To begin, insert a 10-millimeter trocar into the created pneumoperitoneum and introduce the laparoscope through the third arm of the robot. Explore the intraperitoneal organs using the laparoscope to confirm the absence of ascites and ensure there are no signs of tumor implantation or metastasis. After inserting the three 10-millimeter trocars, prepare two 12-millimeter auxiliary ports, one at the midpoint between trocars 2 and 3 on a vertical line, and the other medial to the left midclavicular line.
Connect the robotic operating lever and begin the laparoscopic operation with robotic assistance. Using a kocher incision, mobilize the descending and horizontal parts of the duodenum. Using an ultrasonic knife, dissect approximately eight centimeters of the descending part of the duodenum and identify the duodenal papillary mass.
Then, with the ultrasonic knife, incise the duodenal fold and muscle layer to a depth of 3 to 5 millimeters around the tumor. Fully excise the tumor and freeze the specimens immediately for examination. Using a 4.0 absorbable suture, discontinuously anastomose the incised duodenal fold, muscle layer, and the stump of the confluent part of the biliary pancreatic duct.
Place a stent tube to support the anastomosis and secure the stent into the distal part of the duodenum with a 4.0 prolene suture. Using a 3.0 putus suture, intermittently suture the mucosal layer and plasma muscle layer of the duodenal incision to bury the wound. Finally, rinse the abdominal cavity with saline to check for bleeding points and place a drain at Winslow foramena and the paraduodenum.
Close the incision with a 4.0 silk suture to conclude the operation. The robotic assisted pancreatic cobiliary junction resection was completed in 3.5 hours with minimal intraoperative bleeding volume of 30 milliliters, eliminating the need for a blood transfusion. Postoperative drainage amylase levels decreased significantly from 8, 855 units per liter on postoperative Day 2 to 49.96 units per liter on postoperative Day 9, indicating recovery without pancreatic complications.
Drain total bilirubin levels decreased from 27.45 micromoles per liter on postoperative Day 3 to 9.3 micromoles per liter on Day 9, reflecting improved bile duct function and absence of leakage. Pathological findings confirmed the presence of a duodenal papillary villous tubular adenoma consistent with preoperative diagnoses. Postoperative imaging showed complete removal of the duodenal tumor and accurate placement of the biliary stent supporting the efficacy of the surgical technique.
