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366
Fig. 20.20 An end-to-side
duodenojejunostomy is
constructed in four layers,
with running barbed
sutures, and in an antecolic
fashion (Figure reproduced
with permission of Horacio
J Asbun)
N. Lluís et al.
nostomy as well the duodenojejunostomy. It is positioned into the left upper
quadrant up behind the tip of the spleen and run under the left lobe of the liver.
Postoperative Course
A nasogastric tube is not left in place postoperatively, and the urinary catheter is
usually removed on the rst postoperative day. The patient is started on a clear liquid diet in the immediate postoperative period. Early ambulation is enforced, as is
avoidance of narcotics if possible. Drain amylase is checked regularly and prior to
removal. Length of stay ranges between 4 and 6days if no complications arise.
Conclusions
This minimally invasive approach for PD is reproducible, yet advanced laparoscopic skills are required. Although there are variations in technique, this chapter
summarizes the authors’ experience with the goal of maximizing the safety, reproducibility, and efciency of this complex operation.
Conict of Interest The authors have no conict of interest to declare.
20 Laparoscopic Pancreatoduodenectomy
367
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N. Lluís et al.
Chapter 21
Robotic Pancreatoduodenectomy
SharonaRoss, HarelJacoby, CameronSyblis, IswantoSucandy,
andAlexanderRosemurgy
Introduction
Pancreaticoduodenectomy is one of the most complex and challenging abdominal
operations. It requires high surgical skill with meticulous precision and excellent
anatomic knowledge. Ever since Whipple reported his experience with three patients
who underwent a two-stage pancreaticoduodenectomy, this operation has evolved
tremendously [1]. With experience gained over the years, along with the improvement of surgical tools, the pancreatoduodenectomy has become a common operation with acceptable morbidity and mortality [2, 3].
Minimally invasive surgery has gained popularity in many surgical elds including pancreatic surgery. The rst laparoscopic pancreaticoduodenectomy was performed in 1994 and ever since the laparoscopic approach gradually increased but
eventually plateaued [4–6]. This approach was criticized by many surgeons stating
it required a long learning curve and had the potential for high morbidity and mortality [7, 8].
The robotic platform transformed pancreatic surgery and led to a new era of
minimally invasive surgery. The robotic platform has several advantages compared
S. Ross (*) · I. Sucandy · A. Rosemurgy
Department of Surgery, University of Central Florida, Orlando, FL, USA
Advent Health Tampa| Digestive Health Institute, Tampa, FL, USA
H. Jacoby
Advent Health Tampa| Digestive Health Institute, Tampa, FL, USA
Sheba Medical Center, Tel-Aviv, Israel
C. Syblis
University of South Florida Morsani College of Medicine, Tampa, FL, USA
Advent Health Tampa Digestive Health Institute, Tampa, FL, USA
Switzerland AG 2025
E. P. Ceppa et al. (eds.), The SAGES Manual of Evolving Techniques in
Pancreatic Surgery, https://doi.org/10.1007/978-3-031-78409-5_21
369© The Author(s), under exclusive license to Springer Nature
370
to conventional laparoscopy including elimination of hand tremor, seven degrees of
freedom, high resolution three-dimensional visualization, stable camera, ambidextrous suturing, and excellent ergonomics [9–13]. These advantages enable surgeons
to overcome the limitations of traditional laparoscopy to perform complex operations safely and meticulously without compromising oncologic outcomes. RPD has
already been implemented in several centers worldwide with promising results
[14–18]. The purpose of this chapter is to describe the key steps for performing a
RPD. As this technology continues to evolve and become widely adopted, we
believe that the robotic platform will become the preferred approach among pancreatic surgeons.
S. Ross et al.
Preoperative Workup
Preoperative Planning
• Following diagnosis of pancreatic malignancies or high-risk neoplastic lesions,
all patients should complete a preoperative assessment including overall perfor-
mance status, medical comorbidities, and clinical staging when indicated.
• All patients with pancreatic cancer should be discussed in a multidisciplinary
tumor board, with a special focus on those with borderline resectable/locally
advanced lesions or patients with signicant comorbidities [19].
• Multidisciplinary review should consider involving expertise from diagnostic
imaging, interventional endoscopy, medical oncology, radiation oncology, hep-
ato-pancreatico-biliary (HPB) surgery, pathology, geriatric medicine, genetic
counseling, and palliative care [20].
• Cardiac assessment is recommended for patients with a presumably higher risk
for perioperative cardiac events [21].
• Age and frailty may predict a difcult postoperative course and should be con-
sidered preoperatively [22, 23].
• Preoperative counseling for Enhanced Recovery After Surgery (ERAS) protocol
is recommended to achieve early recovery and improved outcomes [24].
• Malnourished patients should be given special attention and may need preopera-
tive nutritional optimization by a nutritionist.
Imaging andAdditional Diagnostic Studies
• In most institutions, computed tomography (CT) is the initial modality for stag-
ing. We use triphasic pancreatic protocol CT scan with 1mm cuts with recon-
struction for all patients during the month preceding their operation.
• Magnetic resonance imaging (MRI) with magnetic resonance cholangiopancrea-
tography (MRCP) offers additional information to equivocal CT ndings regard-
21 Robotic Pancreatoduodenectomy
371
ing localized disease description and providing additional information regarding
hepatic lesions. However, it does not add superior sensitivity or specicity and
therefore should be used in selected cases [25].
• F-uorodeoxyglucose-positron emission tomography (FDG-PET)/CT is a con-
troversial modality in the staging of pancreatic cancer. We use it to rule out meta-
static disease in high-risk patients.
• Endoscopic ultrasound (EUS) with EUS-guided biopsy is the preferred method
of obtaining histologic conrmation. While it is not recommended as a routine
staging stool as it is highly operator dependent, we nd it to be a very useful tool
and use it in most patients [26].
• Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement
is recommended for patients with active infection (cholangitis), patients planned
for neoadjuvant chemotherapy, or patients with long-standing jaundice with high
bilirubin.
Surgical Management
Patient Preparation
• Patient lies supine with their legs secured to the table using a belt around the
pelvis, and both arms are extended and secured to the arm board.
• A single shot of intra-thecal morphine sulfate is injected prior to induction.
• Following endotracheal intubation, a urinary catheter, nasogastric tube, and arte-
rial line are inserted.
• Perioperative measures are taken which include IV Zosyn within 30min prior to
the initial skin incision and sequential compression devices to prevent deep vein
thrombosis (DVT).
Diagnostic Laparoscopy andPort Placement
• We begin the operation with a small incision at the umbilicus and insertion of an
8mm robotic trocar.
• Once pneumoperitoneum is established, diagnostic laparoscopy is undertaken to
exclude liver metastasis and peritoneal carcinomatosis. After ruling out distant
metastases, additional trocars are placed under videoscopic visualization.
• An 8-mm trocar is inserted at the level of the umbilicus just to the right of the
right midclavicular line. A 12-mm trocar, to accommodate the 45mm EndoWrist
Stapler (Intuitive Surgical Inc., Sunnyvale, CA), is placed at the level of the
umbilicus in the left midclavicular line. An 8-mm trocar is placed along the left
anterior axillary line slightly cephalad to the umbilicus.
®
372
S. Ross et al.
• An additional 3–5cm incision is made, between and slightly caudal to the umbil-
ical trocar and the right midclavicular line trocar, for a multi-trocar port, and an
Applied GelPoint® (Applied Medical, Rancho Santa Margarita, CA) (Fig.21.1).
AirSeal® Access Port (Conmed Corporation, Utica, NY) is placed through the
multi-trocar port.
• The bed is placed in 15–22° (depending on BMI) reverse Trendelenburg and 5°
tilted to the left.
• The Da Vinci Xi™ robot (Intuitive Surgical Inc., Sunnyvale, CA) is then docked
from the right side of the patient. The scrub tech stands on the left and the rst
assistant on the right side of the patient (Fig.21.2).
• We use integrated table motion that enables dynamical positioning of the patient
while the surgeon operates.
Fig. 21.1 Port placement
21 Robotic Pancreatoduodenectomy
373
Fig. 21.2 Operation room setup
Surgical Steps
Step 1: Kocher Maneuver
• Arms setup:
– Arm #1: Fenestrated bipolar
– Arm #2: Camera
– Arm #3: Monopolar scissors
– Arm #4: Small grasping retractor (Bowel Grasper)
– Bedside assistant: laparoscopic bowel grasper and suctioning device
• The operation begins with retraction of the right lobe of the liver utilizing a 12-inch,
3-0 V-Loc™ wound closure device (Medtronic™, Minneapolis, MN, USA), the
hepatic exure is partially mobilized until the duodenum is well exposed.
• The duodenum is medially mobilized starting by freeing the lateral attachments
of D2 using the monopolar scissors and the fenestrated bipolar. The dissection is
carried superiorly to the border of D1 and D2 and then toward to D3 and D4
374
S. Ross et al.
while Arm #4 is used for medial retraction of the duodenum to facilitate full
exposure (Fig.21.3).
• An important landmark for sufcient mobilization is identifying the left renal
vein entering the inferior vena cava (IVC).
• The bedside assistant has an important role in this step, retracting the transverse
colon toward the right lower quadrant using a laparoscopic bowel grasper while
using the suction device to retract medially the mesocolon to enable access to the
ligament of Treitz. (Using single incision laparoscopic principals for instruments
placement through the multi-trocar ports.)
• After dividing the ligament of Treitz, the jejunum is pulled back enough to enable
transection using a robotic blue load da Vinci® Xi EndoWrist Stapler 45mm with
SmartClamp™ technology (Intuitive Surgical, Sunnyvale, CA, USA) (Figs.21.4
and 21.5).
• Tips and Key points:
– Retracting medially the duodenum using arm #4, improves the retraction for
better exposure after sufcient dissection is completed.
– Medial retraction of the transverse mesocolon using the suction device by the
bedside surgeon is needed to expose and dissect the ligament of Treitz.
– Replace as needed arm #1 and arm #3 to bowel graspers to pull back the jeju-
num behind the mesenteric root.
Step 2: Gastrohepatic andHepatoduodenal Dissection
• Arms setup:
– Arm #1: Fenestrated bipolar
– Arm #2: Camera
Fig. 21.3 Kocher
Maneuver. IVC inferior
vena cava
21 Robotic Pancreatoduodenectomy
Fig. 21.4 Pulling back the
proximal jejunum behind
the mesenteric root
Fig. 21.5 Transection of
the proximal jejunum
375
– Arm #3: Monopolar scissors, hook cautery, and medium-size clip
– Arm #4: Small grasping retractor (bowel grasper)
– Bedside assistant: suctioning device
• Using the monopolar scissors, the lesser sac is entered at the gastrohepatic liga-
ment, and the common hepatic artery is identied (Fig.21.6).
• The right gastric vessels are identied, ligated, and divided using the fenestrated
bipolar and monopolar scissors.
• Lymphadenectomy is completed starting at the common hepatic artery lymph
node and continuing toward the celiac trunk. Lymph nodes along the celiac
trunk, gastric vessels, splenic artery, and portal vein are all excised.