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Robotic hepatopancreatic surgery 129
primary benefit of avoiding a splenectomy, of course, is
preservation of intact immunity against encapsulated
organisms and avoiding overwhelming postsplenectomy
sepsis. This is of particular importance for younger
patients, such as those with SPPT. Moreover, splenic
preservation has also been reported to be associated
with a decreased incidence of postpancreatectomy diabetes mellitus. In our practice, splenic preservation is
attempted whenever possible when performing distal
pancreatectomy for benign and premalignant tumors.
Malignant tumors, on the other hand, are still resected
with en bloc splenectomy.
Contraindications to robotic-assisted distal pancreatectomy include the same contraindications to open distal
pancreatectomy (e.g. metastatic disease, locally unresectable tumors) in addition to pneumoperitoneum
intolerance, elevated intracranial pressure, and presence
of significant adhesive disease that would prohibit a safe
operation.
8.4.2 Preoperative planning
In planning a distal pancreatectomy for PDAC, a thorough
staging work-up must be undertaken. A high-quality
computed tomography (CT) scan of the abdomen and
pelvis with intravenous contrast is obtained to assess the
extent of tumor invasion and look for metastatic disease.
Although thin-cut CT scans are accurate in determining
local tumor extent, their sensitivity in detecting small
peritoneal or liver surface implants remains suboptimal,
with failure rates up to 30%. Since pancreatic body and
tail tumors do not produce early symptoms, they bear a
high probability of having metastasized by the time of
diagnosis.
Conversely, cross-s ectional imaging is of tremendous
value in distinguishing b enign from malignant pancreatic cystic neoplasms, a distinction that is critical in
guiding management. Serous cystadenomas (SCA)
are benign and do not warrant surgical resection, unless
they cause symptoms, whereas MCNs and main duct
IPMNs may harbor i nvasive components and should be
completely resected with clear margins in many cases.
On imaging, SCAs may appear either as a nonenhancing m ass containing multiple small cysts separated by
internal septations, possi bly with a central starbust
calcification (polycystic microcystic variant), or as a
macrocyst with a dist inctive lobulated contour that
is most commonly found in the pancreatic head
(oligocystic variant). MCNs, o n the other hand, appear
as a thick-walled, usually septated macrocyst with
smooth sharp boundaries, with no surrounding
inflamed pancreatic tissue. They are most often located
in the pancreatic body or tail, and may contain papillary
excrescences or mural nodules and possibly calcifications within the cyst walls. Finally, IPMNs appear as
lobulated, poorly demarcated, polycystic masses associated with dilatation of the mai n pancreatic duct or its
side branches; fi ndings suggestive of malignant main
duct disease include mural nodules, main pancreatic
duct dilatation (>10 mm), and presence of intraluminal
calcifications [51].
Preoperative imaging must be carefully reviewed to
identify potential anatomical variations, especially with
regard to vascular aberrancies, and in the case of a spleenpreserving distal pancreatectomy, to define the degree of
pancreatic tail extension into the splenic hilum.
Basic blood tests, including liver function tests and
coagulation parameters, are checked. If splenectomy is
anticipated, appropriate vaccinations are provided two
weeks prior to surgery.
8.4.3 Surgery
While several robotic-assisted distal pancreatectomy
approaches have been described in the literature, our
preferred technique is the hybrid method, whereby
the operation is begun laparoscopically to gain access
to the lesser sac and expose the pancreas, and the
robot – the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) – is then docked to complete the
dissection and resection.
8.4.3.1 Positioning
The patient is placed in the supine position on the operating table, with a bump or wedge behind the left side so
as to tilt him/her towards the right. The bed is then tilted
in slight (30°) reverse Trendelenburg position, and the
patient’s arms are tucked. Care must be taken to properly
pad the patient’s head and all pressure points along the
extremities and to preserve safe access to the patient’s
head and neck for anesthesia monitoring and airway
protection. A Foley catheter and an orogastric tube are
inserted, and the abdomen is prepped and draped widely.
The patient is provided with appropriate prophylactic
antibiotics as well as pharmacological and mechanical
thromboprophylaxis.
130 Chapter 8
Figure 8.1 Operating room set-up after robot docking. The
robotic cart is brought in from above the patient’s left shoulder.
The anesthesia team (A) remains above the patient’s right
shoulder. The first assistant (FA) is situated to the patient’s
right side, while the scrub nurse (SN) stands on the left side of
the patient and is responsible for instrument exchanges. The
surgeon (S) is seated at the robotic console (RC).
When the robotic portion of the operation is reached,
the bulky robot cart will be brought in from above the
patient’s left shoulder; it is imperative to properly situate
all operating personnel accordingly. The anesthesia team
will remain above the patient’s right shoulder and ensure
adequate access to the patient’s head and airway. The first
assistant, who must be skilled in laparoscopy, will be
situated to the patient’s right side while the scrub nurse
will stand to the patient’s left side (Figure 8.1).
8.4.3.2 Incision/exposure
The operation is commenced with establishment of
pneumoperitoneum. A 12 mm trocar is placed to the
left of the midline, 2– 3 cm above the level of the umbilicus, using the Hassan technique, and the abdominal
cavity is insufflated to 14 mmHg. This will also serve
as the camera port. A 30° laparoscope is introduced to
visually inspect peritoneal surfaces before proceeding
with additional port placement under direct vi sual ization.Intotal,sixportsareplaced– four for the robotic
arms (including the camera port) and two for the assistant, as illustrated in Figure 8.2.
8.4.3.3 Surgical technique
The laparoscopic-assisted robotic distal pancreatectomy
can be broken down into five main steps:
1 entry into lesser sac and exposure of the pancreas
2 pancreatic mobilization and dissection
3 vascular control and pancreatic transection
Figure 8.2 Port placement for robotic assisted distal
pancreatectomy. Robotic ports are represented in blue;
laparoscopic ports are represented in red. The 12 mm robotic
camera trocar (C) is placed in the left paraumbilical area. The
robotic working arms 1 and 2 are placed through 8 mm ports
R1 and R2, respectively. The third robotic arm (8 mm) is placed
in the right upper quadrant (R3) and is used primarily for
retraction. The assistant’s right-hand instrument is placed
through a 12 mm port (AR). The assistant’s left-hand 8 mm
port (AL) may be optional.
4 posterior dissection and separation of the pancreas
from splenic vessels and retroperitoneum in a medial
to lateral direction
5 specimen removal and closure.
Exposure of pancreas
After pneumoperitoneum has been established and upon
completion of peritoneal surface inspection to rule out
metastatic disease, additional ports are placed to carry out
this step laparoscopically.
• The small bowel is mobilized to the patient’s right and the
transverse colon is retracted cephalad to expose the mesentery of the left colon. The left colon is then medialized in
acaudadtocephaladmannertowardthesplenicflexure.
• Next, the transverse colon is deflected inferiorly by
mobilizing the splenic flexure from its lateral and retroperitoneal attachments. The greater omentum is
dissected away from the transverse colon along the
avascular plane. Conversely, it can also be divided
below and along the course of the gastroepiploic arcade,
ligating the minimum number of short gastric vessels
Robotic hepatopancreatic surgery 131
Figure 8.3 Laparoscopic exposure of the pancreas. Entry into the lesser sac is achieved by dividing the greater omentum below the
gastroepiploic arcade. The transverse colon is retracted caudally, and the stomach lifted to expose the anterior surface of the
pancreas. A tumor can be seen protruding from the body of the pancreas (arrow).
necessary to provide good exposure to the pancreatic
tail if the spleen is to be preserved.
• The colon is then retracted inferiorly and the omentum
lifted up to enter the lesser sac, exposing the anterior
surface of the pancreas and the transverse mesocolon
(Figure 8.3).
• Separation of the posterior wall of the stomach from the
pancreas can be accomplished bluntly with relative
ease but may at times require sharp dissection in the
setting of prior inflammation. Medially, near the pylorus, we routinely look for and divide a communicating
vein between the right gastroepiploic vein and the
middle colic vein so as to avoid tearing it during upward
retraction of the stomach.
• To aid in retraction of the stomach, we tack it to the
anterior abdominal wall with a suture which will
then be removed upon completion of the pancreatic
resection.
• Laparoscopic ultrasound can be performed, if neces-
sary, along the anterior surface of the pancreas to
confirm tumor locatio n. Some of the inferior pancr eatic dissection can be performed at this time a s well
(Figure 8.4).
At this stage of the operation, the remaining trocars are
placed and the robot is docked. The robotic cart is brought
in over the patient’s left shoulder and oriented obliquely,
aiming toward the patient’s right foot.
Pancreatic mobilization and dissection
With the pancreas now fully exposed anteriorly, the
transverse mesocolon is stretched caudally to outline
the pancreatic inferior border. Dissection is begun at
the pancreatic neck.
• Using the monopolar cautery hook, the peritoneal layer
overlying the inferior pancreatic border is incised and
the areolar tissue layer is entered and gently dissected to
elevate the pancreas. This dissection is carried out
towards the tail of the pancreas, exposing the splenic
vein along its course (Figure 8.5).
• Medially, the superior mesenteric vein (SMV) is iden-
tified and, with the pancreas retracted upwards by the
third robotic arm, gentle blunt dissection is carried out
along the anterior surface of the SMV as it transitions
into the portal vein (PV) upon joining the splenic vein,
thereby creating the retropancreatic tunnel and identifying the pancreatic neck (Figure 8.6).
132 Chapter 8
Figure 8.4 Dissection of the inferior border of the pancreas. The laparoscopic equipment can be used to commence dissection of the
inferior pancreatic border along a relatively avascular plane. Care must be taken to avoid dissecting into the transverse mesocolon.
• Retraction of the pancreas can be more gently
achieved by lifting it with the flat surface of the
instrument’s closed jaws while providing additional
traction with the elbow of the instrument rather
Figure 8.5 Exposure of the splenic vein along the inferior border of the pancreas. Following docking of the robot, the plane below
the inferior pancreatic border is further developed so as to expose the splenic vein. This dissection is carried laterally toward the tail
of the pancreas.
than by grasping the gland between the jaws of the
instrument.
• Surgical tape is then used to encircle the pancreatic
neck to assist in retraction (Figure 8.7).
Robotic hepatopancreatic surgery 133
Figure 8.6 Development of the retropancreatic tunnel at the level of the pancreatic neck. Medial dissection exposes the junction of
the splenic vein (SV) and superior mesenteric vein (SMV) as they merge to form the portal vein (PV). This represents the area of
pancreatic transection for this pancreatic body tumor.
Figure 8.7 Encircling of the pancreatic neck with surgical tape. A piece of surgical tape is tied around the pancreatic neck to facilitate
retraction of the pancreas for further dissection and pancreatic transection.
134 Chapter 8
Figure 8.8 Skeletonization of the splenic artery during dissection along the superior border of the pancreas. The splenic artery (SA) is
identified during dissection of the superior border of the pancreas, near its origin. It is skeletonized in a medial to lateral fashion. The
splenic vein (SV) can be seen inferiorly.
We next turn our attention to the superior border of the
pancreas to obtain vascular control.
Vascular control and pancreatic transection
Beginning at the level of the pancreatic neck, with the
pancreas retracted caudally, the arterial dissection is
addressed. Vascular dissection can be accomplished
with great precision thanks to the fine controlled movements afforded by the robotic platform.
• The common hepatic artery is identified and skeleton-
ized back to the celiac axis, sweeping the lymphatic
tissue toward the specimen.
• The splenic artery is identified next and dissected dis-
tally towards the pancreatic tail (Figure 8.8). If the
artery runs behind the pancreas rather than above it,
we prefer to delay this distal dissection until after
having initiated our retropancreatic dissection.
In our experience, dividing the pancreatic neck early
helps with the rest of the pancreatic mobilization. This
step is completed prior to the retropancreatic dissection.
• The neck of the pancreas is divided with an EndoGIA
stapler loaded with a vascular staple load fitted with a
Seamguard attachment, introduced through the assis-
tant’s 12 mm port (Figure 8.9). The stapler should be
applied slowly to minimize trauma. We typically take
2–3 minutes to fire the stapler completely. We do not
oversew the staple line (Figure 8.10).
• If the neck of the pancreas is particularly thick, the
pancreas is divided instead with a combination of cautery and suture ligation. The pancreatic stump is closed
with a running 3-0 prolene suture, and the pancreatic
duct is oversewnwith a vertical mattress, nonabsorbable
suture. While some authors have advocated using fibrin
glue to reinforce the suture line, its efficacy in reducing
pancreatic leak or fistulization remains questionable.
If en bloc splenectomy is planned, we prefer to control the
splenic vessels as the next step after pancreatic neck
transection.
• The splenic artery is skeletonized, locking clips are applied,
and the artery is sharply divided. The arterial stump is then
suture-ligated, which can be accomplished with relative
easeusingtherobot.
• Similarly, the splenic vein is dissected free starting from
the splenomesenteric junction, and divided with a
vascular stapler.
Retropancreatic dissection and vascular separation
The distal pancreatic stump can now be grasped with the
third robotic arm and retracted laterally to expose the
posterior pancreatic surface.
• The pancreas is gently dissected off the retroperito-
neum and off the splenic artery and vein in a medial
to lateral direction. There are invariably several tribu-
taries behind the pancreas draining directly into the
Robotic hepatopancreatic surgery 135
Figure 8.9 Division of the pancreatic neck. An endoGIA stapler loaded with a vascular staple load and fitted with a Seamguard
attachment is introduced by the assistant through the 12 mm trocar. After closing the stapler, we typically wait 15 seconds before
firing the staple load.
splenic vein (Figure 8.11). These must be meticulously
dissected and controlled; they can usually be divided
with ultrasonic shears (Figure 8.12).
• With adequate traction, th e plane of dissection
should be kept anterior to Gerota’s fascia, avoiding
Figure 8.10 Appearance of the staple line after firing. Following firing of the endoGIA fitted with a Seamguard attachment, the
staple line on the pancreatic remnant does not need to be oversewn.
potential injury to the left adrenal gland and left
renal vein.
• The pancreatic tail is next dissected off the splenic
hilum; large branches in this area may necessitate
suture ligation. In some patients, the pancreatic tail
136 Chapter 8
Figure 8.11 Identification of a tributary draining into the splenic vein (arrow). During the retropancreatic dissection, tributaries from
the posterior surface of the pancreas must be carefully dissected and controlled as they drain directly into the splenic vein.
does not extend into the splenic hilum; the specimen will be freed upon separation of the pancreatic
tail for the splenic vessels instead (Figure 8.13).
• When the goal is en bloc distal pancreatectomy with
splenectomy, hilar dissection is avoided. Lateral and
retroperitoneal attachments of the spleen are dissected
with shears instead, and short gastric vessels are com-
pletely ligated.
Completion of these steps will have completely freed up
the specimen, which is then placed in an endoscopic bag
for extraction.
Figure 8.12 Ligation of splenic vein tributaries during retropancreatic dissection. Ultrasonic shears are used to ligate splenic vein
tributaries.
Robotic hepatopancreatic surgery 137
Figure 8.13 Completion of the distal pancreatectomy. In this spleen-sparing distal pancreatectomy, the tail of the pancreas ends
short of the splenic hilum, such that the lateral attachments between the splenic artery (SA) and splenic vein (SV) and the tail of the
pancreas (P) represent the last step of our dissection. The specimen is then retrieved in an endobag and extracted through an
extension of the assistant’s right-hand port.
Specimen extraction and abdominal closure
To allow for removal of the specimen, a small incision is
made, either in the lower abdomen through a Pfannenstiel incision or locally in the left upper quadrant, extending from one of the ports.
• Following specimen removal, the extraction site is
closed, and the abdominal cavity reinsufflated. Hemostasis is verified, paying special attention to the pancreatic bed.
• A 19 Fr silastic drain is placed near the pancreatic stump
under direct visualization, exiting laterally through the
left robotic arm port site.
• The robot is undocked, and the 12 mm port sites are
closed under laparoscopic visualization using an endo-
scopic suture passer device.
The abdomen is desufflated, the remaining ports are
removed, and each wound is closed with subcuticular
absorbable sutures. The patient is extubated and taken to
the recovery room.
8.4.4 Postoperative management/
complications
The patient is admitted to the regular ward postoperatively, and analgesia is provided with IV narcotics.
A clear liquid diet is started on postoperative day 1 and
advanced as tolerated. As with all patients undergoing
abdominal surgery, pulmonary exercises with incentive
spirometry are instituted.
Laboratory checks include close monitoring of blood
sugar levels, as a permanent or transient diabetic state
may develop. We do not routinely check serial serum
amylase levels.
The drain output is closely monitored, and if minimal,
the drain is removed prior to discharge. Conversely, if the
output is high or rising, a drain amylase is sent along with
a serum amylase level to diagnose a pancreatic fistula. If
present, the drain is left in place until its output diminishes
to minimal levels, a process that may take several weeks.
In our experience, rates of clinically significant pancreatic
fistulas (grades B and C) are low when proper surgical
techniques are employed.
8.5 Conclusion
Hepatic and pancreatic resections are among the most
advanced, technically challenging abdominal operations
encountered. While enthusiasm for minimally invasive
surgery has been widespread, the field of HP surgery has
been relatively slow to adopt the laparoscopic technique
138 Chapter 8
because of inherent limitations of this technology. The
computer-assisted robot, by offering a stable platform that
allows for precise maneuvering, seven degrees of freedom, a 3D visual field, and improved ergonomics, may
present some advantages over laparoscopy for HP surgery. So far, robotic-assisted HP surgery has yielded
encouraging results. Perioperative outcomes, including
morbidity and mortality, have been mostly similar
between the two groups, while the robotic approach is
generally associated with shorter hospital LOS, especially
when compared with the open HP experience. The main
drawbacks of robotic-assisted HP are the longer OT, the
lack of haptic feedback, and the higher cost of the equipment, although this may be offset by the financial savings
associated with a shorter hospital LOS. Short-term surrogate markers of oncological adequacy have been encouraging, with excellent rates of negative margins and
KEY POINTS
• Among the minimally invasive approaches to hepatopancreatobiliary surgery, there are important differences between a
laparoscopic and a robotic approach.
• The advantages of a robotic approach are improved ergonomics, three-dimensional vision, and greater degrees of freedom of the
instruments.
• The disadvantages are the need for an additional experienced hepatopancreatobiliary surgeon at the table to manage acute
complications, inferior three-dimensional vision compared with the view provided by newer laparoscopic three-dimensional
cameras, limited options in advanced energy devices that facilitate liver surgery.
• In particular, reconstruction is facilitated with a robotic approach.
• A robotic approach may help surgeons to transition from an open to a minimally invasive technique.
• Key concepts of advanced minimally invasive surgery regarding acute complication management must be comprehended before
performing robotic hepatopancreatobiliary surgery.
• Further innovation at the instrument-surgeon interface will elevate robotic surgery from “tele-manipulation” (the surgeon is
remote from the operative field) to true automatically enhanced surgery.
• Proctoring, supervision, case selection, and noncompromised oncological outcomes are important concepts when gaining
robotic experience.
adequate lymph node yield. Long-term oncological outcomes are eagerly awaited.
Enthusiasm for robotic-assisted HP surgery must be
tempered by both this dearth of long-te rm oncological
outcomes and the r ealizati on that the currently available data are derived from highly selected patients,
operated on by highly skilled surgeons, in hig hly specialized centers. It i s likely that the robotic approach to
HP surgery will be assimilated into the treatment of
liver and pa ncreatic pathologies before any randomized
controlled trial will demonstrate its noninferiority,
much less its superiority, to the open and laparoscopic
approaches. It is therefore important to be reminded
that the robot is but a tool in the surgeon’sarmamentarium, albeit an advanced one, and, like the laparoscope before it, should always serve as a means to an
end and never become an end in itself.
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