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Cancer Research

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer: Surgical Planning and Technique

Published: August 14th, 2021

DOI:

10.3791/62232

1Division of Surgical Oncology, Department of Surgery, West Virginia University, 2Department of Microbiology, Immunology and Cell Biology, West Virginia University

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), 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.

Pancreatic cancers involving the body and tail of the pancreas are traditionally surgically managed with a distal pancreatectomy and splenectomy. Approximately 30% of pancreatic cancers present in a locally advanced stage with involvement of structures beyond the pancreas1. A subset of these patients present with involvement of the celiac axis or proximal hepatic artery without involvement of the aorta. In this circumstance, an aggressive pre-operative strategy involving neo-adjuvant chemotherapy of FOLFIRINOX2,3 or Gemcitabine-Abraxane4 with potential neoad....

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All aspects of this protocol fall within our institutions ethical guidelines of the human research ethics committee

1. Pre-operative planning

  1. Evaluate the patient pre-operatively.
    NOTE: Patients present generally with vague abdominal complains and will be diagnosed primarily by imaging studies. This patient is a 65 year old Caucasian female presented with vague abdominal pain and underwent several CT imaging studies, eventually resulting in a diagnosis of pancreatic mass inv.......

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The duration of the procedure was 228 minutes with a blood loss of 50 mL. Post-treatment final pathology revealed a moderately differentiated (G2) ypT1c ductal adenocarcinoma. No nodal involvement was noted (0/21 total nodes). The circumferential resection margin was negative. The patient's post-operative course was uncomplicated. Her drain amylase levels post-operatively were in the normal range and the drain was removed on post-operative day 3. She was discharged home on post-operative day 4 tolerating a regular di.......

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With proper pre-operative planning, patient selection, and surgeon experience, it is clinically feasible and safe to approach locally advanced pancreatic tumors of the body/tail of the pancreas with celiac involvement with robot assisted distal pancreatectomy, splenectomy, and celiac axis resection. Proper patient selection requires comprehensive pre-operative planning with cross-sectional imaging to identify the tumor and its anatomical relationship to surrounding vascular structures. At this time, it is also imperative.......

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Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health under award number 5U54GM104942-04 (BAB).

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Name Company Catalog Number Comments
Da Vinci Robotic Platform XI Intuitive Surgical
Lightworks Video Editer Lightworks
Studio 3 Video logging platform Stryker

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