This video demonstrates all steps of a robot-assisted D3 partial duodenal resection with primary side to side anastomosis. A 75-year-old female presented with dysphagia, pain, and malnutrition several months after partial endoscopic mucosal resection of a 5-centimeter sized polyp, located in the ante-mesenteric ruminal part of the duodenum, D3.Pre-preoperative imaging with computing tomography scan was used in order to assess the localization and the extent of the duodenal stenosis and its relation with the Vater papilla. Diagnostic esophagogastroduodenoscopy revealed a large, intractable fibrotic stenosis, 10 centimeters distal to the papilla in D3.A small marking to two was injected in the submucosa, one to two centimeters orally from the stenosis, in order to facilitate surgical resection.
The present protocol follows the ethics guidelines of Amsterdam UMC. Informed consent was obtained from the patient for this article and the video. Induction of general anesthesia by the anesthesiologist.
Place the patient in French position with the right arm lowered on an arm board alongside the patient, and the left arm out in an 90-degree abduction. Tilt the table 20 degrees to the left and in a 20 degrees reverse Trendelenburg position with the legs horizontal and a large 3D screen to the patient's right side, to facilitate a sitting table side surgeon. Perform the safety check procedures as required by the institution, and create a sterile exposition.
Create pneumoperitoneum by inserting a Veress needle at Palmer's point. Then, insufflating to 10 to 12 millimeters carbon dioxide. After insufflation, trocar positions are marked.
First, the longest Throne, from two centimeters to the right of the umbilicus, to the costal margin at the level of the gallbladder. And this line, 13 centimeters from the costal margin. The camera trocar, rubbered arm three is marked.
On a horizontal line, seven centimeters to the left and right, two trocars are placed. Robot arms two and four. Finally, placed seven centimeters craniolateral from robot arm trocar two to trocar one.
Place two 12 millimeters, table side surgeon trocars below, and in between trocars two, three, and three, four. The distance between all these trocars is seven centimeters. After inspection and removal of the various needle, place the four 8 millimeters robotic trocars and two 12 millimeters table side surgeon trocars.
Install the robot over the patient's right shoulder and dock the robot arms to the robotic trocars. Cranialized the greater omentum and colon. Identify the first duodenal loop and Treitz ligament.
Dissect the left side of the ligament of Treitz to free the most distal part of the duodenum and the first part of the duodenum from the aorta, using the robotic cautery hook on arm four and the laparoscopic LigaSure Maryland. Perform tunneling through the hepatocolic ligament in older despair vascular structures. Perform mobilization of the hepatic flexure and the ascending colon with the robotic cautery hook on the arm four and the laparoscopic LigaSure Maryland.
Pay attention to any vascular abnormalities of the right colonic artery. Perform Kocher maneuver by mobilizing the duodenum and the head of the pancreas from caudal-to-cranial using the robotic cautery hook and the laparoscopic sealing device. Traction of the deuodenal loop in the retroperitoneal cavity.
Staple intestinal loop 10 centimeters distally to the causal tattoo. Detach the duodenum from its mesentery with a laparoscopic sealing device. Staple the duodenum at the level of the 70 causal tattoo, including a tattoo in the specimen.
Create two small endarterectomies using robotic scissors with diathermia at the antimesenteric side of the duodenal and jejunal stump. Make a side-to-side duodenal jejunostomy using an end stapler Echelon, 60 millimeters with a vascular cartridge. Close the remaining opening of the anastomosis with two layers of a running V-Loc 4-0 15 centimeters suture.
The postoperative course was uneventful. The nasogastric tube was removed on postoperative day one, and the patient started a soft liquid diet and expanded to a normal diet in 24 hours. The patient was discharged on postoperative day three.
after a total hospital stay of four days. The pathological assessment revealed a radically removed five centimeters adenoma with focal high grade dysplasia. Robot assisted, day three, segmental duodenal resection with primary side-to-side anastomosis is found to be safe and visible in experienced hands in a high volume center.
The robotic approach combines the benefits of the open and laparoscopic approach. The primary side-to-side duodeno-jejunal anastomosis is an alternative to the more traditional Roux-en-Y anastomosis.
