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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5193_Библиотеки_им_академика_М_И_Перельмана.pdf
24 Liver Resection andBiliary Reconstruction
323
cholangiogram. The technique to perform a catheter cholangiogram with the robot
docked involves creating a space between the robotic arms for the C-arm machine.
This space is made by increasing the gap between robotic arms 2 and 3 and introducing the C-arm here from the patient’s right shoulder.
The type of biliary reconstruction is dependent on the type and location of the
bile duct injury but will usually involve formation of a roux limb for anastomosis
between the bile ducts and jejunum. The injured bile duct stump(s) should be
debrided until healthy tissue is reached.
Resection ofHilar Cholangiocarcinoma or Palliative Biliary Bypass
Upon completion of the resection of hilar cholangiocarcinoma, the extrahepatic bile
duct is removed en bloc with the hepatectomy specimen. The stump of the bile duct
to the remnant is prepared for anastomosis.
For palliative biliary bypass, the bile duct proximal to the malignant obstruction
is divided and the distal stump is closed with clips, staples, or suture-ligature. The
proximal stump is then prepared for anastomosis.
Roux-en-Y Hepaticojejunostomy
The ligament of Treitz is located and a suitable location of the proximal jejunum is
chosen where that the bowel can be brought up to the hilum without tension. The
jejunum and the mesentery are transected at this area, and the distal jejunum is run
for 40cm (this will be the roux limb). This site is then anastomosed to the proximal
jejunum using a stapled anastomosis and the enterostomy is sutured closed in two
layers. The stump of the roux limb is brought up to the hilum in an antecolic fashion.
The bile duct stump is anastomosed end to side to an enterostomy in the roux
limb using interrupted 5/0 or 6/0 polydioxanone (PDS) (Fig.24.16). For large bile
ducts, the posterior wall of the anastomosis can be performed with a continuous
Fig. 24.16 Stitches
inserted forming posterior
wall of
hepaticojejunostomy
anastomosis between
separate right (RHD), left
(LHD), and caudate ducts
and roux limb of jejunum
324
Fig. 24.17 Anterior wall
of hepaticojejunostomy
sutured with interrupted
stitches
Y. L. Cheah and C. J. Simon
suture. If there are two bile duct stumps that are too short to be combined into one,
it is often easier to complete the back wall stitches on both ducts before starting on
the front walls of the anastomoses (Fig.24.17).
Conclusion
The robotic platform provides some advantages over conventional laparoscopic
technique for complex hepatobiliary surgery. Robotic instrumentation enables
meticulous dissection of the liver hilum, enabling isolation of inow vessels, dissection of the biliary tree, and biliary anastomosis. Adjuncts can be utilized, such as
ICG cholangiogram, multi-image display to facilitate identication of biliary anatomy, and intraoperative ultrasound to guide liver resection. We are still in the early
stages of adoption of this minimally invasive approach in hepatobiliary surgery, and
larger multicenter studies are needed to dene standardized techniques and investigate surgical and oncological outcomes.
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Robotic-Assisted Pancreaticoduodenectomy (Whipple)
AhmadAbou Abbass andMohamadOthmanEl Helou
Abbreviations
BD Bile duct
CHA Common hepatic artery
ERAS Early recovery after surgery
GDA Gastroduodenal artery
IPDA Inferior pancreaticoduodenal artery
IVC Inferior vena cava
MIS Minimally invasive surgery
PV Portal vein
SMA Superior mesenteric artery
SMV Superior mesenteric vein
25
Robotic Whipple
Over the last decade, there has been a global surge in interest in the robotic approach
for hepatobiliary surgery [9]. Notably, there has been a signicant rise in the worldwide adoption of the robotic Whipple procedure, with the majority of major medical
centers in the United States now offering this robotic approach to patients. Both
patients and referring physicians have shown a growing curiosity about the benets
of the robotic [17].
A. Abou Abbass (*)
Directory of Hepatobiliary Surgery, Mission Hospital, Mission Viejo, CA, USA
M. O. El Helou
Department of Surgery, Yale New Haven Hospital, Yale School of Medicine,
New Haven, CT, USA
Department of Surgery, Henry Ford Providence Hospital, Southeld, MI, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
S. Samreen et al. (eds.), The SAGES Manual of Robotic Surgery,
https://doi.org/10.1007/978-3-031-86927-3_25
327
328
A. Abou Abbass and M. O. El Helou
Minimally invasive surgery (MIS) has demonstrated its equivalency or superiority to open surgery in various cases, characterized by reduced pain, shorter hospital
stays, minimized uid shifts, and improved cosmetic outcomes [17, 19]. In the context of colorectal surgery, MIS has been proven to yield comparable oncologic outcomes in terms of surgical margins, harvested lymph nodes, patient survival, and the
occurrence of local or distant colon cancer recurrences [11].
These advantages are not exclusive to colorectal surgery and are also applicable
to pancreatic cancer cases. Patients undergoing robotic surgery for pancreatic cancermay experience faster recovery times, enabling them to commence adjuvant
therapy sooner. This prompt initiation of treatment could potentially translate into
improved long-term survival rates [5, 12].
Since its introduction in 1994, laparoscopic Whipple has been shown to be a safe
alternative to open procedures, demonstrating comparable short- and long-term outcomes. Notably, some studies reported fewer complications, shorter hospital stays,
and reduced postoperative pain compared to open procedures [7].
Despite these advantages, the adoption of laparoscopic Whipple procedures has
been limited within the surgical community due to inherent challenges. The complexity of resection, particularly in terms of reconstruction, places a signicant
physical burden on surgeons, making the procedure demanding and challenging.
Consequently, only a small number of surgeons in the United States regularly perform laparoscopic Whipple procedures [3, 16].
In contrast, the robotic approach offers a more viable solution. With a stable
platform, a three-dimensional view, and articulated instruments, it addresses the
challenges faced by laparoscopic Whipple procedures, facilitating both dissection
and reconstruction [15]. Moreover, the robotic approach enhances surgeon comfort
as they can sit throughout the procedure, which can last between 4 and 8hours
(Fig.25.1) [15]. This combination of technical advantages and increased comfort
may contribute to the broader acceptance of robotic approaches within the surgical
community.
The stable three-dimensional view and articulated instruments enable surgeons
to navigate critical dissection around major vessels with increased precision.
Moreover, the robotic platform facilitates the execution of demanding anastomoses,
specically those involving the pancreas and biliary system (Fig.25.2). This techni-
cal prowess not only enhances the overall feasibility of the procedure but also positions the robotic approach as a valuable option for surgeons engaged in intricate
surgeries like the Whipple procedure [13].
25 Robotic-Assisted Pancreaticoduodenectomy (Whipple)
Fig. 25.1 Surgeon
working on the robotic
console
329
Fig. 25.2 Surgeon
performing demanding
anastomosis using the
robotic system
330
A. Abou Abbass and M. O. El Helou
Pathway toBuilding aRobotic Whipple Program
Currently, the predominant approach for Whipple procedures among surgeons in
the United States is the open method, and training programs predominantly focus on
imparting skills related to this traditional approach. However, there is a growing
acknowledgment of the feasibility of transitioning to a robotic approach, particularly for practicing surgeons already procient in open Whipple surgeries [22].
Venturing into robotic Whipple procedures necessitates two key prerequisites: prociency in both open Whipple techniques and prior experience in robotic surgery.
For a surgeon to successfully adopt the robotic approach, a requisite level of
expertise and caseload volume is essential. Rapidly gaining experience and overcoming the learning curve is facilitated by performing multiple robotic cases in a
condensed timeframe [22]. It is important to note that a surgeon regularly performing Whipple procedures every few months, albeit safely, might nd it more benecial to adhere to the open approach. Thus, the decision to transition to a robotic
approach should be a deliberate and informed one, grounded in the surgeon’s dual
prociency and readiness for the complexities of robotic Whipple procedures.
Furthermore, embarking on a robotic Whipple procedure should not mark the
initial foray into robotic surgery for a surgeon. Instead, a surgeon contemplating
such complex robotic interventions must possess a high level of prociency with the
robotic platform, having gained extensive experience and familiarity with its capabilities and nuances. While the precise number of cases required varies for each
surgeon, it is generally recommended that a surgeon accumulates a substantial
experience base, potentially in the hundreds of cases, before considering a robotic
Whipple.
Establishing a robust robotic practice follows a strategic progression, commencing with smaller, less complex cases and gradually advancing toward more intricate
procedures, culminating in the Whipple. This step-up approach is underlined by a
synergistic effect, where skills honed in various robotic procedures, such as dissecting the pancreatic neck in a distal pancreatectomy or harvesting the hilar lymph
nodes for a radical cholecystectomy, contribute to the prociency needed for a
Whipple.
Crucially, a surgeon’s journey to becoming procient in robotic surgery hinges
on adopting an “all in” approach. Embracing this mindset entails prioritizing robotic
methods over laparoscopic or open approaches in the majority of cases. This immersive commitment is key to accelerating the learning curve and cultivating the necessary skills for mastering complex robotic surgeries like the Whipple procedure [10].
Initiating a robotic Whipple program demands unwavering commitment from
the surgeon, along with support from both the department and hospital administration. A dedicated team is indispensable, encompassing a procient bedside assistant, skilled scrub tech, and adept circulating nurses [14]. The collaborative efforts
of this team are pivotal in executing the intricate surgery.
The primary robotic platform employed in nearly all robotic Whipple procedures
is the Da Vinci XI Surgical System by Intuitive. Early collaboration with Intuitive,
specically their local representative, is crucial. They serve as a valuable resource,
25 Robotic-Assisted Pancreaticoduodenectomy (Whipple)
331
connecting the surgeon with experienced mentors, facilitating case observations,
providing advanced courses on simulated models, and arranging for surgeon support and proctoring during initial cases.
A practical starting point involves leveraging digital resources to observe robotic
Whipple procedures. Platforms like “YouTube” offer a wealth of videos from surgeons worldwide, showcasing diverse techniques and tools. However, advancing
from virtual observation to in-person experiences is paramount. Being physically
present in the operating room enables real-time communication with the surgeon, an
understanding of the entire workow, and the ability to learn troubleshooting should
something go wrong. Ideally, the entire team should participate in these observations to enhance collaborative learning.
For hands-on preparation, Intuitive offers two robotic hepatobiliary courses hosted
by seasoned surgeons across multiple locations in the United States. Planning a series
of cases immediately following the training optimizes the application of newly
acquired skills. Collaboration with Intuitive beforehand ensures the availability of a
proctoring surgeon on selected dates, offering invaluable support for the initial cases.
Patient Selection
Choosing the right patients is crucial, especially when starting with robotic surgeries. It’s recommended to begin with early-stage, clearly resectable cancer cases.
Cases involving non-pancreatic cancers like ampullary or duodenal tumors, as well
as pancreatic neuroendocrine tumors, are also ideal for the initial robotic approach.
These cases are advantageous because they require less extensive dissection around
major blood vessels like the superior mesenteric vein (SMV) or artery (SMA). Early
on, surgeons may nd working closely with these vessels challenging, but as they
gain experience, they’ll become more comfortable with the intricate dissection. One
potential challenge might be a harder pancreatic anastomosis with a soft pancreas
and small duct, but the robotic platform makes the process feasible.
While vascular resection and reconstruction have been reported in the literature
and are technically achievable, it is recommended to avoid these cases until the
surgeon has gained substantial experience in robotic Whipple procedures. Some
surgeons may choose to never perform robotic vascular resections, especially if they
do not perform them using an open approach and prefer vascular surgeons to handle
the actual anastomosis [1]. This cautious approach ensures a gradual and safe progression in adopting complex robotic techniques.
Furthermore, it is advisable to steer clear of cases that pose challenging dissections, such as those involving obese patients, individuals with a history of pancreatitis, or those who have undergone radiation therapy. Patients with a surgical history
that includes procedures like surgery for peptic ulcer disease or gastric bypass
should also be avoided. However, a previous abdominal cholecystectomy is generally not a concern. For patients with a history of exploratory laparotomy, there may
be extensive small bowel adhesions, potentially complicating the mobilization of
the jejunum enough to perform anastomoses.
332
A. Abou Abbass and M. O. El Helou
Achieving favorable outcomes in robotic Whipple procedures requires selecting
patients who are suitable candidates for major surgery, akin to open procedures.
Preoperative optimization is crucial, encompassing cardiovascular, nutritional, and
physical aspects. In cases where surgery is delayed, addressing jaundice is essential.
Additionally, resolving any existing infections prior to surgery contributes to the
overall readiness and well-being of the patient, laying the groundwork for a successful robotic Whipple procedure [8, 20].
Operating Room Setup andInstrumentation
A robotic Whipple procedure is typically conducted in a specialized robotic room
designed to accommodate the robot, console, and laparoscopy towers, ensuring
ample space for seamless operation. Essential equipment includes an ultrasound
machine featuring a dedicated robotic probe, such as the BK5000 (R). The surgical
setup involves utilizing laparoscopic and robotic trays, with open trays and an open
retractor readily available in case a conversion to an open procedure becomes necessary (Figs.25.3a, b).
The robotic instruments employed in a Whipple procedure commonly include a
hook, monopolar scissors, fenestrated bipolar, tip-up instrument, and an energy
device like the vessel sealer or synchro seal. Additionally, a robotic stapler, requiring a 12mm robotic port, or a laparoscopic stapler used by the assistant can be
incorporated. For ne dissection, a Maryland instrument is effective, while a large
suture cut is suitable for suturing. Various clip appliers in large, medium, and small
sizes are available for vessels like the gastroduodenal artery (GDA).
Sutures utilized during a robotic Whipple are often similar to those used in an
open Whipple, but they need to be shorter, typically ranging from 6 to 8 inches. The
choice of sutures includes 3–0 silk for the outer layer of the pancreatic anastomosis,
4–0 or 5–0 Monocryl for the duct-to-mucosa anastomosis, 4–0 PDS for the hepaticojejunostomy, 3–0V-Loc sutures for the gastrojejunostomy, and 4–0 Prolene for
controlling bleeding if necessary (Fig.25.4).
The presence of vascular clamps is critical in an open Whipple procedure, making it essential to ensure availability of clamps that can pass through a 12mm trocar
and be easily applied in both laparoscopic and robotic settings (Fig.25.5). Many
hospitals typically already have these clamps readily accessible, as they are commonly used by urologists during procedures such as partial nephrectomies.
Airseal (R) can be benecial as it maintains pneumoperitoneum in cases suction
is needed for bleeding. That can be used with a dedicated assistant 12mm trocar.
25 Robotic-Assisted Pancreaticoduodenectomy (Whipple)
a
b
333
Fig. 25.3 (a) Operating room conguration for robotic Whipple. (b) Room setup for robotic
Whipple. The robot comes from the left side. All needed robotic instruments are on the table, and
open trays are readily available. Ultrasound machine is connected to the vision cart for picture-inpicture view when needed
Fig. 25.4 Sutures used in
a robotic Whipple