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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5193_Библиотеки_им_академика_М_И_Перельмана.pdf
334
Fig. 25.5 Scanlan (R)
vascular clamps
A. Abou Abbass and M. O. El Helou
Fig. 25.6 Robotic Whipple port placement
Operative Steps
The patient is placed supine on the operating table with the arms extended. Access to
the abdominal cavity is achieved and the abdomen is insufated. The camera port is
placed right to the umbilicus as that provides optimal view for uncinate dissection
and for the pancreatic anastomosis. A diagnostic laparoscopy is performed to rule out
occult peritoneal or liver metastases. Then an 8mm port is placed to the right of the
camera port and a 12mm robotic port is placed on the left side. Another 8mm port
is placed on the left side of the 12mm port. All the ports are placed in a straight line
facing the target anatomy, and 8–10cm apart. An assistant 12mm port is placed in
the left lower quadrant below and between the camera and the 12mm robotic ports.
Another 5mm port can be placed in the right lower quadrant. (Figs.25.6 and 25.7).
25 Robotic-Assisted Pancreaticoduodenectomy (Whipple)
Fig. 25.7 Robotic
Whipple port placement
335
The patient is then placed in 15–18 degrees of reverse Trendelenburg and the
robot is docked. The instruments are placed under direct visualization and the surgeon then scrubs out and goes to the console.
The conduct of the operation follows a stepwise approach identical to open
approach. The surgeon should follow a basic plan but allow for improvisation based
on each individual case. If a step appears difcult, the surgeon can move on and
come back to that step later and leave the most challenging step till the end of the
dissection. The rst few Whipples will take a long time, so it is best if the surgeon
is prepared and have no other cases booked for the day. As the experience build up,
the efciency will improve, and the operative times will shorten.
The operation is performed almost entirely by the console surgeon, and the bedside assistant provides retraction and suction as needed as well as instrument
exchange. Some centers adopted a hybrid approach where the bedside surgeon does
a lot of the energy device division, clipping, and stapling.
Entering theLesser Sac, Colon Mobilization
The rst step after docking the robot is to divide the gastrocolic omentum and
expose the pancreas. Dissection is carried toward the right side and the right colon
is mobilized all the way to expose the head of the pancreas and duodenum. Gravity
will retract the colon downward which helps in subsequent steps.
Kocher Maneuver, Ligament ofTreitz Dissection
After the duodenum has been fully exposed, it is mobilized from the retroperitoneum and retracted to the left side by the third robotic arm. This dissection is carried
by either hook or vessel sealer. This will expose the inferior vena cava (IVC) and
336
A. Abou Abbass and M. O. El Helou
left renal vein. Dissection is carried until the origin of the SMA is exposed as it
crossed above the left renal vein (Fig.25.8). The artery doesn’t need to be circumferentially isolated.
Afterward, the duodenum is followed distally toward the ligament of Treitz and
the proximal jejunum pulled to the right underneath the mesentery (Fig.25.9). The
proximal jejunum is then divided with robotic white load stapler.
If this step is difcult, then the transverse colon can be elevated and the ligament
of Treitz dissection done to the left of the mesentery. Then the jejunum can be
divided, and the proximal end is pulled from under the mesentery to the right upper
quadrant.
Fig. 25.8 Dissection of
SMA over the IVC and left
renal vein (LRV)
Fig. 25.9 Ligament of
Treitz dissection from the
right side of the mesentery.
IVC inferior vena cava.
GV gonadal vein
25 Robotic-Assisted Pancreaticoduodenectomy (Whipple)
337
Infra-pancreatic Neck Dissection, Isolating theSMV
It is important to expose the SMV under the neck of the pancreas and see how easy
it separates from the pancreas to assess resectability and possible need for vascular
control. The SMV is exposed under the neck of the pancreas with gentle retraction
on the pancreas and division of the areolar tissues with ne instruments like the
hook until the vein is exposed (Fig.25.10). It can be helpful to follow the middle
colic vein backward toward the SMV.If there’s a lot of fatty tissue, intro ultrasound
can be very useful in nding the vein and save time trying to locate the vein.
After the vein is located, it is dissected anteriorly and separated from the neck of
the pancreas starting the tunnel, which will be completed later.
The SMV is then followed distally separating it from the uncinate process. This
is continued until the rst jejunal vein is exposed. The right gastroepiploic vein will
be encountered and needs to be divided which will further improve the exposure of
the SMV (Fig.25.11).
Once the vein has been dissected and it appears easily separable from the pancreatic headband uncinate process, then resectability is conrmed and the surgeon can
proceed with the rest of the procedure.
Fig. 25.10 SMV exposed
below the pancreatic neck
Fig. 25.11 The SMV
appears to easily separate
from the uncinate process,
a good indicator of
resectability. The right
gastroepiploic vein has
been divided between
hemolock clips
338
A. Abou Abbass and M. O. El Helou
Supra-pancreatic/Hilar Dissection
This step is started by division of the stomach as that gives better caudal access to the
area. The stomach is divided with robotic stapler green or blue loads. If pylorus preservation is being done, the duodenum is divided with stapler distal to the pylorus.
Exposure of the liver hilum requires some sort of liver retraction. Both the falciform ligament and the gallbladder are sutured to the abdominal wall, which provides
great exposure without the need for an external retractor (Figs.25.12 and 25.13).
After the exposure is achieved, the hepatic artery lymph node (8A) is resected,
which provides access to the common hepatic artery (CHA) . The artery is dissected
distally until the gastroduodenal artery is encountered and isolated. It is then divided
between hemlock clips with a tie or with a stapler (Fig.25.14).
Dividing the GDA provides access to the underlying portal vein (PV), which is
then exposed anteriorly and separated from the common bile duct on the right side.
Any venous branches can be divided. The bile duct is isolated and either divided
now or at the end of the resection to minimize bile spillage. This concludes the hilar
dissection (Fig.25.15). The cholecystectomy is done after the bile duct anastomosis
as it is sutured to the abdominal wall to provide exposure.
Fig. 25.12 Suturing of the
falciform ligament to the
abdominal wall
Fig. 25.13 Suturing of the
gallbladder to the
abdominal wall
25 Robotic-Assisted Pancreaticoduodenectomy (Whipple)
Fig. 25.14 Removal of
the hepatic artery lymph
nodes exposes the
underlying common
hepatic artery CHA
Fig. 25.15 The hilar
dissection has been
completed. The portal vein
(PV) is well exposed. The
bile duct (BD) has been
encircled with a vessel
loop to be divided later. SV
(splenic vein)
339
340
A. Abou Abbass and M. O. El Helou
Creating theTunnel/Pancreatic Transection
Attention is then turned toward dividing the pancreas. After exposing the PV above and
the SMV below the neck of the pancreas, the SMV is gently peeled off the overlying
pancreatic neck using a blunt instrument like the Maryland bipolar forceps or synchro
seal as there are no venous branches anteriorly. The tip-up forceps are great to complete
the tunnel all the way to the other side as it is blunt and long enough (Fig.25.16).
Sometimes, the pancreas is too stuck to the vein even if there’s no tumor involvement particularly in patients with history of pancreatitis or radiation. In these cases,
creating the full tunnel might be very difcult or even dangerous. So in these cases,
it’s best to start dividing the pancreas and dissecting it off the SMV in small steps at
the same time until the pancreatic neck is fully divided.
The pancreatic neck is divided with monopolar scissors using energy. There’s no
need to place any sutures in the pancreas. The bleeders are easily controlled with
monopolar energy. Once the pancreatic duct is reached, it is divided sharply with the
scissors with a 1–2mm stump which makes subsequent anastomosis easier (Fig.25.17).
Fig. 25.16 Creating the
tunnel for pancreatic
transection
Fig. 25.17 Pancreatic
neck division with scissors.
The assistant protects the
PV by pushing down on it
with suction
25 Robotic-Assisted Pancreaticoduodenectomy (Whipple)
341
A piece of pancreas from the specimen side is cut out and sent to pathology for
frozen section if indicated.
Uncinate Dissection
This is the challenging part of the dissection as it involves being very close to the
SMA and SMV and there’s a risk of bleeding that can be difcult to control. The
dissection is started in the caudal to cranial direction dissecting the SMV rst then
exposing and dissecting the SMA.This is started by retracting the specimen to the
right by the left hand and exposing the rst jejunal vein. There is usually a branch
to the uncinate that needs to be divided (Fig.25.18).
The SMV is then gently separated from the uncinate process with blunt dissection using the robotic hook. Any branches can be controlled with vessel sealing
device. After the vein is freed, it is rolled to the left by the third arm exposing the
underlying SMA.The SMA is surrounded with thick brous and nerve tissue, and
it is best to do this dissection to use a ne instrument like the hook cautery. This will
gradually expose the SMA for a good oncologic dissection and prevent injury to the
artery and its branches. If the artery is difcult to locate, an intraoperative ultrasound is invaluable as one cannot feel for the pulse of the SMA (Fig.25.19).
Once the artery is identied, it is skeletonized for 180 degrees on the right side
with the hook cautery. The inferior pancreaticoduodenal artery (IPDA) is dissected
and ligated close to the SMA with hemlock clips. There might be more than one
arterial branch so extreme care is taken until the SMA is completely dissected
(Fig.25.20).
The SMA is followed down to its origin from the aorta which was exposed early
in the procedure. All the lymph vascular tissues behind the PV including lymph
node stations 12 P and B are brought with the specimen. If there’s a replaced right
hepatic artery off the SMA, extra care is taken to identify and preserve it.
At this point, the specimen is only attached by the bile duct, which is divided
with scissors or stapler to minimize bile spillage (Fig. 25.21). The specimen is
parked in the right lower quadrant to be removed at the end of the procedure.
Fig. 25.18 Beginning of
uncinate dissection. J1:
rst jejunal vein
342
Fig. 25.19 Exposing the
SMA and the use of
intraoperative ultrasound
for detection
Fig. 25.20 IPDA is
divided close to its origin
between hemlock clips.
The tip-up instrument is
used in the third arm, and
it gently retracts the SMV
to the left to provide full
exposure to the SMA.The
SMA can even be grabbed
with the tip-up
A. Abou Abbass and M. O. El Helou
25 Robotic-Assisted Pancreaticoduodenectomy (Whipple)
Fig. 25.21 Using the
monopolar scissors to
divide the specimen from
the bile duct
343
Fig. 25.22 Pancreaticojejunostomy
Reconstruction Phase
This phase is much less risky than the resection phase. However, it is very critical to
perform a perfect anastomosis to minimize postoperative complications. The surgeon should take a short break at this time to be prepared for the reconstruction.
Pancreaticojejunostomy (Fig.25.22)
The jejunum is brought through the natural ligament of Treitz opening or through a
defect in the mesocolon, and the pancreatic anastomosis is performed. A modied
Blumgart technique is done with outer seromuscular layer through and through