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.

All aspects of this protocol fall within our institutions ethical guidelines of the human research ethics committee
1. Pre-operative planning
<ol>
	<li>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 involving the body of the pancreas and abutting the common hepatic and splenic arteries (Figure 1).</li>
	<li>Preoperative Imaging and Biopsy
	<ol>
		<li>Proceed initially with cross-sectional imaging to diagnose the mass and identify anatomical relationships, arterial/venous involvement, and any aberrant arterial and venous anatomy. Once identified, proceed with biopsy for tissue diagnosis, if the mass is accessible. This patient&#39;s lesion was biopsied during EUS and confirmed as pancreatic ductal adenocarcinoma.</li>
		<li>Carefully note and consider any aberrant arterial anatomy or portosplenic confluence aberrancies and involvement of additional structure outside of the celiac axis prior to pursuing surgical resection.</li>
	</ol>
	</li>
	<li>Consider preoperative therapy. 
	NOTE: Many different preoperative treatment protocols are available for treatment of locally advanced pancreatic cancer. Patient tolerance and standards of practice at various institutions can guide therapy. In the case of our patient, she was initially started on FOLFIRINOX, but after significant intolerance requiring hospitalization, she was ultimately transitioned to gemcitabine/nab-paclitaxel and completed 6 months of treatment.</li>
	<li>Repeat imaging and serum studies.
	<ol>
		<li>Consider follow up imaging to evaluate treatment response prior to moving forward with resection. Serum studies, such as CA 19-9, will additionally help evaluate treatment response. In our patient, imaging demonstrated a promising treatment response as well as a 94% reduction in her serum CA 19-9 levels. However, she continued to have persistent soft tissue infiltration of her celiac axis on repeat imaging (Figure 2). As a result, she was scheduled for a robotic DP-CAR.</li>
	</ol>
	</li>
</ol>
2. Initial Operative Steps: Diagnostic Laparoscopy and Robot Docking
<ol>
	<li>Begin with a diagnostic laparoscopy to ensure no evidence of metastatic disease.</li>
	<li>Once no metastatic disease is confirmed, place the remainder of the ports and dock the robot from the right side of the operating table. 
	NOTE: Several variations of port placement have been successfully utilized. However, our approach utilizes 4 robotic ports across the upper abdomen, two assistant ports and a liver retractor. A skilled bedside assistant is critical to successful completion of the procedure, utilizing the two assistant ports for operating the bipolar vessel sealing device, suction, and endovascular stapler.</li>
</ol>
3. Robot-Assisted Dissection
<ol>
	<li>Open lesser sac and mobilize stomach along greater curve.
	<ol>
		<li>Following robot docking, proceed with opening the lesser sac with electrocautery and bipolar vessel sealer.</li>
		<li>Completely mobilize the greater curve of the stomach with care to avoid sacrificing the gastroepiploic vessels (Figure 3).</li>
		<li>Cauterize the short gastric arteries with vessel sealing device to the level of the diaphragm. Then retract the stomach and liver edge cephalad to allow for dissection of the porta hepatis.</li>
	</ol>
	</li>
	<li>Identify hepatic arterial anatomy and assess for adequate retrograde flow into proper hepatic artery and liver through the gastroduodenal artery.
	<ol>
		<li>After cephalad retraction of the stomach and liver, identify the porta hepatis. Dissect and isolate the hepatic artery node (Station 8a) for removal and permanent pathological evaluation.</li>
		<li>At this time, carefully dissect and identify the gastroduodenal artery (GDA). Evaluate for adequate retrograde flow through the GDA into the hepatic circulation with intra-operative Doppler ultrasound.</li>
		<li>Identify pulsatile flow in the liver and GDA before and after clamping of the common hepatic artery (Figure 4).</li>
	</ol>
	</li>
	<li>Dissect the inferior border of the pancreas and create a retropancreatic tunnel.
	<ol>
		<li>After identification of adequate retrograde flow through the GDA, dissect along the inferior border of the pancreas. Continue dissection with electrocautery and bipolar vessel sealer to identify the superior mesenteric vein.</li>
		<li>Create a retropancreatic tunnel over the vein with a sufficient margin from the tumor (Figure 5).</li>
	</ol>
	</li>
	<li>Divide the pancreas and continue the retropancreatic dissection to divide the splenic vein and coronary vein.
	<ol>
		<li>Divide the pancreas with an endovascular stapler. Mobilize the inferior and posterior border of the pancreas laterally with electrocautery and bipolar assisted dissection.</li>
		<li>Divide the splenic vein and coronary vein to assist in visualization of arterial anatomy and retraction. Additionally, the inferior mesenteric vein may be ligated if it inserts into the splenic vein.</li>
	</ol>
	</li>
	<li>Divide the hepatic artery and expose the superior mesenteric artery.
	<ol>
		<li>Turn attention back to the hepatic artery and continue dissection to fully delineate the anatomy if required. Divide the hepatic artery proximal the gastroduodenal artery (Figure 6).</li>
		<li>Once the hepatic artery is divided, retract the specimen laterally and continue to mobilize the pancreas to expose the superior mesenteric artery (SMA).</li>
	</ol>
	</li>
	<li>Identify and trace the superior mesenteric artery to its root on the aorta.
	<ol>
		<li>Once the SMA is identified, dissect cephalad along the superior border to trace it back to the origin on the aorta (Figure 7). Continue the dissection cephalad with electrocautery and bipolar cautery through dense connective tissue.</li>
	</ol>
	</li>
	<li>Dissect cephalad from the root of the SMA through dense connective tissue, nerve bundles, and lymphatic tissue until muscle fibers from the diaphgramatic crura are identified.
	<ol>
		<li>During this en bloc mobilization of the tissue overlying the superior mesenteric artery and celiac axis as well as the final lateral dissection, sample lymph node stations 14, 16 and 18.</li>
	</ol>
	</li>
	<li>Ligate the left gastric artery near its origin with an endovascular stapler to maximize collateral blood flow to the stomach.</li>
	<li>Expose and divide the celiac axis.
	<ol>
		<li>Continue retracting the sample to the patient&#39;s left and dissect through the crural muscle fibers until the origin of the celiac axis is visualized (Figure 8). It is of utmost importance to maintain sufficient lateral retraction on the specimen to rotate the celiac axis to the left of the patient. This will facilitate ligation of the celiac trunk by providing a favorable angle for the endovascular stapling device.</li>
	</ol>
	</li>
	<li>Continue retroperitoneal dissection laterally to fully mobilize pancreas and spleen and remove specimen.
	<ol>
		<li>Continue the retroperitoneal dissection laterally with a combination of hook and bipolar cautery. Remove the specimen through the left lower quadrant incision, which can be extended if necessary. A detailed view of the final resection bed vascular anatomy is available in the supplementary figures (Figure 9).</li>
		<li>Complete a final intra-operative ultrasound of the proper hepatic artery continues to demonstrate pulsatile, triphasic flow in the artery and parenchyma of the liver. Evaluate the stomach for external signs of ischemia.</li>
		<li>Once a final inspection is completed, undock the robot, and close the fascia and skin. The procedure is complete.</li>
	</ol>
	</li>
</ol>

<ol><li>American Cancer Society. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((American+Cancer+Society+%282016%29+Cancer+Facts+%26+Figures%5BTitle%5D)+AND+%22American+Cancer+Society%22%5BJournal%5D)">American Cancer Society (2016) Cancer Facts & Figures.</a> American Cancer Society. , (2016).</li>
<li>Suker, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((FOLFIRINOX+for+locally+advanced+pancreatic+cancer%3A+a+systematic+review+and+patient-level+meta-analysis%5BTitle%5D)+AND+%22Lancet+Oncology%22%5BJournal%5D)">FOLFIRINOX for locally advanced pancreatic cancer: a systematic review and patient-level meta-analysis.</a> Lancet Oncology. 17 (6), 801-810 (2016).</li>
<li>Faris, J. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((FOLFIRINOX+in+locally+advanced+pancreatic+cancer%3A+the+Massachusetts+General+Hospital+Cancer+Center+experience%5BTitle%5D)+AND+%22Oncologist%22%5BJournal%5D)">FOLFIRINOX in locally advanced pancreatic cancer: the Massachusetts General Hospital Cancer Center experience.</a> Oncologist. 18 (5), 543-548 (2013).</li>
<li>Ueno, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Randomized+phase+III+study+of+gemcitabine+plus+S-1%2C+S-1+alone%2C+or+gemcitabine+alone+in+patients+with+locally+advanced+and+metastatic+pancreatic+cancer+in+Japan+and+Taiwan%3A+GEST+study%5BTitle%5D)+AND+%22Journal+of+Clinical+Oncology%22%5BJournal%5D)">Randomized phase III study of gemcitabine plus S-1, S-1 alone, or gemcitabine alone in patients with locally advanced and metastatic pancreatic cancer in Japan and Taiwan: GEST study.</a> Journal of Clinical Oncology. 31 (13), 1640-1648 (2013).</li>
<li>Hirono, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Treatment+Strategy+for+Borderline+Resectable+Pancreatic+Cancer+With+Radiographic+Artery+Involvement%5BTitle%5D)+AND+%22Pancreas%22%5BJournal%5D)">Treatment Strategy for Borderline Resectable Pancreatic Cancer With Radiographic Artery Involvement.</a> Pancreas. 45 (10), 1438-1446 (2016).</li>
<li>Schmocker, R. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((An+Aggressive+Approach+to+Locally+Confined+Pancreatic+Cancer%3A+Defining+Surgical+and+Oncologic+Outcomes+Unique+to+Pancreatectomy+with+Celiac+Axis+Resection+%28DP-CAR%29%5BTitle%5D)+AND+%22Annals+of+Surgical+Oncology%22%5BJournal%5D)">An Aggressive Approach to Locally Confined Pancreatic Cancer: Defining Surgical and Oncologic Outcomes Unique to Pancreatectomy with Celiac Axis Resection (DP-CAR).</a> Annals of Surgical Oncology. , (2020).</li>
<li>Klompmaker, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((E-AHPBA+DP-CAR+study+group.+Outcomes+and+Risk+Score+for+Distal+Pancreatectomy+with+Celiac+Axis+Resection+%28DP-CAR%29%2C+An+International+Multicenter+Analysis%5BTitle%5D)+AND+%22Annals+of+Surgical+Oncology%22%5BJournal%5D)">E-AHPBA DP-CAR study group. Outcomes and Risk Score for Distal Pancreatectomy with Celiac Axis Resection (DP-CAR), An International Multicenter Analysis.</a> Annals of Surgical Oncology. 26 (3), 772-781 (2019).</li>
<li>Ocuin, L. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Robotic+and+open+distal+pancreatectomy+with+celiac+axis+resection+for+locally+advanced+pancreatic+body+tumors%3A+a+single+institutional+assessment+of+perioperative+outcomes+and+survival%5BTitle%5D)+AND+%22HPB%22%5BJournal%5D)">Robotic and open distal pancreatectomy with celiac axis resection for locally advanced pancreatic body tumors: a single institutional assessment of perioperative outcomes and survival.</a> HPB. 18 (10), Oxford. 835-842 (2016).</li>
<li>Caba Molina, D., Lambreton, F., Arrangoiz Majul, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Trends+in+Robotic+Pancreaticoduodenectomy+and+Distal+Pancreatectomy%5BTitle%5D)+AND+%22Journal+of+Laparoendoscopic+%26+Advanced+Surgical+Techniques+A%22%5BJournal%5D)">Trends in Robotic Pancreaticoduodenectomy and Distal Pancreatectomy.</a> Journal of Laparoendoscopic & Advanced Surgical Techniques A. 29 (2), 147-151 (2019).</li>
<li>Kornaropoulos, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Total+robotic+pancreaticoduodenectomy%3A+a+systematic+review+of+the+literature%5BTitle%5D)+AND+%22Surgical+Endoscopy%22%5BJournal%5D)">Total robotic pancreaticoduodenectomy: a systematic review of the literature.</a> Surgical Endoscopy. 31 (11), 4382-4392 (2017).</li>
<li>Peng, L., Lin, S., Li, Y., Xiao, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Systematic+review+and+meta-analysis+of+robotic+versus+open+pancreaticoduodenectomy%5BTitle%5D)+AND+%22Surgical+Endoscopy%22%5BJournal%5D)">Systematic review and meta-analysis of robotic versus open pancreaticoduodenectomy.</a> Surgical Endoscopy. 31 (8), 3085-3097 (2017).</li>
<li>Zureikat, A. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+Multi-institutional+Comparison+of+Perioperative+Outcomes+of+Robotic+and+Open+Pancreaticoduodenectomy%5BTitle%5D)+AND+%22Annals+of+Surgery%22%5BJournal%5D)">A Multi-institutional Comparison of Perioperative Outcomes of Robotic and Open Pancreaticoduodenectomy.</a> Annals of Surgery. 264 (4), 640-649 (2016).</li>
<li>Zureikat, A. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((500+Minimally+Invasive+Robotic+Pancreatoduodenectomies%3A+One+Decade+of+Optimizing+Performance%5BTitle%5D)+AND+%22Annals+of+Surgery%22%5BJournal%5D)">500 Minimally Invasive Robotic Pancreatoduodenectomies: One Decade of Optimizing Performance.</a> Annals of Surgery. 273 (5), 966-972 (2021).</li>
<li>Cai, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Robotic+Pancreaticoduodenectomy+Is+Associated+with+Decreased+Clinically+Relevant+Pancreatic+Fistulas%3A+a+Propensity-Matched+Analysis%5BTitle%5D)+AND+%22Journal+of+Gastrointestinal+Surgery%22%5BJournal%5D)">Robotic Pancreaticoduodenectomy Is Associated with Decreased Clinically Relevant Pancreatic Fistulas: a Propensity-Matched Analysis.</a> Journal of Gastrointestinal Surgery. 24 (5), 1111-1118 (2020).</li>
<li>Strasberg, S. M., Linehan, D. C., Hawkins, W. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Radical+antegrade+modular+pancreatosplenectomy+procedure+for+adenocarcinoma+of+the+body+and+tail+of+the+pancreas%3A+ability+to+obtain+negative+tangential+margins%5BTitle%5D)+AND+%22Journal+of+the+American+College+of+Surgeons%22%5BJournal%5D)">Radical antegrade modular pancreatosplenectomy procedure for adenocarcinoma of the body and tail of the pancreas: ability to obtain negative tangential margins.</a> Journal of the American College of Surgeons. 204 (2), 244-249 (2007).</li>
<li>Chun, Y. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Role+of+Radical+Antegrade+Modular+Pancreatosplenectomy+%28RAMPS%29+and+Pancreatic+Cancer%5BTitle%5D)+AND+%22Annals+of+Surgical+Oncology%22%5BJournal%5D)">Role of Radical Antegrade Modular Pancreatosplenectomy (RAMPS) and Pancreatic Cancer.</a> Annals of Surgical Oncology. 25 (1), 46-50 (2018).</li>
</ol>

No financial conflicts of interest to disclose on the part of any of the authors involved.

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 to identify any anomalous arterial or venous circulation that would imperil the attempted resection or make it infeasible.
Intra-operative findings may also shift our treatment approach in real time. Findings suggesting the continued involvement of the celiac root at the time of surgery would make resection infeasible. Therefore, high quality post-treatment imaging prior to surgery is also critically important to evaluate the degree of treatment response. Additionally, findings on inadequate retrograde arterial flow through the gastroduodenal artery to the proper hepatic artery or liver may require an arterial reconstruction, and pre-operative preparedness for this reconstruction is imperative. After resection, gastric ischemia or congestion due to division of major vascular structures is a potential and morbid sequela. However, despite division of the short gastric vessels and left gastric artery, the gastroepiploic circulation remains unviolated in the course of this dissection. These vessels are often adequate to ensure adequate perfusion of the stomach and therefore gastrectomy can be avoided. However, the stomach must be observed closely for ischemic changes prior to conclusion of this procedure.
The traditional operative approach to management of tumors involving the body and tail of the pancreas is a distal pancreatectomy. However, more recently, radical antegrade pancreaticosplenectomy (RAMPS) has been proposed as an alternative procedure that is increasingly utilized and has been suggested to offer an increased rate of negative tangential margins15. Despite these promising results, no large prospective studies yet exist that show a demonstrable improvement in overall survival or recurrence free survival when compared with traditional distal pancreatectomy. Additional prospective studies are needed to establish clear clinical guidelines for routine use of RAMPS during distal pancreactomy16.
The robot platform has seen ever increasing use in a variety of complex pancreatic resections. This protocol and video highlights one potential operative approach utilizing this platform for approaching a clinically challenging disease process.

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&#160;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 neoadjuvant radiation prior to surgical resection with a modified version of the original Appleby procedure is considered5. The procedure involves resecting the celiac axis at its origin and relying on collateral flow to hepatic artery proper through the GDA. While this aggressive approach for locally advanced pancreatic cancer is performed only in highly selected patients, there is suggestion of potential oncologic benefit in retrospective series6,7,8.
The robotic surgical platform offers numerous technical advantages compared with open and laparoscopic techniques, including enhanced three-dimensional visualization, instrument wrist articulation and the ability for the operating surgeon to control multiple instruments and the camera. Additionally, limited retrospective case series of patients undergoing robotic pancreatic surgery have suggested decreased intra-operative blood loss, decreased peri-operative pain, lower pancreatic fistula rates and improved recovery when compared with open pancreatic resections9,10,11,12,13,14. These technical and clinical benefits along with increased robotic training have led to an expansion of the robotic approach in pancreatic surgery, demonstrating the versatility of the platform to perform a variety of pancreatic resections and procedures, including pancreaticoduodenectomy and distal pancreatectomy with and without splenic preservation. Herein, we will&#160;provide the pre-surgical and surgical evaluation and decision making that is involved in proper selection of patients as well as detail the patient characteristics, pre-operative management, and a detailed review of the surgical technique of the DP-CAR performed with the robotic platform on a singular patient in our practice.

<table><tbody><tr><td>Da Vinci Robotic Platform XI</td><td>Intuitive Surgical</td><td></td><td></td></tr><tr><td>Lightworks Video Editer</td><td>Lightworks</td><td></td><td></td></tr><tr><td>Studio 3 Video logging platform</td><td>Stryker</td><td></td><td></td></tr></tbody></table>

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.

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&#39;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 diet. Her follow appointments in clinic demonstrated that her recovery was progressing well.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/62232/62232fig01.jpg" /> 
Figure 1: Pre-treatment CT imaging demonstrating locally advanced body of pancreas mass involving celiac axis and splenic vein. <a href="https://www.jove.com/files/ftp_upload/62232/62232fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/62232/62232fig02.jpg" /> 
Figure 2: Post-treatment CT imaging demonstrating locally advanced body of pancreas mass involving celiac axis and splenic vein with persistent soft tissue infiltration surrounding celiac cells. <a href="https://www.jove.com/files/ftp_upload/62232/62232fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/62232/62232fig03.jpg" /> 
Figure 3: Opening of lesser sac and mobilization of greater curve. Short gastric vessels are ligated with care taken to preserve gastroepiploic vessels. <a href="https://www.jove.com/files/ftp_upload/62232/62232fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/62232/62232fig04.jpg" /> 
Figure 4: Dissection of porta hepatis with identification of common and proper hepatic artery and gastroduodenal artery with triphasic ultrasound signal. <a href="https://www.jove.com/files/ftp_upload/62232/62232fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/62232/62232fig05.jpg" /> 
Figure 5: Dissection of inferior border of pancreas with identification of superior mesenteric vein and creation of retropancreatic tunnel overlying vein. <a href="https://www.jove.com/files/ftp_upload/62232/62232fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/62232/62232fig06.jpg" /> 
Figure 6: Final identification of arterial Following division landmarks and adequate flow prior to ligation of common hepatic artery. <a href="https://www.jove.com/files/ftp_upload/62232/62232fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 7" class="xfigimg" src="/files/ftp_upload/62232/62232fig07.jpg" /> 
Figure 7: Following division of pancreas, the superior mesenteric artery is exposed and dissection proceeds cephalad to its root on the aorta. <a href="https://www.jove.com/files/ftp_upload/62232/62232fig07large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 8" class="xfigimg" src="/files/ftp_upload/62232/62232fig08.jpg" /> 
Figure 8: Celiac axis origin exposed and oriented to patient left by laterally retracting the specimen prior to division. <a href="https://www.jove.com/files/ftp_upload/62232/62232fig08large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 9" class="xfigimg" src="/files/ftp_upload/62232/62232fig09.jpg" /> 
Figure 9: Final resection bed anatomy highlight. <a href="https://www.jove.com/files/ftp_upload/62232/62232fig09large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Watch this Scientific Journal Video about Robot Assisted Distal Pancreatectomy with Celiac Axis Resection DP-CAR for Pancreatic Cancer: Surgical Planning and Technique at JoVE.com

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.

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), ...

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6.2K Views.  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.

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

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 ...

Application of End-to-end Anastomosis in Robotic Central Pancreatectomy

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of pancreatic body. With technological development, the robotic surgical system has shown its advantage in minimally invasive surgery and been increasingly applied in central pancreatectomy. However, reconstruction of the continuity of pancreas with end-to-end anastomosis after robotic central pancreatectomy has not been applied. In this study, we report surgical techniques for robotic central pancreatectomy with end-to-end anastomosis. The pancreas is reconstructed by duct-to-duct anastomosis of the pancreatic duct with a pancreatic stent inserted in the two stumps of pancreatic duct, and by end-to-end anastomosis of the pancreatic parenchyma. Compared with traditional central pancreatectomy with pancreaticoenteric anastomosis, this approach decreases the operative injury to the patient, and also conserves the integrity and continuity of the digestive duct and pancreatic duct. The robotic surgical system integrated with multiple instruments with flexible and precise movement is particularly suitable for the dissection and reconstruction of the pancreatic duct. We found that robotic central pancreatectomy with end-to-end anastomosis is safe and feasible, and we need more experience to evaluate its best indications and long-term outcomes.

The robotic central pancreatectomy with end-to-end anastomosis is feasible and safe for tumor in the pancreatic neck and proximal portion of pancreatic body. The operative techniques of this operation are presented.

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of ...

Medicine

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 ...

Robotic Enucleation of an Intra-Pancreatic Insulinoma in the Pancreatic Head

Pancreatic parenchyma sparing surgery for insulinomas avoids the risk of endocrine and exocrine insufficiency, and potential high-risk anastomoses associated with pancreatic resection. Robotic surgery may be used as an alternative for open pancreatic enucleation without compromising dexterity and 3D-vision.
We present the case of a 42-year old woman who presented with sweating, tremor and episodes of hypoglycemia. A fasting test confirmed endogenic insulin overproduction. After inconclusive CT- and MRI imaging, endoscopic ultrasonography showed a hypoechoic lesion, which was fully within the pancreatic head. Although consent was obtained for pancreatoduodenectomy, robotic enucleation seemed feasible. After mobilization, intraoperative ultrasonography was used to identify the lesion and its relation with the pancreatic duct. Dissection was performed using a traction suture, hot shears and bipolar diathermia. A sealant patch was applied for hemostasis and a drain placed. The patient developed a grade B pancreatic fistula for which endoscopic sphincterotomy was performed; the surgical drain could be removed in the outpatient clinic after 20 days. Prospective studies should confirm the short- and long-term benefits of robotic enucleation of insulinomas.

Here, we present a robotic approach to enucleate an insulinoma in the pancreatic head.

Pancreatic parenchyma sparing surgery for insulinomas avoids the risk of endocrine and exocrine insufficiency, and potential high-risk anastomoses ...

Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological resection of left-sided pancreatic cancer. Several surgical techniques have been described in recent years, but few were specifically designed for minimally invasive approaches. This study describes and demonstrates a standardized and reproducible technique for an adequate oncological resection of pancreatic cancer: laparoscopic radical left pancreatectomy (LRLP).
A 61-year-old woman presented with an incidental finding of a 3 cm mass in the left pancreas suspect for malignancy. Imaging did not reveal distant metastases, central vascular involvement, or morbid obesity, hence the patient was suitable for LRLP. This study describes the main steps of LRLP for pancreatic cancer. First, the lesser sac is opened by transecting the gastrocolic ligament. The splenic flexure of the colon is mobilized and the inferior border of the pancreas including Gerota&#39;s fascia is dissected down to the inferior border of the spleen. The pancreas is tunneled and hung, including Gerota&#8217;s fascia with a vessel loop. At the pancreatic neck, a tunnel is created between the pancreas and the portal vein, likewise a vessel loop is passed. The pancreas is then transected using the graded compression technique with an endostapler. Both the splenic vein and artery are transected before completing the resection. The entire specimen is extracted in a retrieval bag via a small Pfannenstiel incision.
Duration of the surgery was 210 min with 250 mL blood loss. Pathology revealed a R0-resection (&#62;1 mm) of a well-to-moderately differentiated adenocarcinoma originating from an intraductal papillary mucinous neoplasm. A total of 15 tumor-negative lymph nodes were resected. This is a detailed description of LRLP for left-sided pancreatic cancer as is currently being used within the international, multicenter randomized DIPLOMA (Distal Pancreatectomy Minimally Invasive or Open for PDAC) trial.

Oncologically safe left pancreatectomy requires radical resection (R0), Gerota&#8217;s (perirenal) fascia resection, and adequate lymph node dissection. This study describes the technical details of laparoscopic radical left pancreatectomy (LRLP), used in the first international multicenter randomized trial comparing minimally invasive with open left pancreatectomy for pancreatic cancer, the DIPLOMA trial.

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological ...

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 ...

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic resection and reconstruction techniques, it is difficult to perform LPD for patients with locally advanced pancreatic head cancer after neoadjuvant therapy. Our team initiates LPD using the in-situ No-Touch isolation technique. The innovation and optimization of this modified No-Touch isolation technique emphasize exploring the distal section of superior mesenteric vein&#160;(SMV) and the left side of the superior mesenteric artery (SMA) prior to evaluating the resectability by subcolonic mesenteric approach, which is an ideal exploring approach. After that, we use the median-anterior, and left-posterior of SMA approaches to cut off the blood flow of the pancreatic head to make the tumor isolated intact, then move and dissect the tumor. It is a process fitting the surgical principle of tumor-free. This article aims to demonstrate the feasibility and safety of performing LPD using the in-situ No-Touch isolation technique, which might elevate the R0 resection rate. It is an oncological ideal operation process.

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

No-Touch isolation procedures might prevent the dissemination of cancer cells from the primary tumor. However, these techniques are not widely accepted in laparoscopic pancreatoduodenectomy (LPD) by now. We herein present in-situ No-Touch isolation LPD with partial resection and reconstruction of the superior mesenteric vein (SMV) for pancreatic cancer after neoadjuvant therapy.

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic ...

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who have had neoadjuvant chemotherapy. Here, we present a technique to perform laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) using the dorsal-caudal artery approach by making full use of the high-definition vision and operation modes of the laparoscope.
The innovation and optimization of this operation are provided in the protocol. Priority should be given to the dorsal resection plane, including the dorsal side of the superior mesenteric artery (SMA), the dorsal side of the pancreatic head, the root of the celiac artery (CeA), the ventral side of the left renal vessels, and the renal hilum. On the condition that the operation for pancreatic neck-body cancer is feasible and safe, the second step is to perform tumor resection en bloc surrounding the SMA and CeA from the caudal to the cephalic side to increase the rate of R0 (radical zero) resection and further prognosis.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

With advancements in laparoscopic techniques, laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has been widely recognized. However, owing to several technical difficulties in this procedure, the artery-first approach in L-RAMPS still remains uncommon. Here, we developed the dorsal-caudal artery approach for L-RAMPS, which might be safe and beneficial for pancreatic neck tumors.

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who ...

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.

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

Summary

Explore More Videos

Robotic Pancreatoduodenectomy for Pancreatic Head Cancer: a Case Report of a Standardized Technique

Application of End-to-end Anastomosis in Robotic Central Pancreatectomy

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Robotic Enucleation of an Intra-Pancreatic Insulinoma in the Pancreatic Head

Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction

Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

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