Robotic pylorus-preserving pancreaticoduodenectomy and cholecystectomy

Introduction

The application of minimally invasive techniques in hepatopancreaticobiliary (HPB) surgery has lagged behind other surgical specialties, such as bariatric and colorectal surgery. This is a testament to the unique and complex nature of HPB operations, particularly pancreaticoduodenectomies. The application of laparoscopic techniques has demonstrated limited efficacy due to the inherent difficulty to perform fine motor tasks, such as reconstruction of a pancreaticojejunostomy. The meticulous surgical steps include dissection of the major mesenteric vessels and reconstruction with biliary, enteric, and pancreatic anastomoses. Due to the nature of HPB operations, there are only a handful of institutions in the world that have accrued noteworthy experience with robotic pancreaticoduodenectomies.

The development and implementation of robotic platforms have provided a mechanism to circumvent the downfalls of laparoscopy, allowing for dynamic movements unattainable via laparoscopy. The da Vinci Xi system EndoWrist technology (Intuitive Surgical, Inc., Sunnyvale, CA), in particular, introduces seven degrees of freedom and removes physiological tremor and motion scaling, allowing for accurate movements to be performed from the console. ^, In addition, 3D-immersive vision generates high-resolution images and further aids surgeons to perform precise dissections. These advancements have generated great excitement for robotic pancreaticoduodenectomy, particularly at high-volume institutions around the globe.

Peng et al. reported similar perioperative outcomes following robotic pancreaticoduodenectomy as open pancreaticoduodenectomy in a multi-institutional study consisting of 680 patients. Upon analysis, the robotic approach was associated with a higher rate of R0 margins, lower overall complication rate, and shorter length of hospital stay. The reoperation rate, delayed gastric emptying, bile leak, pancreatic fistula, and lymph nodes harvested were comparable to those obtained following the open approach.

This chapter will discuss the steps of the operation being undertaken in the order in which they are described. However, there is some latitude. The reason for the steps of the operation being undertaken in a particular order will be denoted in the description of each step.

Indications

Patients with pancreatic lesions of the head, uncinate process, and/or neck of the pancreas, such as pancreatic adenocarcinoma, malignant intraductal papillary mucinous neoplasm, neuroendocrine tumor, periampullary adenocarcinoma, duodenal carcinoma, and cholangiocarcinoma.

Contraindications

Patients with locally advanced or metastatic disease and patients who underwent neoadjuvant therapy for locally advanced disease who are now resectable but will require major vascular resection and reconstruction.

Preoperative planning

• Computed tomography of the chest, abdomen, and pelvis with triple phase IV contrast and 1-mm thin cuts through the pancreas

• Endoscopic ultrasound and fine-needle aspiration to delineate the pancreatic mass and associated blood vessels and to obtain tissue biopsy for histological diagnosis and staging.

• Comprehensive laboratory examination (i.e., CMP, CBC, CA 19-9 tumor marker levels)

• Endoscopic retrograde cholangiopancreatography with placement of an intraductal stent when necessary (i.e., obstruction of the common bile duct with hyperbilirubinemia). Patients undergoing neoadjuvant therapy generally have self-expanding metallic stents placed.

• Magnetic resonance cholangiopancreatography to delineate the biliary and pancreatic ducts (not always necessary)

• Risk analysis including cardiac, pulmonary, hepatic, and renal function. We routinely obtain cardiac risk stratification for patients older than 50 years of age or for patients under the age of 50 with risk factors.

• Enhanced recovery after surgery protocol, beginning with patient education and nutritional support preoperatively, pain and fluid management intraoperatively ( Fig. 32.1 ), and physical therapy postoperatively

  

Beginning the operation

The operation begins with thorough preoperative planning. In the preoperative holding area, an epidural catheter is placed. The patient is taken to the operating room and laid supine upon the operating table with the arms out. The patient is placed in approximately a 10–12-degree reverse Trendelenburg position with a tilt of approximately 3–4 degrees to the patient’s left.

An incision is made at the umbilicus. An 8-mm trocar is inserted and diagnostic laparoscopy utilizing the robotic scope is undertaken. In the absence of cancer beyond the extent of our planned operation, additional trocars are placed. A 5-mm trocar is placed along the right anterior axillary line at the subcostal margin. An 8-mm port is placed just lateral to the midclavicular line on the right side at the level of the umbilicus, and a mirror 12-mm port is placed on the left side of the umbilicus. An 8-mm trocar is placed along the left anterior axillary line just cephalad to the umbilicus. Between the umbilical trocar and the trocar near the right midclavicular line, the GelPOINT Advanced Access Platform (Applied Medical, Santa Margarita, CA) is placed caudal to the umbilicus ( Fig. 32.2 ). This port is for the bedside surgeon or first assist to participate actively in the operation and, ultimately, for specimen extraction ( Fig. 32.3 ). The da Vinci Xi (Intuitive Surgical, Inc., Sunnyvale, CA) is docked, as noted in Fig. 32.4 .

Initial steps

1)

Kocher maneuver and division of the jejunum

• Arm #1: Fenestrated Bipolar Forceps (fenestrated bipolar)

• Arm #2: Camera

• Arm #3: Permanent Cautery Hook (hook cautery), Hot Shears (monopolar curved scissors) [Hot Scissors], Vessel Sealer Extend (vessel sealer)

• Arm #4: Small Graptor (grasping retractor)

A laparoscopic bowel grasper is placed through the applied port and the colon is retracted to the patient’s right and toward the feet. The Kocher maneuver is undertaken, beginning in the foramen of Winslow where the inferior vena cava is identified. Then, dissecting in a caudal direction, the duodenum is rolled progressively to the patient’s left as more and more of the inferior vena cava is exposed. It is worthwhile to visualize the left renal vein. This dissection is continued until the ligament of Treitz is violated and completely taken down so that the proximal jejunum can be advanced under the root of the mesentery ( Figs 32.5 A–C). A defect in its mesentery is made with the hook cautery, taking down several vascular branches into the bowel. The jejunum is then divided using an EndoWrist Stapler 45 Instrument (stapler) with a 3.5 Blue SureForm Reload (blue-load) placed through Arm #3 ( Fig. 32.6 ).

If the duodenum just distal to the pylorus is divided before the Kocher maneuver is undertaken, the Kocher maneuver becomes more difficult. In general, however, the Kocher maneuver can be quite difficult, and once this portion of the operation is accomplished, the operation can move along quite nicely. Needless to say, prior open abdominal operations with resultant adhesions and/or an obese patient make the initial portion of the procedure and the Kocher maneuver with mobilization of the proximal jejunum quite difficult.

2)

Dividing the gastroduodenal artery

• Arm #1: Fenestrated bipolar

• Arm #2: Camera

• Arm #3: Hook cautery or hot scissors

• Arm #4: Small Graptor

Utilizing the hook cautery in Arm #3, the gastrohepatic omentum is opened in a stellate fashion. Dissection is carried along the common hepatic artery, beginning near the celiac trunk. Enlarged nodes overlying the common hepatic artery should be removed and sent for frozen section ( Fig. 32.7 ). Without any other disease apparent outside the pancreas or distal biliary tree, we would continue. The right gastric artery is identified and controlled at or near its origin. The gastroduodenal artery (GDA) is identified, grasped, and occluded, and pulsations in the proper hepatic artery are sought. The GDA is then doubly clipped proximally and distally and divided with the robotic hot scissors ( Fig. 32.8 ).

Preoperative imaging and intraoperative ultrasound can also be helpful in sorting out confusing anatomy. In the presence of a completely replaced common hepatic artery, which then arises from the superior mesenteric artery, this portion of the procedure is moot. Special considerations for anatomy will be mentioned later.