We would like to acknowledge Melissa Hogg, Herbert Zeh III, Amer Zureikat, and Safi Dokmak for training and advice regarding robotic pancreatic surgery and central pancreatectomy. This clinical research was enabled by HPB-Amsterdam.

The present protocol follows the ethics guidelines of the Amsterdam UMC. Informed consent was obtained from the patient for this article and the video.
1. Preoperative management
<ol>
	<li>Perform preoperative imaging to assess the extent of the pancreatic lesion and for indications of vascular involvement.</li>
	<li>Evaluate the eligibility for the surgical approach and relative contraindications.</li>
</ol>
2. Operative setting
<ol>
	<li>Place the patient in French position with the right arm lowered on an arm board alongside the patient and the left arm in a 90&#176; abduction. Tilt the table 20-30&#176; to the left and in 20-30&#176; reverse Trendelenburg position.</li>
	<li>Perform the required safety check procedures and create a sterile exposition with chlorohexidine.</li>
	<li>Create a pneumoperitoneum by inserting a Veress needle at Palmer&#39;s point, then insufflating to 10-12 mm CO2.</li>
	<li>After insufflation, mark the positions of the trocars and place them as shown in Figure 1 and Figure 2 (4 robot trocars, 2 (12 mm) laparoscopic tableside surgeon trocars, 1 (5 mm) trocar for snake liver retractor).</li>
	<li>After insufflation, place a 12 mm tableside surgeon trocar (preferably, one with a blunt clear dome at the distal end, which encloses a crescent-shaped knife blade) to the right of the umbilicus.</li>
	<li>After inspection and removal of the Veress needle, place the four 8 mm robotic trocars 11-12 cm from the pancreatic body (i.e., target area). Place the trocar at the patient&#39;s right side for robot arm 1, more cranial than the others as it is used for contraction.</li>
	<li>Place a second 12 mm table-side surgeon trocar. 
	NOTE: Make sure the distance between all the trocars is approximately 7 cm.</li>
	<li>Finally, place a 5 mm trocar in the left upper quadrant to hold the laparoscopic stomach/liver retractor.</li>
	<li>Install the robot at the right side of the patient and dock the robot arms to the robotic trocars. 
	NOTE: The final operative setting is shown in Figure 3. Robotic arm 1 holds a cadiere forceps, arm 2 a bipolar forceps, arm 3 the camera and arm 4 a cautery hook. The tableside surgeon is positioned between the patient&#39;s legs.</li>
</ol>
3. Pancreatic identification and mobilization
<ol>
	<li>Open the lesser sac by transecting the gastrocolic ligament approximately 2 cm distal from the gastroepiploic vessels with the sealing device, controlled by the tableside surgeon.</li>
	<li>After this, install the liver retractor (5 mm trocar) in the left upper quadrant just subcostally to retract the stomach and the left side of the liver.</li>
	<li>Perform an intraoperative ultrasound using a robotic ultrasound probe to identify and locate the tumor and mark the future resection margins with the robotic cautery hook.</li>
	<li>Mobilize the pancreas first caudally and then cranially using the robotic cautery hook on arm 4 and the laparoscopic sealing device.</li>
	<li>First, place a 1/3 length vessel loop at the left side of the tumor between the pancreas and the splenic vein.</li>
	<li>Then, further mobilize the pancreas at the proximal side.</li>
	<li>Place another 1/3 length vessel loop between the pancreas and the portomesenteric vein. 
	&#8203;NOTE: Fix the vessel loops using clips.</li>
	<li>Use the robot arm 1 to lift the vessel loops cranially to create a clear window and to further complete the mobilization of the pancreatic body between the pancreas and the portomesenteric vein.</li>
</ol>
4. Pancreatic transection
<ol>
	<li>First, transect the pancreas at the right side of the tumor, typically ventral from the superior mesenteric vein with an endo-stapler with a vascular cartridge. 
	NOTE: Closing of the stapler using the grade compression approach as described by Asbun15, may take up to 4-5 min.</li>
	<li>Then take care of venous mobilization.</li>
	<li>After venous mobilization, transect the pancreas at the left side of the tumor using robotic scissors with diathermia. The pancreatic duct is cut without diathermia, i.e., cold cut at the site of the pancreatic duct.</li>
	<li>Insert a 4.8 French stent to identify the pancreatic duct after the resection.</li>
</ol>
5. Window in the mesocolon
<ol>
	<li>Create a window in the avascular part of the transverse mesocolon at the (patient&#39;s) left side of the colonic vessels using the cautery hook with the mesocolon in the caudal position. 
	NOTE: Usually, this location can be identified by locating the proximal jejunum, which is visible through the mesocolon.</li>
	<li>Hereafter, place and hold the mesocolon in the cranial position held with arm 1. Identify the window by lifting the transverse colon cranially. Identify the ligament of Treitz.</li>
</ol>
6. Creating Roux-limb
<ol>
	<li>Create a small opening in the proximal jejunum approximately 20 cm distally from the ligament of Treitz to divide the proximal jejunum with an endo-stapler with a vascular cartridge.</li>
	<li>Divide the mesentery at the jejunal transection site using the sealing device.</li>
</ol>
7. Positioning Roux-limb
<ol>
	<li>While lifting the transverse colon cranially using robotic arm 1, pass the Roux limb cranially through the window in the mesocolon.</li>
	<li>Place the transverse colon back in the caudal position.</li>
	<li>Fixate the end of the Roux limb together with the end of a 50 cm suture using robot arm 1. Use robot arms 2 and 4 to measure a 50 cm distance to the future S-S jejuno-jejunostomy.</li>
	<li>Mark this location with a metal clip on the mesentery and lift the transverse colon cranially again.</li>
</ol>
8. Jejuno-jejunostomy
<ol>
	<li>Place a polyglactin 4-0 8 cm stay suture through the small bowel at the location of the metal clip and the transected proximal jejunum to facilitate the anastomosis. Use arm 1 to retract this stay suture cranially to a location ventrally of the colon to facilitate stapling.</li>
	<li>Create two small enterotomies using robotic scissors with diathermia.</li>
	<li>Then, make a side-to-side jejuno-jejunostomy using an endo-stapler with a vascular cartridge.</li>
	<li>Close the remaining opening of the anastomosis with a 3-0 15 cm barbed suture.</li>
</ol>
9. Pancreaticojejunostomy
<ol>
	<li>Position the Roux limb for the end-to-side pancreaticojejunostomy. Place a polyglactin 4-0 8 cm suture to close the window in the transverse mesocolon and to fixate the jejunal mesentery.</li>
	<li>Perform the end-to-side pancreaticojejunostomy using a modified Blumgart technique, which is currently highly standardized by the Pittsburgh group and also used in robotic pancreatoduodenectomy16.</li>
	<li>Mattress
	<ol>
		<li>Start the anastomosis with three transpancreatic silk 2&#173;-0 20 cm mattress sutures. Drive the first suture at the cranial side of the pancreas through the pancreas and jejunum from a cranial to a caudal position. Drive the suture backward, similar to the anterior side of the pancreas and retract both ends with robot arm 1.</li>
		<li>Repeat this step for the remaining two transpancreatic mattress sutures centrally and caudally in the pancreas. 
		NOTE: Avoid suturing the pancreatic duct by placing a stent in the pancreatic duct.</li>
		<li>Tie the three sutures without removing the needles and remove the stent afterward.</li>
	</ol>
	</li>
	<li>Duct-to-mucosa
	<ol>
		<li>Create a small enterotomy in the Roux limb with the robotic scissors in preparation for the future duct-to-mucosa sutures.</li>
		<li>Suture the posterior duct-to-mucosa with 4-5 PDS 5-0 8 cm sutures in a clockwise manner.</li>
		<li>Replace the 4.8 French 6 cm single loop stent in the pancreatic duct and Roux limb to avoid suturing the pancreatic duct when suturing the anterior duct-to-mucosa side.</li>
		<li>Suture the anterior side with 4-5 PDS 5-0 8 cm sutures.</li>
		<li>Tie the sutures after performing the last suture for optimal exposure. 
		NOTE: Through the whole duct-to-mucosa procedure arm 2 and arm 4 are equipped with needle drivers and arm 1 is used to retract the sutures cranially and ventrally, thus releasing tension.</li>
	</ol>
	</li>
	<li>Buttress
	<ol>
		<li>Reuse the three transpancreatic silk sutures from the mattress procedure to perform the anterior buttress layer of the pancreaticojejunostomy.</li>
		<li>For all the three sutures, drive the needle through the jejunum and tie these with the remaining end of its suture to complete the anastomosis.</li>
	</ol>
	</li>
</ol>
10. Drain placement
<ol>
	<li>After finishing the pancreaticojejunostomy, introduce a drain through trocar arm 1 to a position cranial of the pancreaticojejunostomy.</li>
</ol>
11. Postoperative management
<ol>
	<li>Remove the nasogastric tube. Start a soft liquid diet and expand to a normal diet in 72 h.</li>
	<li>Assess serum CRP on postoperative day 3, day 4, and day 5. Perform a CT or MRI of the abdomen if CRP on day four is elevated compared to day three.</li>
	<li>Assess drain amylase on postoperative day 3. Remove the drain when drain amylase levels are less than 3 times the upper limit of normal serum amylase.</li>
</ol>

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<li>Xiao, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+role+of+central+pancreatectomy+in+pancreatic+surgery%3A+a+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22HPB%22%5BJournal%5D)">The role of central pancreatectomy in pancreatic surgery: a systematic review and meta-analysis.</a> HPB. 20 (10), Oxford. 896-904 (2018).</li>
<li>Regmi, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Overall+postoperative+morbidity+and+pancreatic+fistula+are+relatively+higher+after+central+pancreatectomy+than+distal+pancreatic+resection%3A+A+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22Biomed+Res+Int%22%5BJournal%5D)">Overall postoperative morbidity and pancreatic fistula are relatively higher after central pancreatectomy than distal pancreatic resection: A systematic review and meta-analysis.</a> Biomed Res Int. 2020, 7038907(2020).</li>
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<li>Zhou, Y. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pancreatic+fistula+after+central+pancreatectomy%3A+case+series+and+review+of+the+literature%5BTitle%5D)+AND+%22Hepatobiliary+and+Pancreatic+Disease+International%22%5BJournal%5D)">Pancreatic fistula after central pancreatectomy: case series and review of the literature.</a> Hepatobiliary and Pancreatic Disease International. 13 (2), 203-208 (2014).</li>
<li>Goldstein, M. J., Toman, J., Chabot, J. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pancreaticogastrostomy%3A+a+novel+application+after+central+pancreatectomy%5BTitle%5D)+AND+%22Journal+of+the+American+College+of+Surgeons%22%5BJournal%5D)">Pancreaticogastrostomy: a novel application after central pancreatectomy.</a> Journal of the American College of Surgeons. 198 (6), 871-876 (2004).</li>
<li>Sudo, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Middle+pancreatectomy+with+pancreaticogastrostomy%3A+A+technique%2C+operative+outcomes%2C+and+long-term+pancreatic+function%5BTitle%5D)+AND+%22Journal+of+Surgical+Oncology%22%5BJournal%5D)">Middle pancreatectomy with pancreaticogastrostomy: A technique, operative outcomes, and long-term pancreatic function.</a> Journal of Surgical Oncology. 101 (1), 61-65 (2010).</li>
<li>Borel, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pancreatico-jejunostomy+decreases+post-operative+pancreatic+fistula+incidence+and+severity+after+central+pancreatectomy%5BTitle%5D)+AND+%22ANZ+Journal+of+Surgery%22%5BJournal%5D)">Pancreatico-jejunostomy decreases post-operative pancreatic fistula incidence and severity after central pancreatectomy.</a> ANZ Journal of Surgery. 88 (1-2), 77-81 (2018).</li>
<li>Qin, H., Luo, L., Zhu, Z., Huang, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pancreaticogastrostomy+has+advantages+over+pancreaticojejunostomy+on+pancreatic+fistula+after+pancreaticoduodenectomy.+A+meta-analysis+of+randomized+controlled+trials%5BTitle%5D)+AND+%22International+Journal+of+Surgery%22%5BJournal%5D)">Pancreaticogastrostomy has advantages over pancreaticojejunostomy on pancreatic fistula after pancreaticoduodenectomy. A meta-analysis of randomized controlled trials.</a> International Journal of Surgery. 36, Pt A 18-24 (2016).</li>
<li>Crippa, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pancreaticojejunostomy+is+comparable+to+pancreaticogastrostomy+after+pancreaticoduodenectomy%3A+an+updated+meta-analysis+of+randomized+controlled+trials%5BTitle%5D)+AND+%22Langenbecks+Archives+of+Surgery%22%5BJournal%5D)">Pancreaticojejunostomy is comparable to pancreaticogastrostomy after pancreaticoduodenectomy: an updated meta-analysis of randomized controlled trials.</a> Langenbecks Archives of Surgery. 401 (4), 427-437 (2016).</li>
<li>Benini, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Residual+pancreatic+function+after+pancreaticoduodenectomy+is+better+preserved+with+pancreaticojejunostomy+than+pancreaticogastrostomy%3A+A+long-term+analysis%5BTitle%5D)+AND+%22Pancreatology%22%5BJournal%5D)">Residual pancreatic function after pancreaticoduodenectomy is better preserved with pancreaticojejunostomy than pancreaticogastrostomy: A long-term analysis.</a> Pancreatology. 19 (4), 595-601 (2019).</li>
<li>Knab, L. M., Zureikat, A. H., Zeh, H. J., Hogg, M. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Towards+standardized+robotic+surgery+in+gastrointestinal+oncology%5BTitle%5D)+AND+%22Langenbecks+Archives+of+Surgery%22%5BJournal%5D)">Towards standardized robotic surgery in gastrointestinal oncology.</a> Langenbecks Archives of Surgery. 402 (7), 1003-1014 (2017).</li>
<li>Zwart, M. J. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Outcomes+of+a+multicenter+training+program+in+robotic+pancreatoduodenectomy+%28LAELAPS-3%29%5BTitle%5D)+AND+%22Annals+of+Surgery%22%5BJournal%5D)">Outcomes of a multicenter training program in robotic pancreatoduodenectomy (LAELAPS-3).</a> Annals of Surgery. , (2021).</li>
<li>Jones, L. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Robotic+pancreatoduodenectomy%3A+patient+selection%2C+volume+criteria%2C+and+training+programs%5BTitle%5D)+AND+%22Scandinavian+Journal+of+Surgery%22%5BJournal%5D)">Robotic pancreatoduodenectomy: patient selection, volume criteria, and training programs.</a> Scandinavian Journal of Surgery. 109 (1), 29-33 (2020).</li>
<li>Asbun, H. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Technique+and+audited+outcomes+of+laparoscopic+distal+pancreatectomy+combining+the+clockwise+approach%2C+progressive+stepwise+compression+technique%2C+and+staple+line+reinforcement%5BTitle%5D)+AND+%22Surgical+Endoscopy%22%5BJournal%5D)">Technique and audited outcomes of laparoscopic distal pancreatectomy combining the clockwise approach, progressive stepwise compression technique, and staple line reinforcement.</a> Surgical Endoscopy. 34 (1), 231-239 (2020).</li>
<li>Hogg, M. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Training+in+minimally+invasive+pancreatic+resections%3A+a+paradigm+shift+away+from+%22see+one%2C+do+one%2C+teach+one%22%5BTitle%5D)+AND+%22HPB%22%5BJournal%5D)">Training in minimally invasive pancreatic resections: a paradigm shift away from "see one, do one, teach one".</a> HPB. 19 (3), Oxford. 234-245 (2017).</li>
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</ol>

The authors have nothing to disclose.

This report demonstrates that robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy is feasible in selected patients and in experienced hands. In our experience, the robotic approach has benefits compared to the laparoscopic approach, especially when an anastomosis has to be made, due to its enhanced technical capabilities such as surgeon controlled high definition three-dimensional vision, facilitated and magnified instrument movement, and inherently to this improved suturing control due to its wristed instruments18,19. In particular, our report demonstrated that the standard pancreatico-jejunal anastomosis from robotic pancreatoduodenectomy could be used.
A recent multicenter NSQIP analysis reported a reduced risk of POPF after robotic as compared to open pancreatoduodenectomy20. Therefore, the question arises whether robotic central pancreatectomy could reduce the risk of POPF when compared to open central pancreatectomy.
Nonetheless, patient characteristics and the risk of a POPF should be taken into account when determining whether to perform a central pancreatectomy. The rate of POPF after central pancreatectomy will remain higher than after distal pancreatectomy given the POPF rate of pancreaticojejunostomy. Therefore, central pancreatectomy should be reserved for patients who are at low risk of POPF or other complications. Whereas well-defined contra-indications for central pancreatectomy are lacking, not all patients with pre-malignant or low-grade malignant neoplasms in the body or neck of the pancreas are eligible. The most important selection criteria are probably the patient&#39;s age and condition and tumor characteristics as size and location. A central pancreatectomy would seem more indicated for a younger patient with a small tumor, good performance status, and no diabetes than an elderly patient already suffering from diabetes.
In addition to this, patient selection is as important as experience with the operative technique. It has to be noted that complication and mortality rates are reduced in centers performing at least 20 robotic pancreatoduodenectomy procedures per year. For this reason, the Miami guidelines advise to only perform this procedure in high volume centers by experienced surgeons18,21.
With regard to the choice of anastomosis, despite the good clinical outcomes of the pancreatico-jejunostomy in our report, the question remains how this anastomosis compares to a pancreatico-gastrostomy. No reliable evidence is available to support the use of one particular anastomosis22.
In conclusion, we have shown that robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy is a feasible and safe parenchyma-sparing minimally invasive alternative to open or laparoscopic central pancreatectomy or distal pancreatectomy. Unnecessary pancreatic resections with loss of parenchyma and thereby potential loss of long-term pancreatic function could thus be avoided. The general applicability in non-selected patients remains uncertain.

Central pancreatectomy has been described as a parenchyma-sparing alternative surgical procedure to distal pancreatectomy for benign or low-grade malignant lesions located in the body of the pancreas1,2. Central pancreatectomy will prevent life-long pancreatic endocrine and exocrine dysfunction in most patients. Still, most surgeons chose to perform a distal pancreatectomy over a central pancreatectomy because of the increased risk of postoperative morbidity, mainly due to postoperative pancreatic fistula (POPF) after central pancreatectomy3,4,5. In fact, central pancreatectomy combines the POPF risk of a distal pancreatectomy and a pancreato-enteric anastomosis.
Most studies on central pancreatectomy advise to perform a pancreatico-gastrostomy anastomosis because of the presumed lower risk of POPF6,7. However, current randomized trials are inconclusive regarding the risk for POPF incidence for pancreatico-gastrostomy and pancreaticojejunostomy8,9,10. Furthermore, pancreatico-gastrostomy has been suggested to impair long-term pancreatic exocrine function due to gastric mucosal overgrowth11. In addition, the minority of surgeons are experienced with pancreatico-gastrostomy in daily clinical practice, which will also reduce enthusiasm for this solution.
Robotic pancreatoduodenectomy, supported by the work of the Pittsburgh University Medical Center team and large-scale training programs such as the Dutch LAELAPS-3 and the European LEARNBOT programs, has now become an accepted approach in selected patients in many centers across the world12,13,14. For surgeons experienced with robotic pancreatoduodenectomy, including the highly standardized robotic pancreatico-jejunal anastomosis, a robotic central pancreatectomy is an attractive alternative to open or laparoscopic central pancreatectomy or laparoscopic distal pancreatectomy.
In this article, we describe a case of a 16-year-old adolescent patient with a pancreatic lesion suspected for solid pseudopapillary tumor who underwent robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy reconstruction. Our aim is to demonstrate the technical approach and clinical safety of robotic-assisted central pancreatectomy and its surgical outcomes when performed in high-volume centers by experienced surgeons.

<table><tbody><tr><td>&lt;u&gt;&lt;strong&gt;SYSTEMS&lt;/strong&gt;&lt;/u&gt;</td><td></td><td></td><td></td></tr><tr><td>Arietta Ultrasound</td><td>Hitachi</td><td>L43K / arietta v70</td><td>Used for intraoperative laparoscopic ultrasonography.</td></tr><tr><td>da Vinci Surgeon Console</td><td>IS</td><td>SS999</td><td>Used to control the surgical robot.</td></tr><tr><td>da Vinci Vision Cart</td><td>IS</td><td>VS999</td><td>The vision cart houses advanced vision and energy technologies and provides communications across da Vinci system components.</td></tr><tr><td>da Vinci Xi</td><td>IS</td><td>K131861</td><td>The surgical robot: &amp;rsquo;patient side-cart&amp;rsquo;</td></tr><tr><td>&lt;u&gt;&lt;strong&gt;INSTRUMENTS&lt;/strong&gt;&lt;/u&gt;</td><td></td><td></td><td></td></tr><tr><td>Cobra Liver Retractor Diamond-Flex</td><td>CareFusion</td><td>89-6216</td><td>Retracting the liver for optimal exposure of the surgical site.</td></tr><tr><td>da Vinci Xi Endoscope with Camera, 8 mm, 30&amp;deg;</td><td>IS</td><td>470027</td><td>The camera of the da Vinci robot.</td></tr><tr><td>ENDOEYE Rigid Video Laparoscope, 10 mm, 30&amp;deg;</td><td>Olympus</td><td>WA50042A</td><td>To see within the intra-abdominal cavity.</td></tr><tr><td>ENDOWRIST Fenestrated Bipolar Forceps</td><td>IS</td><td>470205</td><td>Used for dissection and coagulation.</td></tr><tr><td>&lt;u&gt;&lt;strong&gt;ENDOWRIST HOT SHEARS&lt;/strong&gt;&lt;/u&gt;</td><td>IS</td><td>470179</td><td>Used for cutting and coagulation.</td></tr><tr><td>ENDOWRIST Mega SutureCut Needle Driver</td><td>IS</td><td>470309</td><td>Used as a needle driver.</td></tr><tr><td>ENDOWRIST Permanent Cautery Hook</td><td>IS</td><td>470183</td><td>Used for coagulation.</td></tr><tr><td>ENDOWRIST PROGrasp Forceps</td><td>IS</td><td>470093</td><td>Used for dissecton.</td></tr><tr><td>LigaSure Maryland Jaw</td><td>Medtronic</td><td>LF1937</td><td>Used for vessel sealing and dividing.</td></tr><tr><td>SUTURES/STENTS</td><td></td><td></td><td></td></tr><tr><td>Vicryl 4-0 8cm x2</td><td></td><td></td><td></td></tr><tr><td>V-loc barbed 3-0 15 cm x1</td><td></td><td></td><td></td></tr><tr><td>Silk 2-0 20cm x3</td><td></td><td></td><td></td></tr><tr><td>PDS 5-0 8cm 8-10x</td><td></td><td></td><td></td></tr><tr><td>Standing suture Vicryl 50 cm x1</td><td></td><td></td><td></td></tr><tr><td>Internal pancreatic duct stent 4.8 French</td><td></td><td></td><td></td></tr></tbody></table>

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.

Representative results are shown in Table 1. The operation time was 248 min with a measured blood loss of 20 mL. The postoperative course was uncomplicated. Because of initially high drain amylase the patient received octreotide and antibiotics for 3 days. This treatment was stopped when drain amylase levels normalized on postoperative day 7, when the drain was also removed. Because of this medical treatment, this was graded as a grade B POPF17. A normal diet could be restarted after 4 days. The patient was discharged in good condition on postoperative day 8. The patient did not develop diabetes or pancreatic exocrine insufficiency during the follow-up.
Pathology assessment revealed a 2.2 cm solid pseudopapillary tumor (Figure 4) and thus confirming the preoperative diagnosis. Microscopically, an R0 resection was confirmed. One lymph node was excised, in which localization of tumor tissue was not found.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/62862/62862fig01.jpg" /> 
Figure 1: Trocar placement. Red: 8 mm robotic trocars, blue: 12 mm laparoscopic trocars, yellow: 5 mm trocar for stomach/liver retractor. <a href="https://www.jove.com/files/ftp_upload/62862/62862fig01large.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/62862/62862fig02.jpg" /> 
Figure 2: Schematic trocar placement. <a href="https://www.jove.com/files/ftp_upload/62862/62862fig02large.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/62862/62862fig03.jpg" /> 
Figure 3: Set up and installation of the robot during surgery. <a href="https://www.jove.com/files/ftp_upload/62862/62862fig03large.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/62862/62862fig04.jpg" /> 
Figure 4: Macroscopic specimen. <a href="https://www.jove.com/files/ftp_upload/62862/62862fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Variable</td>
			<td>Outcome</td>
		</tr>
		<tr>
			<td>Intraoperative</td>
			<td></td>
		</tr>
		<tr>
			<td>Operative time, minutes</td>
			<td>248</td>
		</tr>
		<tr>
			<td>Intraoperative blood loss, mL</td>
			<td>20</td>
		</tr>
		<tr>
			<td>Postoperative</td>
			<td></td>
		</tr>
		<tr>
			<td>Postoperative pancreatic fistula (POPF)</td>
			<td>Grade B</td>
		</tr>
		<tr>
			<td>Clavien-Dindo complication grade</td>
			<td>2</td>
		</tr>
		<tr>
			<td>Drain removal, postoperative day</td>
			<td>7</td>
		</tr>
		<tr>
			<td>Postoperative hospital stay, days</td>
			<td>8</td>
		</tr>
		<tr>
			<td>Pathological diagnosis</td>
			<td>Radically (R0) resected solid pseudopapillary tumor (i.e. Frantz tumor), 2.2 cm</td>
		</tr>
	</tbody>
</table>
Table 1: Representative results of the surgery.

Watch this Scientific Journal Video about Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy at JoVE.com

Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

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 ...

robotic-central-pancreatectomy-with-roux-en-y-pancreaticojejunostomy

Research

JoVE Journal

Medicine

5.4K Views.  University of Amsterdam, Cancer Center Amsterdam. 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. 

Video: Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

Roux-en-Y Gastric Bypass Operation in Rats

Currently, the most effective therapy for the treatment of morbid obesity to induce significant and maintained body weight loss with a proven mortality benefit is bariatric surgery1,2. Consequently, there has been a steady rise in the number of bariatric operations done worldwide in recent years with the Roux-en-Y gastric bypass (gastric bypass) being the most commonly performed operation3. Against this background, it is important to understand the physiological mechanisms by which gastric bypass induces and maintains body weight loss. These mechanisms are yet not fully understood, but may include reduced hunger and increased satiation4,5, increased energy expenditure6,7, altered preference for food high in fat and sugar8,9, altered salt and water handling of the kidney10 as well as alterations in gut microbiota11. Such changes seen after gastric bypass may at least partly stem from how the surgery alters the hormonal milieu because gastric bypass increases the postprandial release of peptide-YY (PYY) and glucagon-like-peptide-1 (GLP-1), hormones that are released by the gut in the presence of nutrients and that reduce eating12.
During the last two decades numerous studies using rats have been carried out to further investigate physiological changes after gastric bypass. The gastric bypass rat model has proven to be a valuable experimental tool not least as it closely mimics the time profile and magnitude of human weight loss, but also allows researchers to control and manipulate critical anatomic and physiologic factors including the use of appropriate controls. Consequently, there is a wide array of rat gastric bypass models available in the literature reviewed elsewhere in more detail 13-15. The description of the exact surgical technique of these models varies widely and differs e.g. in terms of pouch size, limb lengths, and the preservation of the vagal nerve. If reported, mortality rates seem to range from 0 to 35%15. Furthermore, surgery has been carried out almost exclusively in male rats of different strains and ages. Pre- and postoperative diets also varied significantly.
Technical and experimental variations in published gastric bypass rat models complicate the comparison and identification of potential physiological mechanisms involved in gastric bypass. There is no clear evidence that any of these models is superior, but there is an emerging need for standardization of the procedure to achieve consistent and comparable data. This article therefore aims to summarize and discuss technical and experimental details of our previously validated and published gastric bypass rat model.

Numerous studies using gastric bypass rat models have been recently conducted to uncover the underlying physiological mechanisms of Roux-en-Y gastric bypass operations. This article aims to demonstrate and discuss the technical and experimental details of our published gastric bypass rat model to understand advantages and limitations of this experimental tool.

Currently, the most effective therapy for the treatment of morbid obesity to induce significant and maintained body weight loss with a proven mortality ...

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.

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.

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), ...

Cancer Research

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 ...

Robotic Ablation of Atrial Fibrillation

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between pulmonary vein (PV) and left atrium (LA) is created. This conduction block prevents AF, which is triggered by irregular electric activity originating from the PV. However, transmural atrial lesions are required which can be challenging. Re-conduction and AF recurrence occur in 20 - 40% of the cases. Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new remote catheter system (RCS), is presented. Objective of this article is to show feasibility of robotic AF ablation with a novel system. Materials and Methods: After interatrial trans-septal puncture is performed using a long sheath and needle under fluoroscopic guidance. The needle is removed and a guide wire is placed in the left superior PV. Then an ablation catheter is positioned in the LA, using the sheath and wire as guide to the LA. LA angiography is performed over the sheath. A circular mapping catheter is positioned via the long sheath into the LA and a three-dimensional (3-D) anatomical reconstruction of the LA is performed. The handle of the ablation catheter is positioned in the robotic arm of the Amigo system and the ablation procedure begins. During the ablation procedure, the operator manipulates the ablation catheter via the robotic arm with the use of a remote control. The ablation is performed by creating point-by-point lesions around the left and right PV ostia. Contact force is measured at the catheter tip to provide feedback of catheter-tissue contact. Conduction block is confirmed by recording the PV potentials on the circular mapping catheter and by pacing maneuvers. The operator stays out of the radiationfield during ablation. Conclusion: The novel catheter system allows ablation with high stability on low operator fluoroscopy exposure.

Pulmonary vein isolation (PVI) with an ablation catheter is a curative treatment for atrial fibrillation (AF). Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new robotic catheter system is presented. The goal of the procedure is electrical block between pulmonary vein and left atrium.

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between ...

Modeling and Simulations of Olfactory Drug Delivery with Passive and Active Controls of Nasally Inhaled Pharmaceutical Aerosols

There are many advantages of direct nose-to-brain drug delivery in the treatment of neurological disorders. However, its application is limited by the extremely low delivery efficiency (&#60; 1%) to the olfactory mucosa that directly connects the brain. It is crucial to develop novel techniques to deliver neurological medications more effectively to the olfactory region. The objective of this study is to develop a numerical platform to simulate and improve intranasal olfactory drug delivery. A coupled image-CFD method was presented that synthetized the image-based model development, quality meshing, fluid simulation, and magnetic particle tracking. With this method, performances of three intranasal delivery protocols were numerically assessed and compared. Influences of breathing maneuvers, magnet layout, magnetic field strength, drug release position, and particle size on the olfactory dosage were also numerically studied.
From the simulations, we found that clinically significant olfactory dosage (up to 45%) were feasible using the combination of magnet layout and selective drug release. A 64 -fold higher delivery of dosage was predicted in the case with magnetophoretic guidance compared to the case without it. However, precise guidance of nasally inhaled aerosols to the olfactory region remains challenging due to the unstable nature of magnetophoresis, as well as the high sensitivity of olfactory dosage to patient-, device-, and particle-related factors.

This manuscript reviews the modeling and simulations of different protocols to deliver medications to the olfactory region in image-based nasal airway models. Multiple software modules are used to develop the anatomically accurate nose model, generate computational mesh, simulate nasal airflows, and predict particle deposition at the olfactory region.

There are many advantages of direct nose-to-brain drug delivery in the treatment of neurological disorders. However, its application is limited by the ...

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 ...

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 Lateral Pancreaticojejunostomy for Chronic Pancreatitis

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The recent rise of robotic and laparoscopic pancreatic surgery has found benefits such as reduced time to functional recovery. Few studies have reported on the feasibility, technique and outcome of robotic LPJ, especially including transection of the gastroduodenal artery. The present study describes the main steps for robotic LPJ in a patient with painful chronic pancreatitis with a dilated main pancreatic duct. The patient underwent robotic LPJ. The LPJ anastomosis is performed using a running suture technique in a longitudinal side-to-side manner. Routinely, the gastroduodenal artery is transected to drain the entire length of the main pancreatic duct. The patient is in French position; 7 trocars are placed (4 robotic, 2 laparoscopic assistants, 1 liver-retractor). After docking of the robot system, the omental bursa is opened, and the right gastroepiploic artery and vein are ligated at their base at the lower border of the pancreas. Intraoperative ultrasonography is performed in order to determine trajectory of the dilated main pancreatic duct which is opened for its entire length after the gastroduodenal artery has been suture ligated both cranially and caudally from the main pancreatic duct. A Roux limb is created, and a latero-lateral PJ is fashioned using several 3-0 barbed sutures. A stapled jejuno-jejunostomy is created at sufficient distance from the pancreatic anastomosis, aided by a 50 cm suture. The described technique for robotic LPJ is a complex but feasible operation for patients with treatment refractory CP and a dilated main pancreatic duct. Due to its complexity, implementation in high volume centers with extensive experience with CP surgery may improve outcomes.

Robotic lateral pancreaticojejunostomy (RLPJ) may be used in patients with painful, morphine dependent, chronic pancreatitis and a dilated main pancreatic duct. We describe a standardized and reproducible technique for RLPJ, which includes transection of the gastroduodenal artery.

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The ...

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 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.