostomía lateral robótica para pancreatitis crónica. La pancreaticojunostomía lateral ha demostrado ser un procedimiento exitoso para la pancreatitis crónica sintomática obstructiva, incluyendo excelentes resultados a largo plazo. Rara vez se han descrito procedimientos robóticos, incluida la división de la arteria gastroduodenal.Un hombre de 45 años presentó pancreatitis crónica refractaria que no responde al manejo conservador del dolor durante tres años. El ...

Video: Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

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 ...

Urinary Bladder Distention Evoked Visceromotor Responses as a Model for Bladder Pain in Mice

Approximately 3-8 million people in the United States suffer from interstitial cystitis/bladder pain syndrome (IC/BPS), a debilitating condition characterized by increased urgency and frequency of urination, as well as nocturia and general pelvic pain, especially upon bladder filling or voiding. Despite years of research, the cause of IC/BPS remains elusive and treatment strategies are unable to provide complete relief to patients. In order to study nervous system contributions to the condition, many animal models have been developed to mimic the pain and symptoms associated with IC/BPS. One such murine model is urinary bladder distension (UBD). In this model, compressed air of a specific pressure is delivered to the bladder of a lightly anesthetized animal over a set period of time. Throughout the procedure, wires in the superior oblique abdominal muscles record electrical activity from the muscle. This activity is known as the visceromotor response (VMR) and is a reliable and reproducible measure of nociception. Here, we describe the steps necessary to perform this technique in mice including surgical manipulations, physiological recording, and data analysis. With the use of this model, the coordination between primary sensory neurons, spinal cord secondary afferents, and higher central nervous system areas involved in bladder pain can be unraveled. This basic science knowledge can then be clinically translated to treat patients suffering from IC/BPS.

Approximately 3-8 million people in the United States suffer from interstitial cystitis/bladder pain syndrome (IC/BPS), a debilitating condition characterized in part by pelvic pain. In order to study nervous system contributions to the condition, a physiological model of urinary bladder pain is used in mice and rats.

Approximately 3-8 million people in the United States suffer from interstitial cystitis/bladder pain syndrome (IC/BPS), a debilitating condition ...

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 ...

Colonial Wig Pancreaticojejunostomy

Postoperative pancreatic fistula (POPF) is one of the most problematic complications after pancreaticoduodenectomy (PD). We describe a series of 48 pancreatic-head resections from our institution, in which we compare a new technique to create the pancreaticojejunostomy (PJ) reconstruction with standard techniques. The goal is to achieve a lower rate of POPF. This new PJ is termed the &#34;Colonial Wig&#34; (CW) PJ due to the novel appearance of the jejunum wrapping around the pancreas, resembling a Colonial wig wrapping around the head of a Colonial Whig (e.g.,&#160;George Washington). In our consecutive series, 22 cases were performed using the new CW technique to perform the PJ and were compared to 26 traditional PDs with traditional reconstruction. There was an incidence of clinically relevant POPF of 0% in the CW group, compared to 15% in 26 conventional PJs. Our proposed CW PJ reconstruction is&#160;associated with a lower the incidence of POPF following PD, and hence may be a way to improve outcomes after PD.

We describe a new technique for pancreaticojejunostomy reconstruction after pancreaticoduodenectomy that is associated with a very low rate of postoperative pancreatic fistula.

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Sodium Taurocholate Induced Severe Acute Pancreatitis in C57BL/6 Mice

Biliary acute pancreatitis induction by sodium taurocholate infusion has been widely used by the scientific community due to the representation of the human clinical condition and reproduction of inflammatory events corresponding to the onset of clinical biliary pancreatitis. The severity of pancreatic damage can be assessed by measuring the concentration, speed, and volume of the infused bile acid. This study provides an updated checklist of the materials and methods used in the protocol reproduction and shows the main results from this acute pancreatitis (AP) model. Most of the previous publications have limited themselves to reproducing this model in rats. We have applied this method in mice, which provides additional advantages (i.e., the availability of an arsenal of reagents and antibodies for these animals along with the possibility of working with genetically modified strains of mice) that may be relevant to the study. For acute pancreatitis induction in mice, we present a systematic protocol, with a defined dose of 2.5% sodium taurocholate at an infusion speed 10 &#181;L/min for 3 min in C57BL/6 mice that reaches its maximal level of severity within 12 h of induction and highlight results with outcomes that validate the method. With practice and technique, the total estimated time, from the induction of anesthesia to the completion of the infusion, is 25 min per animal.

Animal models for severe acute pancreatitis enable the study of pathophysiological changes at the initial stage, facilitating observation of the evolution of inflammatory events. Here we provide a protocol for the induction of severe acute biliary pancreatitis by retrograde infusion of sodium taurocholate into the pancreatic duct of anesthetized C57BL/6 mice.

Biliary acute pancreatitis induction by sodium taurocholate infusion has been widely used by the scientific community due to the representation of the ...

A Mouse Model for Chronic Pancreatitis via Bile Duct TNBS Infusion

Chronic pancreatitis (CP) is a complex disease involving pancreatic inflammation and fibrosis, glandular atrophy, abdominal pain and other symptoms. Several rodent models have been developed to study CP, of which the bile duct 2,4,6 -trinitrobenzene sulfonic acid (TNBS) infusion model replicates the features of neuropathic pain seen in CP. However, bile duct drug infusion in mice is technically challenging. This protocol demonstrates the procedure of bile duct TNBS infusion for generation of a CP mouse model. TNBS was infused into the pancreas through the ampulla of Vater in the duodenum. This protocol optimized drug volume, surgical techniques, and drug handling during the procedure. TNBS-treated mice showed features of CP as reflected by bodyweight and pancreas weight reductions, changes in pain-associated behaviors, and abnormal pancreatic morphology. With these improvements, mortality associated with TNBS injection was minimal. This procedure is not only critical in generating pancreatic disease models but is also useful in local pancreatic drug delivery.

Chronic pancreatitis (CP) is a disease characterized by inflammation and fibrosis of the pancreas, often associated with intractable abdominal pain. This article focuses on refining the technique to generate a mouse model of CP via bile duct infusion with 2,4,6 -trinitrobenzene sulfonic acid (TNBS).

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Use of 3D Robotic Ultrasound for In Vivo Analysis of Mouse Kidneys

Common modalities for in vivo imaging of rodents include positron emission tomography (PET), computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US). Each method has limitations and advantages, including availability, ease of use, cost, size, and the use of ionizing radiation or magnetic fields. This protocol describes the use of 3D robotic US for in vivo imaging of rodent kidneys and heart, subsequent data analysis, and possible research applications. Practical applications of robotic US are the quantification of total kidney volume (TKV), as well as the measurement of cysts, tumors, and vasculature. Although the resolution is not as high as other modalities, robotic US allows for more practical high throughput data collection. Furthermore, using US M-mode imaging, cardiac function may be quantified. Since the kidneys receive 20%-25% of the cardiac output, assessing cardiac function is critical to the understanding of kidney physiology and pathophysiology.

Use of 3D Robotic Ultrasound for In Vivo Analysis of Mouse Kidneys

This protocol demonstrates robotic ultrasound (US) as a practical, cost-effective, and quick alternative to traditional non-invasive image modalities.

Common modalities for in vivo imaging of rodents include positron emission tomography (PET), computed tomography (CT), magnetic resonance imaging (MRI), ...

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.

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Robotic Taj Mahal Hepatectomy for Hilar Cholangiocarcinoma

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In this study, a 32-year-old male patient with Bismuth Type IVa hilar cholangiocarcinoma underwent radical robotic resection of hepatic S4b, S5, and S1 (Taj Mahal hepatectomy) combined with regional lymphadenectomy, hilar bile duct reconstruction, and hepaticojejunostomy by the robotic surgical system. Postoperative pathological examination showed moderately-differentiated adenocarcinoma of the hilar bile duct. The surgical margins of the liver and bile ducts were negative. Recovery was smooth and the patient was discharged on the 17th postoperative day. The robotic surgical system and associated multiple instruments along with flexible and precise movements is suitable for the local hepatectomy around the porta hepatis, and delicate reconstruction of the hilar bile duct with a smaller diameter. This first clinical application study found that robotic Taj Mahal hepatectomy for hilar cholangiocarcinoma is safe and feasible and needs more experience for the evaluation of its long-term outcomes.

Robotic resection of hepatic S4b, S5, and S1 using the Taj Mahal procedure is feasible and safe for selected patients with hilar cholangiocarcinoma. The step-by-step details for this surgery are presented here.

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In ...

Robotic Cochlear Implantation for Direct Cochlear Access

Robot-assisted systems offer great potential for gentler and more precise cochlear implantation. In this article, we provide a comprehensive overview of the clinical workflow for robotic cochlear implantation using a robotic system specifically developed for a minimally invasive, direct cochlear access. The clinical workflow involves experts from various disciplines and requires training to ensure a smooth and safe procedure. The protocol briefly summarizes the history of robotic cochlear implantation. The clinical sequence is explained in detail, beginning with the assessment of patient eligibility and covering surgical preparation, preoperative planning with the special planning software, drilling of the middle ear access, intraoperative imaging to confirm the trajectory, milling of the inner ear access, insertion of the electrode array, and implant management. The steps that require special attention are discussed. As an example, the postoperative outcome of robotic cochlear implantation in a patient with advanced otosclerosis is presented. Finally, the procedure is discussed in the context of the authors' experience.

Robotic cochlear implantation is a procedure for minimally invasive inner ear access. Compared to conventional surgery, robotic cochlear implantation involves additional steps that need to be carried out in the operating room. In this article we give a description of the procedure and highlight the important aspects of robotic cochlear implantation.

Robot-assisted systems offer great potential for gentler and more precise cochlear implantation. In this article, we provide a comprehensive overview of ...