This protocol presents a case of a robotic partial duodenal resection with primary side-to-side duodeno-jejunal reconstruction in a patient with a 5 cm duodenal stenosis. This is done at the third duodenal segment (D3) after an endoscopic mucosal resection (EMR) for a duodenal polyp.
Duodenal stenosis is a condition that can be related to several diseases, being either intrinsic, such as neoplasm and inflammatory stenosis, or extrinsic, such as pancreatic pseudocyst, superior mesenteric artery syndrome, and foreign bodies. Current treatments range from endoscopic approaches, such as endoscopic resection and stent placement, to surgical approaches, including duodenal resection, pancreaticoduodenectomy, and gastrointestinal bypass. Minimally invasive robot-assisted surgery is gaining importance due to its potential to decrease surgical stress, intraoperative blood loss, and postoperative pain, while its instruments and 3D-vision facilitate fine dissection and intra-abdominal suturing, all leading to a reduced time to functional recovery and shorter hospital stay. We present a case of a 75-year-old female who underwent robotic D3 partial duodenal resection with primary side-to-side duodeno-jejunal anastomosis for a 5 cm adenoma with focal high-grade dysplasia.
Indications for partial duodenal resection are few and very specific. These mainly rely on treating gastrointestinal stromal tumors (GISTs), early duodenal carcinomas, and duodenal adenomas that cannot be removed endoscopically. Partial duodenal resection has gained relevance as an alternative to more invasive procedures such as pancreaticoduodenectomy. The anatomical complexity at the junction of the biliary tract, pancreas, and gastrointestinal tract, as well as the special physiological functions of the duodenum, makes it difficult for any surgeon to approach it during surgery. Therefore, as with any complex surgical technique, it is difficult to have a consensus of choice1,2. Due to its complexity and tight surgical indications, partial duodenal resection should be performed only at centers performing pancreatoduodenectomies.
In the last decades, there has been a rapid development in robot-assisted minimally invasive surgery with the aim to reduce pain and enhance recovery compared to open surgical procedures. Nowadays, when dealing with partial duodenal resection, reconstruction with Roux-en-Y anastomosis is feasible and reliable. Even if partial excision of the affected duodenum with side-to-side duodeno-jejunal anastomosis seems equally effective, technical difficulty and outcome of the methods have not been described in detail2,3.
We present a case of a 75-year-old female who underwent endoscopic mucosal resection (EMR) for a 5 cm adenoma with focal high-grade dysplasia, which results in reactive stenosis. Due to severe dysphagia, the inability to cure the stenosis with endoscopy, and the absence of relation to the papilla of Vater (no obstruction in the pancreatobiliary tree), the multidisciplinary team decided to enroll the patient in a robotic D3 partial duodenal resection with primary side-to-side duodeno-jejunal anastomosis.
The present protocol follows the ethics guidelines of Amsterdam UMC. Informed consent was obtained from the patient for this article and the video.
1. Preoperative management
2. Anesthesia, positioning of the patient, and safety check procedures
3. Pneumoperitoneum creation and trocars' placement
4. Port placement
5. Docking
6. Treitz mobilization
7. Ascending colon and hepatic flexure mobilization
8. Pancreatic head identification and mobilization
9. Duodenal resection
10. Duodeno-jejunostomy
11. Drain-placement
12. Postoperative management
13. Post-discharge management
Representative results are shown in Table 1. The operative time was 84 min with 20 mL of blood loss. The postoperative course of the patient was uneventful. The nasogastric tube (NGT) was removed early in the morning of postoperative day 1 (POD1). The patient restarted feeding at POD2 and was discharged in a good condition on POD3. Pathological assessment reported the removal of a 5 cm adenoma with focal high-grade dysplasia and negative margins.
The patient had a follow-up visit two weeks after surgery, where she reported postprandial pain associated with episodes of vomit and occasional episodes of fever (T°< 38 °C). She underwent a CT scan, which reported no fluid collection in the abdomen and no signs of suffering to the liver, pancreas, stomach, and small intestine (Figure 5 and Figure 6). At a further follow-up visit, the patient reported a total reduction of the previously reported symptoms. The surgical follow-up was then stopped.
Figure 1: Preoperative assessment. Preoperative imaging with CT scan to assess the localization and the extent of the duodenal stenosis. Please click here to view a larger version of this figure.
Figure 2: Preoperative assessment. Preoperative gastroscopy to describe the stenosis, its location, and its relationship with the papilla of Vater. Please click here to view a larger version of this figure.
Figure 3: Trocars' placement. Red: 8 mm robotic trocars, blue: 12 mm laparoscopic trocars, yellow: 5 mm trocar for stomach/liver retractor. Please click here to view a larger version of this figure.
Figure 4: Set up of the robot during surgery. Please click here to view a larger version of this figure.
Figure 5: Coronal plane CT scan performed two weeks after surgery. Coronal plane at the level of the duodeno-jejunal anastomosis Please click here to view a larger version of this figure.
Figure 6: Axial plane CT scan performed two weeks after surgery. Axial plane at the level of the duodenojejunal anastomosis Please click here to view a larger version of this figure.
Intraoperative | |
Operative time, minutes | 84 |
Intraoperative blood loss, ml | 20 |
Postoperative | |
Postoperative complications | none |
Hospital length of stay, days | 4 |
Discharge, postoperative day | 3 |
Pathology | Radical removal of a 5cm adenoma High-grade dysplasia |
Table 1: Representative results of the surgery.
Stenosis of the duodenum produces vague and confounding symptoms whose severity is mainly related to its severity (partial stenosis, total obstruction) and is often resistant to early attempts at diagnosis. Given the underlying anatomical complexities, the choice of treatment options is difficult, and if possible, it should only be undertaken by an adequate multidisciplinary team (MDT)3,8,9 with experience in robotic pancreatoduodenectomy10,11.
Performing a proper preoperative investigation is crucial. Indeed, endoscopic procedures, such as enteroscopy and endoscopic ultrasound (EUS), are mandatory for investigating the extension of stenosis and its relationship to the papilla of Vater. During the endoscopic procedure, marking with a small 1 cm submucosal ink tattoo, proximally to the lesion, supports intraoperative identification and obtaining negative surgical margins.
The real advantage of limited resection is the possibility of avoiding invasive procedure, such as pancreaticoduodenectomy (PD), without increasing the postoperative morbidity and decreasing the long-term survival12. Due to this rationale, minimally-invasive surgery should be taken into consideration. Indeed, both laparoscopic and robotic approaches could be used to perform this type of intestinal resection. However, the robotic approach has several benefits compared to the laparoscopic approach. Indeed, high-definition 3D vision facilitates and magnifies instrument movement, whereas wristed instruments allow easier intra-abdominal suturing as compared to laparoscopy.
In 2021, a single-center retrospective study in patients with duodenal gastrointestinal stroma cell tumors reported benefits of the robotic approach, compared to the open approach, in terms of a shorter operative time, less intraoperative bleeding, and smaller surgical incisions2. Partial excision of the affected duodenum with side-to-side duodeno-jejunal anastomosis remains controversial due to the technical difficulty of this procedure2,3, particularly concerning the anastomosis. Indeed, a partial duodenectomy is mainly combined with a Roux-en-Y anastomosis since it is feasible and reliable. However, it should be taken into consideration that Roux-en-Y reconstruction could hold an increased risk of gastrointestinal leak due to the execution of one additional anastomosis compared to side-to-side duodeno-jejunal anastomosis.
As far as malignant diseases are concerned, the choice of the type of surgery is controversial. Some surgeons prefer pancreatoduodenectomy to reduce the risk of residual disease, even if it results in significantly higher postoperative morbidity and mortality13. Besides the higher perioperative morbidity and mortality rates, it is mandatory to consider that pancreatoduodenectomy is mainly performed when dealing with advanced diseases like carcinoma, which in itself has a high recurrence rate14. Recently, it has been reported that limited segmentectomy for limited duodenal cancer appears to offer statistically equivalent long-term survival rates with considerably less morbidity15. Additionally, specific preoperative factors such as tumor, node and metastasis (TNM) stage, tumor grade on histological report, and preoperative radiotherapy seem to be more reliable predictors of patient outcomes than the type of resection15.
A recent systematic review reported that in patients with cancer-related gastric outlet obstruction, endoscopic stent placement is associated with many positive outcomes compared to gastro-jejunostomy, including reduced hospital stays, lower postoperative mortality, and faster relief of symptoms, despite comparable benefits and complication rates16. However, in patients with longer prognoses, recurrence of obstructive symptoms appears to be significantly more likely after stent placement17. This scenario may encourage stronger consideration of surgical approaches to avoid the need for endoscopic re-intervention.
The main limitation of this surgical technique is related to identifying the diseased loop. Indeed, a small, inked tattoo is the only way to define where the lesion is and perform the resection. However, ink may spread too widely along the submucosa and mark the entire loop, making it almost impossible to identify the correct lines of resections. In order to reduce this risk, the ink tattoo must be as small as possible, and this should be communicated, prior to endoscopy, to the responsible gastroenterologist.
In conclusion, robotic partial duodenal resection with primary side-to-side duodeno-jejunal anastomosis is possible, especially if performed in patients with benign disease (e.g., inflammatory duodenal stenosis) and in highly specialized centers. Future larger prospective studies should confirm the safety and efficacy of this approach.
The authors have nothing to disclose.
The clinical research was enabled by HPB-Amsterdam and F de Graaf, operating rooms Amsterdam UMC.
SYSTEM | |||
da Vinci Surgeon Console | IS | SS999 | Used to control the surgical robot. |
da Vinci Vision Cart | IS | VS999 | The vision cart houses advanced vision and energy technologies and provides communications across da Vinci system components |
da Vinci Xi | IS | K131861 | The surgical robot: ’patient side-cart’ |
INSTRUMENTS | |||
Cobra Liver Retractor Diamond-Flex | CareFusion | 89-6216 | Retracting the liver for optimal exposure of the surgical site. |
da Vinci Xi Endoscope with Camera, 8 mm, 30° | IS | 470027 | The camera of the da Vinci robot. |
ENDOEYE Rigid Video Laparoscope, 10 mm, 30° | Olympus | WA50042A | Toseewithintheintra-abdominal cavity. |
ENDOWRIST Fenestrated Bipolar Forceps | IS | 470205 | Used for dissection and coagulation |
ENDOWRIST HOT SHEARS | IS | 470179 | Used for cutting and coagulation. |
ENDOWRIST Mega SutureCut Needle Driver | IS | 470309 | Used as a needle driver. |
ENDOWRIST Permanent Cautery Hook | IS | 470183 | Used for coagulation. |
ENDOWRIST PROGrasp Forceps | IS | 470093 | Used for dissection. |
LigaSure Maryland Jaw | Medtronic | LF1937 | Used for vessel sealing |
SUTURES | |||
Vicryl 2-0 x2 | |||
V-loc barbed 4-0 15 cm x2 | |||
Monocryl 4-0 x2 | |||
STAPLER | |||
Echelon 60mm white cartridge | Ethicon | GST60W | Used for stapling |