The clinical research was enabled by HPB-Amsterdam and F de Graaf, operating rooms Amsterdam UMC.

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
<ol>
	<li>Perform preoperative imaging with a CT scan to assess the localization and the extent of the duodenal stenosis and its relationship with the papilla of Vater (Figure 1).</li>
	<li>Perform esophagogastroduodenoscopy to describe the stenosis and its location. The duodenal lumen must be partially/entirely obstructed by the lesion, making it impossible for the endoscope to proceed any further and complete curative endoscopic treatment (Figure 2). Place, before the stenosis, a small 1 cm mark with an inked tattoo on the submucosa for intraoperative identification of the lesion.</li>
	<li>Evaluate the eligibility for the surgical approach and relative contraindications (severe stenosis causing dysphagia, pain, malnutrition, feasibility of treating the disease endoscopically, duodenal stenosis far and distal from the papilla of Vater, no history of abdominal surgery, and in more general terms any benign, premalignant, malignant local entity in D3 duodenum which can be treated with a partial duodenectomy).</li>
</ol>
2. Anesthesia, positioning of the patient, and safety check procedures
<ol>
	<li>Induce the patient with general anesthesia with the help of an anesthesiologist.</li>
	<li>Place the patient in a French position. Lower the right arm alongside the patient on an arm board while placing the left arm in a 90&#176; position. Tilt the table 20&#176; to the left of the patient and in a 20&#176; reverse Trendelenburg position.</li>
	<li>Perform the safety check procedures as required by the Institution (e.g., patient&#39;s name and surname, date of birth, type of surgery, prophylactic antibiotic therapy, etc.) and create a sterile area using chloride surgical solution and surgical drapes.</li>
</ol>
3. Pneumoperitoneum creation and trocars&#39; placement
<ol>
	<li>Insert a Veress needle at Palmer&#39;s point, 2 cm below the left coastal margin following the mid-clavicular line, in order to create a pneumoperitoneum. Then insufflate to 10-12 mm CO2.</li>
	<li>After insufflation, mark the positions of the trocars and place them as shown in Figure 3&#160;(4 robot trocars, 2 (12 mm) laparoscopic table-side surgeon trocars).
	<ol>
		<li>First, draw a line from a point, 2 cm to the right of the umbilicus to the costal margin left of the gallbladder. On this line, 11-12 cm downwards from the costal margin, mark the robotic camera trocar, number 3.</li>
		<li>At 7 cm distance left and right from trocar 3, mark trocars 2 and 4.</li>
		<li>Mark trocar 1, 7 cm craniolateral from trocar 2. 
		&#8203;NOTE: This follows the Pittsburgh approach for robot-assisted pancreaticoduodenectomy4,5,6. However, this procedure can also be performed with only one laparoscopic trocar, which can later be used for the extraction of the specimen.</li>
	</ol>
	</li>
</ol>
4. Port placement
<ol>
	<li>Insufflate with a Verres needle at the Palmers&#39; point connected to the CO2 resource. Place a 12 mm table-side surgeon trocar, 7 cm from both robot trocars 2 and 3, to the right of the umbilicus.</li>
	<li>Place the four 8 mm robotic trocars as marked after inspection and removal of the Veress needle.</li>
	<li>Place a second 12 mm table-side surgeon trocar, 7 cm from both trocars 3 and 4. 
	&#8203;NOTE: Make sure the distance between all the trocars is approximately 7 cm.</li>
</ol>
5. Docking
<ol>
	<li>Install the robot over the patient&#39;s right shoulder and dock the robot arms to the robotic trocars. 
	&#8203;NOTE: The final operative setting is shown in Figure 3 and Figure 4. To facilitate a large standalone 3D screen to the patient&#39;s right, have the robot come in cranially, over the patient&#39;s shoulder. To facilitate a comfortable position for the table-side surgeon, ensure that this surgeon sits down with cranially placed trocars and a favorable screen position.</li>
</ol>
6. Treitz mobilization
<ol>
	<li>Cranialize the greater omentum and colon by pushing them aside towards the diaphragm.</li>
	<li>Identify the first jejunal loop from the retroperitoneal cavity through the Treitz ligament.</li>
	<li>Dissect the left side of the ligament of Treitz to free the most distal part of the duodenum and the first part of the jejunum from the aorta using the robotic cautery hook on arm 4 and the laparoscopic vessel sealer.</li>
</ol>
7. Ascending colon and hepatic flexure mobilization
<ol>
	<li>Perform tunneling through the hepatocolic ligament in order to spare vascular structures.</li>
	<li>Perform mobilization of the hepatic flexure and the ascending colon using the robotic cautery hook on arm 4 and the laparoscopic sealing device. 
	&#8203;NOTE: Pay attention to any vascular abnormalities of the right colonic artery.</li>
</ol>
8. Pancreatic head identification and mobilization
<ol>
	<li>Perform the Kocher maneuver by mobilizing the duodenum and the head of the pancreas from the caudal to cranial using the robotic cautery hook and the laparoscopic sealing device. To do so, incise the peritoneum at the right edge of the duodenum and move the duodenum and the head of the pancreas to the left of the patient7.</li>
	<li>Perform the traction of the jejunal loop in the retroperitoneal cavity.</li>
</ol>
9. Duodenal resection
<ol>
	<li>Staple the intestinal loop, 10 cm distally, to the submucosal tattoo.</li>
	<li>Detach the duodenum from its mesentery using a laparoscopic sealing device, by performing a safe and feasible dissection of the mesentery.</li>
	<li>Staple the duodenum at the level of the submucosal tattoo, including the tattoo in the specimen. A robotic endo stapler can be used as well. 
	&#8203;NOTE: The minimum distance of the lesion from the papilla of Vater should be 5 cm. In other situations (e.g., 2-5 cm), a Fogarty balloon-tipped catheter can be passed through the papilla of Vater. This can be confirmed intraoperatively by endoscopy.</li>
</ol>
10. Duodeno-jejunostomy
<ol>
	<li>Create two small enterotomies using robotic scissors with diathermia at the antimesenteric side of the duodenal and jejunal stump.</li>
	<li>Make a side-to-side jejuno-jejunostomy of 60 mm using an endo-stapler with a vascular cartridge (white cartridge).</li>
	<li>Close the remaining anastomosis opening with two layers of running 4-0 suture (~15 cm).</li>
</ol>
11. Drain-placement
<ol>
	<li>In case of a misfire of the stapler or in case of accidental contamination of the abdomen from intestinal fluids, place a drain. 
	&#8203;NOTE: Drain was not placed in this specific case. The patient underwent elective operation with no operative events, so no drain was needed.</li>
</ol>
12. Postoperative management
<ol>
	<li>Remove the nasogastric tube early in the morning of postoperative day 1. Start a soft liquid diet and move on to a normal diet in 24 h.</li>
	<li>Assess serum C-reactive protein (CRP) and leucocyte levels on postoperative days 2, 3, and 4. Perform a CT or MRI scan of the abdomen if CRP on day four is elevated compared to day three or when there are undesired changes in the postoperative course (drain quality, insufficient clinical improvement).</li>
	<li>Discharge the patient earlier if clinically well, eating sufficiently, pain-free, and CRP &#60;150. 
	&#8203;NOTE: The patient was discharged on postoperative day 3, almost pain-free, clinically well, with a CRP value of 67 mg/L.</li>
</ol>
13. Post-discharge management
<ol>
	<li>Perform follow-up medical examination after 10-14 days.</li>
</ol>

<ol>
	<li>Lee, S. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+strategy+and+outcomes+in+duodenal+gastrointestinal+stromal+tumor.">Surgical strategy and outcomes in duodenal gastrointestinal stromal tumor.</a> Annals of Surgical Oncology. 24 (1), 202-210 (2017).</li><li>Zhou, Z. -. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+resection+of+duodenal+gastrointestinal+stromal+tumour:+Preliminary+experience+from+a+single+centre.">Robotic resection of duodenal gastrointestinal stromal tumour: Preliminary experience from a single centre.</a> World Journal of Gastrointestinal Oncology. 13 (7), 706-715 (2021).</li><li>McGuirk, M., Gachabayov, M., Gogna, S., Da Dong, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+duodenal+(D3)+resection+with+Roux-en-Y+duodenojejunostomy+reconstruction+for+large+GIST+tumor:+Step+by+step+with+video.">Robotic duodenal (D3) resection with Roux-en-Y duodenojejunostomy reconstruction for large GIST tumor: Step by step with video.</a> Surgical Oncology. 36, 130 (2021).</li><li>Nota, C. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Developing+a+robotic+pancreas+program:+the+Dutch+experience.">Developing a robotic pancreas program: the Dutch experience.</a> Journal of Visualized Surgery. 3, 106 (2017).</li><li>Hogg, M. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Mastery-based+virtual+reality+robotic+simulation+curriculum:+the+first+step+toward+operative+robotic+proficiency.">Mastery-based virtual reality robotic simulation curriculum: the first step toward operative robotic proficiency.</a> Journal of Surgical Education. 74 (3), 477-485 (2017).</li><li>Tam, V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+pancreatoduodenectomy+biotissue+curriculum+has+validity+and+improves+technical+performance+for+surgical+oncology+fellows.">Robotic pancreatoduodenectomy biotissue curriculum has validity and improves technical performance for surgical oncology fellows.</a> Journal of Surgical Education. 74 (6), 1057-1065 (2017).</li><li>Niederle, B. V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Surgery of the Biliary Tract. , (1981).</li><li>Marano, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+treatment+for+large+duodenal+gastrointestinal+stromal+tumor.">Robotic treatment for large duodenal gastrointestinal stromal tumor.</a> Annals of Surgical Oncology. 27 (4), 1101-1102 (2020).</li><li>Thomas, J., Abraham, K., Osilli, D., Mukherjee, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Adult+distal+duodenal+obstruction:+a+diagnostic+and+therapeutic+challenge.">Adult distal duodenal obstruction: a diagnostic and therapeutic challenge.</a> Cureus. 14 (4), e24095 (2022).</li><li>Emmen, A. M. L. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+shifting+from+laparoscopic+to+robotic+surgery+during+600+minimally+invasive+pancreatic+and+liver+resections.">Impact of shifting from laparoscopic to robotic surgery during 600 minimally invasive pancreatic and liver resections.</a> Surgical Endoscopy. 37 (4), 2659-2672 (2023).</li><li>Zwart, M. J. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Outcomes+of+a+multicenter+training+program+in+robotic+pancreatoduodenectomy+(LAELAPS-3).">Outcomes of a multicenter training program in robotic pancreatoduodenectomy (LAELAPS-3).</a> Annals of Surgery. 276 (6), e886-e895 (2022).</li><li>Chok, A. -. Y., Koh, Y. -. X., Ow, M. Y. L., Allen, J. C., Goh, B. K. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+systematic+review+and+meta-analysis+comparing+pancreaticoduodenectomy+versus+limited+resection+for+duodenal+gastrointestinal+stromal+tumors.">A systematic review and meta-analysis comparing pancreaticoduodenectomy versus limited resection for duodenal gastrointestinal stromal tumors.</a> Annals of Surgical Oncology. 21 (11), 3429-3438 (2014).</li><li>Lau, J. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Through-the-scope+balloon+dilation+for+pyloric+stenosis:+long-term+results.">Through-the-scope balloon dilation for pyloric stenosis: long-term results.</a> Gastrointestinal Endoscopy. 43 (2 Pt 1), 98-101 (1996).</li><li>Shen, Z., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreaticoduodenectomy+versus+limited+resection+for+duodenal+gastrointestinal+stromal+tumors:+a+systematic+review+and+meta-analysis.">Pancreaticoduodenectomy versus limited resection for duodenal gastrointestinal stromal tumors: a systematic review and meta-analysis.</a> BMC Surgery. 19, 121 (2019).</li><li>Cloyd, J. M., Norton, J. A., Visser, B. C., Poultsides, G. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Does+the+extent+of+resection+impact+survival+for+duodenal+adenocarcinoma?+Analysis+of+1,611+cases.">Does the extent of resection impact survival for duodenal adenocarcinoma? Analysis of 1,611 cases.</a> Annals of Surgical Oncology. 22 (2), 573-580 (2015).</li><li>Nagaraja, V., Eslick, G. D., Cox, M. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+stenting+versus+operative+gastrojejunostomy+for+malignant+gastric+outlet+obstruction-a+systematic+review+and+meta-analysis+of+randomized+and+non-randomized+trials.">Endoscopic stenting versus operative gastrojejunostomy for malignant gastric outlet obstruction-a systematic review and meta-analysis of randomized and non-randomized trials.</a> Journal of Gastrointestinal Oncology. 5 (2), 92-98 (2014).</li><li>Jeurnink, S. M., van Eijck, C. H. J., Steyerberg, E. W., Kuipers, E. J., Siersema, P. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stent+versus+gastrojejunostomy+for+the+palliation+of+gastric+outlet+obstruction:+a+systematic+review.">Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review.</a> BMC Gastroenterology. 7, 18 (2007).</li></ol>

The authors have nothing to disclose

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.

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.

<table><tbody><tr><td>&lt;u&gt;&lt;strong&gt;SYSTEM&lt;/strong&gt;&lt;/u&gt;</td><td></td><td></td><td></td></tr><tr><td>da Vinci Surgeon Console&amp;nbsp;</td><td>IS&amp;nbsp;</td><td>SS999&amp;nbsp;</td><td>Used to control the surgical robot.&amp;nbsp;</td></tr><tr><td>da Vinci Vision Cart&amp;nbsp;</td><td>IS</td><td>VS999&amp;nbsp;</td><td>The vision cart houses advanced vision and energy technologies and provides communications across da Vinci system components&amp;nbsp;</td></tr><tr><td>da Vinci Xi&amp;nbsp;</td><td>IS&amp;nbsp;</td><td>K131861&amp;nbsp;</td><td>The surgical robot: &amp;rsquo;patient side-cart&amp;rsquo;&amp;nbsp;</td></tr><tr><td>&lt;u&gt;&lt;strong&gt;INSTRUMENTS&amp;nbsp;&lt;/strong&gt;&lt;/u&gt;</td><td></td><td></td><td></td></tr><tr><td>Cobra Liver Retractor Diamond-Flex&amp;nbsp;</td><td>CareFusion&amp;nbsp;</td><td>89-6216&amp;nbsp;</td><td>Retracting the liver for optimal exposure of the surgical site.&amp;nbsp;</td></tr><tr><td>da Vinci Xi Endoscope with Camera, 8 mm, 30&amp;deg;&amp;nbsp;</td><td>IS</td><td>470027</td><td>The camera of the da Vinci robot.&amp;nbsp;</td></tr><tr><td>ENDOEYE Rigid Video Laparoscope, 10 mm, 30&amp;deg;&amp;nbsp;</td><td>Olympus</td><td>WA50042A&amp;nbsp;</td><td>Toseewithintheintra-abdominal cavity.&amp;nbsp;</td></tr><tr><td>ENDOWRIST Fenestrated Bipolar Forceps&amp;nbsp;</td><td>IS</td><td>470205</td><td>Used for dissection and coagulation&amp;nbsp;</td></tr><tr><td>&lt;u&gt;&lt;strong&gt;ENDOWRIST HOT SHEARS&amp;nbsp;&lt;/strong&gt;&lt;/u&gt;</td><td>IS&amp;nbsp;</td><td>470179</td><td>Used for cutting and coagulation.&amp;nbsp;</td></tr><tr><td>ENDOWRIST Mega SutureCut Needle Driver&amp;nbsp;</td><td>IS</td><td>470309</td><td>Used as a needle driver.</td></tr><tr><td>ENDOWRIST Permanent Cautery Hook&amp;nbsp;</td><td>IS&amp;nbsp;</td><td>470183</td><td>Used for coagulation.&amp;nbsp;</td></tr><tr><td>ENDOWRIST PROGrasp Forceps</td><td>IS</td><td>470093</td><td>Used for dissection.</td></tr><tr><td>LigaSure Maryland Jaw</td><td>Medtronic&amp;nbsp;</td><td>LF1937</td><td>Used for vessel sealing&amp;nbsp;</td></tr><tr><td>&lt;u&gt;&lt;strong&gt;SUTURES&lt;/strong&gt;&lt;/u&gt;</td><td></td><td></td><td></td></tr><tr><td>Vicryl 2-0&amp;nbsp; x2</td><td></td><td></td><td></td></tr><tr><td>V-loc barbed 4-0 15 cm x2&amp;nbsp;</td><td></td><td></td><td></td></tr><tr><td>Monocryl 4-0 x2</td><td></td><td></td><td></td></tr><tr><td>&lt;u&gt;&lt;strong&gt;STAPLER&lt;/strong&gt;&lt;/u&gt;</td><td></td><td></td><td></td></tr><tr><td>Echelon 60mm white cartridge&amp;nbsp;</td><td>Ethicon</td><td>GST60W</td><td>Used for stapling</td></tr></tbody></table>

robotic d3 partial duodenal resection with primary side-to-side anastomosis

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.

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&#176;&#60; 38 &#176;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.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/65742/65742fig01.jpg" /> 
Figure 1: Preoperative assessment. Preoperative imaging with CT scan to assess the localization and the extent of the duodenal stenosis. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65742/65742fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/65742/65742fig02.jpg" /> 
Figure 2: Preoperative assessment. Preoperative gastroscopy to describe the stenosis, its location, and its relationship with the papilla of Vater. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65742/65742fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/65742/65742fig03.jpg" /> 
Figure 3: Trocars&#39; placement. Red: 8 mm robotic trocars, blue: 12 mm laparoscopic trocars, yellow: 5 mm trocar for stomach/liver retractor. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65742/65742fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/65742/65742fig04.jpg" /> 
Figure 4: Set up of the robot during surgery. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65742/65742fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/65742/65742fig05.jpg" /> 
Figure 5: Coronal plane CT scan performed two weeks after surgery. Coronal plane at the level of the duodeno-jejunal anastomosis <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65742/65742fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/65742/65742fig06.jpg" /> 
Figure 6: Axial plane CT scan performed two weeks after surgery. Axial plane at the level of the duodenojejunal anastomosis <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65742/65742fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Intraoperative</td>
			<td></td>
		</tr>
		<tr>
			<td>Operative time, minutes</td>
			<td>84</td>
		</tr>
		<tr>
			<td>Intraoperative blood loss, ml</td>
			<td>20</td>
		</tr>
		<tr>
			<td>Postoperative</td>
			<td></td>
		</tr>
		<tr>
			<td>Postoperative complications&#160;</td>
			<td>none</td>
		</tr>
		<tr>
			<td>Hospital length of stay, days</td>
			<td>4</td>
		</tr>
		<tr>
			<td>Discharge, postoperative day</td>
			<td>3</td>
		</tr>
		<tr>
			<td>Pathology</td>
			<td>Radical removal of a 5cm adenoma 
			High-grade dysplasia</td>
		</tr>
	</tbody>
</table>
Table 1: Representative results of the surgery.

Watch this Scientific Journal Video about Robotic D3 Partial Duodenal Resection with Primary Side-to-Side Anastomosis at JoVE.com

Robotic D3 Partial Duodenal Resection with Primary Side-to-Side Anastomosis

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 ...

robotic-d3-partial-duodenal-resection-with-primary-side-to-side

Nanyang Technological University

Research

JoVE Journal

Medicine

1.7K Views.  University of Amsterdam. Deze video demonstreert alle stappen van een robotgeassisteerde D3 partiële duodenale resectie met primaire zijwaartse anastomose. Een 75-jarige vrouw presenteerde zich met dysfagie, pijn en ondervoeding enkele maanden na gedeeltelijke endoscopische mucosale resectie van een poliep van 5 centimeter, gelegen in het antemesenteriale pensgedeelte van de twaalfvingerige darm, D3. Pre-preoperatieve beeldvorming met computertomografiescan werd gebruikt om de lokalisatie en de omvang van de stenose...

Video: Robotic D3 Partial Duodenal Resection with Primary Side-to-Side Anastomosis

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer: Surgical Planning and Technique

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), relying on collateral flow to the liver through the gastroduodenal artery (GDA). In the current manuscript, the technical conduct of robotic DP-CAR is outlined. The greater curve of the stomach is mobilized with care to avoid sacrificing the gastroepiploic vessels. The stomach and liver are retracted cephalad to facilitate dissection of the porta hepatis. The hepatic artery (HA) is dissected and encircled with a vessel loop. The gastroduodenal artery (GDA) is carefully preserved. The common HA is clamped and triphasic flow in the proper HA via the GDA is confirmed using intra-operative ultrasound. A retropancreatic tunnel is made over the superior mesenteric vein (SMV). The pancreas is divided with an endovascular stapler at the neck. The inferior mesenteric vein (IMV) and splenic vein are ligated. The HA is stapled proximal to the GDA. The entire specimen is retracted laterally with further dissection cephalad to expose the superior mesenteric artery (SMA). The SMA is then traced back to the aorta. The dissection continues cephalad along the aorta with the bipolar energy device used to divide the crural fibers and celiac nerve plexus. The specimen is mobilized from the patient's right to left until the origin of the celiac axis is identified and oriented towards the left. The trunk is circumferentially dissected and stapled. Additional dissection with hook cautery and the bipolar energy device fully mobilizes the pancreatic tail and spleen. The specimen is removed from the left lower quadrant extraction site and one drain is left in the resection bed. A final intra-operative ultrasound of the proper HA confirms pulsatile, triphasic flow in the artery and liver parenchyma. The stomach is inspected for evidence of ischemia. Robotic DP-CAR is safe, feasible and when used in conjunction with multi-modality therapy, offers potential for long-term survival in selected patients.

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection DP-CAR for Pancreatic Cancer: Surgical Planning and Technique

We present our operative approach to robot assisted distal pancreatectomy, splenectomy, and celiac axis resection (DP-CAR), demonstrating that the procedure is safe and feasible with proper planning, patient selection, and surgeon experience.

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), ...

Cancer Research

Robotic Pancreatoduodenectomy for Pancreatic Head Cancer: a Case Report of a Standardized Technique

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several studies have described the safety of RPD in case of a replaced or aberrant right hepatic artery, but detailed video descriptions of the approach are lacking. This case report describes a step-&#173;by-&#173;step technical video in case of a replaced right hepatic artery. A 58-year-old woman presented with an incidental finding of a 1.7 cm pancreatic head mass. RPD was performed using the da Vinci Xi system and involves a robotic-assisted pancreatico- and hepatico-jejunostomy and open gastro-jejunostomy at the specimen extraction site. The operation time was 410 min with 220 mL of blood loss. The patient had an uncomplicated postoperative course and was discharged after 5 days. Pathology revealed a pancreatic head cancer. RPD is a feasible and safe procedure in case of a replaced hepatic artery when performed in selected patients in high-volume centers by experienced surgeons.

Robotic pancreatoduodenctomy (RPD) has been highly standardized in recent years and may be used in selected patients with pancreatic head cancer, including those with a replaced right hepatic artery. This case report describes a standardized and reproducible technique for RPD, which includes the approach of the Dutch LAELAPS-3 training program to an aberrant vasculature.

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several ...

Application of End-to-end Anastomosis in Robotic Central Pancreatectomy

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of pancreatic body. With technological development, the robotic surgical system has shown its advantage in minimally invasive surgery and been increasingly applied in central pancreatectomy. However, reconstruction of the continuity of pancreas with end-to-end anastomosis after robotic central pancreatectomy has not been applied. In this study, we report surgical techniques for robotic central pancreatectomy with end-to-end anastomosis. The pancreas is reconstructed by duct-to-duct anastomosis of the pancreatic duct with a pancreatic stent inserted in the two stumps of pancreatic duct, and by end-to-end anastomosis of the pancreatic parenchyma. Compared with traditional central pancreatectomy with pancreaticoenteric anastomosis, this approach decreases the operative injury to the patient, and also conserves the integrity and continuity of the digestive duct and pancreatic duct. The robotic surgical system integrated with multiple instruments with flexible and precise movement is particularly suitable for the dissection and reconstruction of the pancreatic duct. We found that robotic central pancreatectomy with end-to-end anastomosis is safe and feasible, and we need more experience to evaluate its best indications and long-term outcomes.

The robotic central pancreatectomy with end-to-end anastomosis is feasible and safe for tumor in the pancreatic neck and proximal portion of pancreatic body. The operative techniques of this operation are presented.

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of ...

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic platform, including three-dimensional vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate the principles of open pancreatoduodenectomy allowing safe oncologic dissection, hemostasis, and meticulous reconstruction. Over the course of the past decade, significant strides have been achieved in outlining the safety, feasibility, and learning curve of the robotic Whipple. When performed by high volume pancreatic surgeons experienced in RPD, recent comparative effectiveness studies show potential advantages compared to the open technique, including reductions in hospital stay and morbidity. National data also show reductions in conversion rates compared to its laparoscopic counterpart. Although long-term oncologic data are still needed, short-term oncologic surrogates of margin resection and lymph node harvest suggest no compromise in oncologic outcomes. As pancreatic surgeons increasingly integrate robotics into their practice, proficiency-based training and credentialing will be necessary for the safe application and dissemination of RPD. Here, we provide the detailed steps of a robotic pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.&#160;

The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic ...

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The recent rise of robotic and laparoscopic pancreatic surgery has found benefits such as reduced time to functional recovery. Few studies have reported on the feasibility, technique and outcome of robotic LPJ, especially including transection of the gastroduodenal artery. The present study describes the main steps for robotic LPJ in a patient with painful chronic pancreatitis with a dilated main pancreatic duct. The patient underwent robotic LPJ. The LPJ anastomosis is performed using a running suture technique in a longitudinal side-to-side manner. Routinely, the gastroduodenal artery is transected to drain the entire length of the main pancreatic duct. The patient is in French position; 7 trocars are placed (4 robotic, 2 laparoscopic assistants, 1 liver-retractor). After docking of the robot system, the omental bursa is opened, and the right gastroepiploic artery and vein are ligated at their base at the lower border of the pancreas. Intraoperative ultrasonography is performed in order to determine trajectory of the dilated main pancreatic duct which is opened for its entire length after the gastroduodenal artery has been suture ligated both cranially and caudally from the main pancreatic duct. A Roux limb is created, and a latero-lateral PJ is fashioned using several 3-0 barbed sutures. A stapled jejuno-jejunostomy is created at sufficient distance from the pancreatic anastomosis, aided by a 50 cm suture. The described technique for robotic LPJ is a complex but feasible operation for patients with treatment refractory CP and a dilated main pancreatic duct. Due to its complexity, implementation in high volume centers with extensive experience with CP surgery may improve outcomes.

Robotic lateral pancreaticojejunostomy (RLPJ) may be used in patients with painful, morphine dependent, chronic pancreatitis and a dilated main pancreatic duct. We describe a standardized and reproducible technique for RLPJ, which includes transection of the gastroduodenal artery.

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The ...

Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the spleno-mesenteric junction, for cancer of the body-tail of the pancreas. The patient is placed supine with the legs parted and a pneumoperitoneum is established and maintained at 10 mmHg. To use the surgical system, four 8 mm ports and one 12 mm port are required. The optic port is placed at the umbilicus. The other ports are placed, on either side, along the pararectal line and the anterior axillary line at the level of the umbilical line. The assistant port (12 mm) is placed along the right pararectal line. Dissection begins by detaching the gastrocolic ligament, thus opening the lesser sac, and by a wide mobilization of the splenic flexure of the colon. The superior mesenteric vein is identified along the inferior border of the pancreas. Lymph node number 8a is removed to permit clear visualization of the common hepatic artery. A tunnel is then created behind the neck of the pancreas. To permit safe resection and reconstruction of the spleno-mesenteric junction, further preemptive dissection is required before dividing the pancreatic neck to bring in clear view all relevant vascular pedicles. Next, the splenic artery is ligated and divided, and the pancreatic neck is divided, with selective ligature of the pancreatic duct. After vein resection and reconstruction, dissection proceeds to complete the clearance of peripancreatic arteries that are peeled off from all lympho-neural tissues. Both celiac ganglia are removed en-bloc with the specimen. The Gerota fascia covering the upper pole of the left kidney is also removed en-bloc with the specimen. Division of short gastric vessels and splenectomy complete the procedure. A drain is left near the pancreatic stump. The round ligament of the liver is mobilized to protect the vessels.

The robotic technique shown herein aims at faithfully reproducing the open procedure for radical treatment of cancer of the body-tail of the pancreas. The protocol also demonstrates the ability to master involvement of major peripancreatic vessels without conversion to open surgery.

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the ...

Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of the pancreas. The aim of central pancreatectomy is to prevent postoperative life-long endocrine and exocrine insufficiency. The downside of central pancreatectomy is the high rate of postoperative pancreatic fistula, which is the main reason that many surgeons do not routinely use central pancreatectomy in eligible patients. Most studies report open or laparoscopic central pancreatectomy with a pancreatico-gastrostomy anastomosis in adults. This is the first description of a standardized approach to robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy reconstruction in an adolescent (16-year-old boy) with a pseudopapillary tumor in the body of the pancreas. The operation time was 248 min with 20 mL of blood loss. The postoperative course was uneventful except for the short-term medical treatment for a grade B pancreatic fistula. Robotic central pancreatectomy can be safely applied in selected patients in experienced centers.

Robotic central pancreatectomy may be used in selected patients in experienced centers. This protocol presents all steps and the feasibility of a robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy in a 16-year-old adolescent patient.

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of ...

Robotic Vagus-Sparing Total Gastrectomy for CDH1 Gene Mutation Treatment

Hereditary diffuse gastric cancer (HDGC) caused by the CDH1 gene mutation is an inherited cancer syndrome that increases the risk of diffuse gastric cancer and is nearly impossible to detect by screening gastroscopy. The recommended preventative treatment is a total gastrectomy. Robotic surgery facilitates the use of minimally invasive surgical (MIS) techniques for anastomoses and posterior vagus preservation to potentially reduce adverse functional outcomes. An asymptomatic 24 year old male with the CDH1 gene mutation proven by genetic testing and a family history of a brother having a total gastrectomy for HDGC was treated with this technique. This video case report demonstrates the techniques and pitfalls of robotic surgery in terms of the patient positioning and port placement, posterior vagus-preserving dissection, sutured esophagojejunostomy, jejunal pouch formation, and Roux-en-Y reconstruction with a staple-stapled jejunojejunostomy. While these techniques are demonstrated in the case of prophylactic gastrectomy, many of them can be applied to other benign and bariatric foregut and general surgery types.Robotic surgery can facilitate the foregut MIS technique, as described in this case of a vagus-sparing total gastrectomy.

This article focuses on robotic vagus-sparing total gastrectomy. The techniques and pitfalls of vagus preservation, sutured esophagojejunostomy, jejunal pouch formation, and Roux-en-Y reconstruction with a staple-stapled jejunojejunostomy are discussed.

Hereditary diffuse gastric cancer (HDGC) caused by the CDH1 gene mutation is an inherited cancer syndrome that increases the risk of diffuse gastric ...

Robotic Spleen-Preserving Distal Pancreatectomy: The Warshaw and Kimura Techniques

Spleen-preserving distal pancreatectomy offers an alternative surgical approach to the traditional distal pancreatectomy combined with splenectomy for removing benign and low-grade malignant lesions in the distal pancreas, avoiding complications associated with splenectomy. This procedure can be accomplished either by resecting and ligating the splenic vessels (Warshaw technique) or by preserving them (Kimura technique). Currently, the widespread use of minimally invasive surgery has established laparoscopic and robotic approaches for spleen-preserving distal pancreatectomy as valid and safe options for treating such conditions. Our protocol aims to describe how the Warshaw and Kimura techniques of spleen-preserving distal pancreatectomy can be performed robotically. The first patient is a 36-year-old female with a neuroendocrine tumor (NET) in the pancreatic body who underwent a spleen-preserving distal pancreatectomy with the ligation of the splenic vessels (WT). The second patient is a 76-year-old male with chronic pancreatitis presenting with a dilated main pancreatic duct in the tail of the pancreas who underwent a spleen-preserving distal pancreatectomy with a vessel-preserving approach (KT).

Here, we present a step-by-step protocol of robotic spleen preserving distal pancreatectomy, with and without preserving the splenic vessels (i.e., the Kimura and Warshaw techniques, respectively).

Spleen-preserving distal pancreatectomy offers an alternative surgical approach to the traditional distal pancreatectomy combined with splenectomy for ...

Application of Robot-assisted Pancreaticobiliary Junction Resection in Benign Duodenal Tumors

Robot-assisted pancreaticobiliary junction resection is a surgical technique employed to treat benign duodenal tumors. The procedure involves several key steps: making a longitudinal incision in the duodenum, excising the tumor at the pancreaticobiliary junction, inserting a biliary stent, connecting the biliary and duodenal mucosa, and suturing the duodenal incision during phase I. The robotic system enhances visibility, facilitates precise operations, minimizes duodenal traction injuries to the duodenum and surgical trauma, ensures accurate suture and fixation of bile duct stents, connects the bile duct and duodenal mucosa and reduces postoperative recovery time. Given the complexity of the operation and the associated risk of postoperative duodenal fistula, a thorough preoperative evaluation and meticulous perioperative preparation are crucial. Prior to the procedure, a comprehensive assessment was conducted, integrating the patient's medical history, family history, serological tests, and imaging studies. Special emphasis was placed on determining the benign or malignant nature of the tumor and evaluating the status of the duodenal artery blood supply network to ascertain the feasibility and efficacy of the surgery. During the operation, efforts were made to minimize duodenal trauma and avoid compromising the duodenal artery blood supply network. Additionally, the use of bile duct stents was considered essential to prevent biliary strictures, facilitate bile discharge, and mitigate biliary complications. Postoperatively, real-time monitoring of amylase and jaundice indicators in drainage fluid informed the timely removal of drainage tubes in accordance with the enhanced recovery after surgery (ERAS) protocol. Subsequent follow-up indicated a successful recovery, characterized by a notable reduction in preoperative abdominal pain, the absence of long-term complications, and no evidence of tumor recurrence. Consequently, robot-assisted pancreaticobiliary junction resection demonstrates a safe and effective surgical approach for the treatment of benign duodenal tumors.

The current protocol delineates the use of robot-assisted pancreaticobiliary junction resection for the surgical management of benign duodenal tumors. This approach provides an effective solution for treating these tumors while minimizing duodenal loss and reducing associated complications.

Robot-assisted pancreaticobiliary junction resection is a surgical technique employed to treat benign duodenal tumors. The procedure involves several key ...

Robotic D3 Partial Duodenal Resection with Primary Side-to-Side Anastomosis

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