Name: robot assisted distal pancreatectomy with celiac axis resection (dp-car) for pancreatic cancer: surgical planning and technique
Uploaded: 2021-08-14T14:00:00
Description: 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

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 inv...

<ol>
	<li>American Cancer Society. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=American+Cancer+Society+(2016)+Cancer+Facts+&amp;+Figures.">American Cancer Society (2016) Cancer Facts &amp; Figures.</a> American Cancer Society. , (2016).</li><li>Suker, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=FOLFIRINOX+for+locally+advanced+pancreatic+cancer:+a+systematic+review+and+patient-level+meta-analysis.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=FOLFIRINOX+in+locally+advanced+pancreatic+cancer:+the+Massachusetts+General+Hospital+Cancer+Center+experience.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=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.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+Strategy+for+Borderline+Resectable+Pancreatic+Cancer+With+Radiographic+Artery+Involvement.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+Aggressive+Approach+to+Locally+Confined+Pancreatic+Cancer:+Defining+Surgical+and+Oncologic+Outcomes+Unique+to+Pancreatectomy+with+Celiac+Axis+Resection+(DP-CAR).">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=E-AHPBA+DP-CAR+study+group.+Outcomes+and+Risk+Score+for+Distal+Pancreatectomy+with+Celiac+Axis+Resection+(DP-CAR),+An+International+Multicenter+Analysis.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+and+open+distal+pancreatectomy+with+celiac+axis+resection+for+locally+advanced+pancreatic+body+tumors:+a+single+institutional+assessment+of+perioperative+outcomes+and+survival.">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), 835-842 (2016).</li><li>Caba Molina, D., Lambreton, F., Arrangoiz Majul, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Trends+in+Robotic+Pancreaticoduodenectomy+and+Distal+Pancreatectomy.">Trends in Robotic Pancreaticoduodenectomy and Distal Pancreatectomy.</a> Journal of Laparoendoscopic &amp; 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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Total+robotic+pancreaticoduodenectomy:+a+systematic+review+of+the+literature.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Systematic+review+and+meta-analysis+of+robotic+versus+open+pancreaticoduodenectomy.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+Multi-institutional+Comparison+of+Perioperative+Outcomes+of+Robotic+and+Open+Pancreaticoduodenectomy.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=500+Minimally+Invasive+Robotic+Pancreatoduodenectomies:+One+Decade+of+Optimizing+Performance.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+Pancreaticoduodenectomy+Is+Associated+with+Decreased+Clinically+Relevant+Pancreatic+Fistulas:+a+Propensity-Matched+Analysis.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Radical+antegrade+modular+pancreatosplenectomy+procedure+for+adenocarcinoma+of+the+body+and+tail+of+the+pancreas:+ability+to+obtain+negative+tangential+margins.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Role+of+Radical+Antegrade+Modular+Pancreatosplenectomy+(RAMPS)+and+Pancreatic+Cancer.">Role of Radical Antegrade Modular Pancreatosplenectomy (RAMPS) and Pancreatic Cancer.</a> Annals of Surgical Oncology. 25 (1), 46-50 (2018).</li></ol>

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...

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 border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<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 di...

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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