This work was supported by grants from the Project of Guangdong Clinical Medical Research Center of Digestive Diseases (2020B1111170004), National Key Clinical Discipline, and the program of Guangdong Provincial Clinical Research Center for Digestive Diseases.

The operation is routine and has received ethical approval. The research content and methods meet the medical ethics norms and requirements. The Ethics Committee of the Six Affiliated Hospitals of Sun Yat-sen University approved this study. The patient provided written informed consent.
1. Patient selection
<ol>
	<li>Use the following inclusion criteria: benign duodenal tumors, including adenoma, stromal cell tumor, lipoma, fibroma, and hemangioma.</li>
	<li>Use the following exclusion criteria: malignant tumors of the duodenum, including adenocarcinoma, leiomyosarcoma, malignant lymphoma, carcinoid, etc. Additionally, patients with severe comorbidities such as heart disease and diabetes, coagulation disorders or predispositions to bleeding, severe systemic infections, or a poor overall health status that renders them unsuitable for surgery are excluded. Furthermore, patients who have personally declined the surgical procedure will also be excluded.</li>
</ol>
2. Preoperative preparation, operative position, and anesthesia
<ol>
	<li>Ask the patient to adhere to a low-fat, low-salt, and low-sugar diet the day before the surgical operation and to refrain from consuming food or water for at least 8 h prior to the surgery.</li>
	<li>Place the patient in a supine position with the head elevated and slightly tilted to the left.</li>
	<li>Administer general anesthesia using 1%-4% sevoflurane, cyclopofol (10 mg/mL), cisatracurium (2 mg/mL), and sufentanil (5 &#181;g/mL). Perform endotracheal intubation. Evaluate the anesthetic effect based on the patient&#39;s post-anesthesia and intraoperative conditions, including the presence of a complete anesthesia block, the absence of additional drugs during the procedure, and the stability of vital signs.</li>
</ol>
3. Surgical procedure
<ol>
	<li>Make a vertical incision 1 cm below the navel and insufflate carbon dioxide using a Veress needle into the abdominal cavity to create a pneumoperitoneum. This causes the abdomen to inflate, providing a larger and clearer surgical field, which facilitates the procedure. Then, insert a 10 mm trocar and introduce the laparoscope (the third arm of the robot) after establishing the pneumoperitoneum.</li>
	<li>Explorate the intraperitoneal organs to observe that there were no ascites (identified as fluid visible inside the abdomen) and there were no signs of tumor implantation or metastasis. If there are signs of tumor implantation or metastasis, nodules or lesions will be visible in areas outside the primary tumor site on the camera.</li>
	<li>Place the other three trocars in the following positions: a 10 mm trocar in the right anterior axillary line level (the first arm of the robot), a 10 mm trocar in the medial to the intersection of the umbilical level and the midclavicular line (the second arm of the robot), a 10 mm trocar in the 5 cm above the umbilicus, at the left midclavicular line (the fourth arm of the robot). Additionally, prepare two 12 mm auxiliary ports located on the vertical line at the midpoint between trocars numbered 2 and 3 and medial to the left midclavicular line (see Figure 4).</li>
	<li>Connect to the robot operating lever and perform the laparoscopic operation with the robot&#39;s assistance (see Figure 5).</li>
	<li>Mobilize the descending and horizontal parts of the duodenum through a Kocher incision.</li>
	<li>Use an ultrasonic knife to dissect the descending part of the duodenum of about 8 cm (see Figure 6) and identify the duodenal papillary mass.</li>
	<li>Use an ultrasonic knife to incise the duodenal fold and muscle layer with a cut depth of 3-5 mm around the tumor. Fully excise the tumor and freeze the specimens immediately to examine. The results revealed no malignant evidence in the duodenal papillary adenoma.</li>
	<li>Use a 4-0 absorbable line to anastomose discontinuously the incised duodenal fold, muscle layer, and the stump of the confluent part of the biliary pancreatic duct.</li>
	<li>Place the stent tube to support them (see Figure 7). Use 4-0 priline to suture and place the stent into the distal part of the duodenum (see Figure 8). 
	NOTE: The diameter and length of the stent tube were 2.67 mm and 10 cm, respectively. (see Table of Materials).</li>
	<li>Suture intermittently the mucosal layer of the duodenal incision and the plasma muscle layer to bury the wound using 3-0 putis (see Figure 9).</li>
	<li>Rinse the abdominal cavity with saline to check for any bleeding points and place a drain at Winslow foramena and para duodenum, respectively. Finally, use 4-0 silk to suture the incision, and the operation is concluded.</li>
</ol>
4. Postoperative nursing and monitoring
<ol>
	<li>Perform ECG monitoring and administer low-flow oxygen post-operation.</li>
	<li>Encourage the patient to consume a semi-liquid diet and engage in bed exercises on the 1st day after surgery.</li>
	<li>Administer anti-inflammatory, hemostatic, analgesic, albumin, and acid suppression treatments.</li>
	<li>Monitor changes in amylase and bilirubin levels in the drainage tube on the 1st, 2nd, 3rd, 5th, 7th, and 9th day post-operation. 
	NOTE: It is crucial to maintain the patency of the drainage tube and to ensure the early recovery of gastrointestinal function.</li>
</ol>

<ol><li>Siegel, R. L., Giaquinto, A. N., Jemal, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Cancer+statistics%2C+2024%5BTitle%5D)+AND+%22CA+Cancer+J+Clin%22%5BJournal%5D)">Cancer statistics, 2024.</a> CA Cancer J Clin. 74 (1), 12-49 (2024).</li>
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<li>Chappuis, C. W., Divincenti, F. C., Cohn, I. Jr <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Villous+tumors+of+the+duodenum%5BTitle%5D)+AND+%22Ann+Surg%22%5BJournal%5D)">Villous tumors of the duodenum.</a> Ann Surg. 209 (5), 593-599 (1989).</li>
<li>Li, Z., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+value+of+endoscopic+resection+for+non-ampullary+duodenal+lesions%3A+A+single-center+experience%5BTitle%5D)+AND+%22Saudi+J+Gastroenterol%22%5BJournal%5D)">The value of endoscopic resection for non-ampullary duodenal lesions: A single-center experience.</a> Saudi J Gastroenterol. 27 (5), 302-308 (2021).</li>
<li>Farnell, M. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Villous+tumors+of+the+duodenum%3A+Reappraisal+of+local+vs.+extended+resection%5BTitle%5D)+AND+%22J+Gastrointest+Surg%22%5BJournal%5D)">Villous tumors of the duodenum: Reappraisal of local vs. extended resection.</a> J Gastrointest Surg. 4 (1), 13-21 (2000).</li>
<li>Heidecke, C. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Impact+of+grade+of+dysplasia+in+villous+adenomas+of+Vater%27s+papilla%5BTitle%5D)+AND+%22World+J+Surg%22%5BJournal%5D)">Impact of grade of dysplasia in villous adenomas of Vater's papilla.</a> World J Surg. 26 (6), 709-714 (2002).</li>
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<li>Cavallini, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Large+periampullary+villous+tumor+of+the+duodenum%5BTitle%5D)+AND+%22J+Hepatobiliary+Pancreat+Surg%22%5BJournal%5D)">Large periampullary villous tumor of the duodenum.</a> J Hepatobiliary Pancreat Surg. 14 (5), 526-528 (2007).</li>
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</ol>

The authors have no conflicts of interest or financial ties to disclose.

Duodenal benign tumors are infrequent in clinical practice, yet they can lead to severe complications1,15,16. The choice of treatment depends on factors such as the size, location, and tissue type of the lesion. Given the relatively fixed position of the duodenum, which is often situated posterior to the peritoneum and closely associated with the head of the pancreas and the ampulla of the bile pancreatic duct, intraoperative bleeding can present significant challenges due to their shared blood supply17. Additionally, perforation complicates suturing and clinical management. Therefore, surgical planning for duodenal benign tumors must take into account the unique anatomy of the duodenum as well as the characteristics of the tumor itself. For example, villous adenoma has a recurrence rate of 32%-43% following local resection, with a subsequent malignant transformation rate of 24%-50% after recurrence18,19. Consequently, duodenal villous adenoma with a high malignant potential should be promptly addressed through surgical intervention upon detection.
In 1899, Halsted first described transduodenal papillectomy or ampullectomy, as a treatment for benign tumors of the duodenum20. Perez et al. suggested that endoscopic removal could be considered for duodenal tumors smaller than 1 cm, while tumors larger than 2 cm may require surgical resection3. Furthermore, Cavallini et al. recommended pancreaticoduodenectomy for large villous adenomas21. Various surgical options have been employed historically, including endoscopic local tumor resection, laparoscopic or open duodenotomy local tumor resection, intestinal wedge resection, pancreato-sparing duodenectomy, and pancreaticoduodenectomy11,19,21,22,23. Among these, local tumor resection for small benign duodenal masses has demonstrated lower postoperative complication rates, including pancreatic fistula, biliary fistula, infection, and bleeding, as well as reduced mortality rates24,25,26,27. In 2003, Rosen et al. reported the first case of laparoscopic resection of a tubular villous adenoma in the ampulla11. Laparoscopic transduodenal tumor resection, particularly involving the duodenal papilla, has been rarely reported12,28. The introduction of robotic surgery has provided a three-dimensional, stable, and enlarged surgical field of view, along with enhanced instrument maneuverability, enabling fine and precise surgical procedures. Stephanie et al. presented the first multicenter experience of robot-assisted duodenectomy, demonstrating the feasibility and safety of the procedure29.
When it comes to the significance with respect to existing methods, the surgical approach described in this study employs a novel technique that combines local tumor resection with robotic assistance. Robot-assisted techniques present several advantages over traditional open and laparoscopic surgeries, including enhanced precision, reduced blood loss, and shorter recovery times. The specific steps include a longitudinal incision in the duodenum to excise the pancreaticobiliary junction tumor, the placement of a bile duct stent, a mucosa-to-mucosa anastomosis between the bile duct and the duodenum, and suturing of the duodenal incision at stage I. The use of this system enhanced visualization, facilitated precise operations, reduced duodenal pull injury and surgical trauma, improved the accuracy of biliary stent suture fixation, and allowed for a more effective biliary-duodenal mucosa-to-mucosa anastomosis, ultimately resulting in a shorter postoperative recovery time. Furthermore, it is recommended to perform endoscopic ultrasonography prior to surgery to assess tumor depth and mitigate the risk of perforation. To minimize the risk of postoperative duodenal intestinal stenosis, it is advised to excise the tumor along the longitudinal axis of the duodenum as extensively as possible during local resection. Notably, due to the challenges associated with preoperative biopsy for malignancy determination, a pathological examination of frozen sections during surgery is preferred. If malignancy is suspected, pancreaticoduodenectomy should be considered30. In instances where intraoperative frozen pathology results are benign but postoperative pathology results indicate cancer, pancreaticoduodenectomy may be employed as a corrective measure21.
While this technique presents numerous advantages, it also has certain limitations. The learning curve associated with mastering robotic systems can be steep, necessitating extensive training and experience. Furthermore, the high cost and limited availability of robotic equipment may hinder widespread adoption, especially in resource-constrained environments31,32. Additionally, there are potential risks linked to robotic surgery, including equipment malfunctions and the necessity to convert to open surgery in the event of complications.
To sum up, robot-assisted pancreaticobiliary junction resection for benign tumors of the duodenal papilla is a feasible procedure, as evidenced by the successful recovery of the patient in this case. The critical steps of the protocol include a longitudinal incision of the duodenum, tumor removal at the pancreaticobiliary junction, placement of a bile duct stent, bile duct mucosa-to-mucosa anastomosis with the duodenum, and stage I suturing of the duodenal incision. Modifications to the technique may be necessary to accommodate patient-specific anatomy or tumor characteristics. In our experience, adjustments to the positioning of robotic arms can enhance access to challenging areas. For example, altering the angle of the camera port can improve visualization of the duodenal papilla. Close post-operative monitoring and timely intervention are essential to minimize complications. This approach not only eliminates the need for resections of the pancreatic head and biliary tract but also reduces the risk of pancreatic and biliary fistulas that may occur with digestive tract reconstruction following resection while avoiding damage to adjacent organs. It enhances surgical safety, accelerates patient recovery, decreases complications, and shortens hospital stays.
Furthermore, the potential future applications of robot-assisted pancreaticobiliary junction resection are extensive. This technique may be adapted for more complex pancreaticobiliary surgeries, including those involving malignant tumors. Further research could investigate the integration of robotic systems with augmented reality and artificial intelligence to enhance surgical planning and execution. Such innovations hold promises for improving surgical outcomes and broadening the scope of minimally invasive surgery. However, given the limited scope of this study, which involves only one case and the relatively underutilized nature of robot-assisted procedures, further research is warranted to validate the advantages of robot-assisted pancreaticobiliary junction resection.

Duodenal tumors are relatively rare, exhibiting a low incidence, and can be classified as benign or malignant. Primary duodenal tumors (PTD) are the most common, while secondary tumors are less frequent1,2. Common benign tumors in the duodenum include adenoma, stromal cell tumor, lipoma, fibroma, and hemangioma, with adenoma being the most prevalent and possessing the potential for malignant transformation3,4,5. The disease typically presents insidiously, with early stages often being asymptomatic or displaying non-specific symptoms such as upper abdominal fullness, dull pain, and discomfort. As the disease progresses, symptoms may include anemia, jaundice, gastrointestinal bleeding, fever, abdominal mass, and intestinal obstruction, thus posing a significant threat to public health6. Surgical resection remains the preferred treatment for benign neoplasms in the duodenum7.
The generalized pancreaticobiliary junction encompasses the pancreatic head, the duodenal wall segment of the common bile duct, the pancreatic segment, the descending part of the duodenum, and the surrounding tissue of the pancreatic head. More specifically, it is defined as the point where the common bile duct terminates, the main pancreatic duct opens, and the area between the duodenal papilla anatomically referred to as the ampulla of Vater or the papilla8. Tumors at this junction can obstruct the outflow of fluids, leading to increased pressure within the ducts, dilation, stasis, and stone formation. Additionally, these tumors can disrupt fluid flow, leading to reflux, inflammation, and further tumor growth9,10. In recent years, laparoscopic biliary and pancreatic surgeries have gained popularity and success due to advancements in minimally invasive techniques. Traditional treatment methods for benign tumors of the duodenal papilla include endoscopic resection, local transduodenal resection, and pancreaticoduodenectomy11,12.
Although laparoscopy has been widely adopted in surgical practice, there have been few reports on the resection of benign duodenal tumors, particularly those involving the duodenal papilla11,13,14. In this study, an innovative treatment method was employed, involving robot-assisted pancreaticobiliary junction resection and duodenal anastomosis following biliary stent implantation. The overall goal of this approach is to restore bile duct patency while excising the tumor, preserving digestive system function, and minimizing the risk of complications. The rationale for this approach lies in its capacity to merge the precision of robotic surgery with the advantages of minimally invasive techniques. This method provides enhanced visualization, increased dexterity, and improved control during complex dissections, especially in delicate anatomical regions such as the pancreaticobiliary junction. By integrating an advanced robotic system, this approach not only facilitates lesion removal but also restores bile duct patency, preserves digestive system functionality, and minimizes complications such as bile leakage, pancreatic leakage, bleeding, and infection, ultimately demonstrating positive clinical outcomes.
CASE PRESENTATION: 
This study presents a 66-year-old female patient who was admitted to the hospital due to abdominal pain persisting for over a month. A CT scan revealed a 13 mm x 13 mm mass in the duodenal papillary area, characterized by a distinct boundary (see Figure 1). Preoperative gastroscopy indicated an enlarged duodenal papilla with surface congestion and erosion (see Figure 2A-B). Additionally, ultrasound gastroscopy demonstrated an occupied duodenal papilla measuring approximately 19.1 mm x 15.4 mm, extending to the end of the main pancreatic duct (see Figure 2C-D). Pathological analysis using Hematoxylin and Eosin (HE) staining confirmed the presence of a duodenal papillary villous tubular adenoma (see Figure 3). The patient had no significant medical history, and her physical examination findings and laboratory results were unremarkable.

<table><tbody><tr><td>Abdominal instrument button</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Abdominal instrument cap</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Abdominal instrument collar</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Abdominal instrument connector</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Barbs</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Blade</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Blood pad</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Cloth towel forceps</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Da Vinci robot (IV)</td><td>Intuitive Surgical, USA</td><td>/</td><td>/</td></tr><tr><td>Disposable drainage tube</td><td>Johnson &amp;amp; Johnson</td><td>412280</td><td>10 cm x 2.67 mm</td></tr><tr><td>Electric knife head</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Forceps</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Hilt</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Holding flask</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Intestinal forceps</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Laparoscope</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Laparoscopic instruments</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Long curved forceps</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Medium curved forceps</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Needle holders</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Ovoid forceps</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Paraffin oil</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Purse string forceps</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Right angled forceps</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Right angled forceps</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Scissors</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Siphonhead</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Small cup</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Small curved forceps</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Sonotome keyhole</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Steel ruler</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Straight forceps</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Suction needle plate</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Suture needle</td><td>Johnson &amp;amp; Johnson</td><td>Vcp397H</td><td>/</td></tr><tr><td>Syringe</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Syringe needle</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Tissue forceps</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Trocar(XCEL)</td><td>Ethicon Endo-Surgery</td><td>695C71</td><td>/</td></tr><tr><td>Ultrasonic knife spacers</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Ultrasound knife</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr><tr><td>Yarn ball</td><td>Johnson &amp;amp; Johnson</td><td>/</td><td>/</td></tr></tbody></table>

application of robot-assisted pancreaticobiliary junction resection in benign duodenal tumors

Robot-assisted pancreaticobiliary junction resection is a surgical technique employed to treat benign duodenal tumors. The procedure involves several key steps: making a longitudinal incision in the duodenum, excising the tumor at the pancreaticobiliary junction, inserting a biliary stent, connecting the biliary and duodenal mucosa, and suturing the duodenal incision during phase I. The robotic system enhances visibility, facilitates precise operations, minimizes duodenal traction injuries to the duodenum and surgical trauma, ensures accurate suture and fixation of bile duct stents, connects the bile duct and duodenal mucosa and reduces postoperative recovery time. Given the complexity of the operation and the associated risk of postoperative duodenal fistula, a thorough preoperative evaluation and meticulous perioperative preparation are crucial. Prior to the procedure, a comprehensive assessment was conducted, integrating the patient's medical history, family history, serological tests, and imaging studies. Special emphasis was placed on determining the benign or malignant nature of the tumor and evaluating the status of the duodenal artery blood supply network to ascertain the feasibility and efficacy of the surgery. During the operation, efforts were made to minimize duodenal trauma and avoid compromising the duodenal artery blood supply network. Additionally, the use of bile duct stents was considered essential to prevent biliary strictures, facilitate bile discharge, and mitigate biliary complications. Postoperatively, real-time monitoring of amylase and jaundice indicators in drainage fluid informed the timely removal of drainage tubes in accordance with the enhanced recovery after surgery (ERAS) protocol. Subsequent follow-up indicated a successful recovery, characterized by a notable reduction in preoperative abdominal pain, the absence of long-term complications, and no evidence of tumor recurrence. Consequently, robot-assisted pancreaticobiliary junction resection demonstrates a safe and effective surgical approach for the treatment of benign duodenal tumors.

On January 14, 2024, a robot-assisted pancreaticobiliary junction resection was performed at the hospital, followed by biliary stent implantation and anastomosis of the bile duct and duodenum. Postoperative pathology results were consistent with the preoperative findings from other hospitals. Postoperative drainage amylase and bilirubin levels showed a significant decrease (see Table 1), and the patient experienced a smooth recovery following surgery. We have conducted follow-ups for over 6 months post-surgery.
The representative results demonstrate the efficacy and safety of the technique. These findings highlight several key metrics that reflect both surgical outcomes and patient recovery. Firstly, the procedure was completed in 3.5 h, with a minimal intraoperative bleeding volume of 30 mL, eliminating the need for a blood transfusion, indicating that the robotic approach facilitates a precise and controlled surgical procedure. Importantly, no short-term complications were observed, and the patient&#39;s postoperative recovery was successful, suggesting that the technique is not only effective but also safe, thereby minimizing immediate surgical risks. The total duration of the hospital stay was 21 days, with 12 days specifically allocated to postoperative care, indicating a moderate recovery period typical for major abdominal surgeries. Notably, the drain amylase levels decreased from 8855 U/L on postoperative day 2 to 49.96 U/L on postoperative day 9. The drain total bilirubin levels decreased from 27.45 &#181;mol/L on postoperative day 3 to 9.30 &#181;mol/L on postoperative day 9. The drain direct bilirubin levels decreased from 6.91 &#181;mol/L on postoperative day 3 to 2.70 &#181;mol/L on postoperative day 9 (see Table 1). These indicators are crucial for the early detection of potential complications, such as leakage or infection, and their normalizing values provide reassurance of a controlled recovery. Postoperative images can be seen in Figure 10. The post-surgical removal of the duodenal tumor can be observed, along with the placement of the biliary stent. Postoperative pathological findings of the tumor can be seen in Figure 11. Pathological analysis confirmed the presence of a duodenal papillary villous tubular adenoma.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/67441/67441fig01.jpg" /> 
Figure 1: Preoperative images. Preoperative CT coronal view imaging. In this image, the location of the duodenal papillary tumor in the patient before surgery can be observed. <a href="https://www.jove.com/files/ftp_upload/67441/67441fig01large.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/67441/67441fig02.jpg" /> 
Figure 2: Gastroscopic and Ultrasound gastroscopy results. A-B. Gastroscopic results. C-D. Ultrasound gastroscopy results. <a href="https://www.jove.com/files/ftp_upload/67441/67441fig02large.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/67441/67441fig03v2.jpg" /> 
Figure 3: Tumor pathology. Preoperative pathological findings of the tumor. The results are from HE staining at 100x. <a href="https://www.jove.com/files/ftp_upload/67441/67441fig03large.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/67441/67441fig04.jpg" /> 
Figure 4: The layout of trocars. There were 6 trocars in total, including one observation port numbered 3, three operating ports numbered 1, 2, and 4, and two auxiliary ports numbered 5 and 6. <a href="https://www.jove.com/files/ftp_upload/67441/67441fig04large.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/67441/67441fig05.jpg" /> 
Figure 5: Robot device connected successfully. Connect the four arms of the robot to the four trocars numbered 1-4 in Figure 4. The numbers 1 and 4 refer to the robotic arms connected to the system. The other two numbers correspond to the auxiliary ports, which are operated by the first assistant surgeon and do not need to be connected to the robot. <a href="https://www.jove.com/files/ftp_upload/67441/67441fig05large.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/67441/67441fig06.jpg" /> 
Figure 6: Incise the duodenum longitudinally. Dissect the descending part of the duodenum longitudinally about 8 cm. <a href="https://www.jove.com/files/ftp_upload/67441/67441fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 7" class="xfigimg" src="/files/ftp_upload/67441/67441fig07.jpg" /> 
Figure 7: Placement of the biliary stent. Place the stent tube to support them. <a href="https://www.jove.com/files/ftp_upload/67441/67441fig07large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 8" class="xfigimg" src="/files/ftp_upload/67441/67441fig08.jpg" /> 
Figure 8: Place the stent into the distal part of the duodenum. Use 4-0 priline to suture and place the stent into the distal part of the duodenum. <a href="https://www.jove.com/files/ftp_upload/67441/67441fig08large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 9" class="xfigimg" src="/files/ftp_upload/67441/67441fig09.jpg" /> 
Figure 9: Suture intermittently the duodenal incision. Suture intermittently the mucosal layer of duodenal incision, and the plasma muscle layer to bury the wound using 3-0 putis. <a href="https://www.jove.com/files/ftp_upload/67441/67441fig09large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 10" class="xfigimg" src="/files/ftp_upload/67441/67441fig10.jpg" /> 
Figure 10: Postoperative images. Postoperative CT coronal view imaging. In this image, the post-surgical removal of the duodenal tumor can be observed, along with the placement of the biliary stent. <a href="https://www.jove.com/files/ftp_upload/67441/67441fig10large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 11" class="xfigimg" src="/files/ftp_upload/67441/67441fig11.jpg" /> 
Figure 11: Tumor pathology. Postoperative pathological finding of the tumor. The result is from HE staining at 100x. <a href="https://www.jove.com/files/ftp_upload/67441/67441fig11large.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>Items</td>
			<td>Results</td>
		</tr>
		<tr>
			<td>Operation time (min)</td>
			<td>210</td>
		</tr>
		<tr>
			<td>Intraoperative bleeding volume (mL)</td>
			<td>30</td>
		</tr>
		<tr>
			<td>Blood transfusion volume (mL)</td>
			<td>0</td>
		</tr>
		<tr>
			<td>Postoperative complication</td>
			<td>None</td>
		</tr>
		<tr>
			<td>Duration of hospital stay (day)</td>
			<td>21</td>
		</tr>
		<tr>
			<td>Postoperative hospital stay (day)</td>
			<td>12</td>
		</tr>
		<tr>
			<td>Drain AMY on POD2 (U/L)</td>
			<td>8855</td>
		</tr>
		<tr>
			<td>Drain AMY on POD9 (U/L)</td>
			<td>49.96</td>
		</tr>
		<tr>
			<td>Drain TBIL on POD3 (&#181;mol/L)</td>
			<td>27.45</td>
		</tr>
		<tr>
			<td>Drain TBIL on POD9 (&#181;mol/L)</td>
			<td>9.3</td>
		</tr>
		<tr>
			<td>Drain DBIL on POD3 (&#181;mol/L)</td>
			<td>6.91</td>
		</tr>
		<tr>
			<td>Drain DBIL on POD9 (&#181;mol/L)</td>
			<td>2.7</td>
		</tr>
	</tbody>
</table>
Table 1: Relevant outcomes of the patient. Abbreviations:&#160;POD = postoperative day; AMY = amylase; TBIL = total bilirubin; DBIL = direct bilirubin.

The current protocol delineates the use of robot-assisted pancreaticobiliary junction resection for the surgical management of benign duodenal tumors. This approach provides an effective solution for treating these tumors while minimizing duodenal loss and reducing associated complications.

Application of Robot-assisted Pancreaticobiliary Junction Resection in Benign Duodenal Tumors

Robot-assisted pancreaticobiliary junction resection is a surgical technique employed to treat benign duodenal tumors. The procedure involves several key ...

application-robot-assisted-pancreaticobiliary-junction-resection

Nanyang Technological University

Research

JoVE Journal

Medicine

484 Views.  Sun Yat-sen University. The current protocol delineates the use of robot-assisted pancreaticobiliary junction resection for the surgical management of benign duodenal tumors. This approach provides an effective solution for treating these tumors while minimizing duodenal loss and reducing associated complications.

Video: Application of Robot-assisted Pancreaticobiliary Junction Resection in Benign Duodenal Tumors

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 ...

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 ...

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

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the spleno-mesenteric junction, for cancer of the body-tail of the pancreas. The patient is placed supine with the legs parted and a pneumoperitoneum is established and maintained at 10 mmHg. To use the surgical system, four 8 mm ports and one 12 mm port are required. The optic port is placed at the umbilicus. The other ports are placed, on either side, along the pararectal line and the anterior axillary line at the level of the umbilical line. The assistant port (12 mm) is placed along the right pararectal line. Dissection begins by detaching the gastrocolic ligament, thus opening the lesser sac, and by a wide mobilization of the splenic flexure of the colon. The superior mesenteric vein is identified along the inferior border of the pancreas. Lymph node number 8a is removed to permit clear visualization of the common hepatic artery. A tunnel is then created behind the neck of the pancreas. To permit safe resection and reconstruction of the spleno-mesenteric junction, further preemptive dissection is required before dividing the pancreatic neck to bring in clear view all relevant vascular pedicles. Next, the splenic artery is ligated and divided, and the pancreatic neck is divided, with selective ligature of the pancreatic duct. After vein resection and reconstruction, dissection proceeds to complete the clearance of peripancreatic arteries that are peeled off from all lympho-neural tissues. Both celiac ganglia are removed en-bloc with the specimen. The Gerota fascia covering the upper pole of the left kidney is also removed en-bloc with the specimen. Division of short gastric vessels and splenectomy complete the procedure. A drain is left near the pancreatic stump. The round ligament of the liver is mobilized to protect the vessels.

The robotic technique shown herein aims at faithfully reproducing the open procedure for radical treatment of cancer of the body-tail of the pancreas. The protocol also demonstrates the ability to master involvement of major peripancreatic vessels without conversion to open surgery.

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the ...

Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

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

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

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

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.

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

Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic pancreatoduodenectomy (LPD), laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has not yet obtained wide acceptance. This could be attributed to the technical challenges involved in preserving the blood supply of the duodenum and bile duct.
This study describes and demonstrates all the steps of LDPPHR. A 48-year-old woman was diagnosed with a 3.0 cm x 2.5 cm pancreatic head cystic mass, which was detected unexpectedly. The surgery was performed using the 3D laparoscopy via an inferior infracolic approach. The operation lasted approximately 310 min with 100 mL of blood loss. Postoperatively, the patient experienced no complications and was discharged 5 days later. Pathology revealed intraductal papillary mucinous neoplasms.
LDPPHR via an inferior infracolic approach is feasible and safe when performed by experienced surgeons in selected patients with thin mesenteric fat layers. The described technique for LDPPHR via inferior infracolic approach should be well standardized and performed at high-volume centers with experienced surgeons in both open and laparoscopic pancreatology.

This article provides a whole technical process of laparoscopic duodenum-preserving pancreatic head resection via an inferior infracolic approach. This is a surgical approach for benign tumors without intraoperative fluorescence image guidance.

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic ...

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 ...

Robotics in Surgery: A Modular Robotic Platform Driven Gastric Wedge Resection

Robotic-assisted surgery has become increasingly popular since the introduction of the first robotic platform. Recently, a modular robotic system was approved for in-human use in Europe. Possible applications for this new robotic system are being explored, and standardized approaches are evolving. In lieu of this, a gastric wedge resection and the standardized setup for upper gastrointestinal procedures using this new system are presented here. This safe and feasible robotic procedure is demonstrated in a 69-year-old patient with a gastric tumor. All steps of the surgery are described in a detailed and reproducible manner. The article also details trocar positioning, arm adjustments, and required surgical instruments. Docking time amounted to 13 min, whereas the console time took 115 min. The patient was discharged after 4 days after ensuring an uneventful course. The presented method is also suitable for other surgical purposes, such as fundoplications or hiatoplasties, and ensures both generalizability and reproducibility.

Robotically assisted surgery has become highly popular in recent years. Presented here is the standard care for upper gastrointestinal procedures, including a demonstration of a robotic-assisted gastric wedge resection using a modular robotic device.

Robotic-assisted surgery has become increasingly popular since the introduction of the first robotic platform. Recently, a modular robotic system was ...