Name: robotic pancreatoduodenectomy for pancreatic head cancer: a case report of a standardized technique
Uploaded: 2022-06-24T12:30:00
Duration: 13 min 38 s
Description: Watch this Scientific Journal Video about Robotic Pancreatoduodenectomy for Pancreatic Head Cancer: a Case Report of a Standardized Technique at JoVE.com

We would like to acknowledge Amer Zureikat, Melissa Hogg, Olivier Saint-Marc, Ugo Boggi, and Herbert Zeh III who supported and trained us in robotic pancreatic surgery in the Dutch Pancreatic Cancer Group - LAELAPS-3 program.

<ol>
	<li>Torphy, R. J., Fujiwara, Y., Schulick, R. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreatic+cancer+treatment:+better,+but+a+long+way+to+go.">Pancreatic cancer treatment: better, but a long way to go.</a> Surgery Today. 50 (10), 1117-1125 (2020).</li><li>Asbun, H. 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=The+Miami+International+Evidence-based+Guidelines+on+Minimally+Invasive+Pancreas+Resection.">The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection.</a> Annals of Surgery. 271 (1), 1-14 (2020).</li><li>Boone, B. A., 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=Assessment+of+Quality+Outcomes+for+Robotic+Pancreaticoduodenectomy.">Assessment of Quality Outcomes for Robotic Pancreaticoduodenectomy.</a> JAMA Surgery. 150 (5), 416 (2015).</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>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.">500 Minimally Invasive Robotic Pancreatoduodenectomies.</a> Annals of Surgery. 273 (5), 966-972 (2019).</li><li>Jones, L. R., 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+Pancreatoduodenectomy:+Patient+Selection,+Volume+Criteria,+and+Training+Programs.">Robotic Pancreatoduodenectomy: Patient Selection, Volume Criteria, and Training Programs.</a> Scandinavian Journal of Surgery. 109 (1), 29-33 (2020).</li><li>Zwart, M. J. W., 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=Outcomes+of+a+Multicenter+Training+Program+in+Robotic+Pancreatoduodenectomy+(LAELAPS-3).">Outcomes of a Multicenter Training Program in Robotic Pancreatoduodenectomy (LAELAPS-3).</a> Annals of Surgery. 269 (2), 344-350 (2021).</li><li>Balzan, S. M. P., 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=Prevalence+of+hepatic+arterial+variations+with+implications+in+pancreatoduodenectomy.">Prevalence of hepatic arterial variations with implications in pancreatoduodenectomy.</a> Arquivos Brasileiros de Cirurgia Digestiva. 32 (3), 1455 (2019).</li><li>Nguyen, T. 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=Robotic+pancreaticoduodenectomy+in+the+presence+of+aberrant+or+anomalous+hepatic+arterial+anatomy:+safety+and+oncologic+outcomes.">Robotic pancreaticoduodenectomy in the presence of aberrant or anomalous hepatic arterial anatomy: safety and oncologic outcomes.</a> HPB. 17 (7), 594-599 (2015).</li><li>Kim, J. H., Gonzalez-Heredia, R., Daskalaki, D., Rashdan, M., Masrur, M., Giulianotti, P. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Totally+replaced+right+hepatic+artery+in+pancreaticoduodenectomy:+is+this+anatomical+condition+a+contraindication+to+minimally+invasive+surgery.">Totally replaced right hepatic artery in pancreaticoduodenectomy: is this anatomical condition a contraindication to minimally invasive surgery.</a> HPB. 18 (7), 580-585 (2016).</li><li>Lee, J. -. M., Lee, Y. -. J., Kim, C. -. W., Moon, K. -. M., Kim, M. -. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+Implications+of+an+Aberrant+Right+Hepatic+Artery+in+Patients+Undergoing+Pancreaticoduodenectomy.">Clinical Implications of an Aberrant Right Hepatic Artery in Patients Undergoing Pancreaticoduodenectomy.</a> World Journal of Surgery. 33 (8), 1727-1732 (2009).</li><li>MacKenzie, S., Kosari, K., Sielaff, T., Johnson, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+robotic+Whipple:+operative+strategy+and+technical+considerations.">The robotic Whipple: operative strategy and technical considerations.</a> Journal of Robotic Surgery. 5 (1), 3-9 (2011).</li><li>Stauffer, J. A., Bridges, M. D., Turan, N., Nguyen, J. H., Martin, J. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aberrant+right+hepatic+arterial+anatomy+and+pancreaticoduodenectomy:+recognition,+prevalence+and+management.">Aberrant right hepatic arterial anatomy and pancreaticoduodenectomy: recognition, prevalence and management.</a> HPB. 11 (2), 161-165 (2009).</li><li>Abdullah, S. 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=Anatomical+variations+of+the+hepatic+artery:+study+of+932+cases+in+liver+transplantation.">Anatomical variations of the hepatic artery: study of 932 cases in liver transplantation.</a> Surgical and Radiologic Anatomy. 28 (5), 468-473 (2006).</li><li>Kowalsky, S. 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=A+Combination+of+Robotic+Approach+and+ERAS+Pathway+Optimizes+Outcomes+and+Cost+for+Pancreatoduodenectomy.">A Combination of Robotic Approach and ERAS Pathway Optimizes Outcomes and Cost for Pancreatoduodenectomy.</a> Annals of Surgery. 269 (6), 1138-1145 (2019).</li><li>Klotz, R., 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=Evaluation+of+robotic+versus+open+partial+pancreatoduodenectomy-study+protocol+for+a+randomised+controlled+pilot+trial+(EUROPA,+DRKS00020407).">Evaluation of robotic versus open partial pancreatoduodenectomy-study protocol for a randomised controlled pilot trial (EUROPA, DRKS00020407).</a> Trials. 22 (1), 40 (2021).</li><li>Baimas-George, 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+pancreaticoduodenectomy+may+offer+improved+oncologic+outcomes+over+open+surgery:+a+propensity-matched+single-institution+study.">Robotic pancreaticoduodenectomy may offer improved oncologic outcomes over open surgery: a propensity-matched single-institution study.</a> Surgical Endoscopy. 34 (8), 3644-3649 (2020).</li></ol>

M.J.W Zwart, L.R. Jones and M.G. Besselink received funding from Intuitive for the European LEARNBOT training program for robotic pancreatoduodenectomy. (Grant Reference&#42889; Impact of a European training program for robot pancreatoduodenectomy using a video databank, da Vinci simulator and robot biotissue anastomoses on clinical outcomes (LEARNBOT): a pan-European prospective study) and MEH received funding from Intuitive for studies on safe implementation of robot-assisted pancreatic surgery.
J.A.M.G. Tol, M. Abu Hilal, F. Daams, S. Festen&#160;and O.R. Buschhave no conflict of interest or financial ties to disclose.

This case report shows that RPD is feasible to perform in case of a replaced right hepatic artery when performed in selected patients by trained surgeons in high-volume centers with an annual volume of at least 20 RPD procedures per center, following the Miami guidelines2. RPD combines the benefits of a minimal invasive approach with enhanced 3D vision and the use of articulating instruments and therefore the inherent possibility of wrist movements. Moreover, the large external movements of the surgeon are scaled down to limited internal movements of the &#34;robotic hands&#34;. This improves ergonomics that results in higher precision and greater ability of the surgeon to perform technically difficult procedures in a limited space.
Aberrant vasculature, most commonly a replaced right hepatic artery, can increase the technical difficulty of the resection phase of RPD8. A replaced right hepatic artery can make it more challenging to dissect the pancreatic head and perform an adequate lymph node dissection. Damage to an aberrant hepatic artery can induce bile duct and liver ischemia13,14. The safety of RPD in patients with a replaced right hepatic artery has been shown by several studies9,10. Adequate description of the preoperative imaging is essential to identify aberrant vascularization such as a replaced hepatic artery or other arterial abnormalities such as a celiac trunk stenosis. It is crucial during surgery to identify the replaced right hepatic artery early, and to circle and retract the artery using a vessel loop to facilitate safe dissection of the pancreatic head and lymph node harvesting.
One of the limitations of the robotic approach compared to the open approach is the loss of haptic feedback2. Furthermore, the robotic approach is a more costly approach, although improved time to functional recovery and shortened hospital stay can partly compensate for this15. Lastly, no randomized trials have been conducted to date, to suggest superiority of RPD as compared to the open approach. The potential improved clinical and oncological outcomes of RPD vs OPD should be researched in future randomized trials such as in two ongoing trials in Heidelberg16 and Johns Hopkins Medical Institutes and by the European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS)4,5,17.
This case report shows a RPD for pancreatic head cancer in a patient with a replaced right hepatic artery and described the surgical technique in detail. In conclusion, RPD for pancreatic head cancer is a feasible procedure in case of a replaced right hepatic artery when performed by experienced surgeons (after overcoming the first learning phase after 22 cases7) in high volume centers, based on the Miami guidelines advice of 20 annual procedures per center per year2.

The combination of surgery and systemic therapy provides the most effective way of prolonging life expectancy in patients with resectable pancreatic cancer1. In recent years, interest in minimally invasive pancreatoduodenectomy has increased, aiming to decrease the impact of surgery and thereby enhancing postoperative recovery2.
Robotic pancreatoduodenectomy (RPD) aims to overcome compromises made by laparoscopy, by the ability of wrist movements, scaled down movements, and enhanced 3D vision combined with benefits of the minimally invasive approach for more precision and improved surgical ability. RPD is associated with a learning curve3,4; an experienced single center study reported that the learning curve based on operative time was overcome after 80 RPD procedures5. A dedicated training program can have a positive impact on this learning curve6. The University of Pittsburgh Medical Center (UPMC) group found improved outcomes after the implementation of a training program for RPD5. In the Netherlands, the LAELAPS-3 multicenter training program for RPD was started by the Dutch Pancreatic Cancer Group (DPCG) in collaboration with the UPMC team and demonstrated good results, including a learning curve based on operative time that was overcome after 22 RPD procedures7. Currently, this is being followed by the European LEARNBOT multicenter training program for RPD.
Aberrant hepatic vasculature is present in 15-20% of patients undergoing RPD, most commonly a replaced right hepatic artery, which may complicate the resection phase8. Currently, specific teaching material for RPD in patients with a replaced right hepatic artery is lacking. Detailed descriptions are crucial to prepare an optimal surgical strategy, also highlighting the importance of preoperative imaging for detecting any aberrant vasculature. The safety of RPD with aberrant hepatic vasculature was confirmed by several studies as long as these procedures are performed by specifically trained and experienced surgeons, working in high volume centers6,8,9,10,11,12.
This case report describes and shows a step-by-step technical approach to RPD in case of a replaced right hepatic artery performed in the Netherlands, aimed to facilitate ongoing (i.e., LEARNBOT) and future training programs. The Amsterdam UMC currently performs &#62;40 RPD procedures per year and therefore conforms to the Miami guidelines volume cut-off of &#62;20 RPD procedures2, as do all Dutch centers that participated in the LAELAPS-3 program. The described technique was standardized after 32 procedures (since November 2019) and a total of 115 procedures have been performed (until February 2022).
The described approach is reproducible and compatible for both normal and aberrant anatomy and includes additional steps for a replaced right hepatic artery.
A 58-year-old woman presented with an incidental finding of a 1.7 cm pancreatic head mass suspect for pancreatic ductal adenocarcinoma. No distant metastases and lymph node involvement was identified on the preoperative CT-scan. However, the CT-scan revealed a replaced right hepatic artery originating from the superior mesenteric artery (SMA) (Figure 1). Patient had a history of cholecystectomy, body mass index 30 kg/m2, and was ASA 1. The pancreatic duct measured 3 mm at the neck of the pancreas, and the hepatic duct measured 7 mm at the intended transection plane. The patient did not receive neoadjuvant chemotherapy, as no definitive preoperative histological diagnosis of pancreatic ductal adenocarcinoma could be made. The patient appeared suitable for a minimally invasive approach.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Sutures:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Internal pancreatic duct stent (12cm)&#160;4 Fr Hobbs stent</td>
			<td>Hobbs medical</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>PDS, RB-1, 8cm 5-0 x6; Z320: taper point. &#189; circle 13/17mm</td>
			<td>Ethicon</td>
			<td>Z320</td>
			<td></td>
		</tr>
		<tr>
			<td>Silk, SH, 18cm 2-0 x5; C016D: taper point, &#189; circle 26mm</td>
			<td>Ethicon</td>
			<td>C016D</td>
			<td></td>
		</tr>
		<tr>
			<td>Straight needle Monocryl</td>
			<td>Ethicon</td>
			<td>Y523H</td>
			<td>For retraction lig. teres</td>
		</tr>
		<tr>
			<td>Vicryl suture without needle 60cm</td>
			<td>Ethicon</td>
			<td>e.g. D7818</td>
			<td>For measuring distance HJ-G</td>
		</tr>
		<tr>
			<td>V-loc L0803: taper point, &#189; circle 17mm, CV-23, 15cm 4-0</td>
			<td>Medtronic</td>
			<td>L0803</td>
			<td>In case of thick wall, dilated bile duct x2</td>
		</tr>
		<tr>
			<td>Instruments laparoscopy:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Autosuture Endo Clip applier 5 mm</td>
			<td>Covidien</td>
			<td>176620</td>
			<td></td>
		</tr>
		<tr>
			<td>ECHELON FLEX ENDOPATH 60mm Stapler</td>
			<td>Ethicon</td>
			<td></td>
			<td>Powered surgical stapler with gripping surface technology</td>
		</tr>
		<tr>
			<td>o&#160;&#160; White filling 60mm x2 (for transection of jejunum, gastroduodenal artery)</td>
			<td>Ethicon</td>
			<td>GST60W</td>
			<td></td>
		</tr>
		<tr>
			<td>o&#160;&#160; Black filling 60mm (for transection of stomach)</td>
			<td>Ethicon</td>
			<td>GST60T</td>
			<td></td>
		</tr>
		<tr>
			<td>Endo Catch II Pouch 15mm</td>
			<td>Covidien</td>
			<td>173049</td>
			<td>Bag for specimen extraction. For single lymph node extractions a cut off finger surgical glove can be used.</td>
		</tr>
		<tr>
			<td>LigaSure Dolphin Tip Laparoscopic Sealer/Divider</td>
			<td>Medtronic</td>
			<td>LS1500</td>
			<td>Dolphin-nose tip sealer and divider, 37 cm shaft</td>
		</tr>
		<tr>
			<td>Mediflex retractor liver</td>
			<td>Mediflex</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Set of laparoscopic bulldog clamps</td>
			<td>Aesculap</td>
			<td></td>
			<td>This set consists of several bulldog clamps (of different shape and size) with dedicated laparoscopic instruments to be used to apply and remove the clamps</td>
		</tr>
		<tr>
			<td>Instruments robot:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Cadiere x2 (470049)</td>
			<td>Intuitive Surgical</td>
			<td>470049</td>
			<td></td>
		</tr>
		<tr>
			<td>&#160;&#160;&#160;&#160;&#160; Endoscope 30&#186; (470026)</td>
			<td>Intuitive Surgical</td>
			<td>470026</td>
			<td></td>
		</tr>
		<tr>
			<td>Fenestrated Bipolar Forceps (470205)</td>
			<td>Intuitive Surgical</td>
			<td>470205</td>
			<td></td>
		</tr>
		<tr>
			<td>Hot Shears, Monopolar Curved Scissors (470179)</td>
			<td>Intuitive Surgical</td>
			<td>470179</td>
			<td></td>
		</tr>
		<tr>
			<td>Large Needle Driver x 1 (470006)</td>
			<td>Intuitive Surgical</td>
			<td>470006</td>
			<td></td>
		</tr>
		<tr>
			<td>&#160;&#160;&#160;&#160;&#160; Medium hem-o-lok Clip applier</td>
			<td>Intuitive Surgical</td>
			<td>470327</td>
			<td></td>
		</tr>
		<tr>
			<td>Permanent Cautery Hook (470183)</td>
			<td>Intuitive Surgical</td>
			<td>470183</td>
			<td></td>
		</tr>
		<tr>
			<td>Suture Cut Needle Driver x1 (470296)</td>
			<td>Intuitive Surgical</td>
			<td>470296</td>
			<td></td>
		</tr>
		<tr>
			<td>Other:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Hem-o-lok Clips MLX</td>
			<td>Weck Surgical Instuments, Teleflex Medical, Durham, NC</td>
			<td>544230</td>
			<td>Vascular clip 3mm - 10mm Size Range</td>
		</tr>
		<tr>
			<td>Hem-o-lok Clips XI</td>
			<td>Weck Surgical Instuments, Teleflex Medical, Durham, NC</td>
			<td>544250</td>
			<td>Vascular clip 7mm - 16mm Size Range</td>
		</tr>
		<tr>
			<td>Medium extraction port (double ring)</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Vessel loops</td>
			<td>Omnia Drains</td>
			<td>NVMR61</td>
			<td>Disposible silicon rubber stripes, typically used to tag relevant anatomical structures</td>
		</tr>
	</tbody>
</table>

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.

During routine work-up, the pancreatic CT-scan revealed a replaced right hepatic artery originating from the superior mesenteric artery (SMA) (Figure 1). Vessel loops used in the hepatic ligament, including the replaced right hepatic artery, are shown in Figure 3.
The sequence of instruments during each operative step are shown in Table 1 and specified in the Table of Materials.
Representative results are shown in Table 2. The operation time was 410 min (including 15 min break between the resection and anastomotic phase) with 220 mL of measured intraoperative blood loss. The postoperative course was unremarkable, with a total postoperative hospital stay of five days without complications. Oral intake was possible after two days with normal diet at day four. Patient started walking on the first postoperative day and expanded this to 200 m on day three. On the early morning of postoperative day three, drain amylase was low (86 U/L)and the drain was removed. The patient was discharged two days later on postoperative day five.
Pathology assessment revealed a 1.7 cm adenocarcinoma of the head cancer. The resection margins were microscopically radical (R0) with &#62;3 mm margin and five of 17 retrieved lymph nodes were positive for tumor. Patient started with adjuvant chemotherapy capecitabine as part of a randomized trial.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/62863/62863fig01.jpg" /> 
Figure 1: 3D reconstruction of hepatic vasculature including replaced right hepatic artery <a href="https://www.jove.com/files/ftp_upload/62863/62863fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a> 
Red: Arterial system 
Translucent yellow: Pancreatic duct 
Translucent green: Biliary system 
Translucent blue/purple: Portal system 
Translucent white: Pancreatic tissue
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/62863/62863fig02.jpg" /> 
Figure 2: Port placement <a href="https://www.jove.com/files/ftp_upload/62863/62863fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a> 
Blue: 8 mm robotic ports 
Red: 12 mm laparoscopic ports 
Green: 5 mm port for liver retractor 
Arrow: Umbilicus
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/62863/62863fig03.jpg" /> 
Figure 3: Vessel loops hepatic ligament <a href="https://www.jove.com/files/ftp_upload/62863/62863fig03large.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 colspan="2"></td>
			<td colspan="4">Instruments Used</td>
		</tr>
		<tr>
			<td colspan="2" rowspan="2"></td>
			<td colspan="3">Robotic</td>
			<td>Laparoscopic</td>
		</tr>
		<tr>
			<td colspan="3">(console surgeon)</td>
			<td>(assistant surgeon)</td>
		</tr>
		<tr>
			<td colspan="2">Operative steps</td>
			<td>Arm 1</td>
			<td>Arm 2</td>
			<td>Arm 4</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="2">2.5 Mobilization</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Permanent cautery hook</td>
			<td>Sealing device, suction, clip-applier, stapler</td>
		</tr>
		<tr>
			<td colspan="2">3.10 Portal dissection</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Permanent cautery hook</td>
			<td>Sealing device, suction, clip-applier, stapler</td>
		</tr>
		<tr>
			<td colspan="2">3.17 Pancreatic neck transection</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Monopolar curved scissors</td>
			<td>Sealing device, suction, clip-applier</td>
		</tr>
		<tr>
			<td colspan="2">2.18-2.23 Pancreatic head dissection</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Cadiere forceps</td>
			<td>Sealing device, suction, clip-applier</td>
		</tr>
		<tr>
			<td colspan="2">4.1 Drain placement</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated grasper</td>
		</tr>
		<tr>
			<td>4.4-4.5 PJ and HJ</td>
			<td>PJ</td>
			<td>Cadiere forceps</td>
			<td>Large needle driver</td>
			<td>Large needle driver with suture cut</td>
			<td>Fenestrated grasper</td>
		</tr>
		<tr>
			<td></td>
			<td>HJ</td>
			<td>Cadiere forceps</td>
			<td>Large needle driver</td>
			<td>Large needle driver with suture cut</td>
			<td>Fenestrated grasper</td>
		</tr>
		<tr>
			<td>4.10 Specimen extraction</td>
			<td>GJ preparation</td>
			<td>Cadiere forceps</td>
			<td>Large needle driver</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated grasper</td>
		</tr>
	</tbody>
</table>
Table 1: Sequence of instruments during each operative step
<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>410</td>
		</tr>
		<tr>
			<td>Resection, minutes</td>
			<td>202</td>
		</tr>
		<tr>
			<td>Reconstruction, minutes</td>
			<td>179</td>
		</tr>
		<tr>
			<td>Estimated intraoperative blood loss, mL</td>
			<td>220</td>
		</tr>
		<tr>
			<td>Postoperative</td>
			<td></td>
		</tr>
		<tr>
			<td>Clavien-Dindo complication grade</td>
			<td>0</td>
		</tr>
		<tr>
			<td>Drain removal, postoperative day</td>
			<td>3</td>
		</tr>
		<tr>
			<td>Postoperative hospital stay, days</td>
			<td>5</td>
		</tr>
		<tr>
			<td>Pathological diagnosis</td>
			<td>Adenocarcinoma of the head cancer</td>
		</tr>
		<tr>
			<td colspan="2">Legend: Operative time comprises steps 2.3-5.3, Resection comprises steps 3-3.25, reconstruction comprises steps 4-4.13</td>
		</tr>
	</tbody>
</table>
Table 2: Representative results

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