Nothing to acknowledge.

<ol>
	<li>Tseng, J. 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=The+learning+curve+in+pancreatic+surgery.">The learning curve in pancreatic surgery.</a> Surgery. 141, 456-463 (2007).</li><li>Cameron, J. L., He, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Two+Thousand+Consecutive+Pancreaticoduodenectomies.">Two Thousand Consecutive Pancreaticoduodenectomies.</a> Journal of the American College of Surgeons. 220, 530-536 (2015).</li><li>Birkmeyer, 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=Effect+of+hospital+volume+on+in-hospital+mortality+with+pancreaticoduodenectomy.">Effect of hospital volume on in-hospital mortality with pancreaticoduodenectomy.</a> Surgery. 125, 250-256 (1999).</li><li>Cirocchi, 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=A+systematic+review+on+robotic+pancreaticoduodenectomy.">A systematic review on robotic pancreaticoduodenectomy.</a> Surgical Oncology. 22, 238-246 (2013).</li><li>Giulianotti, P. 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=Robotics+in+general+surgery:+personal+experience+in+a+large+community+hospital.">Robotics in general surgery: personal experience in a large community hospital.</a> Archives of surgery. 138, 777-784 (2003).</li><li>Wang, S. -. E., Shyr, B. -. U., Chen, S. -. C., Shyr, Y. -. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+between+robotic+and+open+pancreaticoduodenectomy+with+modified+Blumgart+pancreaticojejunostomy:+A+propensity+score-matched+study.">Comparison between robotic and open pancreaticoduodenectomy with modified Blumgart pancreaticojejunostomy: A propensity score-matched study.</a> Surgery. 164 (6), 1162-1167 (2018).</li><li>Magge, D., 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+at+an+experienced+institution+is+not+associated+with+an+increased+risk+of+post-pancreatic+hemorrhage.">Robotic pancreatoduodenectomy at an experienced institution is not associated with an increased risk of post-pancreatic hemorrhage.</a> HPB. 20, 448-455 (2018).</li><li>Zureikat, A. 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=Minimally+invasive+hepatopancreatobiliary+surgery+in+North+America:+an+ACS-NSQIP+analysis+of+predictors+of+conversion+for+laparoscopic+and+robotic+pancreatectomy+and+hepatectomy.">Minimally invasive hepatopancreatobiliary surgery in North America: an ACS-NSQIP analysis of predictors of conversion for laparoscopic and robotic pancreatectomy and hepatectomy.</a> The official journal of Hepato-Pancreato-Billiary Association. 19, 595-602 (2017).</li><li>Zureikat, A. 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=A+Multi-institutional+Comparison+of+Perioperative+Outcomes+of+Robotic+and+Open+Pancreaticoduodenectomy.">A Multi-institutional Comparison of Perioperative Outcomes of Robotic and Open Pancreaticoduodenectomy.</a> Annals of Surgery. 264, 640-649 (2016).</li><li>McMillan, M. 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=A+Propensity+Score-Matched+Analysis+of+Robotic+vs+Open+Pancreatoduodenectomy+on+Incidence+of+Pancreatic+Fistula.">A Propensity Score-Matched Analysis of Robotic vs Open Pancreatoduodenectomy on Incidence of Pancreatic Fistula.</a> JAMA Surgery. 152 (4), 327-335 (2016).</li><li>Nguyen, K., 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=Technical+Aspects+of+Robotic-Assisted+Pancreaticoduodenectomy+(RAPD).">Technical Aspects of Robotic-Assisted Pancreaticoduodenectomy (RAPD).</a> Journal of Gastrointestinal Surgery. 15, 870-875 (2011).</li><li>Zureikat, A. H., Nguyen, K. T., Bartlett, D. L., Zeh, H. J., Moser, J. A. <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+Major+Pancreatic+Resection+and+Reconstruction.">Robotic-Assisted Major Pancreatic Resection and Reconstruction.</a> Archives of Surgery. 146, 256-261 (2011).</li><li>Knab, M. 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=Evolution+of+a+Novel+Robotic+Training+Curriculum+in+a+Complex+General+Surgical+Oncology+Fellowship.">Evolution of a Novel Robotic Training Curriculum in a Complex General Surgical Oncology Fellowship.</a> Annals in Surgical Oncology. 25 (12), 3445-3452 (2018).</li><li>Wu, 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=Recurrent+GNAS+mutations+define+an+unexpected+pathway+for+pancreatic+cyst+development.">Recurrent GNAS mutations define an unexpected pathway for pancreatic cyst development.</a> Science Translational Medicine. 3, 92 (2011).</li><li>Singhi, A. D., 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=American+Gastroenterological+Association+guidelines+are+inaccurate+in+detecting+pancreatic+cysts+with+advanced+neoplasia:+a+clinicopathologic+study+of+225+patients+with+supporting+molecular+data.">American Gastroenterological Association guidelines are inaccurate in detecting pancreatic cysts with advanced neoplasia: a clinicopathologic study of 225 patients with supporting molecular data.</a> Gastrointestinal Endoscopy. 83, 1107-1117 (2016).</li><li>Tanaka, 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=Revisions+of+international+consensus+Fukuoka+guidelines+for+the+management+of+IPMN+of+the+pancreas.">Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas.</a> Pancreatology. 17, 738-753 (2017).</li><li>Malka, D., Castan, F., Conroy, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=FOLFIRINOX+Adjuvant+Therapy+for+Pancreatic+Cancer.">FOLFIRINOX Adjuvant Therapy for Pancreatic Cancer.</a> New England Journal of Medicine. 380, 1187-1189 (2019).</li><li>Nassour, I., 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+Pancreaticoduodenectomy:+a+NSQIP+Analysis.">Robotic Versus Laparoscopic Pancreaticoduodenectomy: a NSQIP Analysis.</a> Journal of Gastrointestinal Surgery Official Journal of the Society for Surgery of the Alimentary Tract. 21, 1784-1792 (2017).</li><li>Gabriel, E., Thirunavukarasu, P., Attwood, K., Nurkin, S. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=National+disparities+in+minimally+invasive+surgery+for+pancreatic+tumors.">National disparities in minimally invasive surgery for pancreatic tumors.</a> Surgical Endoscopy. 31, 398-409 (2017).</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> Surgical Endoscopy. 32, 3691-3696 (2018).</li><li>Kornaropoulos, 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=Total+robotic+pancreaticoduodenectomy:+a+systematic+review+of+the+literature.">Total robotic pancreaticoduodenectomy: a systematic review of the literature.</a> Surgical Endoscopy. 31, 4382-4392 (2017).</li><li>Boone, B. 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=Assessment+of+Quality+Outcomes+for+Robotic+Pancreaticoduodenectomy:+Identification+of+the+Learning+Curve.">Assessment of Quality Outcomes for Robotic Pancreaticoduodenectomy: Identification of the Learning Curve.</a> JAMA Surgery. 150, 416-422 (2015).</li><li>Fisher, W. E., Hodges, S. E., Wu, M. -. F. F., Hilsenbeck, S. G., Brunicardi, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Assessment+of+the+learning+curve+for+pancreaticoduodenectomy.">Assessment of the learning curve for pancreaticoduodenectomy.</a> American Journal of Surgery. 203, 684-690 (2012).</li><li>Hmidt, 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=Effect+of+hospital+volume,+surgeon+experience,+and+surgeon+volume+on+patient+outcomes+after+pancreaticoduodenectomy:+a+single-institution+experience.">Effect of hospital volume, surgeon experience, and surgeon volume on patient outcomes after pancreaticoduodenectomy: a single-institution experience.</a> Archives of Surgery. 145, 634-640 (2010).</li><li>Zureikat, A. H., Hogg, M. E., Zeh, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Utility+of+the+Robot+in+Pancreatic+Resections.">The Utility of the Robot in Pancreatic Resections.</a> Advances in Surgery. 48, 77-95 (2014).</li></ol>

Nothing to disclose.

With advances in the surgical technology, laparoscopic and robot-assisted surgeries are being increasingly used in gastrointestinal and hepatobiliary procedures. Conventional laparoscopy is associated with benefits over open surgery for many procedures. However, inherent limitations such as decreased surgical dexterity, suboptimal ergonomics, lack of wristed instruments, and 2-D visualization, have limited its dissemination to complex gastrointestinal operations such as PD.&#160;
Contrary to laparoscopy, the robotic platform allows for the minimally invasive operations to be performed under 3D vision, with enhanced dexterity and the use of articulating (wristed) instruments. The Si is an older system and is the basis for which the authors have performed the vast majority of RPDs. The main inherent advantage of the older model (e.g., Si) is the use of a larger (12 mm) robotic camera with improved definition over the 8 mm camera (e.g., Xi). However, in this case both the newer and the older versions are used interchangeably for RPD. Regardless of the model, RAS allows for the open PD principles to be adhered to when performing the minimally invasive surgery. Despite concerns over oncologic outcomes, morbidity, cost, and training, several single, multi-institutional, and national series have demonstrated the safety and feasibility of RPD5,7,8,15. More recent data demonstrate that RPD can be associated with improvements in morbidity and length of stay compared to the open approach and reductions in conversion compared to the laparoscopic approach9,18,19,20,21.
Based on our experience at UPMC, several factors are needed for successful implementation of RPD. These include an institutional commitment to program success with necessary training and mentorship, prior surgeon experience in open pancreatic surgery, use of two staff surgeons to navigate through the initial learning, availability of a large case volume (2&#8211;4 cases/month), prospective assessment of perioperative outcomes, and dedicated operating room staff.
Data from our experience suggests the learning curve of RPD to be approximately 80 cases22. Notably, this is quite similar to the learning curve of OPD as demonstrated by three other reports.1,23,24 Reductions in EBL and operative conversions occur early (20 cases), while a decrease in clinically relevant pancreatic fistula rate occurs after 40 cases. Operative time, a surrogate of procedural efficiency, is optimized after 80 cases. Following identification of our learning curve, we established a training program with the objective of disseminating safe robotic pancreatectomy. This stepwise mastery-based curriculum includes five main components: 1) mastery of the console, 2) virtual reality, 3) innanimate and bio-tissue drills, 4) live operative proctoring, and 5) continuous quality improvement and assurance11,13,25.
There are a few technical considerations for RPD that warrant emphasis. During the operation, communication between the bedside and console surgeons is paramount. Both surgeons must adhere to the same operative plan and anticipate each other&#8217;s maneuvers. In the resection phase, A3 plays a key role in retraction of the specimen to allow for optimal exposure. There are three critical parts in the operation that can result in significant intraoperative hemorrhage: 1) dissection of LOT and linearization of the duodenum after the proximal jejunal transection, 2) dissection of the inferior pancreatic border to begin the retropancreatic tunnel, and 3) dissection of the uncinate process. These phases demand extreme caution and warrant a thorough knowledge of operative anatomy. Control of hemorrhage may be challenging and requires a fascile ability to suture with 4&#8211;0 and 5&#8211;0 monoflament sutures, an experienced bedside assistant to control suction, and the ability to perform a quick and safe open conversion if bleeding is not controlled. In the reconstruction phase, A3 similarly plays a major role, since it is often utilized to grasp and retract previously placed sutures in a cranial direction to allow for countertension when placing sutures.
In conclusion, we provide a stepwise description of our RPD technique. Our technique follows principles of open PD, while allowing safe and oncologically sound application of a minimally invasive approach to this complex operation.

Pancreaticoduodenectomy (PD) is a complex operation that combines a challenging resection and a meticolous reconstruction. During its early inception, the traditional open approach was frought with high complication rates and a mortality rate approaching 25%. In the last three decades, improvements in the surgical technique and perioperative care led to corresponding improvements in outcomes, with a reduction in mortality to less than 5%, especially at high volume centers1,2,3. Despite this, morbidity remains substantial. With advancements in surgical technology, minimally invasive surgical approaches through laparoscopy or robot-assisted surgery have emerged in an effort to curb this morbidity. Since its first report in 2003, interest in robotic pancreaticoduodenectomy (RPD) has grown by pancreatic surgeons4,5. Inherent advantages of the robotic platform, including three-dimensional (3D) vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate principles of open PD (OPD) in a minimally invasive manner, including safe oncologic dissection, hemostasis, and meticulous reconstruction4,6,7,8,9,10. The goal of this manuscript is to provide the detailed steps of an RPD performed at the University of Pittsburgh Medical Center (UPMC)11,12,13.
In the presented case study, a 42-year-old female with a previous history of intraductal papillary mucinous neoplasm (IPMN), initially presented with acute pancreatitis. Computed tomography (CT) of the abdomen revealed a 3.3 cm pancreatic head lesion with associated dilatation of the main pancreatic duct (Figure 1A,B), with a mixed type IPMN. Endoscopic ultrasound (EUS) confirmed the existence of an irregular, heterogenous cyst measuring 3.1 x 2.0 cm in the pancreatic head with mixed solid and cystic components and main PD duct dilation (Figure 1C). EUS cytology revealed the presence of atypical cells with no high-risk molecular mutations14,15. Biochemical workup including serum tumor markers were normal, with CA19-9 12 U/mL. Based on the Fukuoka criteria, this patient was recommended to have a PD and was deemed a suitable candidate for the robotic approach16.

<table><tbody><tr><td>3-0 V-Loc sutures</td><td>Medtronic (Minneapolis, MN)</td><td>VLOCMo614</td><td>Barbed Absorable Suture</td></tr><tr><td>4-5 Fr Freeman Pancreatic Flexi-Stent</td><td>Hobbs Medical (Stafford Springs, CT)</td><td>6542, 6552</td><td>Pancreatic Duct Stent</td></tr><tr><td>5-0 PDS (polydiosxanone)</td><td>Ethicon (Somerville, NJ)</td><td>D10063</td><td>Synthetic Absorbable Suture</td></tr><tr><td>Cad&amp;iacute;ere forceps</td><td>Intuitive (Sunnyvale, CA)</td><td>470049</td><td>Surgical Robot Instrument</td></tr><tr><td>Da Vinci Si</td><td>Intuitive (Sunnyvale, CA)</td><td></td><td>Surgical Robot</td></tr><tr><td>Da Vinci Xi</td><td>Intuitive (Sunnyvale, CA)</td><td></td><td>Surgical Robot</td></tr><tr><td>Endo Clip 10 mm Applier</td><td>Covidien (Dublin, Ireland)</td><td>176619</td><td>Laparoscopic Titanium Clip Applier</td></tr><tr><td>Endo GIA 45 mm Curved Tip Articulating Vascular Stapler with Tri-Stapler Technology</td><td>Covidien (Dublin, Ireland)</td><td>EGIA45CTAVM</td><td>Laparoscopic Surgical Stapler</td></tr><tr><td>Endo GIA 60 mm Articulating Stapler with Tri-Stapler Technology</td><td>Covidien (Dublin, Ireland)</td><td>EGIA60AMT</td><td>Laparoscopic Surgical Stapler</td></tr><tr><td>Endo GIA 60 mm Curved Tip Articulating Vascular Stapler with Tri-Stapler Technology</td><td>Covidien (Dublin, Ireland)</td><td>EGIA60CTAVM</td><td>Laparoscopic Surgical Stapler</td></tr><tr><td>EndoCatch Gold 10 mm Specimen Pouch</td><td>Medtronic (Minneapolis, MN)</td><td>173050G</td><td>Specimen Extraction Bag</td></tr><tr><td>EndoCatch II 15 mm Specimen Pouch</td><td>Medtronic (Minneapolis, MN)</td><td>173049</td><td>Specimen Extraction Bag</td></tr><tr><td>Fenestrated bipolar forceps</td><td>Intuitive (Sunnyvale, CA)</td><td>470205</td><td>Surgical Robot Instrument</td></tr><tr><td>GelPOINT Mini Advanced Access Platform</td><td>Applied Medical (Rancho Santa Margarita, CA)</td><td>CNGL3</td><td>Laparoscopic Abdominal Access Platform</td></tr><tr><td>Large needle driver</td><td>Intuitive (Sunnyvale, CA)</td><td>470006</td><td>Surgical Robot Instrument</td></tr><tr><td>Large SutureCut needle driver</td><td>Intuitive (Sunnyvale, CA)</td><td>470296</td><td>Surgical Robot Instrument</td></tr><tr><td>LigaSure Blunt Tip Laparoscopic Sealer/Divider</td><td>Medtronic (Minneapolis, MN)</td><td>LF1844</td><td>Laparoscopic Bioplar Device</td></tr><tr><td>Mediflex liver retractor</td><td>Mediflex (Islandia NY)</td><td></td><td>Laparoscopic Liver Retractor</td></tr><tr><td>Monopolar curved scissors</td><td>Intuitive (Sunnyvale, CA)</td><td>470179</td><td>Surgical Robot Instrument</td></tr><tr><td>Permanent cautery hook</td><td>Intuitive (Sunnyvale, CA)</td><td>470183</td><td>Surgical Robot Instrument</td></tr><tr><td>ProGrasp forceps</td><td>Intuitive (Sunnyvale, CA)</td><td>470093</td><td>Surgical Robot Instrument</td></tr></tbody></table>

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;

In the representative case, the total operative time was 225 min with an estimated blood loss (EBL) of 50 mL (Table 1). The patient was admitted to the surgical ward. Her postoperative course followed the UPMC institutional ERAS pathway. We routinely assess JP amylase at POD#1 and #3 to assess for pancreatic fistula and practice early drain removal on POD 3-5 when possible. The patient&#8217;s JP amylase levels were 403 U/L and 68 U/L, respectively. Therefore, the drain was removed on POD#3. The patient was discharged on POD#6.
Pathologic analysis of the specimen revealed invasive moderately-differentiated adenocarcinoma (0.2 cm) centered in the pancreatic head and arising in a branch-duct IPMN (3.7 cm) with extensive high-grade dysplasia with no positive lymph nodes in any of the 32 resected. There was no evidence of lymphatic, venous, or perineural invasion. Final AJCC 8th edition stage was pT1aN0M0. The patient was recommended to undergo adjuvant chemotherapy with FOLFIRINOX as per the PRODIGE 24 trial17. The patient completed the therapy and remains without any evidence of disease.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/60261/60261fig1.jpg" /> 
Figure 1: Preoperative diagnostic imaging. (A) and (B) IPMN in the head of the pancreas with associated main pancreatic ductal dilatation. (C) EUS demonstrating heterogenous pancreatic head mass with mixed solid and cystic components. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60261/60261fig1large.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/60261/60261fig2.jpg" /> 
Figure 2: Patient positioning and anesthesia setup. Patient is positioned supine in a split leg table with all pressure points padded. Patient table is positioned to accommodate for both the surgical robot and the anesthesia devices. This figure was reproduced with permission from Intuitive Surgical, Inc. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60261/60261fig2large.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/60261/60261fig3.jpg" /> 
Figure 3: Port placement. Purple 8 mm ports (robotic arms [A] 1&#8211;3), green 12 mm umbilical port (camera port), green 12 mm left lower quadrant port (assistant), red 5 mm right lower quadrant port (assistant), left lateral 5 mm port (liver retractor). This figure was adapted with permission from Springer, Journal of Gastrointestinal Surgery, Performing the Difficult Cholecystectomy Using Combined Endoscopic and Robotic Techniques: How I Do It. Magge, D. et al25. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60261/60261fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1">
	<tbody>
		<tr>
			<td colspan="6">Clinicopathologic Treatment and Outcome Data, adopted from Zureikat, AH et al. Ann Surg. 2016.</td>
		</tr>
		<tr>
			<td>Variable</td>
			<td>All Patients</td>
			<td>RPD</td>
			<td>OPD</td>
			<td>P-value</td>
			<td>Represented Case</td>
		</tr>
		<tr>
			<td>Age</td>
			<td>65</td>
			<td>67</td>
			<td>65</td>
			<td>0.07</td>
			<td>44</td>
		</tr>
		<tr>
			<td>Male sex, %</td>
			<td>52.90%</td>
			<td>55.45</td>
			<td>52.26</td>
			<td>0.41</td>
			<td>Female</td>
		</tr>
		<tr>
			<td>BMI, kg/m2</td>
			<td>26.3</td>
			<td>27.5</td>
			<td>26.1</td>
			<td>&#60;0.001</td>
			<td>24.41</td>
		</tr>
		<tr>
			<td>Prior abdominal surgery, %</td>
			<td>43.8</td>
			<td>51.18</td>
			<td>41.86</td>
			<td>&#60;0.001</td>
			<td>None</td>
		</tr>
		<tr>
			<td>Pancreatic cancer, %</td>
			<td>50.8</td>
			<td>33.18</td>
			<td>55.32</td>
			<td>&#60;0.001</td>
			<td>Yes</td>
		</tr>
		<tr>
			<td>Pancreatic duct diameter (&#62;8mm), %</td>
			<td>6.3</td>
			<td>15.74</td>
			<td>3.55</td>
			<td>&#60;0.001</td>
			<td>1 mm</td>
		</tr>
		<tr>
			<td>Pancreatic texture (Soft), %</td>
			<td>49.2</td>
			<td>69.43</td>
			<td>43.35</td>
			<td>&#60;0.001</td>
			<td>Soft</td>
		</tr>
		<tr>
			<td>Operative time, min</td>
			<td>325</td>
			<td>402</td>
			<td>300</td>
			<td>&#60;0.001</td>
			<td>225</td>
		</tr>
		<tr>
			<td>Estimated blood loss</td>
			<td>300</td>
			<td>200</td>
			<td>300</td>
			<td>&#60;0.001</td>
			<td>50</td>
		</tr>
		<tr>
			<td>Transfusion, %</td>
			<td>16.4</td>
			<td>16.11</td>
			<td>16.52</td>
			<td>0.89</td>
			<td>None</td>
		</tr>
		<tr>
			<td>Major complications, %</td>
			<td>23.8</td>
			<td>23.7</td>
			<td>23.87</td>
			<td>0.96</td>
			<td>None</td>
		</tr>
		<tr>
			<td>Severe wound infection, %</td>
			<td>13</td>
			<td>11.37</td>
			<td>13.41</td>
			<td>0.43</td>
			<td>None</td>
		</tr>
		<tr>
			<td>Pancreatic Fistula (Grade B/C), %</td>
			<td>23.8</td>
			<td>13.7</td>
			<td>9.1</td>
			<td>0.04</td>
			<td>None</td>
		</tr>
		<tr>
			<td>Length of stay, days</td>
			<td>8</td>
			<td>8</td>
			<td>8</td>
			<td>0.98</td>
			<td>6</td>
		</tr>
	</tbody>
</table>
Table 1: Comparison of the represented case with national data9.

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Technical Detail for Robot Assisted Pancreaticoduodenectomy

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 ...

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14.3K Views.  University of Pittsburgh Medical Center. The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

Video: Technical Detail for Robot Assisted Pancreaticoduodenectomy

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 ...

Robotic Enucleation of an Intra-Pancreatic Insulinoma in the Pancreatic Head

Pancreatic parenchyma sparing surgery for insulinomas avoids the risk of endocrine and exocrine insufficiency, and potential high-risk anastomoses associated with pancreatic resection. Robotic surgery may be used as an alternative for open pancreatic enucleation without compromising dexterity and 3D-vision.
We present the case of a 42-year old woman who presented with sweating, tremor and episodes of hypoglycemia. A fasting test confirmed endogenic insulin overproduction. After inconclusive CT- and MRI imaging, endoscopic ultrasonography showed a hypoechoic lesion, which was fully within the pancreatic head. Although consent was obtained for pancreatoduodenectomy, robotic enucleation seemed feasible. After mobilization, intraoperative ultrasonography was used to identify the lesion and its relation with the pancreatic duct. Dissection was performed using a traction suture, hot shears and bipolar diathermia. A sealant patch was applied for hemostasis and a drain placed. The patient developed a grade B pancreatic fistula for which endoscopic sphincterotomy was performed; the surgical drain could be removed in the outpatient clinic after 20 days. Prospective studies should confirm the short- and long-term benefits of robotic enucleation of insulinomas.

Here, we present a robotic approach to enucleate an insulinoma in the pancreatic head.

Pancreatic parenchyma sparing surgery for insulinomas avoids the risk of endocrine and exocrine insufficiency, and potential high-risk anastomoses ...

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 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.

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 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 ...