The clinical research was enabled by HPB-Amsterdam and F de Graaf, operating rooms Amsterdam UMC.

The present protocol follows the ethics guidelines of Amsterdam UMC. Informed consent was obtained from the patient for this article and the video.
1. Preoperative management
<ol>
	<li>Perform preoperative imaging with a CT scan to assess the localization and the extent of the duodenal stenosis and its relationship with the papilla of Vater (Figure 1).</li>
	<li>Perform esophagogastroduodenoscopy to describe the stenosis and its location. The duodenal lumen must be partially/entirely obstructed by the lesion, making it impossible for the endoscope to proceed any further and complete curative endoscopic treatment (Figure 2). Place, before the stenosis, a small 1 cm mark with an inked tattoo on the submucosa for intraoperative identification of the lesion.</li>
	<li>Evaluate the eligibility for the surgical approach and relative contraindications (severe stenosis causing dysphagia, pain, malnutrition, feasibility of treating the disease endoscopically, duodenal stenosis far and distal from the papilla of Vater, no history of abdominal surgery, and in more general terms any benign, premalignant, malignant local entity in D3 duodenum which can be treated with a partial duodenectomy).</li>
</ol>
2. Anesthesia, positioning of the patient, and safety check procedures
<ol>
	<li>Induce the patient with general anesthesia with the help of an anesthesiologist.</li>
	<li>Place the patient in a French position. Lower the right arm alongside the patient on an arm board while placing the left arm in a 90&#176; position. Tilt the table 20&#176; to the left of the patient and in a 20&#176; reverse Trendelenburg position.</li>
	<li>Perform the safety check procedures as required by the Institution (e.g., patient&#39;s name and surname, date of birth, type of surgery, prophylactic antibiotic therapy, etc.) and create a sterile area using chloride surgical solution and surgical drapes.</li>
</ol>
3. Pneumoperitoneum creation and trocars&#39; placement
<ol>
	<li>Insert a Veress needle at Palmer&#39;s point, 2 cm below the left coastal margin following the mid-clavicular line, in order to create a pneumoperitoneum. Then insufflate to 10-12 mm CO2.</li>
	<li>After insufflation, mark the positions of the trocars and place them as shown in Figure 3&#160;(4 robot trocars, 2 (12 mm) laparoscopic table-side surgeon trocars).
	<ol>
		<li>First, draw a line from a point, 2 cm to the right of the umbilicus to the costal margin left of the gallbladder. On this line, 11-12 cm downwards from the costal margin, mark the robotic camera trocar, number 3.</li>
		<li>At 7 cm distance left and right from trocar 3, mark trocars 2 and 4.</li>
		<li>Mark trocar 1, 7 cm craniolateral from trocar 2. 
		&#8203;NOTE: This follows the Pittsburgh approach for robot-assisted pancreaticoduodenectomy4,5,6. However, this procedure can also be performed with only one laparoscopic trocar, which can later be used for the extraction of the specimen.</li>
	</ol>
	</li>
</ol>
4. Port placement
<ol>
	<li>Insufflate with a Verres needle at the Palmers&#39; point connected to the CO2 resource. Place a 12 mm table-side surgeon trocar, 7 cm from both robot trocars 2 and 3, to the right of the umbilicus.</li>
	<li>Place the four 8 mm robotic trocars as marked after inspection and removal of the Veress needle.</li>
	<li>Place a second 12 mm table-side surgeon trocar, 7 cm from both trocars 3 and 4. 
	&#8203;NOTE: Make sure the distance between all the trocars is approximately 7 cm.</li>
</ol>
5. Docking
<ol>
	<li>Install the robot over the patient&#39;s right shoulder and dock the robot arms to the robotic trocars. 
	&#8203;NOTE: The final operative setting is shown in Figure 3 and Figure 4. To facilitate a large standalone 3D screen to the patient&#39;s right, have the robot come in cranially, over the patient&#39;s shoulder. To facilitate a comfortable position for the table-side surgeon, ensure that this surgeon sits down with cranially placed trocars and a favorable screen position.</li>
</ol>
6. Treitz mobilization
<ol>
	<li>Cranialize the greater omentum and colon by pushing them aside towards the diaphragm.</li>
	<li>Identify the first jejunal loop from the retroperitoneal cavity through the Treitz ligament.</li>
	<li>Dissect the left side of the ligament of Treitz to free the most distal part of the duodenum and the first part of the jejunum from the aorta using the robotic cautery hook on arm 4 and the laparoscopic vessel sealer.</li>
</ol>
7. Ascending colon and hepatic flexure mobilization
<ol>
	<li>Perform tunneling through the hepatocolic ligament in order to spare vascular structures.</li>
	<li>Perform mobilization of the hepatic flexure and the ascending colon using the robotic cautery hook on arm 4 and the laparoscopic sealing device. 
	&#8203;NOTE: Pay attention to any vascular abnormalities of the right colonic artery.</li>
</ol>
8. Pancreatic head identification and mobilization
<ol>
	<li>Perform the Kocher maneuver by mobilizing the duodenum and the head of the pancreas from the caudal to cranial using the robotic cautery hook and the laparoscopic sealing device. To do so, incise the peritoneum at the right edge of the duodenum and move the duodenum and the head of the pancreas to the left of the patient7.</li>
	<li>Perform the traction of the jejunal loop in the retroperitoneal cavity.</li>
</ol>
9. Duodenal resection
<ol>
	<li>Staple the intestinal loop, 10 cm distally, to the submucosal tattoo.</li>
	<li>Detach the duodenum from its mesentery using a laparoscopic sealing device, by performing a safe and feasible dissection of the mesentery.</li>
	<li>Staple the duodenum at the level of the submucosal tattoo, including the tattoo in the specimen. A robotic endo stapler can be used as well. 
	&#8203;NOTE: The minimum distance of the lesion from the papilla of Vater should be 5 cm. In other situations (e.g., 2-5 cm), a Fogarty balloon-tipped catheter can be passed through the papilla of Vater. This can be confirmed intraoperatively by endoscopy.</li>
</ol>
10. Duodeno-jejunostomy
<ol>
	<li>Create two small enterotomies using robotic scissors with diathermia at the antimesenteric side of the duodenal and jejunal stump.</li>
	<li>Make a side-to-side jejuno-jejunostomy of 60 mm using an endo-stapler with a vascular cartridge (white cartridge).</li>
	<li>Close the remaining anastomosis opening with two layers of running 4-0 suture (~15 cm).</li>
</ol>
11. Drain-placement
<ol>
	<li>In case of a misfire of the stapler or in case of accidental contamination of the abdomen from intestinal fluids, place a drain. 
	&#8203;NOTE: Drain was not placed in this specific case. The patient underwent elective operation with no operative events, so no drain was needed.</li>
</ol>
12. Postoperative management
<ol>
	<li>Remove the nasogastric tube early in the morning of postoperative day 1. Start a soft liquid diet and move on to a normal diet in 24 h.</li>
	<li>Assess serum C-reactive protein (CRP) and leucocyte levels on postoperative days 2, 3, and 4. Perform a CT or MRI scan of the abdomen if CRP on day four is elevated compared to day three or when there are undesired changes in the postoperative course (drain quality, insufficient clinical improvement).</li>
	<li>Discharge the patient earlier if clinically well, eating sufficiently, pain-free, and CRP &#60;150. 
	&#8203;NOTE: The patient was discharged on postoperative day 3, almost pain-free, clinically well, with a CRP value of 67 mg/L.</li>
</ol>
13. Post-discharge management
<ol>
	<li>Perform follow-up medical examination after 10-14 days.</li>
</ol>

<ol>
	<li>Lee, S. Y., 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=Surgical+strategy+and+outcomes+in+duodenal+gastrointestinal+stromal+tumor.">Surgical strategy and outcomes in duodenal gastrointestinal stromal tumor.</a> Annals of Surgical Oncology. 24 (1), 202-210 (2017).</li><li>Zhou, Z. -. 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=Robotic+resection+of+duodenal+gastrointestinal+stromal+tumour:+Preliminary+experience+from+a+single+centre.">Robotic resection of duodenal gastrointestinal stromal tumour: Preliminary experience from a single centre.</a> World Journal of Gastrointestinal Oncology. 13 (7), 706-715 (2021).</li><li>McGuirk, M., Gachabayov, M., Gogna, S., Da Dong, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+duodenal+(D3)+resection+with+Roux-en-Y+duodenojejunostomy+reconstruction+for+large+GIST+tumor:+Step+by+step+with+video.">Robotic duodenal (D3) resection with Roux-en-Y duodenojejunostomy reconstruction for large GIST tumor: Step by step with video.</a> Surgical Oncology. 36, 130 (2021).</li><li>Nota, C. L., 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=Developing+a+robotic+pancreas+program:+the+Dutch+experience.">Developing a robotic pancreas program: the Dutch experience.</a> Journal of Visualized Surgery. 3, 106 (2017).</li><li>Hogg, M. 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=Mastery-based+virtual+reality+robotic+simulation+curriculum:+the+first+step+toward+operative+robotic+proficiency.">Mastery-based virtual reality robotic simulation curriculum: the first step toward operative robotic proficiency.</a> Journal of Surgical Education. 74 (3), 477-485 (2017).</li><li>Tam, V., 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+biotissue+curriculum+has+validity+and+improves+technical+performance+for+surgical+oncology+fellows.">Robotic pancreatoduodenectomy biotissue curriculum has validity and improves technical performance for surgical oncology fellows.</a> Journal of Surgical Education. 74 (6), 1057-1065 (2017).</li><li>Niederle, B. V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Surgery of the Biliary Tract. , (1981).</li><li>Marano, 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=Robotic+treatment+for+large+duodenal+gastrointestinal+stromal+tumor.">Robotic treatment for large duodenal gastrointestinal stromal tumor.</a> Annals of Surgical Oncology. 27 (4), 1101-1102 (2020).</li><li>Thomas, J., Abraham, K., Osilli, D., Mukherjee, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Adult+distal+duodenal+obstruction:+a+diagnostic+and+therapeutic+challenge.">Adult distal duodenal obstruction: a diagnostic and therapeutic challenge.</a> Cureus. 14 (4), e24095 (2022).</li><li>Emmen, A. M. L. 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=Impact+of+shifting+from+laparoscopic+to+robotic+surgery+during+600+minimally+invasive+pancreatic+and+liver+resections.">Impact of shifting from laparoscopic to robotic surgery during 600 minimally invasive pancreatic and liver resections.</a> Surgical Endoscopy. 37 (4), 2659-2672 (2023).</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. 276 (6), e886-e895 (2022).</li><li>Chok, A. -. Y., Koh, Y. -. X., Ow, M. Y. L., Allen, J. C., Goh, B. K. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+systematic+review+and+meta-analysis+comparing+pancreaticoduodenectomy+versus+limited+resection+for+duodenal+gastrointestinal+stromal+tumors.">A systematic review and meta-analysis comparing pancreaticoduodenectomy versus limited resection for duodenal gastrointestinal stromal tumors.</a> Annals of Surgical Oncology. 21 (11), 3429-3438 (2014).</li><li>Lau, J. Y., 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=Through-the-scope+balloon+dilation+for+pyloric+stenosis:+long-term+results.">Through-the-scope balloon dilation for pyloric stenosis: long-term results.</a> Gastrointestinal Endoscopy. 43 (2 Pt 1), 98-101 (1996).</li><li>Shen, Z., 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=Pancreaticoduodenectomy+versus+limited+resection+for+duodenal+gastrointestinal+stromal+tumors:+a+systematic+review+and+meta-analysis.">Pancreaticoduodenectomy versus limited resection for duodenal gastrointestinal stromal tumors: a systematic review and meta-analysis.</a> BMC Surgery. 19, 121 (2019).</li><li>Cloyd, J. M., Norton, J. A., Visser, B. C., Poultsides, G. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Does+the+extent+of+resection+impact+survival+for+duodenal+adenocarcinoma?+Analysis+of+1,611+cases.">Does the extent of resection impact survival for duodenal adenocarcinoma? Analysis of 1,611 cases.</a> Annals of Surgical Oncology. 22 (2), 573-580 (2015).</li><li>Nagaraja, V., Eslick, G. D., Cox, M. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+stenting+versus+operative+gastrojejunostomy+for+malignant+gastric+outlet+obstruction-a+systematic+review+and+meta-analysis+of+randomized+and+non-randomized+trials.">Endoscopic stenting versus operative gastrojejunostomy for malignant gastric outlet obstruction-a systematic review and meta-analysis of randomized and non-randomized trials.</a> Journal of Gastrointestinal Oncology. 5 (2), 92-98 (2014).</li><li>Jeurnink, S. M., van Eijck, C. H. J., Steyerberg, E. W., Kuipers, E. J., Siersema, P. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stent+versus+gastrojejunostomy+for+the+palliation+of+gastric+outlet+obstruction:+a+systematic+review.">Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review.</a> BMC Gastroenterology. 7, 18 (2007).</li></ol>

The authors have nothing to disclose

Stenosis of the duodenum produces vague and confounding symptoms whose severity is mainly related to its severity (partial stenosis, total obstruction) and is often resistant to early attempts at diagnosis. Given the underlying anatomical complexities, the choice of treatment options is difficult, and if possible, it should only be undertaken by an adequate multidisciplinary team (MDT)3,8,9 with experience in robotic pancreatoduodenectomy10,11.
Performing a proper preoperative investigation is crucial. Indeed, endoscopic procedures, such as enteroscopy and endoscopic ultrasound (EUS), are mandatory for investigating the extension of stenosis and its relationship to the papilla of Vater. During the endoscopic procedure, marking with a small 1 cm submucosal ink tattoo, proximally to the lesion, supports intraoperative identification and obtaining negative surgical margins.
The real advantage of limited resection is the possibility of avoiding invasive procedure, such as pancreaticoduodenectomy (PD), without increasing the postoperative morbidity and decreasing the long-term survival12. Due to this rationale, minimally-invasive surgery should be taken into consideration. Indeed, both laparoscopic and robotic approaches could be used to perform this type of intestinal resection. However, the robotic approach has several benefits compared to the laparoscopic approach. Indeed, high-definition 3D vision facilitates and magnifies instrument movement, whereas wristed instruments allow easier intra-abdominal suturing as compared to laparoscopy.
In 2021, a single-center retrospective study in patients with duodenal gastrointestinal stroma cell tumors reported benefits of the robotic approach, compared to the open approach, in terms of a shorter operative time, less intraoperative bleeding, and smaller surgical incisions2. Partial excision of the affected duodenum with side-to-side duodeno-jejunal anastomosis remains controversial due to the technical difficulty of this procedure2,3, particularly concerning the anastomosis. Indeed, a partial duodenectomy is mainly combined with a Roux-en-Y anastomosis since it is feasible and reliable. However, it should be taken into consideration that Roux-en-Y reconstruction could hold an increased risk of gastrointestinal leak due to the execution of one additional anastomosis compared to side-to-side duodeno-jejunal anastomosis. 
As far as malignant diseases are concerned, the choice of the type of surgery is controversial. Some surgeons prefer pancreatoduodenectomy to reduce the risk of residual disease, even if it results in significantly higher postoperative morbidity and mortality13. Besides the higher perioperative morbidity and mortality rates, it is mandatory to consider that pancreatoduodenectomy is mainly performed when dealing with advanced diseases like carcinoma, which in itself has a high recurrence rate14. Recently, it has been reported that limited segmentectomy for limited duodenal cancer appears to offer statistically equivalent long-term survival rates with considerably less morbidity15. Additionally, specific preoperative factors such as tumor, node and metastasis (TNM) stage, tumor grade on histological report, and preoperative radiotherapy seem to be more reliable predictors of patient outcomes than the type of resection15. 
A recent systematic review reported that in patients with cancer-related gastric outlet obstruction, endoscopic stent placement is associated with many positive outcomes compared to gastro-jejunostomy, including reduced hospital stays, lower postoperative mortality, and faster relief of symptoms, despite comparable benefits and complication rates16. However, in patients with longer prognoses, recurrence of obstructive symptoms appears to be significantly more likely after stent placement17. This scenario may encourage stronger consideration of surgical approaches to avoid the need for endoscopic re-intervention.
The main limitation of this surgical technique is related to identifying the diseased loop. Indeed, a small, inked tattoo is the only way to define where the lesion is and perform the resection. However, ink may spread too widely along the submucosa and mark the entire loop, making it almost impossible to identify the correct lines of resections. In order to reduce this risk, the ink tattoo must be as small as possible, and this should be communicated, prior to endoscopy, to the responsible gastroenterologist.
In conclusion, robotic partial duodenal resection with primary side-to-side duodeno-jejunal anastomosis is possible, especially if performed in patients with benign disease (e.g., inflammatory duodenal stenosis) and in highly specialized centers. Future larger prospective studies should confirm the safety and efficacy of this approach.

Indications for partial duodenal resection are few and very specific. These mainly rely on treating gastrointestinal stromal tumors (GISTs), early duodenal carcinomas, and duodenal adenomas that cannot be removed endoscopically. Partial duodenal resection has gained relevance as an alternative to more invasive procedures such as pancreaticoduodenectomy. The anatomical complexity at the junction of the biliary tract, pancreas, and gastrointestinal tract, as well as the special physiological functions of the duodenum, makes it difficult for any surgeon to approach it during surgery. Therefore, as with any complex surgical technique, it is difficult to have a consensus of choice1,2. Due to its complexity and tight surgical indications, partial duodenal resection should be performed only at centers performing pancreatoduodenectomies.
In the last decades, there has been a rapid development in robot-assisted minimally invasive surgery with the aim to reduce pain and enhance recovery compared to open surgical procedures. Nowadays, when dealing with partial duodenal resection, reconstruction with Roux-en-Y anastomosis is feasible and reliable. Even if partial excision of the affected duodenum with side-to-side duodeno-jejunal anastomosis seems equally effective, technical difficulty and outcome of the methods have not been described in detail2,3.
We present a case of a 75-year-old female who underwent endoscopic mucosal resection (EMR) for a 5 cm adenoma with focal high-grade dysplasia, which results in reactive stenosis. Due to severe dysphagia, the inability to cure the stenosis with endoscopy, and the absence of relation to the papilla of Vater (no obstruction in the pancreatobiliary tree), the multidisciplinary team decided to enroll the patient in a robotic D3 partial duodenal resection with primary side-to-side duodeno-jejunal anastomosis.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>SYSTEM</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>da Vinci Surgeon Console&#160;</td>
			<td>IS&#160;</td>
			<td>SS999&#160;</td>
			<td>Used to control the surgical robot.&#160;</td>
		</tr>
		<tr>
			<td>da Vinci Vision Cart&#160;</td>
			<td>IS</td>
			<td>VS999&#160;</td>
			<td>The vision cart houses advanced vision and energy technologies and provides communications across da Vinci system components&#160;</td>
		</tr>
		<tr>
			<td>da Vinci Xi&#160;</td>
			<td>IS&#160;</td>
			<td>K131861&#160;</td>
			<td>The surgical robot: &#8217;patient side-cart&#8217;&#160;</td>
		</tr>
		<tr>
			<td>INSTRUMENTS&#160;</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Cobra Liver Retractor Diamond-Flex&#160;</td>
			<td>CareFusion&#160;</td>
			<td>89-6216&#160;</td>
			<td>Retracting the liver for optimal exposure of the surgical site.&#160;</td>
		</tr>
		<tr>
			<td>da Vinci Xi Endoscope with Camera, 8 mm, 30&#176;&#160;</td>
			<td>IS</td>
			<td>470027</td>
			<td>The camera of the da Vinci robot.&#160;</td>
		</tr>
		<tr>
			<td>ENDOEYE Rigid Video Laparoscope, 10 mm, 30&#176;&#160;</td>
			<td>Olympus</td>
			<td>WA50042A&#160;</td>
			<td>Toseewithintheintra-abdominal cavity.&#160;</td>
		</tr>
		<tr>
			<td>ENDOWRIST Fenestrated Bipolar Forceps&#160;</td>
			<td>IS</td>
			<td>470205</td>
			<td>Used for dissection and coagulation&#160;</td>
		</tr>
		<tr>
			<td>ENDOWRIST HOT SHEARS&#160;</td>
			<td>IS&#160;</td>
			<td>470179</td>
			<td>Used for cutting and coagulation.&#160;</td>
		</tr>
		<tr>
			<td>ENDOWRIST Mega SutureCut Needle Driver&#160;</td>
			<td>IS</td>
			<td>470309</td>
			<td>Used as a needle driver.</td>
		</tr>
		<tr>
			<td>ENDOWRIST Permanent Cautery Hook&#160;</td>
			<td>IS&#160;</td>
			<td>470183</td>
			<td>Used for coagulation.&#160;</td>
		</tr>
		<tr>
			<td>ENDOWRIST PROGrasp Forceps</td>
			<td>IS</td>
			<td>470093</td>
			<td>Used for dissection.</td>
		</tr>
		<tr>
			<td>LigaSure Maryland Jaw</td>
			<td>Medtronic&#160;</td>
			<td>LF1937</td>
			<td>Used for vessel sealing&#160;</td>
		</tr>
		<tr>
			<td>SUTURES</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Vicryl 2-0&#160; x2</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>V-loc barbed 4-0 15 cm x2&#160;</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Monocryl 4-0 x2</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>STAPLER</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Echelon 60mm white cartridge&#160;</td>
			<td>Ethicon</td>
			<td>GST60W</td>
			<td>Used for stapling</td>
		</tr>
	</tbody>
</table>

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.

Representative results are shown in Table 1. The operative time was 84 min with 20 mL of blood loss. The postoperative course of the patient was uneventful. The nasogastric tube (NGT) was removed early in the morning of postoperative day 1 (POD1). The patient restarted feeding at POD2 and was discharged in a good condition on POD3. Pathological assessment reported the removal of a 5 cm adenoma with focal high-grade dysplasia and negative margins.
The patient had a follow-up visit two weeks after surgery, where she reported postprandial pain associated with episodes of vomit and occasional episodes of fever (T&#176;&#60; 38 &#176;C). She underwent a CT scan, which reported no fluid collection in the abdomen and no signs of suffering to the liver, pancreas, stomach, and small intestine (Figure 5 and Figure 6). At a further follow-up visit, the patient reported a total reduction of the previously reported symptoms. The surgical follow-up was then stopped.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/65742/65742fig01.jpg" /> 
Figure 1: Preoperative assessment. Preoperative imaging with CT scan to assess the localization and the extent of the duodenal stenosis. <a href="https://www.jove.com/files/ftp_upload/65742/65742fig01large.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/65742/65742fig02.jpg" /> 
Figure 2: Preoperative assessment. Preoperative gastroscopy to describe the stenosis, its location, and its relationship with the papilla of Vater. <a href="https://www.jove.com/files/ftp_upload/65742/65742fig02large.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/65742/65742fig03.jpg" /> 
Figure 3: Trocars&#39; 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/65742/65742fig03large.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/65742/65742fig04.jpg" /> 
Figure 4: Set up of the robot during surgery. <a href="https://www.jove.com/files/ftp_upload/65742/65742fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/65742/65742fig05.jpg" /> 
Figure 5: Coronal plane CT scan performed two weeks after surgery. Coronal plane at the level of the duodeno-jejunal anastomosis <a href="https://www.jove.com/files/ftp_upload/65742/65742fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/65742/65742fig06.jpg" /> 
Figure 6: Axial plane CT scan performed two weeks after surgery. Axial plane at the level of the duodenojejunal anastomosis <a href="https://www.jove.com/files/ftp_upload/65742/65742fig06large.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>Intraoperative</td>
			<td></td>
		</tr>
		<tr>
			<td>Operative time, minutes</td>
			<td>84</td>
		</tr>
		<tr>
			<td>Intraoperative blood loss, ml</td>
			<td>20</td>
		</tr>
		<tr>
			<td>Postoperative</td>
			<td></td>
		</tr>
		<tr>
			<td>Postoperative complications&#160;</td>
			<td>none</td>
		</tr>
		<tr>
			<td>Hospital length of stay, days</td>
			<td>4</td>
		</tr>
		<tr>
			<td>Discharge, postoperative day</td>
			<td>3</td>
		</tr>
		<tr>
			<td>Pathology</td>
			<td>Radical removal of a 5cm adenoma 
			High-grade dysplasia</td>
		</tr>
	</tbody>
</table>
Table 1: Representative results of the surgery.

Watch this Scientific Journal Video about Robotic D3 Partial Duodenal Resection with Primary Side-to-Side Anastomosis at JoVE.com

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

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.

Duodenal stenosis is a condition that can be related to several diseases, being either intrinsic, such as neoplasm and inflammatory stenosis, or ...

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1.5K Views.  University of Amsterdam. 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. 

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

Murine Ileocolic Bowel Resection with Primary Anastomosis

Intestinal resections are frequently required for treatment of diseases involving the gastrointestinal tract, with Crohn&#8217;s disease and colon cancer being two common examples. Despite the frequency of these procedures, a significant knowledge gap remains in describing the inherent effects of intestinal resection on host physiology and disease pathophysiology. This article provides detailed instructions for an ileocolic resection with primary end-to-end anastomosis in mice, as well as essential aspects of peri-operative care to maximize post-operative success. When followed closely, this procedure yields a 95% long-term survival rate, no failure to thrive, and minimizes post-operative complications of bowel obstruction and anastomotic leak. The technical challenges of performing the procedure in mice are a barrier to its wide spread use in research. The skills described in this article can be acquired without previous surgical experience. Once mastered, the murine ileocolic resection procedure will provide a reproducible tool for studying the effects of intestinal resection in models of human disease.

Ileocolic resection is commonly performed in several human diseases; however, little is known regarding the impact of intestinal resection on surgical illnesses. This article provides instruction on executing the procedure in mice with high success, providing a means to study the effects of ileocolic resection in models of disease.

Intestinal resections are frequently required for treatment of diseases involving the gastrointestinal tract, with Crohn&#8217;s disease and colon cancer ...

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 ...

Endoscopic Septoplasty with Limited Two-line Resection: Minimally Invasive Surgery for Septal Deviation

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal deviation. It has a long history with multiple variations. In this article, a modified endoscopic septoplasty procedure using the limited two-line resection (2LoRs) technique at the posterior and inferior junction of the cartilaginous and bony septum is presented based on embryologic and anatomic knowledge of the nasal septum and the biomechanics of cartilaginous behavior. With this procedure, the quadrangular cartilage can be preserved as much as possible, which is helpful in retaining the supporting framework and rigidness of the septum. 2LoRs has been proven effective and sound for the correction of nasal septal deviation with rare complications. This modified procedure can be applied to correct the deviated nasal septum in the absence of any external nasal deformity to improve nasal patency or to improve access to the middle meatus or to the axillary region of the middle turbinate. It may also be used to expand the indications of septoplasty to children and adolescents because of its minimally invasive approach.

Endoscopic septoplasty is a time-honored surgical procedure with multiple variations. This paper focuses on a step-by-step surgical approach to perform a modified septoplasty procedure known as limited two-line resection. This surgical technique can be applied to correct a deviated nasal septum in the absence of an external nasal deformity.

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal ...

Vessel-sparing Excision and Primary Anastomosis

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short bulbar or posterior urethral strictures, urethroplasty by excision and primary anastomosis (EPA) is recommended. As EPA only requires the excision of the narrowed segment and the surrounding spongiofibrosis, a full-thickness transection of the corpus spongiosum, as performed in the traditional transecting EPA (tEPA), is usually unnecessary. Jordan et al. introduced the idea of a vessel-sparing approach in 2007, aiming to reduce surgical trauma, especially to the dual arterial blood supply of the urethra, and, thus, potentially reducing the risk of postoperative erectile dysfunction or glans ischemia. This approach could also be beneficial for subsequent urethral interventions such as redo urethroplasty using a free graft, in which a well-vascularized graft bed is imperative. Nevertheless, these potential benefits are only assumptions as prospective studies comparing the functional outcome of both techniques with validated questionnaires are currently lacking. Moreover, vessel-sparing EPA (vsEPA) should at least be able to provide similar surgical outcomes as tEPA. The aim of this paper is to give an elaborate, step-by-step overview of how to manage patients with isolated short bulbar or posterior urethral strictures with vsEPA. The main objective of this manuscript is to outline the surgical technique and to report the representative surgical outcome. A total of 117 patients were managed according to the described protocol. The analysis was performed on the entire patient cohort and on the bulbar (n = 91) and posterior (n = 26) vsEPA group separately. Success rates were 93.4% and 88.5% for the bulbar and posterior vsEPA, respectively. To conclude, vsEPA, as outlined in the protocol, provides excellent success rates with low complication rates for isolated short bulbar and posterior urethral strictures.

Here, we present an elaborate and efficient protocol to treat isolated short bulbar or posterior urethral strictures with vessel-sparing excision and primary anastomosis.

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short ...

One-anastomosis Gastric Bypass (OAGB) in Rats

The goal of this protocol is to set up a preclinical model of bariatric surgery and, more specifically, OAGB in obese rats. Based on this preclinical model, longitudinal studies can be carried out to provide an improved understanding of the mechanisms underlying the outcomes seen after bariatric surgery in humans. For this purpose, rats are operated on through a laparotomy under general anesthesia with isoflurane. First, the surgeon creates a long and tubular gastric pouch: after greater curve and hiatal dissection, the nonglandular stomach is stapled and removed. Then, the remaining stomach is also stapled in order to create a gastric tube and exclude the antrum of the stomach. After that, the surgeon performs a single end-to-side gastrojejunostomy 35 cm from the duodenojejunal angle. This limb length has been chosen in order to reproduce the same ratio between the biliopancreatic limb (BPL) and common limb (CL) length as in human bariatric surgery. The operation ends by aponeurotic and cutaneous closure. The early postoperative management consists of subcutaneous hydration, an intramuscular prophylactic antibiotic injection, a parietal injection of xylocaine, the administration of painkillers, and a progressive reintroduction of diet.

One-anastomosis Gastric Bypass OAGB in Rats

This protocol is for the performance of one-anastomosis gastric bypass (OAGB) on rat. The operator performs a long and tubular-stapled gastric pouch followed by hand-sewn anastomosis. For this model, the operator reproduces the same ratio between biliopancreatic and common limb in humans; therefore, the biliopancreatic limb measures 35 cm.

The goal of this protocol is to set up a preclinical model of bariatric surgery and, more specifically, OAGB in obese rats. Based on this preclinical ...

Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of the pancreas. The aim of central pancreatectomy is to prevent postoperative life-long endocrine and exocrine insufficiency. The downside of central pancreatectomy is the high rate of postoperative pancreatic fistula, which is the main reason that many surgeons do not routinely use central pancreatectomy in eligible patients. Most studies report open or laparoscopic central pancreatectomy with a pancreatico-gastrostomy anastomosis in adults. This is the first description of a standardized approach to robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy reconstruction in an adolescent (16-year-old boy) with a pseudopapillary tumor in the body of the pancreas. The operation time was 248 min with 20 mL of blood loss. The postoperative course was uneventful except for the short-term medical treatment for a grade B pancreatic fistula. Robotic central pancreatectomy can be safely applied in selected patients in experienced centers.

Robotic central pancreatectomy may be used in selected patients in experienced centers. This protocol presents all steps and the feasibility of a robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy in a 16-year-old adolescent patient.

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of ...

Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy Model in Mice

Obesity is a major health issue worldwide. As a response, bariatric surgeries have emerged to treat obesity and its related comorbidities (e.g., diabetes mellitus, dyslipidemia, non-alcoholic steatohepatitis, cardiovascular events, and cancers) through restrictive and malabsorptive mechanisms. Understanding the mechanisms by which these procedures allow such improvements often require their transposition into animals, especially in mice, because of the ease of generating genetically modified animals. Recently, the single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) has emerged as a procedure that uses both restrictive and malabsorptive effects, which is being used as an alternative to gastric bypass in case of major obesity. Thus far, this procedure has been associated with strong metabolic improvements, which has led to a marked increase in its use in daily clinical practice. However, the mechanisms underlying these metabolic effects have been poorly studied as a result of a lack of animal models. In this article, we present a reliable and reproducible model of SADI-S in mice, with a special focus on perioperative management. The description and use of this new rodent model will be helpful for the scientific community to better understand the molecular, metabolic, and structural changes induced by the SADI-S and to better define the surgical indications for clinical practice.

Single-anastomosis duodeno-ileal bypass (SADI-S) is an emerging bariatric procedure with important metabolic effects. In this article, we present a reliable and reproducible model of SADI-S in mice.

Obesity is a major health issue worldwide. As a response, bariatric surgeries have emerged to treat obesity and its related comorbidities (e.g., diabetes ...

Microscopic Cyst Resection for the Treatment of Patients Diagnosed with Epididymal Cyst

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative asoedema, hematoma, sustaining pain, and seminal tract obstruction in patients who have undertaken nonmicroscopic epididymal cyst resection or epididymal resection. Nonmicroscopic epididymal cyst surgery is suggested for patients with childbirth plans as a precaution. The treatment of male epididymal cysts via microtechnology is obviously a beneficial option; we took the lead in carrying out microscopic epididymal exploration and cyst resection surgery in China. From September 2017 to April 2021, 41 young and middle-aged male patients diagnosed with epididymal cysts underwent microtechnology treatment in a program titled &#34;microscopic epididymal exploration and cystectomy&#34;. The postoperative follow-up lasted for 3-50 months. The results confirmed that, as microscopic manipulation largely improved visualization of the subtle tissue structures of the epididymis, the cyst could be clearly dissected apart and completely removed intact under the microscope. Bleeding during the operation was significantly reduced (2-3 mL) and wound drainage was not required. According to follow-up data, microscopic treatment significantly reduced the incidence of postoperative scrotal hematoma, edema, and long-term postoperative pain, thereby promising a higher surgical success rate as well as recurrence prevention. Besides, preliminary experience and reflection suggest that microscopic epididymal exploration and cystectomy provide efficient preservation of the epididymal patency through refined treatment, while a better prognosis can be achieved. We recommend that surgery be carried out before the epididymal cyst develops to 0.8 cm in diameter, for fear that a larger epididymal cyst (&#62;0.9 cm in diameter) could cause the complete destruction of all tubules of the ipsilateral epididymis - a more severe case with damage to the testicular output network.

Here, we present a protocol to treat patients diagnosed with an epididymal cyst using microscopic cyst resection. Based on microscopic manipulation, a largely improved visualization of the subtle tissue structures of the epididymis was obtained, so the cyst could be clearly dissected apart and completely removed intact.

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative ...

Robotic Myotomy and Partial Fundoplication for Achalasia

Laparoscopic Heller myotomy is currently considered the standard definitive treatment of achalasia. With the advancements in technology, robotic Heller myotomy has emerged as an alternative approach to traditional laparoscopy due to three-dimensional (3D) visualization, fine motor control, and improved ergonomics provided by the robot. 
Although there is a lack of randomized controlled trials, robotic-assisted Heller myotomy seems to be associated with lower rates of intraoperative perforations compared to the laparoscopic approach. A robotic approach may also improve surgical outcomes by providing a more complete myotomy. 
Here, we describe the detailed steps of robotic myotomy and partial fundoplication for achalasia.

Surgical myotomy with a partial fundoplication may be used in selected patients as a definitive treatment for achalasia. This article provides a step-by-step description of a robotic myotomy and partial fundoplication in a 32-year-old patient with megaesophagus.

Laparoscopic Heller myotomy is currently considered the standard definitive treatment of achalasia. With the advancements in technology, robotic Heller ...

Application of Mid-Pancreatectomy with End-to-End Anastomosis in Pancreatic Benign Tumors

Mid-pancreatectomy combined with end-to-end anastomosis is a surgical procedure used to treat benign pancreatic tumors. It involves removing the tumor from the middle section of the pancreas and connecting the proximal and distal ends through an anastomosis. The traditional surgical approach for resecting the middle segment of the pancreas involves closing the proximal pancreas and creating a Roux-en-Y anastomosis with the jejunum. However, this approach carries a double risk of pancreatic stump fistula and pancreatico enteric anastomotic leak postoperatively. In this paper, a new procedure is described where stent tubes were placed into the proximal and distal sides of the pancreatic ducts after ensuring sufficient freedom from the proximal distal pancreas. The pancreatic parenchyma was then sutured continuously under direct vision to achieve pancreatic end-to-end anastomosis. This procedure helps preserve pancreatic function, reducing the risk of postoperative pancreatic insufficiency. However, due to the complexity and risks involved, thorough evaluation and preparation are necessary before surgery. We carefully assess the patient's history, serology, and imaging results to determine the feasibility and effectiveness of the procedure. During surgery, we consider the use of a suitable pancreatic duct stent to ensure the flow of pancreatic juice into the intestine through physiological pathways. Our goal is to remove the tumor while preserving as much normal pancreatic tissue as possible for the anastomosis. After the operation, it is crucial to monitor the patient's pancreatic function, paying close attention to blood glucose levels, drainage fluid volume, and amylase value of the pancreatic anastomosis. During the postoperative follow-up visit, the patient's pancreatic function was assessed, and there was no significant change in quality of life compared to before the surgery. This indicates that mid-pancreatectomy combined with end-to-end anastomosis is a safe and effective procedure for treating pancreatic benign neoplasms.

The present protocol describes the application of mid-pancreatectomy combined with end-to-end anastomosis in the surgical treatment of pancreatic benign tumors, which presents a feasible solution for managing such tumors while concurrently preserving pancreatic function.

Mid-pancreatectomy combined with end-to-end anastomosis is a surgical procedure used to treat benign pancreatic tumors. It involves removing the tumor ...