The authors gratefully appreciate the ongoing support of our robotic team of nurses Daniela Salber, UIrike Butz, Claudia Hagemann and Beate Gatner-Pytlasinski. Prof. A. Tannapfel and the Institute of Pathology, Ruhr-University, Bochum, Germany provided the histological figures. Furthermore, we thank Mr. Kiril Belyaev for his skillful support on video editing.
The work was not funded.
The research was performed in compliance with institutional guidelines and in accordance to the Declaration of Helsinki.

All steps presented in the surgical method follow the guidelines of the ethics committee of the Ruhr-University Bochum, Germany. The study was approved by the local ethics committee (No.23-7872-BR). Informed consent was obtained from the patient for the presentation of the data and video material.
1. Patient positioning and surgical setting
<ol>
	<li>Patient positioning
	<ol>
		<li>Situate the patient in supine position, anti-Trendelenburg 30&#176; and slightly rolled to the right (10-15&#176;).</li>
		<li>Do not split the legs and position the abdomen at a height of &#62;70 cm above ground by adjusting the operating table.</li>
		<li>Arrange the robotic arms in a &#34;butterfly&#34;-setup with two arm carts on both sides of the patient (Figure 1).</li>
	</ol>
	</li>
	<li>Cutaneous incisions and mini-laparotomy
	<ol>
		<li>Disinfect the skin by using swabs and antiseptics and place self-adhesive sterile covers.</li>
		<li>Incise the skin (1-2 cm) and fascia supraumbilically by using a scalpel and scissors.</li>
		<li>Push the first robotic trocar (11 mm) through the incision. Connect it to a CO2 insufflator.</li>
		<li>Set the insufflator to a pressure of 12 mm Hg. Wait until the favored pressure is reached and control the display.</li>
		<li>Make additional incisions (1 cm) and pierce the abdominal wall with the other trocars by turning and applying constant pressure.</li>
	</ol>
	</li>
	<li>Positioning the trocars 
	NOTE: The optimal positions are shown in Figure 2.
	<ol>
		<li>Insert the surgeon&#39;s left hand-trocar in the right upper abdomen (width 8 mm).</li>
		<li>Position the third trocar (surgeon&#39;s right hand, width 11 mm) in the left upper abdomen and the last robotic trocar for the 4th arm (width 8 mm) laterally in the left upper abdomen.</li>
		<li>Ensure a distance of at least 9 cm between all robotic trocars.</li>
		<li>Place an additional laparoscopic trocar between the endoscope and right-hand port on a more caudal level. For the setup, see Figure 2.</li>
	</ol>
	</li>
	<li>Adjusting of robotic arms
	<ol>
		<li>After a short laparoscopic exploration and the insertion of a gauze swab with a grasping instrument, connect robotic arms to the trocars.</li>
		<li>Adjust arm cart 1 (left side, cranial, surgeon right hand) to a tilt angle of -30&#176; and a docking angle of 40&#176;.</li>
		<li>Set up arm cart 2 (left side, caudal, 4th arm) to a tilt angle of 0&#176; and a docking angle of 110&#176;.</li>
		<li>Align arm cart 3 (right side, caudal, surgeon left hand) to a tilt angle of 0&#176; and a docking angle of 290&#176;.</li>
		<li>Set up arm cart 4 (right side, cranial, endoscope arm) to a tilt angle of -30&#176; and a docking angle of 330&#176;. 
		NOTE: Always control the displays of the arm carts to ensure an optimal setup.</li>
	</ol>
	</li>
	<li>Insertion of the instruments
	<ol>
		<li>Insert the camera into arm cart 4 and use a straight-forward optic (0&#176;), which is indicated by the label.</li>
		<li>Equip the surgeon&#39;s left hand with a bipolar grasper, the surgeon&#39;s right hand with monopolar curved shears, and the 4th arm with a cadiere grasper.</li>
		<li>Insert all instruments strictly under visual control. Set up bipolar energy to 50 watts (standard setup).</li>
		<li>Furthermore, set monopolar energy to 30 watts (blend cut) for cutting and 30 watts (fulguration) for coagulation by adjusting the controls of the electrosurgical generator.</li>
	</ol>
	</li>
</ol>
2. Surgical procedure
<ol>
	<li>Incision of the gastrocolic ligament
	<ol>
		<li>At the beginning of the robotic part of the procedure, grasp and elevate the stomach with the 4th arm and incise the gastrocolic ligament using the bipolar grasper and the monopolar shears in combination with a vessel sealing device.</li>
	</ol>
	</li>
	<li>Dissection of the short gastric vessels
	<ol>
		<li>Insert the sealing device via the additional trocar, which is managed manually by the bedside assistant.</li>
		<li>Cut the gastroepiploic ligament from 3 cm below up to 3 cm above the tumor after coagulation by using the controls of the instrument.</li>
		<li>Use the sealing device to coagulate and dissect all short gastric vessels. For additional coagulation, use the bipolar grasper.</li>
	</ol>
	</li>
	<li>Stapling of the tumor
	<ol>
		<li>Identify the tumor by its shape and superficial appearance compared to normal gastric tissue. Resect the tumor using a laparoscopic stapler (30 mm and 45 mm cartridges).</li>
		<li>Take only small steps and pull the tissue tightly to save as much gastric tissue as possible. The result is a lateral wedge resection of the corpus and fundus of the stomach. After the extirpation, place the specimen on the liver temporarily.</li>
	</ol>
	</li>
	<li>Augmentation of the staple line
	<ol>
		<li>Ask the anesthesiologists to replace the gastric tube below the lesion manually. The tube can be localized visually in the stomach.</li>
		<li>Augment the staple line by single knots. Use absorbable sutures. Cut off surplus sutures laparoscopically and remove the needles fixed to the sutures.</li>
	</ol>
	</li>
	<li>Removal of the specimen and end of surgery.
	<ol>
		<li>Disconnect and remove the robotic arm carts.</li>
		<li>Insert a silicone drain laparoscopically, place it next to the lesion, and fix it to the skin with a suture.</li>
		<li>Remove the tumor using a retrieval bag via a mini laparotomy at the endoscope position.</li>
		<li>Finally, close the fascia with absorbable sutures and the wounds using non-absorbable sutures. Patch up the wounds using plasters.</li>
	</ol>
	</li>
</ol>

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A first world report of safety and feasibility.</a> Int J Med Robot. 19 (4), e2544 (2023).</li><li>Mintz, Y., Pikarsky, A. J., Brodie, R., Elazary, R., Helou, B., Marom, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+inguinal+hernia+repair+with+the+new+Hugo+RASTM+system:+first+worldwide+case+series+report.">Robotic inguinal hernia repair with the new Hugo RASTM system: first worldwide case series report.</a> MITAT: Official Journal of the Society for Minimally Invasive Therapy. 32 (6), 300-306 (2023).</li><li>Raffaelli, 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=The+new+robotic+platform+Hugo&#8482;+RAS+for+lateral+transabdominal+adrenalectomy:+a+first+world+report+of+a+series+of+five+cases.">The new robotic platform Hugo&#8482; RAS for lateral transabdominal adrenalectomy: a first world report of a series of five cases.</a> Updates Surg. 75 (1), 217-225 (2023).</li><li>Raffaelli, 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=Feasibility+of+Roux-en-Y+Gastric+Bypass+with+the+novel+robotic+platform+HUGO+RAS.">Feasibility of Roux-en-Y Gastric Bypass with the novel robotic platform HUGO RAS.</a> Front Surg. 10, e1181790 (2023).</li><li>Vicente, E., Quijano, Y., Ferri, V., Caruso, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+cholecystectomy+with+the+new+HUGO&#8482;+robotic-assisted+system:+first+worldwide+report+with+system+description,+docking+settings,+and+video.">Robot-assisted cholecystectomy with the new HUGO&#8482; robotic-assisted system: first worldwide report with system description, docking settings, and video.</a> Updates in Surg. 75 (7), 2039-2042 (2023).</li><li>Belyaev, O., Fahlbusch, T., Slobodkin, I., Uhl, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Safety+and+feasibility+of+cholecystectomy+with+the+hugotm+ras:+proof+of+setup+guides+and+first-in-human+German+experience.">Safety and feasibility of cholecystectomy with the hugotm ras: proof of setup guides and first-in-human German experience.</a> Visc Med. 39 (3-4), 76-86 (2023).</li><li>Raffaelli, 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-assisted+Roux-en-Y+gastric+bypass+with+the+novel+platform+HugoTM+RAS:+preliminary+experience+in+15+patients.">Robotic-assisted Roux-en-Y gastric bypass with the novel platform HugoTM RAS: preliminary experience in 15 patients.</a> Updates Surg. 76 (1), 179-185 (2024).</li><li>Salem, S. 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=Robotic+Heller's+myotomy+using+the+new+Hugo&#8482;+RAS+system:+first+worldwide+report.">Robotic Heller's myotomy using the new Hugo&#8482; RAS system: first worldwide report.</a> Surg Endosc. 38 (3), 1180-1190 (2024).</li><li>Hoeppner, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotisch+assistierte+totale+Gastrektomie+mit+D2-Lymphadenektomie+und+intrakorporaler+Rekonstruktion.">Robotisch assistierte totale Gastrektomie mit D2-Lymphadenektomie und intrakorporaler Rekonstruktion.</a> Zentralblatt fur Chirurgie. 147 (5), 427-429 (2022).</li><li>Vicente, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+resection+of+gastrointestinal+stromal+tumors+(GIST):+a+single+center+case+series+and+literature+review.">Robot-assisted resection of gastrointestinal stromal tumors (GIST): a single center case series and literature review.</a> Int J Med Robot. 12 (4), 718-723 (2016).</li><li>Furbetta, N., 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=Gastrointestinal+stromal+tumours+of+stomach:+Robot-assisted+excision+with+the+da+Vinci+Surgical+System+regardless+of+size+and+location+site.">Gastrointestinal stromal tumours of stomach: Robot-assisted excision with the da Vinci Surgical System regardless of size and location site.</a> J Minim Access Surg. 15 (2), 142-147 (2019).</li><li>Desiderio, 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+gastric+resection+of+large+gastrointestinal+stromal+tumors.">Robotic gastric resection of large gastrointestinal stromal tumors.</a> Int J Surg (London, England). 11 (2), 191-196 (2013).</li><li>Al-Thani, H., El-Menyar, A., Mekkodathil, A., Elgohary, H., Tabeb, A. 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Prof. Orlin Belyaev and Dr. Tim Fahlbusch are consultants for Medtronic.
Albert Tafelmeier works for Medtronic.
The other authors declare no conflict of interest.

The method is tailored for upper gastrointestinal purposes. Low regions of the abdominal cavity are not able to be reached and require different trocar and arm cart positions. A critical step is the placement of the trocars, which are supposed to be placed at a sufficient distance of at least 9 cm from each other. Otherwise, conflicting movements of the robotic arms may occur. Nevertheless, trocars must not be placed too close to osseous structures. Conflicts of the arms can sometimes be circumvented by slight alteration...

Robot-assisted surgery (RAS) is an advanced minimally invasive technique, which is associated with potential advantages such as fastened recovery times, shortened hospitalization and reduced risk of complications. According to Goh et al.1, surgeons benefit from better visualization, ergonomics, and dexterity.
Recently, a much-awaited modular robotic device was approved for in-human use in Europe in the field of visceral surgery2. Extensive experience has already been gathered by urologists earlier on3,4,5. Nevertheless, surgical experience with this new device is scarce but rapidly increasing6,7,8,9,10,11,12,13,14. The system comprises four arm carts for the endoscope and surgical instruments, a system tower, and a surgeon console2. Trocar positions and adjustments of the arm carts are highly important for the success of the surgical approach. False positions may lead to conflicts with robotic arms and technical inoperability. We developed this setup as a standard method for upper gastrointestinal surgery which includes numerous operations and organs such as the stomach, gallbladder, liver, pancreas or spleen. Therefore, the surgical approach needs to cover a wide range of requirements, especially in anatomical regions that are difficult to access. Due to the novelty of the platform, hardly any approaches for upper gastrointestinal surgery were described before. Other authors concentrated on bariatric procedures12. These setups are designed for a minority of obese patients with special anatomical demands12,15. Salem et. al. use alternate localizations of the arm carts for myotomies, which require an intricate positioning of the patient16. The presented method can be utilized for a wide range of purposes and patients and is easy to perform. Setups for other robotic platforms are not transferable17.
We now describe our surgical method and the case of a 69-year-old male patient who presented with an upper gastrointestinal bleeding. The diagnostic measures, including CT scans and endoscopy, revealed a gastric tumor localized at the greater curvature. It was sized 7 cm x 5 cm x 5 cm. Histological examination of a tissue sample suspected a leiomyoma and CT-scans showed no sign of metastatic spread. The patient did not undergo preceding major surgery, was presented with sufficient physical fitness, and, therefore, qualified for minimal-invasive surgery. The surgical resection of the lesion was indicated and performed at St. Josef-Hospital, University Hospital of the Ruhr-University Bochum, Germany, on January 12th, 2024.

<table><tbody><tr><td>Easy Flo&amp;nbsp;</td><td>P.J. Dahlhausen, K&amp;ouml;ln, Germany</td><td></td><td>12 mm</td></tr><tr><td>Endo GIA Ultra&amp;nbsp;</td><td>Medtronic, Dublin, Ireland</td><td></td><td></td></tr><tr><td>EndoRetrieval Pouch&amp;nbsp;</td><td>M&amp;ouml;lnlycke Health Care GmbH, D&amp;uuml;sseldorf, Germany</td><td></td><td></td></tr><tr><td>Ethilon</td><td>Ethicon, Bridgewater, New Jersey, USA</td><td></td><td>3-0</td></tr><tr><td>Hugo RAS</td><td>Medtronic, Dublin, Ireland</td><td></td><td></td></tr><tr><td>Ligasure&amp;nbsp;</td><td>Medtronic, Dublin, Ireland</td><td></td><td>44 cm, Blunt tip, laparoscopic version</td></tr><tr><td>Stomach Probe</td><td>Medicoplast, Illingen, Germany</td><td></td><td>Probe with plastic guidewire</td></tr><tr><td>UHI CO2 Insufflation Unit</td><td>Olympus, Hamburg Germany</td><td></td><td></td></tr><tr><td>Vicryl Sutures</td><td>Ethicon, Bridgewater, New Jersey, USA</td><td>1 and 3-0</td><td></td></tr></tbody></table>

robotics in surgery: a modular robotic platform driven gastric wedge resection

Robotic-assisted surgery has become increasingly popular since the introduction of the first robotic platform. Recently, a modular robotic system was approved for in-human use in Europe. Possible applications for this new robotic system are being explored, and standardized approaches are evolving. In lieu of this, a gastric wedge resection and the standardized setup for upper gastrointestinal procedures using this new system are presented here. This safe and feasible robotic procedure is demonstrated in a 69-year-old patient with a gastric tumor. All steps of the surgery are described in a detailed and reproducible manner. The article also details trocar positioning, arm adjustments, and required surgical instruments. Docking time amounted to 13 min, whereas the console time took 115 min. The patient was discharged after 4 days after ensuring an uneventful course. The presented method is also suitable for other surgical purposes, such as fundoplications or hiatoplasties, and ensures both generalizability and reproducibility.

Docking time amounted to 13 min, whereas console time took 115 min. The tumor was removed, and the wounds were closed after another 15 min. There were no intraoperative complications or robotic malfunctions and hardly any blood loss. The patient was monitored in the recovery room for 3 hours postoperatively. The further course in the hospital was uneventful. There was no sign of postoperative bleeding or insufficiency of the stapling line. Therefore, the drain was removed after 2 days. There were 3 blood tests screening ...

Robotically assisted surgery has become highly popular in recent years. Presented here is the standard care for upper gastrointestinal procedures, including a demonstration of a robotic-assisted gastric wedge resection using a modular robotic device.

Robotics in Surgery: A Modular Robotic Platform Driven Gastric Wedge Resection

Robotic-assisted surgery has become increasingly popular since the introduction of the first robotic platform. Recently, a modular robotic system was ...

robotics-surgery-modular-robotic-platform-driven-gastric-wedge

Research

JoVE Journal

Medicine

330 Views.  Ruhr-University Bochum, St. Josef-Hospital. Robotically assisted surgery has become highly popular in recent years. Presented here is the standard care for upper gastrointestinal procedures, including a demonstration of a robotic-assisted gastric wedge resection using a modular robotic device.

Video: Robotics in Surgery: A Modular Robotic Platform Driven Gastric Wedge Resection

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), ...

Cancer Research

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 ...

Design and Fabrication of an Elastomeric Unit for Soft Modular Robots in Minimally Invasive Surgery

In recent years, soft robotics technologies have aroused increasing interest in the medical field due to their intrinsically safe interaction in unstructured environments. At the same time, new procedures and techniques have been developed to reduce the invasiveness of surgical operations. Minimally Invasive Surgery (MIS) has been successfully employed for abdominal interventions, however standard MIS procedures are mainly based on rigid or semi-rigid tools that limit the dexterity of the clinician. This paper presents a soft and high dexterous manipulator for MIS. The manipulator was inspired by the biological capabilities of the octopus arm, and is designed with a modular approach. Each module presents the same functional characteristics, thus achieving high dexterity and versatility when more modules are integrated. The paper details the design, fabrication process and the materials necessary for the development of a single unit, which is fabricated by casting silicone inside specific molds. The result consists in an elastomeric cylinder including three flexible pneumatic actuators that enable elongation and omni-directional bending of the unit. An external braided sheath improves the motion of the module. In the center of each module a granular jamming-based mechanism varies the stiffness of the structure during the tasks. Tests demonstrate that the module is able to bend up to 120&#176; and to elongate up to 66% of the initial length. The module generates a maximum force of 47 N, and its stiffness can increase up to 36%.

This paper describes the design and fabrication of a soft unit for surgical manipulators. The base module includes three flexible fluidic actuators to achieve omnidirectional bending and elongation, and a granular jamming-based mechanism to enable stiffness control. A complete mechanical characterization is also reported.

In recent years, soft robotics technologies have aroused increasing interest in the medical field due to their intrinsically safe interaction in ...

Bioengineering

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 ...

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 ...

Robotic Myotomy and Partial Fundoplication for Achalasia

Laparoscopic Heller myotomy is currently considered the standard definitive treatment of achalasia. With the advancements in technology, robotic Heller myotomy has emerged as an alternative approach to traditional laparoscopy due to three-dimensional (3D) visualization, fine motor control, and improved ergonomics provided by the robot. 
Although there is a lack of randomized controlled trials, robotic-assisted Heller myotomy seems to be associated with lower rates of intraoperative perforations compared to the laparoscopic approach. A robotic approach may also improve surgical outcomes by providing a more complete myotomy. 
Here, we describe the detailed steps of robotic myotomy and partial fundoplication for achalasia.

Surgical myotomy with a partial fundoplication may be used in selected patients as a definitive treatment for achalasia. This article provides a step-by-step description of a robotic myotomy and partial fundoplication in a 32-year-old patient with megaesophagus.

Laparoscopic Heller myotomy is currently considered the standard definitive treatment of achalasia. With the advancements in technology, robotic Heller ...

Reoperative Hiatal Hernia Repair

Technical Considerations and Approach to Redo Foregut Surgery

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical considerations have arisen when dealing with reoperation for complications or surgical failure. This study focuses on the technical considerations and approach when dealing with reoperative foregut surgery, particularly redo&#160;hiatal hernia repair. We describe our approach starting from the preoperative workup to the procedural steps of the surgery. The present study describes the main steps for robotic reoperative hiatal hernia repair in a patient who had previously undergone laparoscopic hiatal hernia repair with Nissen fundoplication but did not present a recurrence of reflux and dysphagia symptoms. The patient is positioned supine with arms out and a footboard for steep Trendelenburg. We place six trocars, including an assistant port and a liver retractor port,&#160;to facilitate visualization and retraction. After docking the robot, we use a combination of electrocautery and sharp dissection&#160;to free the hernia sac and reduce the hiatal hernia. The previous fundoplication is then taken down carefully and the esophagus is mobilized through a transhiatal approach with a combination of blunt and sharp dissection until at least 3 cm of intra-abdominal esophageal length is achieved, after which a leak test is performed. We then perform a crural repair to reapproximate the hiatus with two posterior stitches and one anterior stitch. Lastly, a redo Nissen fundoplication is performed over a bougie, and endoscopy is used to confirm a loose stack-of-coin appearance. By emphasizing the crucial steps of redo hiatal hernia repair, including preoperative evaluation, our goal is to provide an approach for the foregut surgeon to maximize patient outcomes.

Author Spotlight: Recent Advancements in Reoperative Foregut Surgery

Redo foregut surgery is associated with increased patient morbidity and presents a technical challenge for the surgeon. We describe our approach and considerations when performing a redo hiatal hernia repair to provide a guide for other surgeons and improve patient outcomes.

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical ...

Robotic Vagus-Sparing Total Gastrectomy for CDH1 Gene Mutation Treatment

Hereditary diffuse gastric cancer (HDGC) caused by the CDH1 gene mutation is an inherited cancer syndrome that increases the risk of diffuse gastric cancer and is nearly impossible to detect by screening gastroscopy. The recommended preventative treatment is a total gastrectomy. Robotic surgery facilitates the use of minimally invasive surgical (MIS) techniques for anastomoses and posterior vagus preservation to potentially reduce adverse functional outcomes. An asymptomatic 24 year old male with the CDH1 gene mutation proven by genetic testing and a family history of a brother having a total gastrectomy for HDGC was treated with this technique. This video case report demonstrates the techniques and pitfalls of robotic surgery in terms of the patient positioning and port placement, posterior vagus-preserving dissection, sutured esophagojejunostomy, jejunal pouch formation, and Roux-en-Y reconstruction with a staple-stapled jejunojejunostomy. While these techniques are demonstrated in the case of prophylactic gastrectomy, many of them can be applied to other benign and bariatric foregut and general surgery types.Robotic surgery can facilitate the foregut MIS technique, as described in this case of a vagus-sparing total gastrectomy.

This article focuses on robotic vagus-sparing total gastrectomy. The techniques and pitfalls of vagus preservation, sutured esophagojejunostomy, jejunal pouch formation, and Roux-en-Y reconstruction with a staple-stapled jejunojejunostomy are discussed.

Hereditary diffuse gastric cancer (HDGC) caused by the CDH1 gene mutation is an inherited cancer syndrome that increases the risk of diffuse gastric ...

Robotic D3 Partial Duodenal Resection with Primary Side-to-Side Anastomosis

Duodenal stenosis is a condition that can be related to several diseases, being either intrinsic, such as neoplasm and inflammatory stenosis, or extrinsic, such as pancreatic pseudocyst, superior mesenteric artery syndrome, and foreign bodies. Current treatments range from endoscopic approaches, such as endoscopic resection and stent placement, to surgical approaches, including duodenal resection, pancreaticoduodenectomy, and gastrointestinal bypass. Minimally invasive robot-assisted surgery is gaining importance due to its potential to decrease surgical stress, intraoperative blood loss, and postoperative pain, while its instruments and 3D-vision facilitate fine dissection and intra-abdominal suturing, all leading to a reduced time to functional recovery and shorter hospital stay. We present a case of a 75-year-old female who underwent robotic D3 partial duodenal resection with primary side-to-side duodeno-jejunal anastomosis for a 5 cm adenoma with focal high-grade dysplasia.

This protocol presents a case of a robotic partial duodenal resection with primary side-to-side duodeno-jejunal reconstruction in a patient with a 5 cm duodenal stenosis. This is done at the third duodenal segment (D3) after an endoscopic mucosal resection (EMR) for a duodenal polyp.