The authors have no acknowledgments.

Written informed consent was obtained from the patient for the publication of this report and any accompanying videos and images.
1. Preoperative Preparation
<ol>
	<li>Carefully evaluate the preoperative images of CT or MRI for the exact location of the tumor and its relation to the surrounding tissues.</li>
	<li>Give the patient a soft diet one day before the operation and begin fasting at midnight before the operation.</li>
	<li>Place the patient on the operating table. Then, place a peripheral venous catheter and induce general anesthesia using standard procedures. Introduce a central venous catheter through the right internal jugular vein for medication fluids and a peripheral arterial catheter for blood pressure monitor.</li>
</ol>
2. Patient&#39;s Position and Port Placement
<ol>
	<li>Place the patient in supine and 20&#176; reverse Trendelenburg position with the legs split. Drape in normal sterile fashion for upper abdominal surgery.</li>
	<li>Position the surgeon console at the left side of patient. Place the patient cart over the patient&#39;s head and the vision cart at the right side of the patient, respectively. Have the assistant surgeon stand between the patient&#39;s legs to perform the procedures. Position the back table for the instruments and supplies (see Table of Materials) at the left rear of the assistant.</li>
	<li>Make a 1-cm incision with the scalpel 3 cm inferior and right lateral to the umbilicus. Insert a Veress needle into the abdominal cavity through this incision, and establish a CO2 pneumoperitoneum of 14 mmHg with the automatic insufflation instrument.</li>
	<li>Remove the Veress needle and then insert a 12-mm trocar through the 1-cm incision as the camera port. Insert the robotic endoscope and perform a diagnostic laparoscopy (have the assistant surgeon hold the robotic endoscope) to confirm the abdominal adhesion status and operative feasibility. Insert the remaining 4 trocars as follows under the view of the endoscope.</li>
	<li>Place an 8-mm trocar in the left anterior axillary line (Figure 2) at the level of the umbilicus for the first robotic arm. Place a 12-mm trocar 2 cm inferior and left lateral to the umbilicus (Figure 2) as the assistant port.</li>
	<li>Place a 12-mm trocar in the right midclavicular line (Figure 2) at the level of the umbilicus. Insert an 8-mm trocar into this 12-mm trocar in a &#34;trocar in trocar&#34; fashion for the second robotic arm. Place an 8-mm trocar under the costal margin in the right middle axillary line for the third robotic arm (Figure 2). After the docking of robotic army, dock the robotic endoscope in the camera arm.</li>
</ol>
3. Mobilization of the Pancreas Neck and Body
<ol>
	<li>Grasp and keep elevating the anterior wall of the stomach by forceps on the third robotic arm to expose the gastrocolic ligament.</li>
	<li>Tension the gastrocolic ligament with the bipolar forceps in the second robotic arm and the grasping forceps in the assistant&#39;s hand. Divide the gastrocolic ligament to enter the lesser sac and expose the anterior surface of the pancreas with the laparoscopic ultrasonic scalpel on the first robotic arm. Perform hemostasis with bipolar forceps on the second robotic arm, until reaching the level of the right gastroepiploic vein.</li>
	<li>Carefully dissect the pancreatic neck from the superior and inferior direction with the cautery hook. Proceeding from the inferior to superior direction, divide the posterior wall of the pancreatic neck from the portal vein (PV), superior mesenteric vein (SMV), inferior mesenteric vein (IMV), and splenic vein (SV) with the cautery hook. Afterwards, create a tunnel between the PV-SMV-IMV-SV and posterior wall of the pancreatic neck.</li>
	<li>Dissect the pancreatic body from the splenic vessels and connective tissues towards the pancreatic tail with the cautery hook and ultrasonic scalpel.</li>
</ol>
4. Transection of the Pancreatic Parenchyma
<ol>
	<li>Insert the laparoscopic ultrasound probe through the assistant trocar and perform the ultrasonography on the pancreas to reconfirm the location and size of the lesion. According to the result of the ultrasonography, mark two transection lines at about 1 cm away from the lesion, on the pancreatic surface with the cautery hook.</li>
	<li>Lift the pancreatic body with the forceps inserting through the inferior margin of the pancreas and further detach the proximal part of pancreatic body from the splenic vessels and connective tissues with the cautery hook or ultrasonic scalpel.</li>
	<li>After mobilizing the pancreatic neck and proximal pancreatic body form the posterior vessels and tissues, incise the pancreas parenchyma along the distal and proximal transection line with the ultrasonic scalpel and expose the pancreatic duct. Then transect the parenchyma around the pancreatic duct.</li>
	<li>Carefully protect and mobilize the pancreatic duct from the transected pancreatic parenchyma. Then sharply transect the pancreatic duct about 1 cm away from the stump, using laparoscopic scissors from the assistant port.</li>
</ol>
5. Reconstruction of the Pancreatic Continuity
<ol>
	<li>To reduce the tension of anastomosis, further mobilize the pancreatic stump from the posterior vessels and connective tissues, using the cautery hook and bipolar forceps.</li>
	<li>Based on the size of the pancreatic duct stumps, choose a 10-cm plastic pancreatic stent with a proper diameter (1.2 mm in diameter in this case). Cut both ends of the stent to oblique planes and make several side perforations. Implant the stent into the abdominal cavity through the assistant port.</li>
	<li>Hold the side wall of pancreatic duct stump in the pancreatic body with micro forceps, and insert the stent caught by the needle driver into the distal pancreatic duct stump gently. Suture the pancreatic duct with the stent by using 5-0 absorbable suture, so that the stent is closely encircled by the pancreatic duct.</li>
	<li>Insert the other end of the stent into the proximal pancreatic duct stump using a similar approach but without suture.</li>
	<li>Suture the proximal and distal pancreatic stumps using the horizontal mattress suture (4-0 non-absorbable suture).</li>
	<li>Pull the two pancreatic stumps closer, and continue to insert the proximal end of stent into the proximal pancreatic duct stump. Finally, keep the whole stent within the pancreatic duct and do not bring it into the duodenum lumen.</li>
	<li>Perform the end-to-end anastomosis of the pancreatic duct stumps using interrupted suture with 5-0 non-absorbable suture.</li>
	<li>Knot the remaining ties on the pancreatic stumps.</li>
	<li>Suture the anterior portion of the pancreatic stumps using continuous suture with 4-0 non-absorbable suture (Figure 3).</li>
</ol>
6. Hemostasis and Drainage
<ol>
	<li>Carefully check for bleeding sites and conduct thorough hemostasis. Encircle the anastomosis site with absorbable hemostatic gauze.</li>
	<li>Put the resected specimen in the plastic bag and remove the bag from an enlarged incision in the camera port.</li>
	<li>Place two drains along the superior and inferior border of the anastomosis site and extract the drains from the port for the third robotic arm.</li>
</ol>
7. Posteoperative Care
<ol>
	<li>After surgery, give the patient intravenous antibiotics (ceftriaxone sodium), parenteral nutrition (glucose, compound vitamin, compound amino acid, fat emulsion, insulin, KCl, and NaCl), analgesic (sufentanil, ondansetron), somatostatin, proton pump inhibitors (lansoprazole) and other treatment as the same as that of conventional central pancreaticectomy. Keep the patient fasting, then remove the nasogastric tube and feed a clear fluid diet on the 2nd postoperative day. Gradually transition to normal diet if the patient can tolerate it.</li>
	<li>Test the drain fluid for the amylase and bacterial culture after the 3rd postoperative day. When there is no evidence of pancreatic fistula and infection, and the drain volume is less than 10 mL/day, remove the drains.</li>
</ol>

<ol>
	<li>Goudard, 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=Reappraisal+of+central+pancreatectomy+a+12-year+single-center+experience.">Reappraisal of central pancreatectomy a 12-year single-center experience.</a> JAMA Surg. 149 (4), 356-363 (2014).</li><li>Iacono, C., 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=Systematic+review+of+central+pancreatectomy+and+meta-analysis+of+central+versus+distal+pancreatectomy.">Systematic review of central pancreatectomy and meta-analysis of central versus distal pancreatectomy.</a> Br J Surg. 100 (7), 873-885 (2013).</li><li>Sperti, C., Beltrame, V., Milanetto, A. C., Moro, M., Pedrazzoli, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Parenchyma-sparing+pancreatectomies+for+benign+or+border-line+tumors+of+the+pancreas.">Parenchyma-sparing pancreatectomies for benign or border-line tumors of the pancreas.</a> World Journal of Gastrointestinal Oncology. 2 (6), 272-281 (2010).</li><li>Kim, D. H., Kang, C. M., Lee, W. J., Chi, H. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+central+pancreatectomy+with+pancreaticogastrostomy+(transgastric+approach)+in+a+solid+pseudopapillary+tumor+of+the+pancreas.">Robotic central pancreatectomy with pancreaticogastrostomy (transgastric approach) in a solid pseudopapillary tumor of the pancreas.</a> Hepato-gastroenterology. 58 (110-111), 1805-1808 (2011).</li><li>Addeo, 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+central+pancreatectomy+with+stented+pancreaticogastrostomy:+operative+details.">Robotic central pancreatectomy with stented pancreaticogastrostomy: operative details.</a> The international journal of medical robotics + computer assisted surgery: MRCAS. 7 (3), 293-297 (2011).</li><li>Abood, G. J., 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-assisted+minimally+invasive+central+pancreatectomy:+technique+and+outcomes.">Robotic-assisted minimally invasive central pancreatectomy: technique and outcomes.</a> J Gastrointest Surg. 17 (5), 1002-1008 (2013).</li><li>Schwarz, 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=Total+Laparoscopic+Central+Pancreatectomy+with+Pancreaticogastrostomy+for+High-Risk+Cystic+Neoplasm.">Total Laparoscopic Central Pancreatectomy with Pancreaticogastrostomy for High-Risk Cystic Neoplasm.</a> Annals of surgical oncology. 23 (3), 1035 (2016).</li><li>Topal, B., 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=Pancreaticojejunostomy+versus+pancreaticogastrostomy+reconstruction+after+pancreaticoduodenectomy+for+pancreatic+or+periampullary+tumours:+a+multicentre+randomised+trial.">Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours: a multicentre randomised trial.</a> The Lancet Oncology. 14 (7), 655-662 (2013).</li><li>Lemaire, 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=Functional+and+morphological+changes+in+the+pancreatic+remnant+following+pancreaticoduodenectomy+with+pancreaticogastric+anastomosis.">Functional and morphological changes in the pancreatic remnant following pancreaticoduodenectomy with pancreaticogastric anastomosis.</a> Br J Surg. 87 (4), 434-438 (2000).</li><li>Rault, 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=Pancreaticojejunal+Anastomosis+Is+Preferable+to+Pancreaticogastrostomy+after+Pancreaticoduodenectomy+for+Longterm+Outcomes+of+Pancreatic+Exocrine+Function.">Pancreaticojejunal Anastomosis Is Preferable to Pancreaticogastrostomy after Pancreaticoduodenectomy for Longterm Outcomes of Pancreatic Exocrine Function.</a> Journal of the American College of Surgeons. 201 (2), 239-244 (2005).</li><li>Lai, E. C., Tang, C. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+distal+pancreatectomy+versus+conventional+laparoscopic+distal+pancreatectomy:+a+comparative+study+for+short-term+outcomes.">Robotic distal pancreatectomy versus conventional laparoscopic distal pancreatectomy: a comparative study for short-term outcomes.</a> Frontiers of medicine. 9 (3), 356-360 (2015).</li><li>Konstantinidis, I. T., 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+total+pancreatectomy+with+splenectomy:+technique+and+outcomes.">Robotic total pancreatectomy with splenectomy: technique and outcomes.</a> Surg Endosc. , (2017).</li><li>Liu, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+surgical+outcomes+of+robot-assisted+laparoscopic+pancreaticoduodenectomy+versus+laparoscopic+pancreaticoduodenectomy+for+periampullary+neoplasms:+a+comparative+study+of+a+single+center.">The surgical outcomes of robot-assisted laparoscopic pancreaticoduodenectomy versus laparoscopic pancreaticoduodenectomy for periampullary neoplasms: a comparative study of a single center.</a> Surg Endosc. 31 (6), 2380-2386 (2017).</li><li>Lui, R., Zhao, G., Yin, Z., Zhao, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+enucleation+for+pancreatic+neoplasm+with+interposition+repair+of+the+main+pancreatic+duct:+a+case+report.">Robotic enucleation for pancreatic neoplasm with interposition repair of the main pancreatic duct: a case report.</a> Chinese Journal of Laparoscopic Surgery. 9 (6), 373-374 (2016).</li><li>Ehrhardt, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ueber+Resektionen+am+Pankreas1.">Ueber Resektionen am Pankreas1.</a> DMW-Deutsche Medizinische Wochenschrift. 34, 595-597 (1908).</li><li>Wolk, S., 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=Evaluation+of+central+pancreatectomy+and+pancreatic+enucleation+as+pancreatic+resections--A+comparison.">Evaluation of central pancreatectomy and pancreatic enucleation as pancreatic resections--A comparison.</a> Int J Surg. 22, 118-124 (2015).</li><li>Ishii, M., 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=Remnant+pancreas+reconstruction+with+duct-to-duct+anastomosis+after+middle+pancreatectomy:+a+report+of+two+cases.">Remnant pancreas reconstruction with duct-to-duct anastomosis after middle pancreatectomy: a report of two cases.</a> Hepato-gastroenterology. 62 (137), 190-194 (2015).</li><li>Di Benedetto, F., 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=Meso-pancreatectomy:+new+surgical+technique+for+Wirsung+reconstruction.">Meso-pancreatectomy: new surgical technique for Wirsung reconstruction.</a> J Am Coll Surg. 214 (2), 1-4 (2012).</li><li>Oida, 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=End-to-end+anastomosis+after+medial+pancreatectomy+for+tumor.">End-to-end anastomosis after medial pancreatectomy for tumor.</a> Hepato-gastroenterology. 54 (76), 1266-1268 (2007).</li><li>Ramesh, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=End-to-end+anastomosis+of+pancreas.">End-to-end anastomosis of pancreas.</a> Surgery. 131 (6), 691-693 (2002).</li><li>Kang, C. M., Kim, D. H., Lee, W. J., Chi, H. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Initial+experiences+using+robot-assisted+central+pancreatectomy+with+pancreaticogastrostomy:+a+potential+way+to+advanced+laparoscopic+pancreatectomy.">Initial experiences using robot-assisted central pancreatectomy with pancreaticogastrostomy: a potential way to advanced laparoscopic pancreatectomy.</a> Surgical endoscopy. 25 (4), 1101-1106 (2011).</li><li>Lee, J. W., Yoo, J., Ko, J. W., Choi, S. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+Central+Pancreatectomy+with+Pancreaticojejunostomy+for+Solid+Pseudopapillary+Neoplasm.">Robotic Central Pancreatectomy with Pancreaticojejunostomy for Solid Pseudopapillary Neoplasm.</a> Journal of Minimally Invasive Surgery. 20 (2), 74-76 (2017).</li><li>Ronnekleiv-Kelly, S. M., Javed, A. A., Weiss, M. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+central+pancreatectomy+and+pancreatogastrostomy+current+surgical+technique+and+outcomes.">Minimally invasive central pancreatectomy and pancreatogastrostomy current surgical technique and outcomes.</a> The Journal of Visualized Surgery. 2 (8), (2016).</li><li>Liu, R., 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+versus+laparoscopic+distal+pancreatectomy:+A+propensity+score-matched+study.">Robotic versus laparoscopic distal pancreatectomy: A propensity score-matched study.</a> Journal of surgical oncology. 116 (4), 461-469 (2017).</li></ol>

No competing financial interests exist.

Malignant tumors located in the pancreas neck and the proximal part of the pancreatic body are often treated with pancreaticoduodenectomy or distal pancreatectomy. However, for benign or low malignant potential tumors in those sites, the standard pancreaticoduodenectomy or distal pancreatectomy will remove excessive normal tissues and result in excessive injury. Therefore, the central pancreatectomy or pancreatic enucleation, known as &#34;parenchyma-sparing pancreatectomy&#34;, becomes a preferable choice for the treatment of benign and low malignant potential tumors in the pancreatic neck and body.
As early as 1908, Ehrhardt had reported the central pancreatectomy15. Currently, the most commonly used reconstructions for pancreatico-intestinal continuity after central pancreatectomy are as follows: (1) over-sewing the proximal pancreatic remnant and performing pancreaticojejunostomy for the distal pancreatic remnant; (2) over-sewing the proximal pancreatic remnant and performing pancreaticogastrostomy for the distal pancreatic remnant. These two reconstruction approaches ensure an appropriate tension for anastomosis. However, they disrupt the anatomic continuity of digestive tracts and changes the exocrine pathway of the pancreas. Because the pancreatic enzymes could be activated by intestinal juice in the pancreaticojejunostomy, the possibility of Grade C pancreatic fistula is relatively higher in central pancreatectomy, so that the short-term complications such as bleeding also increase8,16. Moreover, as the pancreatic stump directly contacts gastric juice in the pancreaticogastrostomy, enzymes could be inactivated, thus, theoretically ameliorating the erosion of anastomosis. But it might also lead to pancreatic exocrine insufficiency, and in the long term jeopardize the patient&#39;s nutritional status9,10.
As a rarely utilized approach, the end-to-end anastomosis of pancreatic stumps might resolve the drawbacks of the aforementioned reconstruction approach; it does not need the pancreaticoenteric anastomosis and could maintain the integrity and continuity of the digestive tract. It could also keep the pancreatic juice secreting from its original physiological structure. However, perhaps because of its technical complexity, only a few cases of open central pancreatectomy with end-to-end anastomosis are reported, and this approach was not applied consecutively17,18,19,20.
As the most advanced representative of minimally invasive surgery, the robotic surgical system has been applied in the central pancreatectomy, and the current reconstruction approaches are over-sewing the proximal pancreatic remnant and performing pancreaticojejunostomy or pancreaticogastrostomy for the distal pancreatic remnant6,21,22,23. Our surgical team has rich experience in robotic pancreaticoduodenectomy, central pancreatectomy, and distal pancreatectomy13,24. We have also performed robotic pancreatic enucleation with main pancreatic duct invasion and injury. In that surgery, we repaired the pancreatic duct injury by inserting a pancreatic stent and using end-to-end anastomosis14. Based on our experience in robotic pancreatic surgery, we have modified the traditional robotic central pancreatectomy with end-to-end anastomosis, to maximize the residual pancreatic parenchyma and minimalize the injury to patients.
Currently, we used the robotic surgical system to perform the central pancreatectomy and reconstruct the pancreatic continuity through the pancreatic duct plasty and end-to-end pancreatic anastomosis. We found that the short-time outcomes were favorable. As the robotic surgical system has a magnifying 3-D view, multi-degree of freedom for the movement of instruments, the elimination of physiological fibrillation, and other characteristics, this surgical system shows inherent advantages in the dissection, plasty, and anastomosis of the pancreatic duct. Compared with conventional reconstruction approaches, this approach avoids the pancreaticoenteric anastomosis of the distal pancreatic stump, shortens the operation time, and reduces the injury. The direct anastomosis of the two pancreatic stumps avoids the pancreatic stump to contact with digestive fluids, which theoretically could reduce the risk of pancreatic fistula and bleeding. The placement of the stent also enables the anastomosis of the pancreatic duct to be more secure and rapid. In addition, continuous support by the stent also helps to prevent the postoperative stricture of the pancreatic duct. On the other hand, even if pancreatic fistula occurred, the pancreatic fluid could flow into the duodenum through the stent instead of flowing outside the pancreas, thereby reducing the damage of pancreatic fistula to the surrounding organs. Because the stent is sutured to the pancreatic duct with absorbable suture, the stent will spontaneously fall off within a few months.
The critical step of the procedure is the anastomosis of the pancreatic duct and parenchyma without tension. To achieve a tension-free anastomosis, the pancreatic stumps should be sufficiently mobilized from their posterior vessels and tissues, especially the distal stump. It should be noted that the transection of the pancreatic duct was performed by scissor instead of energy instruments, which could reduce the damage of the pancreatic duct and facilitate a better duct-to-duct anastomosis. Additionally, the stumps of the pancreatic duct should be dissected from the resected pancreas as much as possible for plasty. For the pancreatic stent, we usually sterilize plastic tubes with different diameters and lengths by the operation center and choose the correct size during the operation.
We found that in selected patients, the robotic central pancreatectomy with end-to-end anastomosis is safe and feasible. This surgical approach reduces the extent of the central pancreatectomy and maintains the integrity and continuity of physiology and anatomy, which reflects the minimally invasive characteristics of the robotic surgical system in pancreatic surgery. As this operation is at an initial phase, many issues are still unclear, such as how to rationally use somatostatin postoperatively; for patients with long defect of pancreatic duct, whether we should choose central pancreatectomy; if the stent does not fall off spontaneously, what is the side-effect, etc. Its technical modification and long-term efficacy also remain to be explored.

Central pancreatectomy is increasingly performed for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of pancreatic body1. Compared with the pancreaticoduodenectomy or distal pancreatectomy, central pancreatectomy resects less tissues and conserves more pancreatic parenchyma and function. Currently, the major approaches for the pancreas reconstruction are over-sewing the cephalic pancreatic stump and performing a pancreaticojejunostomy or pancreaticogastrostomy to the distal stump2,3. These two approaches are widely used in the open, laparoscopic and robotic central pancreatectomies4,5,6,7. However, the aforementioned two reconstruction approaches break the anatomic continuity of digestive tracts and the pathway for the excretion of pancreatic fluid. The directly contact of pancreatic stump with intestinal juice might increase the possibility of bleeding and fistula8. Although the gastric juice could inactive pancreatic enzymes to avoid the erosion of anastomosis, it might lead to pancreatic exocrine insufficiency, and in the long term jeopardize the patient&#39;s nutritional status9,10.
With the development of minimally invasive surgery, robotic surgery has shown great advantages in its 3-D magnifying view, stability, and flexibility of movements, etc., which provides enhanced dissecting and suturing capacity for anastomosis and hemostasis11,12. Based on our experience in robotic pancreatectomy and repair for injured pancreatic duct13,14, we have performed a series of robotic central pancreatectomy with end-to-end anastomosis and seen favorable outcomes. Compared with pancreaticojejunostomy or pancreaticogastrostomy, end-to-end pancreas anastomosis avoids the damage to digestive tracts; thus, theoretically reducing the possibility of pancreaticoenteric fistula. But on the other hand, the end-to-end pancreas anastomosis poses greater technical difficulties. As an update of conventional central pancreatectomy, the candidates for conventional central pancreatectomy are also eligible for this surgery. Here, we present operative techniques for robotic central pancreatectomy with end-to-end anastomosis in a tertiary hepatopancreatobiliary center in this video case presentation.
Indications:
(1) Benign and low-malignant potential tumors located in the pancreatic neck and proximal body are suitable for this operation. 
(2) The defect of the main pancreatic duct should be less than 5 cm after the central pancreatectomy, and the size of tumor is not the main concern for reconstruction.
Case Presentation:
The patient is a 31-year-old man. A lesion in the pancreatic neck was found accidently in a medical examination 2 years ago. He underwent regular re-examination and the lesion was found to be asymptomatically enlarged recently. He had no history of previous abdominal surgery. On physical examination, no positive sign existed. The pancreatic MRI showed a quasi-circular lesion approximately 14-mm in the pancreatic neck; this was presumed as a neuroendocrine tumor. On T1- and T2-weighted imaging, the lesion showed hypointense and hyperintense signal, respectively. On diffusion-weighted imaging, the lesion showed hyperintense signal. The lesion was slightly enhanced in the arterial phase and showed a progressive enhancement pattern in the parenchyma phase and delay phase (Figure 1). Severe fatty liver was also diagnosed by the MRI. No dilation or stricture was detected in the pancreatic duct. Routine blood examination, IgG isoform test, tumor biomarkers, electrocardiogram, and chest X-ray were normal. The biochemical test showed slightly elevated ALT (Alanine aminotransferase) at 147.3 U/L and AST (Aspartate aminotransferase) at 53.9U/L, which may be caused by fatty liver.

<table border="0" cellpadding="0" cellspacing="0" style="width:773px;" width="773">
	<colgroup>
		<col />
		<col />
		<col />
		<col />
	</colgroup>
	<tbody>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">da Vinci Robotic Surgical System</td>
			<td style="width:296px;">Intuitive&#160;Surgical, USA</td>
			<td style="width:113px;">Si</td>
			<td style="width:159px;"></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">EndoWrist Permanent Cautery Hook</td>
			<td>Intuitive&#160;Surgical, USA</td>
			<td style="width:113px;">420183</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:205px;">Harmonic Ace Curved Shears</td>
			<td>Ethicon, USA</td>
			<td style="width:113px;">420275</td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">EndoWrist Large needle Driver</td>
			<td>Intuitive&#160;Surgical, USA</td>
			<td style="width:113px;">420006</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:205px;">EndoWrist Cadiere Forceps</td>
			<td>Intuitive&#160;Surgical, USA</td>
			<td style="width:113px;">420049</td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">EndoWrist Black Diamond Micro Forceps</td>
			<td>Intuitive&#160;Surgical, USA</td>
			<td style="width:113px;">420033</td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Lapro-Clip 8 mm Absorbable Clips</td>
			<td>Covidien&#160; , USA</td>
			<td style="width:113px;">8886848882</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:205px;">5-0 non-absorbable suture</td>
			<td>Ethicon, USA</td>
			<td style="width:113px;">M8717</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:205px;">4-0 non-absorbable suture</td>
			<td>Ethicon, USA</td>
			<td style="width:113px;">D9775</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:205px;">5-0 absorbable suture</td>
			<td>Ethicon, USA</td>
			<td style="width:113px;">D9943</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:205px;">Absorbable hemostas</td>
			<td>Ethicon, USA</td>
			<td style="width:113px;">W1912</td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Laparoscopic Ultrasound Probe</td>
			<td>BK Ultrasound, Denmark</td>
			<td style="width:113px;">8666-RF</td>
			<td>transducer contact surface: 30*5mm; Frequence: 4.3-10 MHz</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:205px;">Pancreatic stent</td>
			<td>Yaxin Medical, Suzhou, China</td>
			<td style="width:113px;">1.2 mm&#160;</td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Antibiotics&#160;(ceftriaxone sodium for injection)</td>
			<td style="width:296px;">Roche, Shanghai, China</td>
			<td style="width:113px;">H10983036</td>
			<td>ceftriaxone sodium (2g) adding to normal saline (100ml), once per day.</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Proton pump inhibitors (lansoprazole injection)&#160;</td>
			<td style="width:296px;">Luoxin Pharmaceutical, Linyi, China</td>
			<td style="width:113px;">H20055118</td>
			<td>lansoprazole injection (30 mg) adding to normal saline (100ml), twice per day.</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Somatostatin (Somatostatin for injection)</td>
			<td style="width:296px;">Merck Serono, Germany</td>
			<td style="width:113px;">H20090929</td>
			<td>Somatostatin for injection (6000ug) adding to nornal saline to a total of 48ml, 2 ml/h</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:205px;">Analgesic</td>
			<td style="width:296px;"></td>
			<td style="width:113px;"></td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Analgesic (sufentanil Citrate injection)</td>
			<td style="width:296px;">Humanwell Healthcare, Fuzhou, China</td>
			<td style="width:113px;">H20054171</td>
			<td>sufentanil Citrate (200ug),&#160; Ondansetron hyrochloride (20mg), adding to normal saline to a total of 80 ml, 1 ml/h</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Analgesic (Ondansetron hyrochloride injection)</td>
			<td style="width:296px;">Qilu Pharmaceutical, Hainan, China</td>
			<td style="width:113px;">H10970065</td>
			<td>sufentanil Citrate (200ug),&#160; Ondansetron hyrochloride (20mg), adding to normal saline to a total of 80 ml, 2 ml/h</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:205px;">Parenteral nutrition&#160;</td>
			<td style="width:296px;"></td>
			<td style="width:113px;"></td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Parenteral nutrition(10% glucose injection)</td>
			<td style="width:296px;">Shijiazhuang No.4 Pharmaceutical&#65292;Shijiazhuang, China</td>
			<td style="width:113px;">H20133313</td>
			<td>1000 ml</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Parenteral nutrition(5% glucose&#160; injection)</td>
			<td style="width:296px;">Shijiazhuang No.4 Pharmaceutical&#65292;Shijiazhuang, China</td>
			<td style="width:113px;">H13022474</td>
			<td style="width:159px;">250 ml</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Parenteral nutrition(Compond vitamin injection)</td>
			<td style="width:296px;">Pude Pharmaceutical, Datong, China</td>
			<td style="width:113px;">H20093720</td>
			<td style="width:159px;">1 piece</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Parenteral nutrition(Compond amino acid injection)</td>
			<td style="width:296px;">Kelun Pharmaceutical, Chengdu, China</td>
			<td style="width:113px;">H20066058</td>
			<td style="width:159px;">500 ml</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Parenteral nutritionz(Fat emulsion injection)</td>
			<td style="width:296px;">Fresenius Kabi AB, Sweden</td>
			<td style="width:113px;">H20160019</td>
			<td style="width:159px;">250 ml</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Parenteral nutrition(10%KCl injection)</td>
			<td style="width:296px;">Jinyao Pharmaceutical, Tianjin, China</td>
			<td style="width:113px;">H12020518</td>
			<td style="width:159px;">50 ml</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Parenteral nutrition(10%NaCl injection)</td>
			<td style="width:296px;">CR, Double-Crane, Beijing, China</td>
			<td style="width:113px;">H11020865</td>
			<td style="width:159px;">50 ml</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:205px;">Parenteral nutrition(Insulin injection)</td>
			<td style="width:296px;">No.1 biochemical and pharmaceutical, Shanghai, China</td>
			<td style="width:113px;">H31020519</td>
			<td style="width:159px;">28 Unit</td>
		</tr>
	</tbody>
</table>

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 operation process was smooth. The operative time was 141 mins and the intraoperative blood loss was about 50 mL. The size of the resected pancreas was about 5.5 &#215; 2.5 &#215; 2.5 cm (Figure 4). The patient recovered smoothly after surgery and discharged on the 6th postoperative day. When the patient was discharged, he had a normal diet and normal defecation, and had no fever, no abdominal pain or distension. The routine blood examination and blood biochemical test had no obvious abnormality. Postopertative CT scan showed slight exudation around the pancreas and no dilation or stricture in the pancreatic duct (Figure 5). The abdominal drain volume was about 100 mL/day. The pathological examination confirmed a solid pseudopapillary tumor with negative margin and the immunohistochemistry test showed that the tumor was B-catenin (nucleus and capsule +), PR (+60%), Vimentin (+), Cga (-), CD10 (+), syn (+), CK (focal+), CD56 (+), ki-67 (+ 2%). The drains were removed on the 20th postoperative day.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/57495/57495fig1.jpg" /> 
Figure 1: Preoperative MRI of the patient. Red arrow indicates a quasi-circular lesion in the pancreatic neck. <a href="/files/ftp_upload/57495/57495fig1large.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/57495/57495fig2.jpg" /> 
Figure 2: Port placement. Five ports were used. 1: port for the first robotic arm; 2: port for the second robotic arm (&#34;trocar in trocar&#34; fashion); 3: port for the third robotic arm; C: camera port; A: assistant port; red circle: 12-mm trocar; blue circle: 8-mm trocar; RMAL: right middle axillary line; RMCL: right midclavicular line; LAAL: left anterior axillary line. <a href="/files/ftp_upload/57495/57495fig2large.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/57495/57495fig3.jpg" /> 
Figure 3: Reconstruction of the pancreatic continuity. (A) The middle portion of the pancreas was resected and the stumps of pancreatic duct were dissected. (B) The pancreatic stent was inserted into the pancreatic duct. (C) The duct-to-duct anastomosis of the pancreatic duct was completed during suturing and pulling together two stumps of the pancreas. (D) The end-to-end anastomosis of the pancreas was completed. Yellow dash line: stumps of the pancreatic duct; Cyan dash line: cutting margin of the pancreas. <a href="/files/ftp_upload/57495/57495fig3large.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/57495/57495fig4.jpg" /> 
Figure 4: Gross morphology of the resected central pancreas. <a href="/files/ftp_upload/57495/57495fig4large.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/57495/57495fig5.jpg" /> 
Figure 5: Postoperative CT scan of the patient. Slight exudation around the pancreas and no dilation or stricture in the pancreatic duct. White arrow indicates the stent in the pancreas. <a href="/files/ftp_upload/57495/57495fig5large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Watch this Scientific Journal Video about Application of End-to-end Anastomosis in Robotic Central Pancreatectomy at JoVE.com

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

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 ...

application-end-to-end-anastomosis-robotic-central

Nanyang Technological University

Research

JoVE Journal

Medicine

7.9K Views.  Chinese People's Liberation Army (PLA) General Hospital. 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.

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

Murine Ileocolic Bowel Resection with Primary Anastomosis

Intestinal resections are frequently required for treatment of diseases involving the gastrointestinal tract, with Crohn&#8217;s disease and colon cancer being two common examples. Despite the frequency of these procedures, a significant knowledge gap remains in describing the inherent effects of intestinal resection on host physiology and disease pathophysiology. This article provides detailed instructions for an ileocolic resection with primary end-to-end anastomosis in mice, as well as essential aspects of peri-operative care to maximize post-operative success. When followed closely, this procedure yields a 95% long-term survival rate, no failure to thrive, and minimizes post-operative complications of bowel obstruction and anastomotic leak. The technical challenges of performing the procedure in mice are a barrier to its wide spread use in research. The skills described in this article can be acquired without previous surgical experience. Once mastered, the murine ileocolic resection procedure will provide a reproducible tool for studying the effects of intestinal resection in models of human disease.

Ileocolic resection is commonly performed in several human diseases; however, little is known regarding the impact of intestinal resection on surgical illnesses. This article provides instruction on executing the procedure in mice with high success, providing a means to study the effects of ileocolic resection in models of disease.

Intestinal resections are frequently required for treatment of diseases involving the gastrointestinal tract, with Crohn&#8217;s disease and colon cancer ...

Robotic Ablation of Atrial Fibrillation

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between pulmonary vein (PV) and left atrium (LA) is created. This conduction block prevents AF, which is triggered by irregular electric activity originating from the PV. However, transmural atrial lesions are required which can be challenging. Re-conduction and AF recurrence occur in 20 - 40% of the cases. Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new remote catheter system (RCS), is presented. Objective of this article is to show feasibility of robotic AF ablation with a novel system. Materials and Methods: After interatrial trans-septal puncture is performed using a long sheath and needle under fluoroscopic guidance. The needle is removed and a guide wire is placed in the left superior PV. Then an ablation catheter is positioned in the LA, using the sheath and wire as guide to the LA. LA angiography is performed over the sheath. A circular mapping catheter is positioned via the long sheath into the LA and a three-dimensional (3-D) anatomical reconstruction of the LA is performed. The handle of the ablation catheter is positioned in the robotic arm of the Amigo system and the ablation procedure begins. During the ablation procedure, the operator manipulates the ablation catheter via the robotic arm with the use of a remote control. The ablation is performed by creating point-by-point lesions around the left and right PV ostia. Contact force is measured at the catheter tip to provide feedback of catheter-tissue contact. Conduction block is confirmed by recording the PV potentials on the circular mapping catheter and by pacing maneuvers. The operator stays out of the radiationfield during ablation. Conclusion: The novel catheter system allows ablation with high stability on low operator fluoroscopy exposure.

Pulmonary vein isolation (PVI) with an ablation catheter is a curative treatment for atrial fibrillation (AF). Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new robotic catheter system is presented. The goal of the procedure is electrical block between pulmonary vein and left atrium.

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between ...

Emergency Undocking in Robotic Surgery: A Simulation Curriculum

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of a robotic system. In traditional robotic training for surgeons, a brief web based overview of performing an emergency undocking is provided during initial introductory training to the robotics system. During such a process, there is no training in delineation of interdisciplinary roles for operating room (OR) personnel. The training presented here uses formative simulation and debriefing followed by a lecture. For the simulation, a modified gynecologic simulator is draped in a steep trendelenburg position consistent with most gynecologic laparoscopic surgery. The training torso is modified using tubing hooked to pressure bags of red food colored IV fluid used to simulate a catastrophic vessel injury on demand. Positioned throughout the operating room setting is an interprofessional team consisting of embedded standardized persons (ESPs) to fulfill the roles of a circulating nurse, scrub nurse, anesthesiologist, and bedside assist surgeon. Robotic surgeons are presented a case scenario necessitating emergency undocking, and given control of the robotic instruments. The scenario is terminated following either successful completion of an emergency undock, or at five minutes due to the emergent nature of the case. A debriefing session with hands on training of the steps to emergency undocking, necessary equipment, troubleshooting techniques, and operating room personnel roles follows the simulation. The learners are presented with a short lecture reemphasizing the material presented in the debriefing for their own self-study. This training results in improved time accessing the patient, improved knowledge, confidence, and completion of critical actions, and can be replicated in most institutions. All robotic surgeons should be able to demonstrate competence in this crucial intervention. A limitation of the curriculum is ability to access the in-situ environment for training purposes.

This training platform is designed to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of the robotic system. Training includes the utilization of the technology and equipment to perform an emergency undocking, as well as delineation of roles for such a scenario.

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of ...

Vessel-sparing Excision and Primary Anastomosis

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short bulbar or posterior urethral strictures, urethroplasty by excision and primary anastomosis (EPA) is recommended. As EPA only requires the excision of the narrowed segment and the surrounding spongiofibrosis, a full-thickness transection of the corpus spongiosum, as performed in the traditional transecting EPA (tEPA), is usually unnecessary. Jordan et al. introduced the idea of a vessel-sparing approach in 2007, aiming to reduce surgical trauma, especially to the dual arterial blood supply of the urethra, and, thus, potentially reducing the risk of postoperative erectile dysfunction or glans ischemia. This approach could also be beneficial for subsequent urethral interventions such as redo urethroplasty using a free graft, in which a well-vascularized graft bed is imperative. Nevertheless, these potential benefits are only assumptions as prospective studies comparing the functional outcome of both techniques with validated questionnaires are currently lacking. Moreover, vessel-sparing EPA (vsEPA) should at least be able to provide similar surgical outcomes as tEPA. The aim of this paper is to give an elaborate, step-by-step overview of how to manage patients with isolated short bulbar or posterior urethral strictures with vsEPA. The main objective of this manuscript is to outline the surgical technique and to report the representative surgical outcome. A total of 117 patients were managed according to the described protocol. The analysis was performed on the entire patient cohort and on the bulbar (n = 91) and posterior (n = 26) vsEPA group separately. Success rates were 93.4% and 88.5% for the bulbar and posterior vsEPA, respectively. To conclude, vsEPA, as outlined in the protocol, provides excellent success rates with low complication rates for isolated short bulbar and posterior urethral strictures.

Here, we present an elaborate and efficient protocol to treat isolated short bulbar or posterior urethral strictures with vessel-sparing excision and primary anastomosis.

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short ...

Creation of Colonic Anastomosis in Mice

Intestinal anastomoses are commonly performed in both elective and emergent operations. Even so, anastomotic leaks are a highly feared complications of colonic surgeries and can occur in up to 26% of surgical anastomoses, with mortality being up to 39% for patients with such a leak. Currently, there remains a paucity of data detailing the cellular mechanisms of anastomotic healing. Devising preventative strategies and treatment modalities for anastomotic leak could be greatly potentiated by a better understanding of appropriate anastomotic healing.
A murine model is ideal as previous studies have shown that the murine anastomosis is the most clinically similar to the human case as compared with other animal models. We offer an easily reproducible murine model of colonic anastomosis in mice that will allow for further illustration of anastomotic healing.

Anastomotic leak or breakdown after surgery is a major cause of postoperative morbidity and mortality. Our surgery for creating a colonic anastomosis is a reliable and reproducible method for studying the healing mechanisms of anastomoses.

Intestinal anastomoses are commonly performed in both elective and emergent operations. Even so, anastomotic leaks are a highly feared complications of ...

One-anastomosis Gastric Bypass (OAGB) in Rats

The goal of this protocol is to set up a preclinical model of bariatric surgery and, more specifically, OAGB in obese rats. Based on this preclinical model, longitudinal studies can be carried out to provide an improved understanding of the mechanisms underlying the outcomes seen after bariatric surgery in humans. For this purpose, rats are operated on through a laparotomy under general anesthesia with isoflurane. First, the surgeon creates a long and tubular gastric pouch: after greater curve and hiatal dissection, the nonglandular stomach is stapled and removed. Then, the remaining stomach is also stapled in order to create a gastric tube and exclude the antrum of the stomach. After that, the surgeon performs a single end-to-side gastrojejunostomy 35 cm from the duodenojejunal angle. This limb length has been chosen in order to reproduce the same ratio between the biliopancreatic limb (BPL) and common limb (CL) length as in human bariatric surgery. The operation ends by aponeurotic and cutaneous closure. The early postoperative management consists of subcutaneous hydration, an intramuscular prophylactic antibiotic injection, a parietal injection of xylocaine, the administration of painkillers, and a progressive reintroduction of diet.

One-anastomosis Gastric Bypass OAGB in Rats

This protocol is for the performance of one-anastomosis gastric bypass (OAGB) on rat. The operator performs a long and tubular-stapled gastric pouch followed by hand-sewn anastomosis. For this model, the operator reproduces the same ratio between biliopancreatic and common limb in humans; therefore, the biliopancreatic limb measures 35 cm.

The goal of this protocol is to set up a preclinical model of bariatric surgery and, more specifically, OAGB in obese rats. Based on this preclinical ...

DIPLOMA Approach for Standardized Pathology Assessment of Distal Pancreatectomy Specimens

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignant cancers. A minority (20%) of PDACs are found in the pancreatic body and tail. Accurate pathology assessment of the pancreatic specimen is essential for providing prognostic information and it may guide further treatment strategies. The recent 8th edition of the American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) staging system for pancreatic tumors has incorporated significant changes to tumor (pT) stage, which is predominantly based on tumor size. This change emphasizes the importance of careful block selection. Owing to the greater prevalence of tumors in the head of the pancreas, efforts are made to standardize the assessment of pancreatoduodenectomy specimens. However, consensus regarding the macroscopic assessment of distal (i.e., left) pancreatectomy specimens is lacking. The DIPLOMA approach includes the standardized measurement of pancreas and other resected organs, inking of relevant surgical margins and anatomical surfaces without removing covering layers of fat, measurement of tumor size (for T-stage), together with assessment of splenic vessel involvement (and other organs if present). All relevant margins are assessed, and relevant blocks are selected to confirm these parameters microscopically. The current protocol describes a standardized approach to the macroscopic assessment of distal pancreatectomy specimens. This approach was developed during several meetings with pathologists and surgeons during the preparation phase for an international multicenter trial (DIPLOMA, ISRCTN44897265), which focuses on radicality of distal pancreatectomy for pancreatic ductal adenocarcinoma. This standardized approach can be instrumental in the design of studies and will uniform reporting on the outcomes of distal pancreatectomy. The described technique is used in the DIPLOMA trial for pancreatic ductal adenocarcinoma but may also be useful for other indications.

The current study highlights a standardized approach to the macroscopic assessment of distal pancreatectomy specimens for pancreatic ductal adenocarcinoma, with special emphasis on the measurement of pancreatic dimensions and those of other organs, inking of margins, measurement of tumor size and proximity to margins, lymph node sampling and block selection.

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignant cancers. A minority (20%) of PDACs are found in the pancreatic body and tail. ...

Application of Lucilia sericata Larvae in Debridement of Pressure Wounds in Outpatient Settings

Biological therapy using Lucilia sericata larvae has numerous advocates worldwide, yet it is still fairly unknown and not commonly applied in daily practice because of the limited awareness and insufficient experience of medical and nursing personnel. There are case reports suggesting that maggot therapy can be applied and supported by lay caregivers, provided they are supervised and informed by physicians/nurses. The foregoing observation suggests that the method should be considered for implementation by a wider group of caregivers if accepted and meticulously supervised by trained and experienced medical staff. The concerns related to the therapeutic use of maggots in certain regions seem understandable, but are not supported by scientific facts. It should be noted that many therapeutic agents (including brood) used in medicine are of natural origin, and are associated with low production costs and high possibilities of implementation in the course of therapy. By analyzing the literature and using our own clinical and research experience, we have come to conclusions related to using larvae therapy, as a quick and safe method providing cleaning and revitalization in the process of treating wounds of various etiologies, especially pressure ulcers. In the current study, medical-grade Lucilia sericata maggots were applied to remove necrotic tissue from deep pressure sores. The treatment is mostly accepted by both caregivers and patients. In most cases, it is conducted by trained and experienced medical personnel in home and outpatient settings. Over the course of the conducted analyzes involving the collected specimens, there were no statistically significant relationships (p&gt; 0.05) confirmed between the wound surface successfully cleared by brood and variables, such as time from wound formation, location, surface size, and the depth of damage to the tissue structure. The lack of statistical dependence may result from the small size of the studied group. Based on the current findings, we have formulated the following conclusions: Maggot Debridement Therapy (MDT) is a fast and effective method enabling the preparation of the wound bed. The use of MDT in outpatient settings is safe and acceptable for patients and their caregivers.

Application of Lucilia sericata Larvae in Debridement of Pressure Wounds in Outpatient Settings

Maggots of Lucilia sericata were used in the debridement of deep pressure sores in outpatient settings for the treatment of pressure sores involving the complete skin thickness. The technique presented in the article does not pose risks for the patient.

Biological therapy using Lucilia sericata larvae has numerous advocates worldwide, yet it is still fairly unknown and not commonly applied in daily ...

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 ...

Transoral Robotic Total Thyroidectomy and Bilateral Central Regional Lymph Node Dissection for Papillary Thyroid Carcinoma

Currently, the common approaches to thyroid surgery include conventional thyroidectomy, bilateral axillo-breast, axillary, retroauricular, and oral vestibule approaches. Essentially, various approaches to thyroid surgery only move the traditional surgical incision to a more concealed position but still leave scars on the body surface. Among them, thyroid surgery via the oral vestibule approach can obtain the best cosmetic outcome through the shortest natural cavity. However, in the early time, thyroid surgery via the oral vestibule approach usually requires three incisions in the mouth and one axillary incision. We have introduced a robotic surgical system into thyroidectomy via the oral vestibule approach and successfully completed total thyroidectomy and bilateral central lymph node dissection. During the operation, only three incisions were made at the oral vestibule without an axillary incision. This article aims to present the unique three-port method of robotic thyroidectomy via oral vestibule for the treatment of patients with papillary thyroid cancer.

The transoral robotic total thyroidectomy and bilateral central regional lymph node dissection using three ports without axillary incision are feasible and safe for early-stage papillary thyroid carcinoma. Here we present the operative techniques of this operation.

Currently, the common approaches to thyroid surgery include conventional thyroidectomy, bilateral axillo-breast, axillary, retroauricular, and oral ...