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Robotic-assisted Duodenal
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Anastomosis for Annular Pancreas
JinfaTou andChengjieLv
20
20.1 Introduction
Annular pancreas means that the pancreas head
tissue is ring-shaped or pincer-like and surrounds
and compresses the descending part of the duodenum, causing duodenal obstruction [1]. It
accounts for approximately 15% of cases of duodenal obstruction, and the ratio of boys and girls
is similar. The disease is mainly seen in the neonatal period, and a few cases occur in infants or
older children. The pancreatic tissue in the circular pancreas surrounding the duodenum can
cause exogenous incomplete duodenal obstruction. If combined with duodenal stenosis and
atresia, the lesion is often under the annular pancreas. The anatomical structure of the pancreas
changes, and the main pancreatic duct traverses
the annular part.
Annular pancreas is usually operated on as
“duodenal side-to-side anastomosis”; the proximal end is cut laterally, and the distal end is cut
longitudinally. This rhombic anastomosis can
maintain the wide and open shape of the anasto-
mosis, and it is easier to allow the contents of the
duodenum [2–8]. The passage of things. Whether
it is open surgery, laparoscopic surgery, or robotic
surgery, all follow this basic principle.
20.2 Indications
andContraindications
20.2.1 Indications
Patients with a preoperative diagnosis of descending duodenal obstruction, considering the annular
pancreas, were generally in good condition, except
for children with related contraindications [2, 4].
20.2.2 Contraindications
1. The general condition is poor, the function of
important organs such as the heart and lungs
is poor, and the pneumoperitoneum cannot be
tolerated.
Supplementary Information The online version contains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_20.
J. Tou (*) · C. Lv
Department of Neonatal Surgery, Children’s Hospital,
Zhejiang University School of Medicine, Hangzhou,
China
e-mail: toujinfa@zju.edu.cn; lcjdr@zju.edu.cn
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_20
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2. Preoperative meconium is puzzling, suspected
to have multiple malformations of the digestive tract, lower digestive tract obstruction,
etc.
3. Very low birth weight infant, unable to tolerate pneumoperitoneum, small abdominal cavity volume, lack of robot operation space.
20.3 Preoperative Preparation
1. The general condition of the patient should be
routinely understood before surgery.
2. To perfect the preoperative examination, routine B-ultrasound examination and upper gastrointestinal radiography examination are
required to conrm the diagnosis.
3. Routine preoperative preparation: preoperative fasting, gastrointestinal decompression,
cleaning enema, blood preparation, correction
of severe anemia, and water and electrolyte
disorders.
4. Surgical instruments: Prepare 3 sets of robotic
puncture trocars, a 3 mm auxiliary trocar,
Debakey forceps, permanent cautery hook,
needle holder, 3 mm laparoscopic grasping
forceps, scissors, suction device, etc.
20.4 Position andDocking
20.4.1 Surgical Position
Adopt a supine position, with head high and feet
low tilted approximately 30°, head, neck, and
trunk height 5–10cm (Fig. 20.1).
J. Tou and C. Lv
Fig. 20.1 Surgical position
20.4.2 Layout ofOperation Hole
1. The observation hole (No. 2 arm) is located in
the left lower abdomen at the intersection of
the transverse stripes of the abdomen and the
midline of the clavicle in patients’ BW within
3000 g. The observation hole (No. 2 arm) is
located at the umbilicus in patients’ BW more
than 3000 g.
2. The operation hole 1 (No. 1 arm) is located on
the anterior axillary line of the left upper
abdomen, 1cm below the rib.
3. Operation hole 2 (No. 3 arm) is located in the
right lower abdomen, where the transverse
stripes of the abdomen intersect with the anterior axillary line.
4. The auxiliary operation hole (assistant hole) is
located at the lower left of the midpoint of the
connection between the observation hole and
operation hole 1, as far away as possible from
the operation area (Fig. 20.2).
ab
cd
20 Robotic-assisted Duodenal Anastomosis for Annular Pancreas
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137
Fig. 20.2 a and b: position of Trocas (BW < 3000 g); c and d: position of Trocas (BW ≥ 3000 g).
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J. Tou and C. Lv
20.5 Surgical Procedures
1. The process of preparation for surgery position,
the positioning layout of the operating hole,
routine disinfection and draping, establishment
of pneumoperitoneum and placement of the
cannula and routine hepatic round ligament
abdominal wall traction and suspension to
increase the abdominal cavity operation space
are the same as parts (1)-(5) in 19.5 Surgical
procedures.
2. Exploring the ileocecal area, the position of
the ligament of Treitz and the mesenteric
condition to rule out malrotation. Then, the
adhesions between the transverse colon and
the right upper abdomen were separated to
expose the duodenum. First, the duodenal
bulb was separated downward, exposing the
descending part, conrming the position of
the annular pancreas, and ensuring anastomosis without tension. Second, 5-0 absorbable
thread was used to pull the left and right sides
of the duodenal bulb through the abdominal
wall, the intestinal wall of the duodenal bulb
was cut approximately 1 cm transverse, the
intestinal wall of the descending part of the
duodenum was cut 1 cm longitudinal, and the
distal bowel was conrmed to be unobstructed. Finally, a 5-0 double-needle absorbable suture was used to suture the back wall
and the front wall of the two incisions continuously (Fig. 20.3).
a
cde
Fig. 20.3 (a) Suspend the bulb of the duodenum to expose
the distal part of the duodenum; (b) Cutting the intestinal
wall of the duodenal bulb; (c) Cut the intestinal wall of the
b
descending part of the duodenum; (d) Anastomosis of the
proximal and distal duodenum wall with 5–0 doubleneedle absorbable suture; (e) Rhomboid anastomosis
20 Robotic-assisted Duodenal Anastomosis for Annular Pancreas
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20.6 Technical Points andSkills
1. The volume of the abdominal cavity of the
newborn is small, and the distance between
the operation holes is limited. When arranging
the holes, try to choose the largest distance to
avoid the mutual interference of the mechanical arms.
2. During the operation, it is necessary to conrm that the distal duodenum can be raised
without tension to meet the rhomboid
anastomosis.
3. The neonatal intestine tissue is fragile, so it
needs to be lifted more gently.
4. After the release is completed, the duodenal
morphology should be observed to rule out
the possibility of the duodenal web and other
deformities.
5. To increase the exposure space, suspending
the round ligament of the liver and the bulb of
the duodenum are used. If necessary, the gallbladder can be suspended to increase the
exposure of the distal part of the annular
pancreas.
20.7 Complications and
Prevention
20.7.1 Intraoperative complications
1. Paracentesis injury: In newborn, the abdomi-
nal space is limited. When establishing a
pneumoperitoneum or puncturing, the intraabdominal blood vessels or organs may be
injured accidentally. Due to the limited
abdominal space, the rst trocar can be placed
under direct vision. After the pneumoperitoneum is established, other trocars can be
placed under laparoscopic monitoring. Once
blood vessels or organs are injured, repair is
needed rapidly.
2. Pneumoperitoneum-related complications:
The high diffusion of CO2 in the peritoneum
of infants or newborns can easily lead to
hypercapnia and heart or lung dysfunction.
Reduced pressure of pneumoperitoneum, and
shortened operation time monitoring blood
gas and end-expiratory PCO2 during the operation are helpful for prevention of hypercapnia. Suspending the operation or
pneumoperitoneum can reverse dysfunction
within a short time. Once the vital signs are
unstable, robotic procedure should be transferred to an open procedure.
3. Thermal damage: Long-term electrocoagulation or electrocision may cause excessive
burns of the tissues and even delayed perforation. Therefore, the electrical separation of the
neonatal intestinal wall and cut tissues requires
a short time and high frequency.
20.7.2 Postoperative complications
1. Postoperative bleeding: Supplementing prothrombin, plasma, and brinogen is effective
for treating wounds bleeding. Massive hemorrhage of mesangial blood vessels requires
another operation.
2. Anastomotic leakage: The incidence of anastomotic leakage of laparoscopic annular pancreatic rhomboid anastomosis is mainly
related to technical factors such as omissions
during stitching, poor t, or excessively high
tension suture. If anastomotic leakage occurs,
fast, gastrointestinal decompression and
abdominal drainage are effective treatments.
With the assistance of robots, the incidence of
anastomotic leakage is lower. There are no relevant data reports yet [2–5].
3. Anastomotic stenosis is a rare complication,
mainly due to the small incision during the
anastomosis. If duodenal obstruction persists,
surgical treatment is needed [2–4].
4. Missing distal obstruction deformity: The
annular pancreas is prone to malrotation
and distal duodenal or jejunal web. If the
patient has abnormal meconium discharge
or partial expansion of the distal intestine,
it is necessary to alert the possibility of distal obstruction deformity. During the operation, it is necessary to determine the
position of the ileocecal junction, the posi-
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J. Tou and C. Lv
tion of the Treitz ligament, and the mesenteric condition to rule out malrotation.
When the distal duodenum is open, an 8Fr
urinary catheter can be inserted into the
intestine, and water can be injected to check
the distal intestine [2–5].
5. Incisional hernia: The neonatal abdominal
wall is thin; if the suture is not meticulous for
an 8-mm trocar incision, it is possible to lead
to abdominal wall hernia.
20.8 The Dierence Between
Robotic Annular PancreasDuodenal Rhomboid
Anastomosis and Traditional
Laparoscopic Procedure
The essence of robotic annular pancreas-duodenal rhomboid anastomosis is laparoscopic procedure with upgraded instruments and equipment.
The surgical principles and steps are the same.
20.8.1 Advantages
The robot’s three-dimensional eld of vision is
clearer, and it is a heat source, which can maintain the clarity of the lens for a long time without
being affected by smoke, etc., which guarantees a
smooth operation process.
The highly exible robotic arm system of the
robot can complete difcult operations such as
grasping, holding, walking hemostasis, suturing,
and ligation in a limited space. At the same time,
it reduces the fatigue of the surgeon and reduces
misoperation.
The learning curve of the robotic system for
difcult surgery is signicantly lower than that of
traditional laparoscopic surgery, and doctors with
a certain amount of laparoscopic surgery experience can quickly adapt to the operation.
The annular pancreas distal intestine is small.
The magnication effect of the robot is more
obvious, and the mechanical arm can lter the
slight jitter of the hand and can very accurately
locate the incision and suture parts.
20.8.2 Limitations
The robotic arm of the robotic system will occupy
a certain amount of space, and the assistant hole
position selection and operation space will be
more limited than traditional laparoscopy.
The operation cost of the robot system and the use
of equipment are higher than those of traditional
laparoscopes, which will increase medical costs.
References
1. Wakeley J. Annular P. The Lancet. 1951;258:811–3.
2. Li B, Chen WB, Wang SQ, et al. Laparoscopic diagno-
sis and treatment of neonates with duodenal obstruc-
tion associated with an annular pancreas: report of 11
cases. Surgery today. 2015;45:17–21.
3. Li B, Chen BW, Xia LS. Laparoscopic side‐to‐side
duodenoduodenostomy versus diamond‐shaped anas-
tomosis for annular pancreas in the neonate. ANZ J
Surg. 2021;91:1504–8.
4. Wang L, Xue J, Chen Y, et al. Clinical analysis of
annular pancreas in neonates. Zhejiang Da Xue Xue
Bao Yi Xue Ban. 2019;48:481–6. (in Chinese).
5. Wang D, Kang Q, Shi S, et al. Annular pancreas in
China: 9 years’ experience from a single center.
Pediatr Surg Int. 2018;34:823–7.
6. Li B, Chen, Wang SQ, et al. Laparoscope diagnosis
and treatment for annular pancreas in neonates: report
of 9 cases. Chin J Pancreatol, 2013;13:227–30.
7. Zilberstein B, Sorbello MP, Orso IR, et al. Laparoscopic
duodenal-Jejunal bypass for the treatment of duodenal
obstruction caused by annular pancreas: description of
a surgical technique. Surg Laparosc Endosc Percutan
Tech. 2011;21:e60–4.
8. Dankovcik R, Jirasek JE, Kucera E, Feyereisl J,
Radonak J, Dudas M. Prenatal diagnosis of annular
pancreas: reliability of the double bubble sign with
periduodenal hyperechogenic band. Fetal Diagn Ther.
2008;24:483–90.
Robotic-Assisted Intestinal
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Duplication Resection
ZhigangGao andYiJin
21
21.1 Introduction
Intestinal duplication is a rare congenital gastrointestinal disorder in children and is a cavernous
organ in a circular or tubular form on the proximal mesenteric side of the intestine with the same
tissue structure as the adjacent small intestine [1].
Its blood supply is independent, and intestinal
duplication can appear in any part of the digestive
tract, with the ileum being the most common site
followed by the esophagus and colon, which can
be seen at any age [2]. The clinical symptoms
vary, including gastrointestinal bleeding, intestinal obstruction, abdominal pain, abdominal distension, and acute abdomen [3]. Some children
have no obvious clinical symptoms and are found
during other surgeries; non-invasive auxiliary
examinations are important for the diagnosis of
intestinal duplication and can assist in preoperative diagnosis. Commonly used examinations
include abdominal ultrasound, CT and ECT
scans. For the treatment of intestinal duplication,
Supplementary Information The online version contains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_21.
Z. Gao (*) · Y. Jin
Department of General Surgery, Children’s Hospital
of Zhejiang University School of Medicine,
Hangzhou, China
e-mail: ebwk@zju.edu.cn; pwck@zju.edu.cn
open surgery was mostly used in the past to
remove the lesion, but traditional open surgery
has obvious abdominal scars and a higher probability of postoperative complications such as
intestinal adhesions and intestinal obstruction.
Therefore, with the popularization and development of laparoscopic technology, it has been
gradually replaced by laparoscopic resection of
intestine duplication [4]; laparoscopic surgery
can be used as both a treatment and an examination tool, when the child has typical clinical
symptoms and no obvious positive lesions are
found in the preoperative examinations. When
the lesion site is detected by laparoscopic surgery, it can be directly surgically removed; laparoscopic surgery can explore the entire
gastrointestinal tract with only a small umbilical
incision, which greatly reduces the time and
length of the intestinal tube exposed outside the
body. This not only enables the postoperative
intestinal function to recover quickly but also signicantly reduces the incidence rate of postoperative intestinal adhesion and obstruction; in
addition, when the lesion site is clearly identied,
the umbilical incision can be slightly enlarged to
bring out the diseased bowel for further surgery
outside the body, thus avoiding the long surgical
incision of traditional open surgery, which is not
only less traumatic, but also improves postoperative aesthetics. The types of umbilical incisions
commonly used today include the “Z” incision
and the “υ” incision [5]. For accidentally discovered intestinal duplication, most researchers now
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_21
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Z. Gao and Y. Jin
believe that the potential complications of repetitive intestinal malformations are very dangerous,
such as severe gastrointestinal bleeding, intestinal obstruction, and intestinal perforation,
although the child is asymptomatic, and hence
advocate timely surgical treatment for asymptomatic children with intestinal duplication.
Since Schleef et al. rst reported laparoscopic
surgery for the treatment of intestinal duplication
in 2000 [6], laparoscopic surgery has become the
main surgical method for the treatment of intestine duplication; laparoscopic resection of the
duplicated intestine is performed mainly by
making a small umbilical incision and placing
two 5-mm trocars, and after nding the lesion,
the umbilical incision is appropriately enlarged,
and the diseased bowel is dragged out through
the umbilicus for further surgery outside the
body. For resection of duplicated malformations
under complete laparoscopy, the operation is
more difcult, mainly because of the limited
magnication of conventional laparoscopic
instruments, making it difcult to remove the
cyst without damaging the normal intestinal
canal with insufcient renement, which can
easily cause abdominal contamination. In addition, this approach requires more skill and a longer learning curve for the operator; the use of
fully laparoscopic surgery is currently less common because of the longer operating time and
the potential risks associated with anesthesia and
pneumoperitoneum. With the progess of minimally invasive technology, the Da Vinci robotic
surgical system ushered in a new era of surgery.
Compared with conventional laparoscopic surgery, the da Vinci robotic surgical system has the
functions of eliminating hand tremors, motion
scaling, and motion indexing. At the same time,
the system has a 3D imaging function with
higher resolution and higher magnication,
which provides a clearer view for the operator.
Its three simulated wrist instruments have seven
degrees of freedom of motion, which greatly
improves the surgical stability, accuracy and
safety [7]; da Vinci robot-assisted technology is
impacting the eld of pediatric surgery with the
momentum of high precision technology.
Currently, many hospitals in China are equipped
with the Da Vinci robotic surgical system, and
robotic- assisted treatment of various diseases
has been carried out, such as choledochal cysts,
with satisfactory results [8]. This chapter focuses
on the application of the Da Vinci robotic surgical system in children with intestine
duplication.
21.2 Indications
andContraindications
There are no absolute contraindications for Da
Vinci robotic-assisted resection of intestinal duplication, but relative contraindications are 1. unstable
vital signs; 2. severe cardiopulmonary insufciency
and inability to tolerate pneumoperitoneum; 3.
emergency surgery for intestinal obstruction and
other reasons, with signicant abdominal distension; and 4. history of previous laparotomy and
severe adhesions in the operated area. For children
with the above conditions, a thorough treatment
plan needs to be developed to assess the suitability
of choosing da Vinci surgery from all aspects.
21.3 Preoperative Preparation
The preoperative preparation for da Vinci intestine duplication resection includes preoperative
perfect imaging to clarify the diagnosis, preoperative intestinal preparation, blood preparation,
and preoperative antibiotic administration.
Imaging examinations included abdominal ultrasound and CT.For children who show gastrointestinal bleeding, preoperative ECT examination
can assist in the diagnosis; preoperative fasting
for 8 hours, preoperative water fasting for
2hours, skin preparation, gastrointestinal decompression, urinary catheter placement, preoperative open-loop laxative, etc.; blood preparation,
correction of severe anemia and water-electrolyte
disorders. Preoperative antibiotics need to be
tested mostly empirically. For children without
obvious abdominal infection, second- or thirdgeneration cephalosporins can be selected.
Intravenous administration of drugs was given
half an hour before surgery.
ab
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Fig. 21.1 (a) Taking the right lower abdomen and the
umbilicus to make a line “a”, then drawing line “b” perpendicular to line “a” through the navel. Taking two points
21.4 Position andDocking
The patient was placed in the supine position
with the head raised, an 8 mm Da Vinci Trocar
was placed at the umbilicus, which was used for
the 3D camera, and another two 8 mm trocars
were placed at the left lower abdomen and right
upper abdomen (between 3 cm and 8 cm from the
umbilical incision) (Fig.21.1).
21.5 Surgical Steps
21.5.1 Step 1
Laying out the holes (same as Position and docking section).
21.5.2 Step 2
Robot-assisted surgery: Robot-assisted abdominal exploration starts from the ileocecum. When
the diseased intestine is discovered, electrocoagulation hooks and separation forceps are placed
in the operation holes, which can suspend the
local intestinal canal and gradually separate the
cyst. Some cysts are large in size and high in tension, and puncturing and aspiration of the cyst
(No. 3 and No. 1) on line b between 3 cm and 8 cm away
from the umbilicus, No. 1, 2 and 3 are the Da Vinci trocar
locations. (b) After laying out the Da Vinci trocar
can be performed rst, followed by stripping of
the cyst after the tension is reduced. After cyst
dissection, the plasma muscle layer of the local
normal intestine was closed by using 4-0 absorbable sutures. The main view scope is entered
through the left abdominal operation hole, and
the cyst is removed under the surveillance of the
umbilical observation hole disposed into the
retrieval bag. If there was no obvious bleeding,
the scope was withdrawn, and then the incision
was sutured.
21.6 Technical Points andSkills
To avoid restrictions on mechanical arm activity, the spacing of trocars should be between 8-3
cm; due to the lack of force feedback, the movement of clamping the intestinal tube or clamping the edges of the intestine should be reduced
as much as possible. The local intestinal tube
can be suspended, which can not only make the
cyst better exposed but also avoid the use of
auxiliary holes, thus being conducive to stripping. For large-size and high-tension cysts, the
cyst uid can be aspirated rst to reduce the
local tension, and then the cyst can be stripped
without damaging the normal intestinal canal
more easily.
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21.7 Postoperative Complications
The postoperative complications of da Vinci
intestine dulpication resection are essentially the
same as those of conventional laparoscopic surgery, including postoperative bleeding, intestinal
leakage, anastomotic stricture, and bowel
obstruction with intestinal adhesions.
1. Postoperative bleeding occurs mostly within
24hours after surgery. The incidence of postoperative bleeding is relatively low due to the
three-dimensional magnication imaging system, the jitter ltering function, and the
robotic hand of the da Vinci system that can
rotate in multiple degrees of freedom, rendering intraoperative vascular processing more
delicate. If postoperative bleeding occurs, the
amount and rate of bleeding need to be determined rst to decide whether immediate reoperation is required to stop the bleeding. If the
amount appears to be small, conservative
treatment can be taken with measures including blood transfusion, uid replacement, and
monitoring of hematocrit changes. In children
with heavy bleeding, reoperation may be considered, and laparoscopic exploration may be
attempted rst to stop the bleeding, if abdominal conditions allow, to minimize trauma.
2. Intestinal leakage can be caused by the leakage of stitches and loose sutures at the dissection surface or by injury to the intestinal
canal during the operation, which can manifest as fever, abdominal pain, and abdominal
distension. For children with possible intestinal stula, if the abdominal symptoms of
the child are physically limited, the changes
in the condition can be closely observed
without immediate surgical investigation.
Conservative treatment measures include
anti- infection, fasting, and uid replacement.
However, for children with signicant systemic and abdominal symptoms and diffuse
peritonitis, immediate surgical investigation
and reintroduction of intestinal anastomosis
are needed.
3. Intestinal stenosis: Intestinal stenosis usually
appears 3months or even longer after surgery
and can manifest as vomiting, abdominal distension, abdominal pain or other symptoms.
Reoperation is required for those with signicant symptoms. The surgery can be attempted
laparoscopically depending on the child’s
condition to nd the lesion and reapply the
intestinal anastomosis.
4. Intestinal adhesions and intestinal obstruction: Intestinal adhesions and intestinal
obstruction may occur after any abdominal
surgery, which can manifest as abdominal
pain, abdominal distension, vomiting and
stopping defecation. For patients who are
considered to have intestinal obstruction, conservative treatment should be taken rst,
including fasting, uid replacement and antiinfection. Those who have obvious symptoms
and cannot improve with conservative treatment need to undergo reoperation to break
down the adhesions and release the obstruction to prevent life-threatening conditions
such as intestinal strangulation and intestinal
necrosis. Minimally invasive surgery is a relatively rare complication because fewer
abdominal organs are exposed outside the
abdominal cavity.
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