Hybrid Laparoscopic and Robotic Pancreaticoduodenectomy

Video Type: CVideo
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Author: Toms Augustin
Published:
Specialties: General Surgery, Robotic Surgery
Schools:
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Basic Info

Contributors: Sricharan Chalikonda and R. Matthew Walsh

Two separate general approaches are described to perform minimally invasive pancreaticoduodenectomy (PD): pure laparoscopic and robotic. The technique shown is a hybrid utilizing laparoscopy for the resection and surgical robot for the reconstruction. We feel that this technique combines the advantages of both laparoscopic and robotic surgery.

Advanced

Procedure

Diagnostic laparoscopy is performed. The gastrocolic ligament is taken down preserving the right gastroepiploic arcade to the pylorus. The mesolon is separated from the stomach with dissection in the avascular plane, which is continued laterally to reduce the hepatic flexure of the colon. A tunnel beneath the neck of the pancreas is started with identification of the portal vein but not completed. This will be completed during the transection phase of the PD.

The gastropiploic vein is divided between clips and the inferior extent of the superior mesenteric vein is exposed. The duodenum is Kocherized. The post pyloric duodenum is exposed circumferentially dividing the right gastric vessels. EndoGIA stapler is used to divide the duodenum followed by division of the gastroepiploic vessels. GDA is circumferentially dissected, test clamped and divided between clips. Cholecystectomy is performed and the common hepatic duct is encircled. The patient is next placed supine for the jejunal dissection.

The mesentery of the jejunum is transected with an Endoshear proceeding proximally in close proximity to the jejunum all the way to the ligament of Treitz, which is divided. The jejunum is then passed to the supramesocolic compartment and divided with an EndoGIA stapler. Finally the pancreatic neck is divided and the uncinate dissected from the superior mesenteric artery. The majority of the gland transection is done thermally until the duct is encountered which is then sharply divided with scissors. Once the specimen is completely liberated it is placed into an endocatch bag. The jejunal limb is oriented for a duodenojejunostomy (DJ) by placing stay sutures on the corners. This anastomosis maybe completed laparoscopically at this time or robotically after the pancreticojejunostomy (PJ) and hepaticojejunostomy (HJ). The robot is next docked.

A PJ is then created using a stented Blumgart technique; the stent aiding in identifying the duct as sutures are placed. An HJ is next created after excess bile duct is trimmed using interrupted sutures, typically absorbable monofilament, 4-0 on RB1 needles. If a DJ has not already been created, then an antecolic single or two-layered anastomosis is completed and a leak test performed. The operation is completed by undocking the robot, closure of extraction site and drain placement.

Indications

1.Pancreatic adenocarcinoma
2.Premalignant pancreatic cysts including intraductal papillary mucinous neoplasm, mucinous cystic neoplasm
3.Solid pseudopapillary tumor
4.Serous cystadenoma meeting resection criteria
5.Cholangiocarcinoma of the lower bile duct
6.Duodenal carcinoma, and periampullary carcinoma
7.Neuroendocrine tumors
8.Chronic pancreatitis including groove pancreatitis

Contraindications

Patient selection evolves with the surgical team¢s experience. Initial patients should include favorable pathology in terms of disease extent, and favorable body habitus, without android adipose distribution. Patient who may require vascular reconstruction or with large tumors may not be favorable candidates early on in the experience.

Instrumentation

Setup

1.The patient is placed in a supine non-French position
2.Principle operating surgeon is either on the right or the left side of the patient depending on the step
3.General access for pneumoperitoneum is achieved via 5 mm optical trocar in the left upper quadrant, and this site is used for a table fixed liver retractor
4.Port placement includes: epigastric Nathonson liver retractor, left ant axillary subcostal 5 mm port, left midclavicular 5 mm port, midline supraumbilical 12 mm port, right midclavicular subcostal 12 mm port and right ant axillary subcostal 5 mm port.

Preoperative Workup

Preoperative work up is guided by the condition for which the surgery is being offered. Generally, a CT scan of the abdomen, pancreas protocol may assist in planning surgery with regard to variant arterial anatomy and exclude vascular invasion. As needed endoscopic ultrasonography and tumor markers may be utilized. General preoperative labs are also sent including complete blood count, serum electrolytes, liver function panel and coagulation profile.

Anatomy and Landmarks

As noted in procedure

Advantages/Disadvantages

Advantages of the laparoscopic techniques include general similarity to other complex intra-abdominal and foregut procedures, comparatively less operative costs, and fluidity of motion for an operation that occurs in multiple areas in the upper abdomen. Robotic techniques have the potential to add high fidelity movement at the operative site which is most effective when the operative field is narrowly focused, can shorten the learning curve for complex procedures, but adds operative costs and effectively limits the operative ports to three. Advantages over the open approach include comparable oncologic outcome but decreased length of stay. Disadvantages over the open approach include longer surgical times, and decreased ability to perform vascular reconstructions.

Complications/Risks

Intraoperative complications include excessive blood loss needing conversion to open surgery. Perioperative morbidity includes infectious complications like surgical site infection, pancreatic fistula (Grades A-C) requiring drain placement and rarely reoperation, anastomotic leaks and bile leaks. Mortality rates range from 1-3% in large institutional studies. Late surgical complications included an incisional hernia at the specimen extraction site.

Disclosure of Conflicts

Intraoperative complications include excessive blood loss needing conversion to open surgery. Perioperative morbidity includes infectious complications like surgical site infection, pancreatic fistula (Grades A-C) requiring drain placement and rarely reoperation, anastomotic leaks and bile leaks. Mortality rates range from 1-3% in large institutional studies. Late surgical complications included an incisional hernia at the specimen extraction site.

Acknowledgements

None

References

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