We would like to acknowledge Amer Zureikat, Melissa Hogg, Olivier Saint-Marc, Ugo Boggi, and Herbert Zeh III who supported and trained us in robotic pancreatic surgery in the Dutch Pancreatic Cancer Group - LAELAPS-3 program.

<ol>
	<li>Torphy, R. J., Fujiwara, Y., Schulick, R. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreatic+cancer+treatment:+better,+but+a+long+way+to+go.">Pancreatic cancer treatment: better, but a long way to go.</a> Surgery Today. 50 (10), 1117-1125 (2020).</li><li>Asbun, H. 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=The+Miami+International+Evidence-based+Guidelines+on+Minimally+Invasive+Pancreas+Resection.">The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection.</a> Annals of Surgery. 271 (1), 1-14 (2020).</li><li>Boone, B. 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=Assessment+of+Quality+Outcomes+for+Robotic+Pancreaticoduodenectomy.">Assessment of Quality Outcomes for Robotic Pancreaticoduodenectomy.</a> JAMA Surgery. 150 (5), 416 (2015).</li><li>Cai, 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+Pancreaticoduodenectomy+Is+Associated+with+Decreased+Clinically+Relevant+Pancreatic+Fistulas:+a+Propensity-Matched+Analysis.">Robotic Pancreaticoduodenectomy Is Associated with Decreased Clinically Relevant Pancreatic Fistulas: a Propensity-Matched Analysis.</a> Journal of Gastrointestinal Surgery. 24 (5), 1111-1118 (2020).</li><li>Zureikat, A. H., 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=500+Minimally+Invasive+Robotic+Pancreatoduodenectomies.">500 Minimally Invasive Robotic Pancreatoduodenectomies.</a> Annals of Surgery. 273 (5), 966-972 (2019).</li><li>Jones, L. 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=Robotic+Pancreatoduodenectomy:+Patient+Selection,+Volume+Criteria,+and+Training+Programs.">Robotic Pancreatoduodenectomy: Patient Selection, Volume Criteria, and Training Programs.</a> Scandinavian Journal of Surgery. 109 (1), 29-33 (2020).</li><li>Zwart, M. J. W., 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=Outcomes+of+a+Multicenter+Training+Program+in+Robotic+Pancreatoduodenectomy+(LAELAPS-3).">Outcomes of a Multicenter Training Program in Robotic Pancreatoduodenectomy (LAELAPS-3).</a> Annals of Surgery. 269 (2), 344-350 (2021).</li><li>Balzan, S. M. 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=Prevalence+of+hepatic+arterial+variations+with+implications+in+pancreatoduodenectomy.">Prevalence of hepatic arterial variations with implications in pancreatoduodenectomy.</a> Arquivos Brasileiros de Cirurgia Digestiva. 32 (3), 1455 (2019).</li><li>Nguyen, T. K., 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+pancreaticoduodenectomy+in+the+presence+of+aberrant+or+anomalous+hepatic+arterial+anatomy:+safety+and+oncologic+outcomes.">Robotic pancreaticoduodenectomy in the presence of aberrant or anomalous hepatic arterial anatomy: safety and oncologic outcomes.</a> HPB. 17 (7), 594-599 (2015).</li><li>Kim, J. H., Gonzalez-Heredia, R., Daskalaki, D., Rashdan, M., Masrur, M., Giulianotti, P. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Totally+replaced+right+hepatic+artery+in+pancreaticoduodenectomy:+is+this+anatomical+condition+a+contraindication+to+minimally+invasive+surgery.">Totally replaced right hepatic artery in pancreaticoduodenectomy: is this anatomical condition a contraindication to minimally invasive surgery.</a> HPB. 18 (7), 580-585 (2016).</li><li>Lee, J. -. M., Lee, Y. -. J., Kim, C. -. W., Moon, K. -. M., Kim, M. -. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+Implications+of+an+Aberrant+Right+Hepatic+Artery+in+Patients+Undergoing+Pancreaticoduodenectomy.">Clinical Implications of an Aberrant Right Hepatic Artery in Patients Undergoing Pancreaticoduodenectomy.</a> World Journal of Surgery. 33 (8), 1727-1732 (2009).</li><li>MacKenzie, S., Kosari, K., Sielaff, T., Johnson, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+robotic+Whipple:+operative+strategy+and+technical+considerations.">The robotic Whipple: operative strategy and technical considerations.</a> Journal of Robotic Surgery. 5 (1), 3-9 (2011).</li><li>Stauffer, J. A., Bridges, M. D., Turan, N., Nguyen, J. H., Martin, J. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aberrant+right+hepatic+arterial+anatomy+and+pancreaticoduodenectomy:+recognition,+prevalence+and+management.">Aberrant right hepatic arterial anatomy and pancreaticoduodenectomy: recognition, prevalence and management.</a> HPB. 11 (2), 161-165 (2009).</li><li>Abdullah, S. 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=Anatomical+variations+of+the+hepatic+artery:+study+of+932+cases+in+liver+transplantation.">Anatomical variations of the hepatic artery: study of 932 cases in liver transplantation.</a> Surgical and Radiologic Anatomy. 28 (5), 468-473 (2006).</li><li>Kowalsky, S. 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=A+Combination+of+Robotic+Approach+and+ERAS+Pathway+Optimizes+Outcomes+and+Cost+for+Pancreatoduodenectomy.">A Combination of Robotic Approach and ERAS Pathway Optimizes Outcomes and Cost for Pancreatoduodenectomy.</a> Annals of Surgery. 269 (6), 1138-1145 (2019).</li><li>Klotz, 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=Evaluation+of+robotic+versus+open+partial+pancreatoduodenectomy-study+protocol+for+a+randomised+controlled+pilot+trial+(EUROPA,+DRKS00020407).">Evaluation of robotic versus open partial pancreatoduodenectomy-study protocol for a randomised controlled pilot trial (EUROPA, DRKS00020407).</a> Trials. 22 (1), 40 (2021).</li><li>Baimas-George, 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=Robotic+pancreaticoduodenectomy+may+offer+improved+oncologic+outcomes+over+open+surgery:+a+propensity-matched+single-institution+study.">Robotic pancreaticoduodenectomy may offer improved oncologic outcomes over open surgery: a propensity-matched single-institution study.</a> Surgical Endoscopy. 34 (8), 3644-3649 (2020).</li></ol>

M.J.W Zwart, L.R. Jones and M.G. Besselink received funding from Intuitive for the European LEARNBOT training program for robotic pancreatoduodenectomy. (Grant Reference&#42889; Impact of a European training program for robot pancreatoduodenectomy using a video databank, da Vinci simulator and robot biotissue anastomoses on clinical outcomes (LEARNBOT): a pan-European prospective study) and MEH received funding from Intuitive for studies on safe implementation of robot-assisted pancreatic surgery.
J.A.M.G. Tol, M. Abu Hilal, F. Daams, S. Festen&#160;and O.R. Buschhave no conflict of interest or financial ties to disclose.

This case report shows that RPD is feasible to perform in case of a replaced right hepatic artery when performed in selected patients by trained surgeons in high-volume centers with an annual volume of at least 20 RPD procedures per center, following the Miami guidelines2. RPD combines the benefits of a minimal invasive approach with enhanced 3D vision and the use of articulating instruments and therefore the inherent possibility of wrist movements. Moreover, the large external movements of the surgeon are scaled down to limited internal movements of the &#34;robotic hands&#34;. This improves ergonomics that results in higher precision and greater ability of the surgeon to perform technically difficult procedures in a limited space.
Aberrant vasculature, most commonly a replaced right hepatic artery, can increase the technical difficulty of the resection phase of RPD8. A replaced right hepatic artery can make it more challenging to dissect the pancreatic head and perform an adequate lymph node dissection. Damage to an aberrant hepatic artery can induce bile duct and liver ischemia13,14. The safety of RPD in patients with a replaced right hepatic artery has been shown by several studies9,10. Adequate description of the preoperative imaging is essential to identify aberrant vascularization such as a replaced hepatic artery or other arterial abnormalities such as a celiac trunk stenosis. It is crucial during surgery to identify the replaced right hepatic artery early, and to circle and retract the artery using a vessel loop to facilitate safe dissection of the pancreatic head and lymph node harvesting.
One of the limitations of the robotic approach compared to the open approach is the loss of haptic feedback2. Furthermore, the robotic approach is a more costly approach, although improved time to functional recovery and shortened hospital stay can partly compensate for this15. Lastly, no randomized trials have been conducted to date, to suggest superiority of RPD as compared to the open approach. The potential improved clinical and oncological outcomes of RPD vs OPD should be researched in future randomized trials such as in two ongoing trials in Heidelberg16 and Johns Hopkins Medical Institutes and by the European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS)4,5,17.
This case report shows a RPD for pancreatic head cancer in a patient with a replaced right hepatic artery and described the surgical technique in detail. In conclusion, RPD for pancreatic head cancer is a feasible procedure in case of a replaced right hepatic artery when performed by experienced surgeons (after overcoming the first learning phase after 22 cases7) in high volume centers, based on the Miami guidelines advice of 20 annual procedures per center per year2.

The combination of surgery and systemic therapy provides the most effective way of prolonging life expectancy in patients with resectable pancreatic cancer1. In recent years, interest in minimally invasive pancreatoduodenectomy has increased, aiming to decrease the impact of surgery and thereby enhancing postoperative recovery2.
Robotic pancreatoduodenectomy (RPD) aims to overcome compromises made by laparoscopy, by the ability of wrist movements, scaled down movements, and enhanced 3D vision combined with benefits of the minimally invasive approach for more precision and improved surgical ability. RPD is associated with a learning curve3,4; an experienced single center study reported that the learning curve based on operative time was overcome after 80 RPD procedures5. A dedicated training program can have a positive impact on this learning curve6. The University of Pittsburgh Medical Center (UPMC) group found improved outcomes after the implementation of a training program for RPD5. In the Netherlands, the LAELAPS-3 multicenter training program for RPD was started by the Dutch Pancreatic Cancer Group (DPCG) in collaboration with the UPMC team and demonstrated good results, including a learning curve based on operative time that was overcome after 22 RPD procedures7. Currently, this is being followed by the European LEARNBOT multicenter training program for RPD.
Aberrant hepatic vasculature is present in 15-20% of patients undergoing RPD, most commonly a replaced right hepatic artery, which may complicate the resection phase8. Currently, specific teaching material for RPD in patients with a replaced right hepatic artery is lacking. Detailed descriptions are crucial to prepare an optimal surgical strategy, also highlighting the importance of preoperative imaging for detecting any aberrant vasculature. The safety of RPD with aberrant hepatic vasculature was confirmed by several studies as long as these procedures are performed by specifically trained and experienced surgeons, working in high volume centers6,8,9,10,11,12.
This case report describes and shows a step-by-step technical approach to RPD in case of a replaced right hepatic artery performed in the Netherlands, aimed to facilitate ongoing (i.e., LEARNBOT) and future training programs. The Amsterdam UMC currently performs &#62;40 RPD procedures per year and therefore conforms to the Miami guidelines volume cut-off of &#62;20 RPD procedures2, as do all Dutch centers that participated in the LAELAPS-3 program. The described technique was standardized after 32 procedures (since November 2019) and a total of 115 procedures have been performed (until February 2022).
The described approach is reproducible and compatible for both normal and aberrant anatomy and includes additional steps for a replaced right hepatic artery.
A 58-year-old woman presented with an incidental finding of a 1.7 cm pancreatic head mass suspect for pancreatic ductal adenocarcinoma. No distant metastases and lymph node involvement was identified on the preoperative CT-scan. However, the CT-scan revealed a replaced right hepatic artery originating from the superior mesenteric artery (SMA) (Figure 1). Patient had a history of cholecystectomy, body mass index 30 kg/m2, and was ASA 1. The pancreatic duct measured 3 mm at the neck of the pancreas, and the hepatic duct measured 7 mm at the intended transection plane. The patient did not receive neoadjuvant chemotherapy, as no definitive preoperative histological diagnosis of pancreatic ductal adenocarcinoma could be made. The patient appeared suitable for a minimally invasive approach.

<table><tbody><tr><td>&lt;strong&gt;Sutures:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Internal pancreatic duct stent (12cm)&amp;nbsp;4 Fr Hobbs stent</td><td>Hobbs medical</td><td></td><td></td></tr><tr><td>PDS, RB-1, 8cm 5-0 x6; Z320: taper point. &amp;frac12; circle 13/17mm</td><td>Ethicon</td><td>Z320</td><td></td></tr><tr><td>Silk, SH, 18cm 2-0 x5; C016D: taper point, &amp;frac12; circle 26mm</td><td>Ethicon</td><td>C016D</td><td></td></tr><tr><td>Straight needle Monocryl</td><td>Ethicon</td><td>Y523H</td><td>For retraction lig. teres</td></tr><tr><td>Vicryl suture without needle 60cm</td><td>Ethicon</td><td>e.g. D7818</td><td>For measuring distance HJ-G</td></tr><tr><td>V-loc L0803: taper point, &amp;frac12; circle 17mm, CV-23, 15cm 4-0</td><td>Medtronic</td><td>L0803</td><td>In case of thick wall, dilated bile duct x2</td></tr><tr><td>&lt;strong&gt;Instruments laparoscopy:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Autosuture Endo Clip applier 5 mm</td><td>Covidien</td><td>176620</td><td></td></tr><tr><td>ECHELON FLEX ENDOPATH 60mm Stapler</td><td>Ethicon</td><td></td><td>Powered surgical stapler with gripping surface technology</td></tr><tr><td>o&amp;nbsp;&amp;nbsp; White filling 60mm x2 (for transection of jejunum, gastroduodenal artery)</td><td>Ethicon</td><td>GST60W</td><td></td></tr><tr><td>o&amp;nbsp;&amp;nbsp; Black filling 60mm (for transection of stomach)</td><td>Ethicon</td><td>GST60T</td><td></td></tr><tr><td>Endo Catch II Pouch 15mm</td><td>Covidien</td><td>173049</td><td>Bag for specimen extraction. For single lymph node extractions a cut off finger surgical glove can be used.</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>Mediflex retractor liver</td><td>Mediflex</td><td></td><td></td></tr><tr><td>Set of laparoscopic bulldog clamps</td><td>Aesculap</td><td></td><td>This set consists of several bulldog clamps (of different shape and size) with dedicated laparoscopic instruments to be used to apply and remove the clamps</td></tr><tr><td>&lt;strong&gt;Instruments robot:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Cadiere x2 (470049)</td><td>Intuitive Surgical</td><td>470049</td><td></td></tr><tr><td>&amp;nbsp;&amp;nbsp;&amp;nbsp;&amp;nbsp;&amp;nbsp; Endoscope 30&amp;ordm; (470026)</td><td>Intuitive Surgical</td><td>470026</td><td></td></tr><tr><td>Fenestrated Bipolar Forceps (470205)</td><td>Intuitive Surgical</td><td>470205</td><td></td></tr><tr><td>Hot Shears, Monopolar Curved Scissors (470179)</td><td>Intuitive Surgical</td><td>470179</td><td></td></tr><tr><td>Large Needle Driver x 1 (470006)</td><td>Intuitive Surgical</td><td>470006</td><td></td></tr><tr><td>&amp;nbsp;&amp;nbsp;&amp;nbsp;&amp;nbsp;&amp;nbsp; Medium hem-o-lok Clip applier</td><td>Intuitive Surgical</td><td>470327</td><td></td></tr><tr><td>Permanent Cautery Hook (470183)</td><td>Intuitive Surgical</td><td>470183</td><td></td></tr><tr><td>Suture Cut Needle Driver x1 (470296)</td><td>Intuitive Surgical</td><td>470296</td><td></td></tr><tr><td>&lt;strong&gt;Other:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Hem-o-lok Clips MLX</td><td>Weck Surgical Instuments, Teleflex Medical, Durham, NC</td><td>544230</td><td>Vascular clip 3mm - 10mm Size Range</td></tr><tr><td>Hem-o-lok Clips XI</td><td>Weck Surgical Instuments, Teleflex Medical, Durham, NC</td><td>544250</td><td>Vascular clip 7mm - 16mm Size Range</td></tr><tr><td>Medium extraction port (double ring)</td><td></td><td></td><td></td></tr><tr><td>Vessel loops</td><td>Omnia Drains</td><td>NVMR61</td><td>Disposible silicon rubber stripes, typically used to tag relevant anatomical structures</td></tr></tbody></table>

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.

During routine work-up, the pancreatic CT-scan revealed a replaced right hepatic artery originating from the superior mesenteric artery (SMA) (Figure 1). Vessel loops used in the hepatic ligament, including the replaced right hepatic artery, are shown in Figure 3.
The sequence of instruments during each operative step are shown in Table 1 and specified in the Table of Materials.
Representative results are shown in Table 2. The operation time was 410 min (including 15 min break between the resection and anastomotic phase) with 220 mL of measured intraoperative blood loss. The postoperative course was unremarkable, with a total postoperative hospital stay of five days without complications. Oral intake was possible after two days with normal diet at day four. Patient started walking on the first postoperative day and expanded this to 200 m on day three. On the early morning of postoperative day three, drain amylase was low (86 U/L)and the drain was removed. The patient was discharged two days later on postoperative day five.
Pathology assessment revealed a 1.7 cm adenocarcinoma of the head cancer. The resection margins were microscopically radical (R0) with &#62;3 mm margin and five of 17 retrieved lymph nodes were positive for tumor. Patient started with adjuvant chemotherapy capecitabine as part of a randomized trial.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/62863/62863fig01.jpg" /> 
Figure 1: 3D reconstruction of hepatic vasculature including replaced right hepatic artery <a href="https://www.jove.com/files/ftp_upload/62863/62863fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a> 
Red: Arterial system 
Translucent yellow: Pancreatic duct 
Translucent green: Biliary system 
Translucent blue/purple: Portal system 
Translucent white: Pancreatic tissue
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/62863/62863fig02.jpg" /> 
Figure 2: Port placement <a href="https://www.jove.com/files/ftp_upload/62863/62863fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a> 
Blue: 8 mm robotic ports 
Red: 12 mm laparoscopic ports 
Green: 5 mm port for liver retractor 
Arrow: Umbilicus
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/62863/62863fig03.jpg" /> 
Figure 3: Vessel loops hepatic ligament <a href="https://www.jove.com/files/ftp_upload/62863/62863fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td colspan="2"></td>
			<td colspan="4">Instruments Used</td>
		</tr>
		<tr>
			<td colspan="2" rowspan="2"></td>
			<td colspan="3">Robotic</td>
			<td>Laparoscopic</td>
		</tr>
		<tr>
			<td colspan="3">(console surgeon)</td>
			<td>(assistant surgeon)</td>
		</tr>
		<tr>
			<td colspan="2">Operative steps</td>
			<td>Arm 1</td>
			<td>Arm 2</td>
			<td>Arm 4</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="2">2.5 Mobilization</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Permanent cautery hook</td>
			<td>Sealing device, suction, clip-applier, stapler</td>
		</tr>
		<tr>
			<td colspan="2">3.10 Portal dissection</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Permanent cautery hook</td>
			<td>Sealing device, suction, clip-applier, stapler</td>
		</tr>
		<tr>
			<td colspan="2">3.17 Pancreatic neck transection</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Monopolar curved scissors</td>
			<td>Sealing device, suction, clip-applier</td>
		</tr>
		<tr>
			<td colspan="2">2.18-2.23 Pancreatic head dissection</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Cadiere forceps</td>
			<td>Sealing device, suction, clip-applier</td>
		</tr>
		<tr>
			<td colspan="2">4.1 Drain placement</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated grasper</td>
		</tr>
		<tr>
			<td>4.4-4.5 PJ and HJ</td>
			<td>PJ</td>
			<td>Cadiere forceps</td>
			<td>Large needle driver</td>
			<td>Large needle driver with suture cut</td>
			<td>Fenestrated grasper</td>
		</tr>
		<tr>
			<td></td>
			<td>HJ</td>
			<td>Cadiere forceps</td>
			<td>Large needle driver</td>
			<td>Large needle driver with suture cut</td>
			<td>Fenestrated grasper</td>
		</tr>
		<tr>
			<td>4.10 Specimen extraction</td>
			<td>GJ preparation</td>
			<td>Cadiere forceps</td>
			<td>Large needle driver</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated grasper</td>
		</tr>
	</tbody>
</table>
Table 1: Sequence of instruments during each operative step
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Variable</td>
			<td>Outcome</td>
		</tr>
		<tr>
			<td>Intraoperative</td>
			<td></td>
		</tr>
		<tr>
			<td>Operative time, minutes</td>
			<td>410</td>
		</tr>
		<tr>
			<td>Resection, minutes</td>
			<td>202</td>
		</tr>
		<tr>
			<td>Reconstruction, minutes</td>
			<td>179</td>
		</tr>
		<tr>
			<td>Estimated intraoperative blood loss, mL</td>
			<td>220</td>
		</tr>
		<tr>
			<td>Postoperative</td>
			<td></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>5</td>
		</tr>
		<tr>
			<td>Pathological diagnosis</td>
			<td>Adenocarcinoma of the head cancer</td>
		</tr>
		<tr>
			<td colspan="2">Legend: Operative time comprises steps 2.3-5.3, Resection comprises steps 3-3.25, reconstruction comprises steps 4-4.13</td>
		</tr>
	</tbody>
</table>
Table 2: Representative results

Watch this Scientific Journal Video about Robotic Pancreatoduodenectomy for Pancreatic Head Cancer: a Case Report of a Standardized Technique at JoVE.com

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

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 ...

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Research

JoVE Journal

Cancer Research

5.1K Views.  Amsterdam UMC, location University of Amsterdam. Deze video illustreert een robotische benadering van een pancreatoduodenectomie voor alvleesklierkanker. Robotische pancreatoduodenectomie is de afgelopen jaren sterk gestandaardiseerd en kan worden gebruikt bij geselecteerde patiënten met alvleesklierkanker, waaronder die met een vervangen rechter leverslagader. Deze studie beschrijft en demonstreert robotica pylorus ring resecting pancreaticoduodenectomie in het geval van een vervangen rechter leverslagader.Een 58-jarige vrouw prese...

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

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), ...

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 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 ...

Medicine

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 Enucleation of an Intra-Pancreatic Insulinoma in the Pancreatic Head

Pancreatic parenchyma sparing surgery for insulinomas avoids the risk of endocrine and exocrine insufficiency, and potential high-risk anastomoses associated with pancreatic resection. Robotic surgery may be used as an alternative for open pancreatic enucleation without compromising dexterity and 3D-vision.
We present the case of a 42-year old woman who presented with sweating, tremor and episodes of hypoglycemia. A fasting test confirmed endogenic insulin overproduction. After inconclusive CT- and MRI imaging, endoscopic ultrasonography showed a hypoechoic lesion, which was fully within the pancreatic head. Although consent was obtained for pancreatoduodenectomy, robotic enucleation seemed feasible. After mobilization, intraoperative ultrasonography was used to identify the lesion and its relation with the pancreatic duct. Dissection was performed using a traction suture, hot shears and bipolar diathermia. A sealant patch was applied for hemostasis and a drain placed. The patient developed a grade B pancreatic fistula for which endoscopic sphincterotomy was performed; the surgical drain could be removed in the outpatient clinic after 20 days. Prospective studies should confirm the short- and long-term benefits of robotic enucleation of insulinomas.

Here, we present a robotic approach to enucleate an insulinoma in the pancreatic head.

Pancreatic parenchyma sparing surgery for insulinomas avoids the risk of endocrine and exocrine insufficiency, and potential high-risk anastomoses ...

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 Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic pancreatoduodenectomy (LPD), laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has not yet obtained wide acceptance. This could be attributed to the technical challenges involved in preserving the blood supply of the duodenum and bile duct.
This study describes and demonstrates all the steps of LDPPHR. A 48-year-old woman was diagnosed with a 3.0 cm x 2.5 cm pancreatic head cystic mass, which was detected unexpectedly. The surgery was performed using the 3D laparoscopy via an inferior infracolic approach. The operation lasted approximately 310 min with 100 mL of blood loss. Postoperatively, the patient experienced no complications and was discharged 5 days later. Pathology revealed intraductal papillary mucinous neoplasms.
LDPPHR via an inferior infracolic approach is feasible and safe when performed by experienced surgeons in selected patients with thin mesenteric fat layers. The described technique for LDPPHR via inferior infracolic approach should be well standardized and performed at high-volume centers with experienced surgeons in both open and laparoscopic pancreatology.

This article provides a whole technical process of laparoscopic duodenum-preserving pancreatic head resection via an inferior infracolic approach. This is a surgical approach for benign tumors without intraoperative fluorescence image guidance.

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic ...

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

Spleen-preserving distal pancreatectomy offers an alternative surgical approach to the traditional distal pancreatectomy combined with splenectomy for removing benign and low-grade malignant lesions in the distal pancreas, avoiding complications associated with splenectomy. This procedure can be accomplished either by resecting and ligating the splenic vessels (Warshaw technique) or by preserving them (Kimura technique). Currently, the widespread use of minimally invasive surgery has established laparoscopic and robotic approaches for spleen-preserving distal pancreatectomy as valid and safe options for treating such conditions. Our protocol aims to describe how the Warshaw and Kimura techniques of spleen-preserving distal pancreatectomy can be performed robotically. The first patient is a 36-year-old female with a neuroendocrine tumor (NET) in the pancreatic body who underwent a spleen-preserving distal pancreatectomy with the ligation of the splenic vessels (WT). The second patient is a 76-year-old male with chronic pancreatitis presenting with a dilated main pancreatic duct in the tail of the pancreas who underwent a spleen-preserving distal pancreatectomy with a vessel-preserving approach (KT).

Here, we present a step-by-step protocol of robotic spleen preserving distal pancreatectomy, with and without preserving the splenic vessels (i.e., the Kimura and Warshaw techniques, respectively).

Spleen-preserving distal pancreatectomy offers an alternative surgical approach to the traditional distal pancreatectomy combined with splenectomy for ...

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

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