Technical Detail for Robot Assisted Pancreaticoduodenectomy

Summary

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

Abstract

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. 

Introduction

Pancreaticoduodenectomy (PD) is a complex operation that combines a challenging resection and a meticolous reconstruction. During its early inception, the traditional open approach was frought with high complication rates and a mortality rate approaching 25%. In the last three decades, improvements in the surgical technique and perioperative care led to corresponding improvements in outcomes, with a reduction in mortality to less than 5%, especially at high volume centers^1,2,3. Despite this, morbidity remains substantial. With advancements in surgical technology, minimally invasive surgical approaches through laparoscopy or robot-assisted surgery have emerged in an effort to curb this morbidity. Since its first report in 2003, interest in robotic pancreaticoduodenectomy (RPD) has grown by pancreatic surgeons^4,5. Inherent advantages of the robotic platform, including three-dimensional (3D) vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate principles of open PD (OPD) in a minimally invasive manner, including safe oncologic dissection, hemostasis, and meticulous reconstruction^4,6,7,8,9,10. The goal of this manuscript is to provide the detailed steps of an RPD performed at the University of Pittsburgh Medical Center (UPMC)^11,12,13.

In the presented case study, a 42-year-old female with a previous history of intraductal papillary mucinous neoplasm (IPMN), initially presented with acute pancreatitis. Computed tomography (CT) of the abdomen revealed a 3.3 cm pancreatic head lesion with associated dilatation of the main pancreatic duct (Figure 1A,B), with a mixed type IPMN. Endoscopic ultrasound (EUS) confirmed the existence of an irregular, heterogenous cyst measuring 3.1 x 2.0 cm in the pancreatic head with mixed solid and cystic components and main PD duct dilation (Figure 1C). EUS cytology revealed the presence of atypical cells with no high-risk molecular mutations^14,15. Biochemical workup including serum tumor markers were normal, with CA19-9 12 U/mL. Based on the Fukuoka criteria, this patient was recommended to have a PD and was deemed a suitable candidate for the robotic approach¹⁶.

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Protocol

This protocol follows the guidelines of the University of Pittsburg Medical Center human research ethics comittee (Institutional Review Board: PRO15040497)

1. Preoperative workup and selection

1. Check the triphasic CT scan (i.e., chest, abdomen, and pelvis with the primary imaging modality) to evaluate the extent of disease, rule out metastasis, and delineate aberrant or anomalous arterial vasculature. 
2. Perform EUS and endoscopic retrograde cholangiopancreatography (ERCP) for the tissue diagnosis and biliary decompression, especially in the setting of the planned neoadjuvant chemotherapy for pancreatic cancer.
3. Check for the relative contraindications for RPD, including tumor involvement of the portal vein or SMV that necessitates a vascular resection and reconstruction, previous upper gastrointestinal reconstruction (e.g., gastric bypass), extensive adhesions, and BMI > 40.

2. Anesthesia

1. Consider all patients for the institutional enhanced recovery pathway after the surgery (ERAS) with multimodal analgesia, including regional nerve blockade or intrathecal morphine, gabapentin, nonsteroidal analgesia, minimization of narcotic administration, and intraoperative goal-directed fluid resuscitation¹³.
2. Perform deep venous thrombosis prophylaxis with a subcutaneous unfractionated heparin 5000 U injection and pneumatic placement of sequential compression devices prior to the induction. Place an arterial line (central lines are not routinely placed).
3. Administer preoperative antibiotics, typically with 4.5 g piperacillin/tazobactam, or 1–2 g ceftriaxone and 500 mg metronidazole, or 150 mg clindamycin and 500 mg metronidazole, 1 h prior to incision. 
4. Place oral gastric tube following intubation and remove after the case.

3. Patient positioning

1. Position the patient in a supine position on a split-leg table with the right arm tucked and secured to the table with pressure points padded (Figure 2).
2. Turn the operating table approximately 45˚ counterclockwise from anesthesia to accommodate the docking of the Si robot. Dock the Xi robot from the side, as this does not require the turning of the table.

4. Placement of ports and liver retractor

1. Establish the access to the intraabdominal cavity by utilizing a 5 mm optical separator trocar in the left upper quadrant, midclavicular line, one hand’s breadth to the left of the umbilicus. Advance the laparoscope into the abdominal cavity and perform a full inspection to rule out any peritoneal or visceral metastasis.     
2. Upsize this trocar to an 8 mm robotic cannula (Arm 1 or A1). 
   1. Place the remaining ports as depicted in Figure 3. Place two 8 mm robotic ports in the right upper abdomen: place arm 2 (A2) in the midclavicular line, place arm 3 (A3) in the subcoastal anterior axillary line.
   2. Place a 12 mm camera port approximately 2 cm above and to the right of the umbilicus.
   3. Place a 12 mm laparoscopic assistant port in the left lower quadrant/midclavicular line, one hand’s breadth lower than the upper robotic ports and between A1 and the camera port.
   4. Place a 5 mm laparoscopic assistant port is placed in the right lower quadrant, one hand’s breadth lower than the upper robotic ports and between A2 and the camera port.
   5. Finally, place a 5 mm laparoscopic port for a liver retractor in the left anterior axillary line. Place the liver retractor to the leftmost lateral port. Ensure that the liver retractor is able to retract the gall bladder and lifts the liver superiorly during the entirety of the resection period.
3. Place the patient in a steep reverse Trendelenburg position and dock the robot.

5. Resection phase

1. The robotic instruments
   1. Ensure that A1 is equipped with hook cautery.
   2. Ensure A2 is equipped with fenestrated bipolar forceps.
   3. Ensure A3 is equipped with bowel grasping forceps (robotic instrument catalog number 470049). 
      NOTE: The bedside assistant (two lower assistant ports) utilizes any combination of laparoscopic atraumatic grasper, laparoscopic suction irrigator, and laparoscopic blunt tip vessel sealing device.
2. Entrance into the lesser sac and mobilization of the right colon
   1. Grasp the anterior stomach and retract anteriorly and cephalad with A3. 
   2. Gain access into the lesser sac through the greater omentum below the gastroepiploic pedicle using A1 and A2. The assistant provides a gentle caudal counter-retraction.
   3. Carry out the dissection along the greater curvature towards the pylorus. Ensure that the right colon flexure is fully mobilized off the duodenum.
   4. Preserve the gastroepiploic pedicle and do not transect it at this point.
3. Kocherization of the duodenum and dissection of the ligament of Treitz (LOT)
   1. Grasp the lateral fibers of the duodenum with A2 and transect with A1. The bedside assistant provides gentle medial counter-retraction of the duodenum.
   2. Carry out the mobilization of the duodenum including its 3^rd and 4^th portions to the LOT. 
      NOTE: Dynamic anterior and cranial retraction of the duodenum with A3 is key to an excellent exposure of the LOT. Extensive kocherization allows for the full visualization of the inferior vena cava, insertion of the left renal vein, and aorta.
   3. Perform the complete release of LOT with A1 to allow for the exposure of the proximal jejunum.
   4. Extract the proximal jejunum through the LOT defect into the right supracolic upper quadrant (creation of the neoduodenum for the reconstruction phase). 
4. Transection of the proximal jejunum
   1. Measure the jejunum approximately 10 cm distal to the LOT.
   2. Transect the jejunum 10 cm distal to the duodenojejunal junction using a 60 mm curved tip vascular linear stapler.
5. Linearization of the duodenum
   1. Divide the mesentery of the proximal jejunum by a sequential ligation with a blunt tip vessel-sealing device up to the uncinate process.
   2. Take extreme care during this dissection because hemorrhage from the branches of the SMV can occur due to the lateral traction of the duodenum.
6. Transection of the distal stomach
   1. Take care to not injure an aberrant or accessory left hepatic artery if present. While A1 and A2 are utilized for the dissection, use A3 to further retract the liver anteriorly.
      NOTE: A3 releases the duodenum and stretches the pars flaccida underneath. The lesser sac is accessed superiorly through the pars flaccida.
   2. Mark the stomach with a 60 mm thick linear stapler 5 cm proximal to the pylorus to perform the classic PD.
   3. Ligate the right gastroepiploic vessels (RGEV) with the blunt tip vessel-sealing device at the corresponding area of the greater curvature. Transect the stomatch utilizing a thick linear stapler.
7. Dissection and transection of right gastric vessels
   1. Ligate the right gastric artery (RGA) with laparoscopic titanium vascular 10 mm clips close to where it branches off from the proper hepatic artery.
   2. Transect the RGA with the blunt tip of the vessel sealing device at the lesser curvature 5 cm proximal to the pylorus.
8. Dissection and excision of common hepatic artery lymph node
   1. Use A3 to grasp the distal gastric staple line and retract the specimen laterally and inferiorly, putting the common hepatic artery (CHA) and the porta hepatis under tension. Continue the dissection through the superior border of the pancreas and into the porta hepatis. Use the energy function of both A1 and A2 to completely dissect the CHA, gastroduodenal artery (GDA), and RGA.
   2. Excise the CHA lymph node, which allows complete exposure of the CHA. Retrieve it with a 10 mm laparoscopic specimen retrieval bag and send the specimen for permanent pathologic analysis. This allows for the full visualization of the GDA.
9. Dissection and transection of GDA
   1. Identify the GDA where it branches off from the CHA. Utilize the robotic hook to fully circumferentially dissect the GDA.
   2. Pass a vessel loop around the GDA. A test clamp may be used with confirmation of flow using visualization from a robotic ultrasound (US) probe. Transect the GDA with a vascular stapler. The proximal stump is reinforced with laparoscopic titanium vascular 10 mm clips.
   3. Now identify the portal vein (PV) above the neck of the pancreas.
10. Dissection and transection of the common bile duct (CBD)
    1. Dissect the PV for 2–3 cm in a cephalad direction. Identify the plane between the CBD and the PV and develop it posteriorly. Dissect all intervening portal lymph nodes and reflect towards the specimen. 
    2. Encircle the CBD/CHD with a vessel loop. If present, take care not to injure a replaced right hepatic artery behind the CBD/CHD.
    3. Transect the CBD/CHD with a 60 mm curved tip vascular linear stapler above the level of the biliary stent (if present) to minimize bile spillage and field contamination.
11. Dissection of SMV and creation of the superior tunnel
    1. Dissect the lateral border of the portal vein using the robotic hook cautery.
    2. Ligate the superior pancreaticoduodenal artery, which is often encountered during this procedure, utilizing the assistance of the blunt tip vessel sealing device. Continue the superior-to-inferior dissection of the portal vein up to the superior border of the pancreas. This dissection allows for the exposure of the superior tunnel.
12. Dissection of the SMV and creation of the inferior tunnel
    1. Using A3, grasp and retract the distal gastric staple line laterally and cephalad to stretch the gastroepiploic vein (GEV) as it enters the anterior SMV. Open the fatty tissue near the pancreatic inferior border using electrocautery in A1. The SMV is now visible.
    2. Identify the gastrocolic trunk (Trunk of Henle). Occasionally, there can be a right branch of the middle colic vein (RBMCV) that drains into the trunk. If present, dissect and transect it with the blunt tip vessel sealing device. Trace the GEV to its insertion into the SMV and transect with the blunt tip vessel sealing device. 
    3. Dissect off the SMV from the inferior border of the pancreas and create a retropancreatic neck tunnel between the pancreas and SMV/PV.
13. Pancreatic parenchymal transection and placement of pancreatic duct (PD) stent
    1. Using A3, now retract the specimen laterally to stretch the pancreatic neck. Control the superior and inferior longitudinal pancreatic arteries with the bipolar in A2, thus obviating the need for transfixation sutures.
    2. Transect the pancreatic neck using monopolar curved scissors in A1 and take care to identify the main duct. The assistant provides anterior lift of the pancreas off the SMV using suction during the parenchymal transection. 
    3. Transect the main PD with monopolar curved scissors without electrocautery. 
    4. Place a 4–5 Fr pancreatic duct stent into the PD to ensure its identification. Transect the remaining pancreatic parenchyma using an electrocautery.
14. Dissection and division of the uncinate process
    NOTE: This portion of the resection requires slow and meticulous dissection, because significant hemorrhage may occur in absence of operative precision. The key to head and uncinate dissection during this phase is the judicious use of A3, which provides superior and lateral retraction of the specimen.
    1. Keep A3 dynamic during the resection and make frequent readjustments to ensure appropriate retraction in an ‘up and out’ orientation, analgous to a surgeon’s left hand in an open PD.
    2. Ensure that all three layers are dissected while performing the uncinate process dissection.
       1. Transect the first layer using a hook cautery in A1. The first layer consists of filamentous fibers between the SMV/PV and the head/uncinate. This layer is devoid of any major vascular branches.  
       2. Use a combination of the hook cautery in A1 and the assistant’s blunt tip vessel sealing device for dissection and ligation of the second layer. The second layer consists of the first jejunal vein (coursing lateral then posterior to the SMA), the Vein of Belcher/posterosuperior pancreaticoduodenal vein (entering the PV at the superior portion of the head/uncinate) and small uncinate branches. Preserve the first jejunal vein.
       3. Transect with a curved tip vascular stapler if it requires ligation due to tumor involvement. Transect the Vein of Belcher with the blunt tip vessel sealing device. Take extreme care during this dissection, because avulsion of any of those vessels will result in significant hemorrhage.
       4. Identify the third layer, which is the SMA/retroperitoneal margin. Rotate the SMV/PV medially with the help of an assistant (using the 12 mm right lower quadrant laparscopic port), while continuing to pull the specimen up and out with A3. Visualize the SMA and dissect along the plane of Leriche utilizing the robotic hook in A1 and the assistant’s blunt tip vessel sealing device (in the left lower quadrant 5 mm laparoscopic port). Identify the inferior PDA in this layer and take with the blunt tip vessel sealing device or between clips.  
    3. Following the completion of the uncinate dissection, perform the cholecystectomy.
15. Specimen extraction
    1. Place the specimen into a laparoscopic 15 mm specimen extraction pouch through a 4 cm extraction incision in the left midclavicular line. 
    2. Place the multi-instrument laparoscopic advanced access gel port through the extraction site and initiate the reconstruction phase. Reinsert a 12 mm laparoscopic port through the gel port to facilitate the passage of sutures for reconstruction.

6. Reconstruction phase

1. Main robotic instruments
   1. Ensure A1 is armed with a large dual function needle driver with suture scissors. This is frequently switched to monopolar curved scissors to perform an enterotomy/gastrotomy.
   2. Ensure A2 is equipped with a large needle driver.
   3. Ensure A3 is equipped with fenestrated bipolar forceps used to grasp the pancreaticobiliary limb and steady it in the right upper quadrant during the pancreaticojejunostomy and hepaticojejunostomy. 
2. Pancreaticojejunostomy (PJ)
   1. Perform the PJ in a two-layer, end to side, duct to mucosa method, with the modified Blumgart technique. Use A3 to grab the previously placed sutures to provide cranial retraction and exposure. 
   2. Place 2–0 silk transpancreatic horizontal mattress sutures to secure the pancreas parenchyma to the jejunum. Place three sutures: one above, one below, and one straddling the pancreatic duct. Tie all three sutures, and keep the needles on the sutures. Take care when tying the middle suture, which straddles the main PD, to avoid accidental ductal ligation.  
   3. Use a 4–5 Fr pancreatic duct stent to interrogate the patency of the duct. Switch A1 to the monopolar scissors that are utilized to perform the enterotomy. Then replace again with the large dual function needle driver with suture scissors. 
   4. Use interrupted 5–0 polydioxanone (PDS) sutures to approximate the jejunal mucosa to the pancreatic duct. Place a minimum of six sutures (two posterior, two lateral, and two anterior). More sutures can be placed if larger ducts are encountered.
   5. Reuse the same three silk needles, previously used for the posterior layer, for the anterior layer of the PJ as well. Place them in a simple fashion in the jejunum and tie these to complete the anastomosis. 
3. Hepaticojejunostomy (HJ)
   1. Perform the HJ approximately 10 cm distal to the PJ, and in a single layer either in interrupted (5–0 PDS) or running (4–0 barbed sutures) fashion.
   2. Use A1 with monopolar curved scissors to transect the CBD staple line and to perform the enterotomy. Replace A1 and A2 with a large dual function needle driver with suture scissors and large needle driver, respectively. 
   3. Perform the anastomosis using 5–0 poly(p-dioxanone) sutures in an interrupted fashion for ducts measuring <1 cm. For larger ducts, use two running 4–0 barbed sutures in a single layer, continuous fashion. Place both sutures at the 9 o’clock position and ensure that they run in opposite directions towards the 3 o’clock position. Tie the sutures after the completion of the anastomosis.
   4. For interrupted anastomosis, first place and tie the posterior sutures. For ducts measuring <1 cm, employ 4–5 Fr stents to keep the patency of anastomosis. Next, place additional 5–0 PDS sutures to complete the anterior anastomosis. Once all the sutures are in place, tie the sutures and complete the anastomosis.
4. Gastrojejunostomy (GJ)
   NOTE: The GJ is a handsewn, antecolic, end-to-side, isoperistaltic anastomosis.
   1. Place two 3–0 silk marking stitches on the jejunum approximately 40–60 cm distal to the HJ to mark the bowel as proximal and distal, respectively, denoting afferent and efferent limbs of the jejunum. Replace A1 and A2 with bowel grasping forceps #1 and #2 (robotic instrument catalog number 470093 and 470049, respectively). The laparoscopic assistant reflects the omentum and mesocolon cephalad, which allows the surgeon to locate the neoduodenum. 
   2. Reduce the distal jejunum and place it back into the infracolic compartment. Identify the two marking stitches, and bring the jejunum in an antecolic, isoperistaltic fashion up to the stomach.
   3. Replace A1 and A2 with a large dual function needle driver with suture scissors and a large needle driver, respectively. Place an interrupted outer layer with 2–0 silk sutures. Hold the most cephalad suture by A3 and use it as a retraction suture. Replace A1 with monopolar curved scissors. 
   4. Transect 6 cm of the gastric staple line with scissors electrocautery and perform a corresponding jejunal enterotomy. Perform the inner layer using two 3–0 barbed sutures in running Connell fashion. Place the interrupted outer layer, 2–0 silk sutures to complete the second layer. 
5. Drain placement
   1. Following the completion of the anastomosis, place a 19 Fr round channel drain posterior to the HJ and anterior to the PJ. A falciform ligament flap may be utilized to cover the GDA stump.
   2. Remove the instruments and liver retractor, and undock the robot. 
   3. Close the fascia and incisions in layers.

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Results

In the representative case, the total operative time was 225 min with an estimated blood loss (EBL) of 50 mL (Table 1). The patient was admitted to the surgical ward. Her postoperative course followed the UPMC institutional ERAS pathway. We routinely assess JP amylase at POD#1 and #3 to assess for pancreatic fistula and practice early drain removal on POD 3-5 when possible. The patient’s JP amylase levels were 403 U/L and 68 U/L, respectively. Therefore, the drain was removed on POD#3. The patient ...

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Discussion

With advances in the surgical technology, laparoscopic and robot-assisted surgeries are being increasingly used in gastrointestinal and hepatobiliary procedures. Conventional laparoscopy is associated with benefits over open surgery for many procedures. However, inherent limitations such as decreased surgical dexterity, suboptimal ergonomics, lack of wristed instruments, and 2-D visualization, have limited its dissemination to complex gastrointestinal operations such as PD. 

Contrary to l...

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Materials

Name	Company	Catalog Number	Comments
3-0 V-Loc sutures	Medtronic (Minneapolis, MN)	VLOCMo614	Barbed Absorable Suture
4-5 Fr Freeman Pancreatic Flexi-Stent	Hobbs Medical (Stafford Springs, CT)	6542, 6552	Pancreatic Duct Stent
5-0 PDS (polydiosxanone)	Ethicon (Somerville, NJ)	D10063	Synthetic Absorbable Suture
Cadíere forceps	Intuitive (Sunnyvale, CA)	470049	Surgical Robot Instrument
Da Vinci Si	Intuitive (Sunnyvale, CA)		Surgical Robot
Da Vinci Xi	Intuitive (Sunnyvale, CA)		Surgical Robot
Endo Clip 10 mm Applier	Covidien (Dublin, Ireland)	176619	Laparoscopic Titanium Clip Applier
Endo GIA 45 mm Curved Tip Articulating Vascular Stapler with Tri-Stapler Technology	Covidien (Dublin, Ireland)	EGIA45CTAVM	Laparoscopic Surgical Stapler
Endo GIA 60 mm Articulating Stapler with Tri-Stapler Technology	Covidien (Dublin, Ireland)	EGIA60AMT	Laparoscopic Surgical Stapler
Endo GIA 60 mm Curved Tip Articulating Vascular Stapler with Tri-Stapler Technology	Covidien (Dublin, Ireland)	EGIA60CTAVM	Laparoscopic Surgical Stapler
EndoCatch Gold 10 mm Specimen Pouch	Medtronic (Minneapolis, MN)	173050G	Specimen Extraction Bag
EndoCatch II 15 mm Specimen Pouch	Medtronic (Minneapolis, MN)	173049	Specimen Extraction Bag
Fenestrated bipolar forceps	Intuitive (Sunnyvale, CA)	470205	Surgical Robot Instrument
GelPOINT Mini Advanced Access Platform	Applied Medical (Rancho Santa Margarita, CA)	CNGL3	Laparoscopic Abdominal Access Platform
Large needle driver	Intuitive (Sunnyvale, CA)	470006	Surgical Robot Instrument
Large SutureCut needle driver	Intuitive (Sunnyvale, CA)	470296	Surgical Robot Instrument
LigaSure Blunt Tip Laparoscopic Sealer/Divider	Medtronic (Minneapolis, MN)	LF1844	Laparoscopic Bioplar Device
Mediflex liver retractor	Mediflex (Islandia NY)		Laparoscopic Liver Retractor
Monopolar curved scissors	Intuitive (Sunnyvale, CA)	470179	Surgical Robot Instrument
Permanent cautery hook	Intuitive (Sunnyvale, CA)	470183	Surgical Robot Instrument
ProGrasp forceps	Intuitive (Sunnyvale, CA)	470093	Surgical Robot Instrument