Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

The present protocol follows the ethics guidelines of the Amsterdam UMC. Informed consent was obtained from the patient for this article and the video.

1. Preoperative management

1. Perform preoperative imaging to assess the extent of the pancreatic lesion and for indications of vascular involvement.
2. Evaluate the eligibility for the surgical approach and relative contraindications.

2. Operative setting

1. Place the patient in French position with the right arm lowered on an arm board alongside the patient and the left arm in a 90° abduction. Tilt the table 20-30° to the left and in 20-30° reverse Trendelenburg position.
2. Perform the required safety check procedures and create a sterile exposition with chlorohexidine.
3. Create a pneumoperitoneum by inserting a Veress needle at Palmer's point, then insufflating to 10-12 mm CO₂.
4. After insufflation, mark the positions of the trocars and place them as shown in Figure 1 and Figure 2 (4 robot trocars, 2 (12 mm) laparoscopic tableside surgeon trocars, 1 (5 mm) trocar for snake liver retractor).
5. After insufflation, place a 12 mm tableside surgeon trocar (preferably, one with a blunt clear dome at the distal end, which encloses a crescent-shaped knife blade) to the right of the umbilicus.
6. After inspection and removal of the Veress needle, place the four 8 mm robotic trocars 11-12 cm from the pancreatic body (i.e., target area). Place the trocar at the patient's right side for robot arm 1, more cranial than the others as it is used for contraction.
7. Place a second 12 mm table-side surgeon trocar.
   NOTE: Make sure the distance between all the trocars is approximately 7 cm.
8. Finally, place a 5 mm trocar in the left upper quadrant to hold the laparoscopic stomach/liver retractor.
9. Install the robot at the right side of the patient and dock the robot arms to the robotic trocars.
   NOTE: The final operative setting is shown in Figure 3. Robotic arm 1 holds a cadiere forceps, arm 2 a bipolar forceps, arm 3 the camera and arm 4 a cautery hook. The tableside surgeon is positioned between the patient's legs.

3. Pancreatic identification and mobilization

1. Open the lesser sac by transecting the gastrocolic ligament approximately 2 cm distal from the gastroepiploic vessels with the sealing device, controlled by the tableside surgeon.
2. After this, install the liver retractor (5 mm trocar) in the left upper quadrant just subcostally to retract the stomach and the left side of the liver.
3. Perform an intraoperative ultrasound using a robotic ultrasound probe to identify and locate the tumor and mark the future resection margins with the robotic cautery hook.
4. Mobilize the pancreas first caudally and then cranially using the robotic cautery hook on arm 4 and the laparoscopic sealing device.
5. First, place a 1/3 length vessel loop at the left side of the tumor between the pancreas and the splenic vein.
6. Then, further mobilize the pancreas at the proximal side.
7. Place another 1/3 length vessel loop between the pancreas and the portomesenteric vein.
   ​NOTE: Fix the vessel loops using clips.
8. Use the robot arm 1 to lift the vessel loops cranially to create a clear window and to further complete the mobilization of the pancreatic body between the pancreas and the portomesenteric vein.

4. Pancreatic transection

1. First, transect the pancreas at the right side of the tumor, typically ventral from the superior mesenteric vein with an endo-stapler with a vascular cartridge.
   NOTE: Closing of the stapler using the grade compression approach as described by Asbun¹⁵, may take up to 4-5 min.
2. Then take care of venous mobilization.
3. After venous mobilization, transect the pancreas at the left side of the tumor using robotic scissors with diathermia. The pancreatic duct is cut without diathermia, i.e., cold cut at the site of the pancreatic duct.
4. Insert a 4.8 French stent to identify the pancreatic duct after the resection.

5. Window in the mesocolon

1. Create a window in the avascular part of the transverse mesocolon at the (patient's) left side of the colonic vessels using the cautery hook with the mesocolon in the caudal position.
   NOTE: Usually, this location can be identified by locating the proximal jejunum, which is visible through the mesocolon.
2. Hereafter, place and hold the mesocolon in the cranial position held with arm 1. Identify the window by lifting the transverse colon cranially. Identify the ligament of Treitz.

6. Creating Roux-limb

1. Create a small opening in the proximal jejunum approximately 20 cm distally from the ligament of Treitz to divide the proximal jejunum with an endo-stapler with a vascular cartridge.
2. Divide the mesentery at the jejunal transection site using the sealing device.

7. Positioning Roux-limb

1. While lifting the transverse colon cranially using robotic arm 1, pass the Roux limb cranially through the window in the mesocolon.
2. Place the transverse colon back in the caudal position.
3. Fixate the end of the Roux limb together with the end of a 50 cm suture using robot arm 1. Use robot arms 2 and 4 to measure a 50 cm distance to the future S-S jejuno-jejunostomy.
4. Mark this location with a metal clip on the mesentery and lift the transverse colon cranially again.

8. Jejuno-jejunostomy

1. Place a polyglactin 4-0 8 cm stay suture through the small bowel at the location of the metal clip and the transected proximal jejunum to facilitate the anastomosis. Use arm 1 to retract this stay suture cranially to a location ventrally of the colon to facilitate stapling.
2. Create two small enterotomies using robotic scissors with diathermia.
3. Then, make a side-to-side jejuno-jejunostomy using an endo-stapler with a vascular cartridge.
4. Close the remaining opening of the anastomosis with a 3-0 15 cm barbed suture.

9. Pancreaticojejunostomy

1. Position the Roux limb for the end-to-side pancreaticojejunostomy. Place a polyglactin 4-0 8 cm suture to close the window in the transverse mesocolon and to fixate the jejunal mesentery.
2. Perform the end-to-side pancreaticojejunostomy using a modified Blumgart technique, which is currently highly standardized by the Pittsburgh group and also used in robotic pancreatoduodenectomy¹⁶.
3. Mattress
   1. Start the anastomosis with three transpancreatic silk 2­-0 20 cm mattress sutures. Drive the first suture at the cranial side of the pancreas through the pancreas and jejunum from a cranial to a caudal position. Drive the suture backward, similar to the anterior side of the pancreas and retract both ends with robot arm 1.
   2. Repeat this step for the remaining two transpancreatic mattress sutures centrally and caudally in the pancreas.
      NOTE: Avoid suturing the pancreatic duct by placing a stent in the pancreatic duct.
   3. Tie the three sutures without removing the needles and remove the stent afterward.
4. Duct-to-mucosa
   1. Create a small enterotomy in the Roux limb with the robotic scissors in preparation for the future duct-to-mucosa sutures.
   2. Suture the posterior duct-to-mucosa with 4-5 PDS 5-0 8 cm sutures in a clockwise manner.
   3. Replace the 4.8 French 6 cm single loop stent in the pancreatic duct and Roux limb to avoid suturing the pancreatic duct when suturing the anterior duct-to-mucosa side.
   4. Suture the anterior side with 4-5 PDS 5-0 8 cm sutures.
   5. Tie the sutures after performing the last suture for optimal exposure.
      NOTE: Through the whole duct-to-mucosa procedure arm 2 and arm 4 are equipped with needle drivers and arm 1 is used to retract the sutures cranially and ventrally, thus releasing tension.
5. Buttress
   1. Reuse the three transpancreatic silk sutures from the mattress procedure to perform the anterior buttress layer of the pancreaticojejunostomy.
   2. For all the three sutures, drive the needle through the jejunum and tie these with the remaining end of its suture to complete the anastomosis.

10. Drain placement

1. After finishing the pancreaticojejunostomy, introduce a drain through trocar arm 1 to a position cranial of the pancreaticojejunostomy.

11. Postoperative management

1. Remove the nasogastric tube. Start a soft liquid diet and expand to a normal diet in 72 h.
2. Assess serum CRP on postoperative day 3, day 4, and day 5. Perform a CT or MRI of the abdomen if CRP on day four is elevated compared to day three.
3. Assess drain amylase on postoperative day 3. Remove the drain when drain amylase levels are less than 3 times the upper limit of normal serum amylase.