This technique was originally described by Abu Hilal et al.16.

1. Patient Selection
<ol>
	<li>Select patients with an upfront resectable pancreatic cancer in the pancreas body or tail visible on a recent contrast enhanced CT scan (maximum of 4 weeks old) without downstaging neoadjuvant therapy.</li>
	<li>Exclude patients with metastatic disease or vascular involvement of vessels other than the splenic vein or artery24.</li>
	<li>During training, it is best to exclude patients with a body max index (BMI) &#62; 35 kg/m2, recurrent acute or chronic pancreatitis, previous major upper abdominal surgery, or pancreas targeted radiotherapy.</li>
</ol>
2. Surgical Technique
<ol>
	<li>Operative setting
	<ol>
		<li>Place the anesthetized patient in the French position on a bean bag. Place both arms in 90&#176; abduction.</li>
		<li>Place sterile drapes so that the suprapubic region is exposed for the Pfannenstiel incision.</li>
		<li>Create pneumoperitoneum via a Veress needle at Palmer&#8217;s point.</li>
		<li>Perform a routine diagnostic laparoscopy to exclude peritoneal and liver metastases.</li>
		<li>The procedure is performed using a 5-port technique. Place additional trocars a shown in Figure 1. 
		NOTE: Use of laparoscopic ultrasound is advisable for staging and localizing the lesion, thereby determining the extent of the resection.</li>
	</ol>
	</li>
	<li>Exploration Phase
	<ol>
		<li>Exposure
		<ol>
			<li>Divide the gastrocolic ligament approximately 2 cm distal from the gastroepiploic artery and vein, thus opening the lesser sac.</li>
			<li>Dissect and ligate the short gastric vessels in preparation of splenectomy. The most superior short gastric vessels may also be spared at this stage to avoid early bleeding without adequate exposure.</li>
			<li>Mobilize the stomach from the pancreas and retract upwards. The stomach may be retracted in various ways. Use of umbilical tape around the stomach, after it has been rolled backwards and secured in this position with surgical gauze between the top of the stomach and the surgical tape is recommended.</li>
			<li>Extract this tape next to the subxiphoidal trocar and grip using a surgical clamp. 
			NOTE: A second piece of tape may pull the pyloric region to the right upper quadrant using a stab incision to extract it25. This second tape is especially useful to obtain maximal exposure of the pancreatic neck and hepatic artery region.</li>
			<li>Divide the splenocolic ligament in order to mobilize the splenic flexure and visualize the pancreatic tail. If needed, the lesion is located using laparoscopic ultrasonography. The transection plane of the pancreas in case of pancreatic cancer is at the portal confluence.</li>
			<li>Mobilize the lower margin of the pancreas from medial to lateral including the splenic inferior border. At this stage, both the superior and inferior mesenteric vein may be visualized. Incise Gerota&#8217;s fascia. 
			NOTE: Care should be taken to avoid venous bleeding. Optionally, the splenic flexure of the colon can be mobilized separately using a lateral to medial approach but often this is not required.</li>
			<li>Identify the splenic vein at the inferior border of the pancreas. 
			NOTE: The inferior mesenteric vein could drain directly into the splenic vein.</li>
			<li>Identify the splenic artery at the superior border of the pancreas.</li>
		</ol>
		</li>
		<li>Pancreatic hanging and dissection of Gerota&#8217;s fascia dissection.
		<ol>
			<li>During the dissection of the posterior plane, mobilize and lift the Gerota&#8217;s fascia (i.e., anterior renal fascia).</li>
			<li>Create the posterior plane underneath the Gerota&#8217;s fascia superior to the adrenal gland toward the superior border of the pancreas. This is an avascular plane. If needed, the adrenal gland can be included (i.e., posterior RAMPS).</li>
			<li>Create a tunnel by dissecting the superior pancreatic margin.</li>
			<li>Pass a quarter length vessel loop through the tunnel and secure with a nonabsorbable locking clip. Use this to hang the pancreas including Gerota&#8217;s fascia.</li>
			<li>Identify the splenic artery at the superior border of the pancreas.</li>
			<li>Mobilize the splenic artery using blunt and sharp dissection and a pass quarter length vessel loop.</li>
			<li>Transect the artery using 3&#8211;4 nonabsorbable locking clips. Alternatively, a vascular endostapler may be used. 
			NOTE: The splenic artery must not be transected until the entire anatomy, especially the hepatic artery, is visualized and confirmed. If the splenic artery cannot be visualized from the pancreatic superior margin, it may identified from beneath the pancreas or by following the hepatic artery towards the celiac artery.</li>
			<li>Perform the same tunneling procedure at the pancreatic neck, on the right side of the pancreatic lesion, mostly above the confluence/portal vein.</li>
			<li>The two vessel loops can be held by an assistant to literally hang the pancreas and expose the posterior margin during the retroperitoneal dissection.</li>
			<li>Determine the transection plane at the inferior border of the pancreas.</li>
			<li>Mobilize the remaining part of the pancreas, including Gerota&#8217;s fascia, exposing the anterior aspect of the kidney.</li>
		</ol>
		</li>
		<li>Pancreatic transection
		<ol>
			<li>Pull the pancreas ventrally using the vessel loops.</li>
			<li>Transect the pancreas at the neck using a stapler with a graded compression technique (vascular or thicker cartridge, based on the pancreatic thickness and texture at the transection level)26. 
			NOTE: With this technique, the stapler is closed very slowly, in steps, until resistance is felt. Before continuing with the compression, the surgeon should wait for 20&#8211;30 s until the resistance decreases. The entire process typically requires 4&#8211;5 min before the stapler is completely closed. Faster closure often leads to rupture of the pancreatic capsule27. If needed, sutures can be applied to the pancreatic stump in case of rupture or bleeding.</li>
			<li>Identify the left gastric vein and the splenic vein. Clip and transect the left gastric vein.</li>
			<li>Mobilize the splenic vein, pass and secure a vessel loop.</li>
			<li>Hereafter, place 3&#8211;4 locking clips on the splenic vein: two on the patient site and at least one on the specimen site. In case of lack of space, an additional metal clip may be placed on the specimen site. 
			NOTE: The standard order of transection is splenic artery, pancreas, splenic vein. This order may be varied based on local anatomy (e.g., by transecting the pancreas first). However, if the splenic vein is transected before the splenic artery, there will be venous congestion with increased risk of conversion due to bleeding.</li>
		</ol>
		</li>
		<li>Lymph node dissection
		<ol>
			<li>Dissect the lymph nodes in a clockwise fashion, according to the description of Strasberg&#8217;s RAMPS procedure15.</li>
			<li>Start with lymph node station 8A at the hepatic artery and station 9 at the celiac trunk. 
			NOTE: If possible, the left gastric artery should be preserved while performing lymphadenectomy. If needed, it can be resected.</li>
			<li>Extend the lymphadenectomy to the left border of the aorta and the left side of the superior mesenteric artery.</li>
			<li>Proceed with the dissection laterally towards the spleen, where any further attached tissue is taken, including the Gerota&#8217;s fascia.</li>
			<li>Detach the spleen by transecting the gastrosplenic ligament, splenorenal ligament, and retroperitoneal adhesion.</li>
		</ol>
		</li>
		<li>Extraction and drain placement
		<ol>
			<li>Once the spleen is detached, remove the specimen using an endo-bag through a Pfannenstiel incision. Turn the camera 180&#176; to the inferior part of the abdomen to visualize the extraction of the specimen.</li>
			<li>The Pfannenstiel incision should be an approximately 6 cm transverse skin incision and 8 cm transverse fascia incision where the midline is divided between both rectus muscles.</li>
			<li>Take caution during the extraction to avoid small bowel injury and compromising of the specimen for pathological assessment.</li>
			<li>Place one surgical drain. This drain enters through the left most trocar site, loops with 2&#8211;3 additional holes through the splenic bed, runs under the stomach, and ends next to the pancreatic stump. 
			NOTE: Care must be taken to avoid direct contact with the pancreas, artery, and vein stump.</li>
		</ol>
		</li>
		<li>Closure
		<ol>
			<li>Close the peritoneum using an absorbable braided suture and the fascia with a monofilament absorbable suture.</li>
			<li>Re-insufflate the abdomen.</li>
			<li>Confirm hemostasis at the transection planes.</li>
			<li>Revert all loops and the gastric hanging.</li>
			<li>Inspect the stomach for any injuries.</li>
			<li>Close any fascia defect larger than 5 mm using an absorbable multifilament suture.</li>
			<li>Close the skin intracutaneously using an absorbable monofilament suture.</li>
		</ol>
		</li>
	</ol>
	</li>
</ol>

<ol>
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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=Laparoscopic+versus+open+distal+pancreatectomy:+a+meta-analysis.">Laparoscopic versus open distal pancreatectomy: a meta-analysis.</a> Asian Journal of Surgery. 35, 1-8 (2012).</li><li>Venkat, R., 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+distal+pancreatectomy+is+associated+with+significantly+less+overall+morbidity+compared+to+the+open+technique:+A+systematic+review+and+meta-analysis.">Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: A systematic review and meta-analysis.</a> Annals of Surgery. 255, 1048-1059 (2012).</li><li>Pericleous, 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=Systematic+review+and+meta-analysis+of+case-matched+studies+comparing+open+and+laparoscopic+distal+pancreatectomy:+is+it+a+safe+procedure.">Systematic review and meta-analysis of case-matched studies comparing open and laparoscopic distal pancreatectomy: is it a safe procedure.</a> Pancreas. 41, 993-1000 (2012).</li><li>Jin, 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=A+systematic+review+and+meta-analysis+of+studies+comparing+laparoscopic+and+open+distal+pancreatectomy.">A systematic review and meta-analysis of studies comparing laparoscopic and open distal pancreatectomy.</a> HPB. 14, 711-724 (2012).</li><li>Jusoh, A. 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The authors have nothing to disclose.

Advantages of the technique 
LRLP is a standardized, reproducible, and safe procedure if performed by experienced surgeons. Moreover, this minimally invasive procedure offers low intraoperative blood loss, early mobilization, and short hospital stays as confirmed by the LEOPARD trial7. Surgery for pancreatic cancer must aim for a radical resection, adequate lymphadenectomy, and a no-touch dissection to prevent seeding and dissemination of tumor cells16...

Surgical resection combined with systemic chemotherapy is the most effective treatment for resectable pancreatic cancer. Several meta-analyses have shown comparable results for minimally invasive and open distal pancreatectomy for benign and premalignant disease1,2,3,4,5,6. Recently, the first multicenter randomized trial demonstrated a shorter time to functional recovery using laparoscopic distal pancreatectomy (LDP) as compared to open distal pancreatectomy (ODP)7. Although minimally invasive techniques have been shown to be safe and feasible for left pancreatectomy when performed by experienced surgeons8,9,10,11,12,13, the non-inferiority of minimally invasive surgery compared to the open surgical approach for the treatment of pancreatic cancer is still debated14,15,16,17. A pan-European survey showed that 31% of pancreatic surgeons considered ODP superior to minimally invasive distal pancreatectomy (MIDP) in terms of oncological margins and lymphadenectomy in pancreatic cancer18. On both a European and global level, 19&#8211;20% of participating surgeons considered malignancy a contraindication for a minimally invasive approach18,19.
Given the current lack of randomized controlled trials on the effectiveness of MIDP, the only available data to compare the procedures are limited to retrospective and prospective cohort studies. In a recent systematic review and meta-analysis on oncological safety in MIDP versus ODP for pancreatic cancer, no differences between the two groups regarding oncologic outcomes (OR = 0.49, p = 0.12) and overall survival (OS = 3 years, HR = 1.03, p = 0.66; OS = 5 years, HR = 0.91, p = 0.59) were seen20. Another systematic review showed comparable outcomes for MIDP versus ODP in overall survival and a somewhat surprising higher margin-negative (R0) resection rate but at the cost of a lower lymph node dissection in MIDP21.
The radical antegrade modular pancreatosplenectomy (RAMPS) technique, as described by Strasberg in 2003, aims to perform a better, radical resection of pancreatic ductal adenocarcinoma (PDAC) in the body or the tail of the pancreas including resection of Gerota&#8217;s fascia15. The laparoscopic radical left pancreatectomy (LRLP) technique, as described by Abu Hilal et al.16, aims to obtain the same results but during minimally invasive surgery by combining a formal lymphadenectomy with the no-touch technique. Hereby, a radical oncological resection can be obtained with a minimized risk of tumor dissemination and seeding15,22. The standardization of this technique allows for reproducibility and adoption in different health care centers. This paper describes LRLP, because this technique is currently used in the international, multicenter randomized DIPLOMA trial16,23.

<table><tbody><tr><td>Arietta Ultrasound</td><td>Hitachi</td><td></td><td>Intraoperative laparoscopic ultrasonography</td></tr><tr><td>Autosuture Endo Clip applier 5 mm</td><td>Covidien</td><td>176620</td><td>Sling use clip applier, 5 mm</td></tr><tr><td>Blue reload for Echelon 60</td><td>Ethicon</td><td>GST60B</td><td>Regular tissue thickness, open staple height 3.6 mm, closed staple height 1.5 mm</td></tr><tr><td>ECHELON FLEX ENDOPATH 60mm Stapler</td><td>Ethicon</td><td>GST60T</td><td>Powered surgical stapler with gripping surface technology</td></tr><tr><td>Endo Catch II Pouch 15 mm</td><td>Covidien</td><td>173049</td><td>For single lymph node extractions a cut off finger surgical glove can be used.</td></tr><tr><td>Green reload for Echelon 60</td><td>Ethicon</td><td>GST60G</td><td>Thick tissue thickness, open staple height 4.1 mm, closed staple height 2.0 mm</td></tr><tr><td>Harmonic Advanced Hemostasis 36 cm</td><td>Ethicon</td><td>HARH36</td><td>Curved tip, energy sealing and dissecting, diameter 5 mm, length 36 cm</td></tr><tr><td>Hem-o-lok Clips MLX</td><td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td><td>544230</td><td>Vascular clip 3 mm &amp;ndash; 10 mm Size Range</td></tr><tr><td>Hem-o-lok clips Xl</td><td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td><td>544250</td><td>Vascular clip 7 mm &amp;ndash; 16 mm Size Range</td></tr><tr><td>Hem-o-Lok Polymer Ligation System</td><td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td><td>544965</td><td></td></tr><tr><td>LigaSure Dolphin Tip Laparoscopic Sealer/Divider</td><td>Medtronic</td><td>LS1500</td><td>Dolphin-nose tip sealer and divider, 37 cm shaft</td></tr><tr><td>White reload for Echelon 60</td><td>Ethicon</td><td>GST60W</td><td>Mesentery/thin tissue thickness, open staple height 2.6 mm, closed staple height 1.0 mm</td></tr></tbody></table>

laparoscopic radical left pancreatectomy for pancreatic cancer: surgical strategy and technique video

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological resection of left-sided pancreatic cancer. Several surgical techniques have been described in recent years, but few were specifically designed for minimally invasive approaches. This study describes and demonstrates a standardized and reproducible technique for an adequate oncological resection of pancreatic cancer: laparoscopic radical left pancreatectomy (LRLP).
A 61-year-old woman presented with an incidental finding of a 3 cm mass in the left pancreas suspect for malignancy. Imaging did not reveal distant metastases, central vascular involvement, or morbid obesity, hence the patient was suitable for LRLP. This study describes the main steps of LRLP for pancreatic cancer. First, the lesser sac is opened by transecting the gastrocolic ligament. The splenic flexure of the colon is mobilized and the inferior border of the pancreas including Gerota&#39;s fascia is dissected down to the inferior border of the spleen. The pancreas is tunneled and hung, including Gerota&#8217;s fascia with a vessel loop. At the pancreatic neck, a tunnel is created between the pancreas and the portal vein, likewise a vessel loop is passed. The pancreas is then transected using the graded compression technique with an endostapler. Both the splenic vein and artery are transected before completing the resection. The entire specimen is extracted in a retrieval bag via a small Pfannenstiel incision.
Duration of the surgery was 210 min with 250 mL blood loss. Pathology revealed a R0-resection (&#62;1 mm) of a well-to-moderately differentiated adenocarcinoma originating from an intraductal papillary mucinous neoplasm. A total of 15 tumor-negative lymph nodes were resected. This is a detailed description of LRLP for left-sided pancreatic cancer as is currently being used within the international, multicenter randomized DIPLOMA (Distal Pancreatectomy Minimally Invasive or Open for PDAC) trial.

A 61-year-old woman presented with mild liver dysfunction at the surgical outpatient clinic. On both CT and MRI scans, an incidental finding of a 3 cm mass in the pancreatic tail suspect for malignancy was seen with potential involvement of the left adrenal gland (See Figure 2). No distant metastasis or lymph node involvement was seen on the preoperative contrast-enhanced CT scan. Therefore, the patient was deemed suitable for a minimally invasive approach.
The to...

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Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

Oncologically safe left pancreatectomy requires radical resection (R0), Gerota&#8217;s (perirenal) fascia resection, and adequate lymph node dissection. This study describes the technical details of laparoscopic radical left pancreatectomy (LRLP), used in the first international multicenter randomized trial comparing minimally invasive with open left pancreatectomy for pancreatic cancer, the DIPLOMA trial.

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological ...

laparoscopic-radical-left-pancreatectomy-for-pancreatic-cancer

Research

JoVE Journal

Medicine

9.4K Views.  University of Amsterdam. Laparoscopische radicale linkse pancreatectomie voor maligniteit. Adequate lymfeklierdissectie en radicale resectiemarges zijn cruciaal bij het verkrijgen van veilige oncologische dissectie van tumoren in distale alvleesklierctomie. We tonen alle stappen van de laparoscopische radicale linker pancreatectomie zoals beschreven door Abu Hilal, et al.Een 61-jarige vrouw presenteerde met een incidentele vondst van een drie centimeter massa, verdacht van maligniteit, in de alvleesklier staar...

Video: Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal pancreatectomy, laparoscopic pancreatoduodenectomy (LPD) has not yet obtained wide acceptance, probably due to technical challenges, especially regarding the pancreatic anastomosis.
The study describes and demonstrates all steps of LPD, including the modified Blumgart pancreaticojejunostomy. Indications for LPD are all pancreatic and peri-ampullary tumors without vascular involvement. Relative contra-indications are body mass index &#62;35 kg/m2, chronic pancreatitis, mid-cholangiocarcinomas and large duodenal cancers.
The patient is in French position, 6 trocars are placed, and dissection is performed using an (articulating) sealing device. A modified Blumgart end-to-side pancreaticojejunostomy is performed with 4 large needles (3/0) barbed trans-pancreatic sutures and 4 to 6 duct-to-mucosa sutures using 5/0 absorbable multifilament combined with a 12 cm, 6 or 8 Fr internal stent using 3D laparoscopy. Two surgical drains are placed alongside the pancreaticojejunostomy.
The described technique for LPD including a modified Blumgart pancreatico-jejunostomy is well standardized, and its merits are currently studied in the randomized controlled multicenter trial. This complex operation should be performed at high-volume centers where surgeons have extensive experience in both open pancreatic surgery and advanced laparoscopic gastro-intestinal surgery.

Laparoscopic pancreatoduodenctomy (LPD) may offer advantages over open pancreatoduodenectomy, including early postoperative mobilization, less delayed gastric emptying and a shorter hospital stay. However, LPD is technically challenging and not well-standardized, especially regarding the pancreatic anastomosis. We describe a standardized technique for the pancreatic anastomosis during LPD: modified Blumgart pancreaticojejunostomy.

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal ...

Cancer Research

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer: Surgical Planning and Technique

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), relying on collateral flow to the liver through the gastroduodenal artery (GDA). In the current manuscript, the technical conduct of robotic DP-CAR is outlined. The greater curve of the stomach is mobilized with care to avoid sacrificing the gastroepiploic vessels. The stomach and liver are retracted cephalad to facilitate dissection of the porta hepatis. The hepatic artery (HA) is dissected and encircled with a vessel loop. The gastroduodenal artery (GDA) is carefully preserved. The common HA is clamped and triphasic flow in the proper HA via the GDA is confirmed using intra-operative ultrasound. A retropancreatic tunnel is made over the superior mesenteric vein (SMV). The pancreas is divided with an endovascular stapler at the neck. The inferior mesenteric vein (IMV) and splenic vein are ligated. The HA is stapled proximal to the GDA. The entire specimen is retracted laterally with further dissection cephalad to expose the superior mesenteric artery (SMA). The SMA is then traced back to the aorta. The dissection continues cephalad along the aorta with the bipolar energy device used to divide the crural fibers and celiac nerve plexus. The specimen is mobilized from the patient's right to left until the origin of the celiac axis is identified and oriented towards the left. The trunk is circumferentially dissected and stapled. Additional dissection with hook cautery and the bipolar energy device fully mobilizes the pancreatic tail and spleen. The specimen is removed from the left lower quadrant extraction site and one drain is left in the resection bed. A final intra-operative ultrasound of the proper HA confirms pulsatile, triphasic flow in the artery and liver parenchyma. The stomach is inspected for evidence of ischemia. Robotic DP-CAR is safe, feasible and when used in conjunction with multi-modality therapy, offers potential for long-term survival in selected patients.

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection DP-CAR for Pancreatic Cancer: Surgical Planning and Technique

We present our operative approach to robot assisted distal pancreatectomy, splenectomy, and celiac axis resection (DP-CAR), demonstrating that the procedure is safe and feasible with proper planning, patient selection, and surgeon experience.

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), ...

Robotic Pancreatoduodenectomy for Pancreatic Head Cancer: a Case Report of a Standardized Technique

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several studies have described the safety of RPD in case of a replaced or aberrant right hepatic artery, but detailed video descriptions of the approach are lacking. This case report describes a step-&#173;by-&#173;step technical video in case of a replaced right hepatic artery. A 58-year-old woman presented with an incidental finding of a 1.7 cm pancreatic head mass. RPD was performed using the da Vinci Xi system and involves a robotic-assisted pancreatico- and hepatico-jejunostomy and open gastro-jejunostomy at the specimen extraction site. The operation time was 410 min with 220 mL of blood loss. The patient had an uncomplicated postoperative course and was discharged after 5 days. Pathology revealed a pancreatic head cancer. RPD is a feasible and safe procedure in case of a replaced hepatic artery when performed in selected patients in high-volume centers by experienced surgeons.

Robotic pancreatoduodenctomy (RPD) has been highly standardized in recent years and may be used in selected patients with pancreatic head cancer, including those with a replaced right hepatic artery. This case report describes a standardized and reproducible technique for RPD, which includes the approach of the Dutch LAELAPS-3 training program to an aberrant vasculature.

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several ...

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic platform, including three-dimensional vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate the principles of open pancreatoduodenectomy allowing safe oncologic dissection, hemostasis, and meticulous reconstruction. Over the course of the past decade, significant strides have been achieved in outlining the safety, feasibility, and learning curve of the robotic Whipple. When performed by high volume pancreatic surgeons experienced in RPD, recent comparative effectiveness studies show potential advantages compared to the open technique, including reductions in hospital stay and morbidity. National data also show reductions in conversion rates compared to its laparoscopic counterpart. Although long-term oncologic data are still needed, short-term oncologic surrogates of margin resection and lymph node harvest suggest no compromise in oncologic outcomes. As pancreatic surgeons increasingly integrate robotics into their practice, proficiency-based training and credentialing will be necessary for the safe application and dissemination of RPD. Here, we provide the detailed steps of a robotic pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.&#160;

The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic ...

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.

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 ...

Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the spleno-mesenteric junction, for cancer of the body-tail of the pancreas. The patient is placed supine with the legs parted and a pneumoperitoneum is established and maintained at 10 mmHg. To use the surgical system, four 8 mm ports and one 12 mm port are required. The optic port is placed at the umbilicus. The other ports are placed, on either side, along the pararectal line and the anterior axillary line at the level of the umbilical line. The assistant port (12 mm) is placed along the right pararectal line. Dissection begins by detaching the gastrocolic ligament, thus opening the lesser sac, and by a wide mobilization of the splenic flexure of the colon. The superior mesenteric vein is identified along the inferior border of the pancreas. Lymph node number 8a is removed to permit clear visualization of the common hepatic artery. A tunnel is then created behind the neck of the pancreas. To permit safe resection and reconstruction of the spleno-mesenteric junction, further preemptive dissection is required before dividing the pancreatic neck to bring in clear view all relevant vascular pedicles. Next, the splenic artery is ligated and divided, and the pancreatic neck is divided, with selective ligature of the pancreatic duct. After vein resection and reconstruction, dissection proceeds to complete the clearance of peripancreatic arteries that are peeled off from all lympho-neural tissues. Both celiac ganglia are removed en-bloc with the specimen. The Gerota fascia covering the upper pole of the left kidney is also removed en-bloc with the specimen. Division of short gastric vessels and splenectomy complete the procedure. A drain is left near the pancreatic stump. The round ligament of the liver is mobilized to protect the vessels.

The robotic technique shown herein aims at faithfully reproducing the open procedure for radical treatment of cancer of the body-tail of the pancreas. The protocol also demonstrates the ability to master involvement of major peripancreatic vessels without conversion to open surgery.

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the ...

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 ...

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic resection and reconstruction techniques, it is difficult to perform LPD for patients with locally advanced pancreatic head cancer after neoadjuvant therapy. Our team initiates LPD using the in-situ No-Touch isolation technique. The innovation and optimization of this modified No-Touch isolation technique emphasize exploring the distal section of superior mesenteric vein&#160;(SMV) and the left side of the superior mesenteric artery (SMA) prior to evaluating the resectability by subcolonic mesenteric approach, which is an ideal exploring approach. After that, we use the median-anterior, and left-posterior of SMA approaches to cut off the blood flow of the pancreatic head to make the tumor isolated intact, then move and dissect the tumor. It is a process fitting the surgical principle of tumor-free. This article aims to demonstrate the feasibility and safety of performing LPD using the in-situ No-Touch isolation technique, which might elevate the R0 resection rate. It is an oncological ideal operation process.

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

No-Touch isolation procedures might prevent the dissemination of cancer cells from the primary tumor. However, these techniques are not widely accepted in laparoscopic pancreatoduodenectomy (LPD) by now. We herein present in-situ No-Touch isolation LPD with partial resection and reconstruction of the superior mesenteric vein (SMV) for pancreatic cancer after neoadjuvant therapy.

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic ...

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who have had neoadjuvant chemotherapy. Here, we present a technique to perform laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) using the dorsal-caudal artery approach by making full use of the high-definition vision and operation modes of the laparoscope.
The innovation and optimization of this operation are provided in the protocol. Priority should be given to the dorsal resection plane, including the dorsal side of the superior mesenteric artery (SMA), the dorsal side of the pancreatic head, the root of the celiac artery (CeA), the ventral side of the left renal vessels, and the renal hilum. On the condition that the operation for pancreatic neck-body cancer is feasible and safe, the second step is to perform tumor resection en bloc surrounding the SMA and CeA from the caudal to the cephalic side to increase the rate of R0 (radical zero) resection and further prognosis.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

With advancements in laparoscopic techniques, laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has been widely recognized. However, owing to several technical difficulties in this procedure, the artery-first approach in L-RAMPS still remains uncommon. Here, we developed the dorsal-caudal artery approach for L-RAMPS, which might be safe and beneficial for pancreatic neck tumors.

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who ...

Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma

Distal pancreatic carcinoma is a highly malignant tumor with strong invasiveness, often growing to the edge of the pancreas and penetrating the pancreatic capsule to infiltrate surrounding tissues. In conventional distal pancreatosplenectomy (DPS), tumor cells are prone to spread along the direction of blood and lymphatic reflux due to surgical compression. Additionally, inflammation makes it challenging to achieve R0 resection, leading to a lower patient survival rate. To address these limitations, radical antegrade modular pancreatosplenectomy (RAMPS) was developed, emphasizing deeper excision, including the left anterior renal fascia, the left anterior renal adipose sac, and even the left adrenal gland, to improve the R0 resection rate. With the advancement of minimally invasive surgical techniques, laparoscopic RAMPS (L-RAMPS) is being considered technically safe and feasible in oncology. However, due to technical difficulties and a lack of supporting evidence for clinical application, only a few institutions are currently conducting L-RAMPS. In this context, this article presents detailed techniques for laparoscopic posterior radical antegrade modular pancreatosplenectomy (L-pRAMPS), offering promise for future clinical applications.

Laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) is currently considered technically safe and feasible. However, due to technical challenges and a lack of supporting evidence for widespread clinical applications, only a limited number of institutions are currently conducting L-RAMPS. This article aims to provide detailed techniques for laparoscopic posterior radical antegrade modular pancreatosplenectomy.

Distal pancreatic carcinoma is a highly malignant tumor with strong invasiveness, often growing to the edge of the pancreas and penetrating the pancreatic ...

Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

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