We would like to acknowledge Melissa Hogg, MD who supported and trained us in robotic pancreatic surgery.

The present protocol follows the ethics guidelines of the Amsterdam UMC.
1. Operative setting and trocar placement
<ol>
	<li>Place the patient in French position with a heating device, laying on a short grain mattress with the right arm tucked in and slightly lowered, and the left arm abducted to 90&#176;.</li>
	<li>After all safety procedures (hood, sterile glove and sterile scrub) are ascertained, create a sterile exposition. Have the first surgeon at the robot console and the table-side surgeon between the patient's legs. Perform the procedure using a 7-port technique.</li>
	<li>Create pneumoperitoneum by placing a Veress needle in the left hypochondrium, then place seven trocars as shown in Figure 2 (4 robotic, 2 laparoscopic assistants, and 1 trocar for the liver snake-retractor). 
	NOTE: The sequence of instruments (Table of Materials) during each operative step is seen in Table 1.</li>
	<li>Place the robot on the right side next to the patient and dock the arms to the previously placed trocars.</li>
	<li>Retract the falciform ligament ventrally using a percutaneous suture by using a straight needle.</li>
</ol>
2. Surgical technique
<ol>
	<li>Mobilization of the stomach
	<ol>
		<li>Open the greater omentum 2 cm distal from the gastroepiploic vessels using a sealing device by the table-side surgeon.</li>
		<li>Use the snake-retractor to retract the stomach and the left liver ventrally and cranially. Expose the anterior surface of the pancreas by dissecting the adhesions between the pancreas and the stomach and duodenum.</li>
		<li>Identify the right gastroepiploic vein and artery at the lower border of the pancreas and transect these using either a sealing device, clips or an endo-stapler using a vascular cartridge.</li>
	</ol>
	</li>
	<li>Ultrasound of the pancreas 
	NOTE: Now, the entire pancreas can be exposed.
	<ol>
		<li>Perform an intraoperative ultra-sound to locate the MPD. 
		NOTE: The ultrasound is integrated in the robotic console and controlled trough a grabbing point intended for a fenestrated robotic grasper.</li>
	</ol>
	</li>
	<li>Opening the MPD, ligation of the gastroduodenal artery
	<ol>
		<li>Determine the trajectory of the MPD and open the pancreas with the robotic monopolar diathermia hook. Insert a 5&#8722;7 Fr, 10 cm stent in the duct which prevents cautery damage to the dorsal surface of the MPD during dissection.</li>
		<li>Start the pancreatic duct incision at the pancreatic neck or body; then follow the duct towards the pancreatic tail.</li>
		<li>Finalize by proceeding from the pancreatic body to the pancreatic head which includes crossing the gastroduodenal artery. Expose and ligate the gastroduodenal artery on both sides, just below and above the pancreatic duct with stitches and subsequently transected.</li>
	</ol>
	</li>
	<li>Identification of the Roux limb 
	NOTE: Pulling up the small bowel to identify the Roux limb.
	<ol>
		<li>Reflect the transverse colon cranially to identify the ligament of Treitz and open the mesocolon in the avascular plane to the (patient's) left of the middle mesocolonic vessels.</li>
		<li>Approximately 30 cm from Treitz ligament, divide the jejunum using an endo-stapler. Mark the proximal end using a long suture which is retained. Pass the Roux limb through the defect and placed in close proximity to the MPD. Place the stapled end/stump of the bowel towards the splenic hilum.</li>
		<li>Mark the future lateral jejuno-jejunostomy site by a single suture after measuring a distance of 50 cm between the pancreatic anastomosis and the lateral jejuno-jejunostomy site.</li>
	</ol>
	</li>
	<li>Pancreaticojejunostomy anastomosis 
	NOTE: The Roux limb is opened with monopolar electrocautery.
	<ol>
		<li>First, complete the caudal part of the anastomosis ('inferior border') with a single row running suture until the medial end is reached, then complete the anterior or cranial wall in the same fashion with a new running suture. 
		NOTE: Both the layers are made using a 3-0 barbed suture (9'' 23 cm, V-20, &#189; circle 26 mm needle).</li>
		<li>Examine the lateral pancreatojejunostomy for leaks. 
		NOTE: A single stitch with a monofilament 5-0 suture (5'' 13 cm, RB, &#189; circle 17-26 mm needle), can be placed over any suspected wall defects. If one single barbed suture is not enough, use a second which can be tied to the first suture.</li>
	</ol>
	</li>
	<li>Jejunojejunostomy anastomosis
	<ol>
		<li>Aid the side-to-side lateral, isoperistaltic jejuno-jejunostomy anastomosis by measuring 60 cm between the pancreatic anastomosis and the site of this anastomosis.</li>
		<li>Align both small bowel loops and perform the enterotomies with monopolar electrocautery in each loop.</li>
		<li>Then, create an anastomosis using an endo-stapler. Close the remaining opening using a 3-0 barbed suture (9'' 23 cm, V-20, &#189; 22-26 mm needle) single layer.</li>
	</ol>
	</li>
	<li>Drain placement
	<ol>
		<li>Place a single tubular drain next to the LPJ site through the right trocar opening at the anterior axillary line and fix it with a single stitch to the external abdominal wall.</li>
	</ol>
	</li>
</ol>

<ol>
	<li>Van Der Gaag, N. 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=Functional+and+medical+outcomes+after+tailored+surgery+for+pain+due+to+chronic+pancreatitis.">Functional and medical outcomes after tailored surgery for pain due to chronic pancreatitis.</a> Annals of Surgery. 255 (4), 763-770 (2012).</li><li>Cahen, D. 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=Long-term+outcomes+of+endoscopic+vs+surgical+drainage+of+the+pancreatic+duct+in+patients+with+chronic+pancreatitis.">Long-term outcomes of endoscopic vs surgical drainage of the pancreatic duct in patients with chronic pancreatitis.</a> Gastroenterology. 141 (5), 1690-1695 (2011).</li><li>Cahen, D. 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=Endoscopic+versus+surgical+drainage+of+the+pancreatic+duct+in+chronic+pancreatitis.">Endoscopic versus surgical drainage of the pancreatic duct in chronic pancreatitis.</a> New England Journal of Medicine. 356, 676-684 (2007).</li><li>Zhao, X., Cui, N., Wang, X., Cui, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+strategies+in+the+treatment+of+chronic+pancreatitis:+An+updated+systematic+review+and+meta-analysis+of+randomized+controlled+trials.">Surgical strategies in the treatment of chronic pancreatitis: An updated systematic review and meta-analysis of randomized controlled trials.</a> Medicine (United States). 96 (9), 6220 (2017).</li><li>Meehan, J. 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J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Retrograde+Surgical+Drainage+of+Pancreas+for+Chronic+Relapsing+Pancreatitis.">Retrograde Surgical Drainage of Pancreas for Chronic Relapsing Pancreatitis.</a> A.M.A Archives of Surgery. 76 (6), 898-907 (1958).</li><li>Adams, D. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Puestow+Procedure:+How+I+Do+It.">The Puestow Procedure: How I Do It.</a> Journal of Gastrointestinal Surgery. 17 (6), 1138-1142 (2013).</li><li>Eid, G. M., Entabi, F., Watson, A. R., Zuckerbraun, B. S., Wilson, M. 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+Laparoscopic+Side-to-Side+Lateral+Pancreaticojejunostomy.">Robotic-Assisted Laparoscopic Side-to-Side Lateral Pancreaticojejunostomy.</a> Journal of Gastrointestinal Surgery. 15, 1243 (2011).</li><li>Wright, G. P., Zureikat, A. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+of+Minimally+Invasive+Pancreatic+Surgery:+an+Evidence-Based+Systematic+Review+of+Laparoscopic+Versus+Robotic+Approaches.">Development of Minimally Invasive Pancreatic Surgery: an Evidence-Based Systematic Review of Laparoscopic Versus Robotic Approaches.</a> Journal of Gastrointestinal Surgery. 20 (9), 1658-1665 (2016).</li><li>D'Haese, J. G., Ceyhan, G. O., Demir, I. E., Tieftrunk, E., Friess, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+options+in+painful+chronic+pancreatitis:+A+systematic+review.">Treatment options in painful chronic pancreatitis: A systematic review.</a> HPB. 16 (6), 512-521 (2014).</li><li>Bachmann, K., Izbicki, J. R., Yekebas, E. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Chronic+pancreatitis:+Modern+surgical+management.">Chronic pancreatitis: Modern surgical management.</a> Langenbeck's Archives of Surgery. 396, 139-149 (2011).</li><li>Khaled, Y., Ammori, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+lateral+pancreaticojejunostomy+and+laparoscopic+berne+modification+of+beger+procedure+for+the+treatment+of+chronic+pancreatitis:+The+first+UK+experience.">Laparoscopic lateral pancreaticojejunostomy and laparoscopic berne modification of beger procedure for the treatment of chronic pancreatitis: The first UK experience.</a> Surgical Laparoscopy Endoscopy &amp; Percutaneous Techniques. 24 (5), 178-182 (2014).</li><li>Palanivelu, 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=Laparoscopic+lateral+pancreaticojejunostomy:+A+new+remedy+for+an+old+ailment.">Laparoscopic lateral pancreaticojejunostomy: A new remedy for an old ailment.</a> Surgical Endoscopy and other Interventional Techniques. 20 (3), 458-461 (2006).</li><li>Tantia, O., Jindal, M. K., Khanna, S., Sen, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+lateral+pancreaticojejunostomy:+Our+experience+of+17+cases.">Laparoscopic lateral pancreaticojejunostomy: Our experience of 17 cases.</a> Surgical Endoscopy and Other Interventional Techiques. 18 (7), 1054-1057 (2004).</li><li>Eid, G. M., Entabi, F., Watson, A. R., Zuckerbraun, B. S., Wilson, M. 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+Laparoscopic+Side-to-Side+Lateral+Pancreaticojejunostomy.">Robotic-Assisted Laparoscopic Side-to-Side Lateral Pancreaticojejunostomy.</a> Journal of Gastrointestinal Surgery. 15 (7), 1243-1243 (2011).</li><li>Hamad, A., Zureikat, A. H., Zeh, H. J., Boggi, U. <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+Drainage+Procedures+for+Chronic+Pancreatitis.">Minimally Invasive Drainage Procedures for Chronic Pancreatitis.</a> Minimally Invasive Surgery of the Pancreas. , 115-121 (2018).</li><li>Wright, G. P., Zureikat, A. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+of+Minimally+Invasive+Pancreatic+Surgery:+an+Evidence-Based+Systematic+Review+of+Laparoscopic+Versus+Robotic+Approaches.">Development of Minimally Invasive Pancreatic Surgery: an Evidence-Based Systematic Review of Laparoscopic Versus Robotic Approaches.</a> Journal of Gastrointestinal Surgery. 20, 1658-1665 (2016).</li></ol>

The authors have nothing to disclose.

Robotic LPJ can be used in selected patients with painful chronic pancreatitis and a dilated MPD. Robotic LPJ combines the advantages of the minimally invasive approach and the freedom of articulating wrists as known from open surgery. Generally, a minimally invasive approach offers enhanced postoperative recovery, a lower postoperative pain, and a shorter length of hospital stay9,16,17,18. The robotic approach has benefits over the standard laparoscopic approach. First, enhanced vision owing to the three-dimensional, high definition imaging allows for better visualization of anatomical structures for the surgeon during both the dissection and the reconstruction phase5,13,19. Secondly, the needle drivers augmented with wristed articulation allow for easy suturing to control bleeding while opening of the MPD. Thirdly, opening of the MPD is not limited by the direction of the laparoscopic instruments, since the monopolar diathermia has wristed articulation.
As observed by Khan et al.8, the intraoperative ultrasound is a useful tool to identify the MPD. Adding the color Doppler, ultrasound may also be very useful in identifying the trajectory of the gastroduodenal artery. Measuring the length of the Roux-loop using a long suture is important. Determining the length of a bowel loop using the robotic view can be particularly challenging. This may be relevant in case of a pancreatic fistula with risk of reflux of bowel content in case of a short Roux loop.
The robotic procedure is a lengthier, more costly, and more challenging procedure than the open approach13. Moreover, the use of this technology requires high experienced surgeons both in open and laparoscopic surgery, especially because tactile feedback is lacking20. The RLPJ is challenging and encompasses many critical steps during the dissection and the reconstruction phases.
The robotic LPJ with double transection of gastroduodenal artery is a complex but feasible operation for patients with painful CP and a dilated MPD unresponsive to conservative treatments. Due to the possible complication of this procedure and concerns on the threshold for annual case volume for minimally invasive pancreatic surgery, we believe it should be performed only in high-volume centers by surgeons with extensive experience in both open and minimally invasive pancreatic surgery21.
Due to the limited indications for surgery, currently, all published series are based on a low number of patients, varying from 6 to 17 inclusions7,16,17,18. Further studies should investigate the long-term outcomes for patients undergoing robotic LPJ to affirm the robotic approach as beneficial and safe.

Surgery is highly effective in selected patients with painful chronic pancreatitis1,2,3. Surgical intervention for chronic pancreatitis (CP) carries high postoperative risks4. Yet, in selected patients it might be the only available treatment, especially for painful CP that is non-responsive to medical therapy5,6. Pain and impaired quality of life are the most common indications for surgery in patients affected by CP3,7. The extension of pancreatic gland involvement and the location of the disease are the main preoperative parameters necessary to assess the best surgical strategy. Both resectional and decompressive techniques have proven to be successful for the treatment of this condition8. Decompressive techniques are preferred since they allow to preserve the pancreatic parenchyma, hence they lower the risk of postoperative endocrine and exocrine insufficiency9. Longitudinal pancreatojejunostomy was fist described in 1958 by Puestow and Gilesby10 and is nowadays one of the most common surgical techniques to treat CP11.
The debate of the best surgical technique and surgical approach, i.e., open or minimally invasive, is unresolved. In the few reported series in literature, laparoscopic LPJ shows advantages regarding postoperative pain and length of hospital stay9. Additionally, robotic surgery augments the minimally invasive approach with enhanced optics (three-dimensional vision) and extended degrees of freedom in the articulated instruments. This allows for very precise movements during suturing for pancreatic bleeding and the reconstruction phase of the operation5,7,9,12,13.
Here, we describe our robotic technique of LPJ which involves transection of the gastroduodenal artery. Patients are selected on the basis of symptoms related to CP (mostly continuous pain), and dilatation of main pancreatic duct (MPD) on preoperative imaging of at least 5 mm. A contrast-enhanced computed tomography (CT) scan is obtained to confirm the diagnosis and to exclude any neoplastic disease, distal biliary duct strictures, the presence of active acute pancreatitis (peripancreatic fluid and alteration in pancreatic parenchyma texture), and to measure the dilatation and the extension of the MPD dilatation. After these considerations, if the patient is deemed suitable for robotic LPJ, schedule a preoperative anesthesiology evaluation14,15.
A 45-year-old male presented with refractory CP non-responsive to conservative (pain) management for three years on the basis of episodes of heavy alcohol consumption. The patient ceased smoking (60-pack year) and drinking prior to surgery, and underwent endoscopic treatment (a 10 Fr, 7 cm stent was positioned in the MPD). Preoperative bilirubin- and lipase level were in the normal range. There was no pancreatic endocrine and exocrine insufficiency. The preoperative CT scan showed a dilated MPD in the body and tail of the pancreas (Figure 1).

<table><tbody><tr><td>&lt;strong&gt;Systems&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Arietta Ultrasound</td><td>Hitachi</td><td>L43K / arietta v70</td><td>Used for intraoperative laparoscopic ultrasonography.</td></tr><tr><td>da Vinci Surgeon Console</td><td>IS</td><td>SS999</td><td>Used to control the surgical robot.</td></tr><tr><td>da Vinci Vision Cart</td><td>IS</td><td>VS999</td><td>The vision cart houses advanced vision and energy technologies and provides communications across da Vinci system components.</td></tr><tr><td>da Vinci Xi</td><td>IS</td><td>K131861</td><td>The surgical robot: &amp;rsquo;patient side-cart&amp;rsquo;</td></tr><tr><td>&lt;strong&gt;Instruments&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Cobra Liver Retractor Diamond-Flex</td><td>CareFusion</td><td>89-6216</td><td>Retracting the liver for optimal exposure of the surgical site.</td></tr><tr><td>da Vinci Xi Endoscope with Camera, 8 mm, 30&amp;deg;</td><td>IS</td><td>470027</td><td>The camera of the da Vinci robot.</td></tr><tr><td>ENDOEYE Rigid Video Laparoscope, 10 mm, 30&amp;deg;</td><td>Olympus</td><td>WA50042A</td><td>To see within the intra-abdominal cavity.</td></tr><tr><td>ENDOWRIST Fenestrated Bipolar Forceps</td><td>IS</td><td>470205</td><td>Used for dissection and coagulation.</td></tr><tr><td>ENDOWRIST HOT SHEARS</td><td>IS</td><td>470179</td><td>Used for cutting and coagulation.</td></tr><tr><td>ENDOWRIST Mega SutureCut Needle Driver</td><td>IS</td><td>470309</td><td>Used as a needle driver.</td></tr><tr><td>ENDOWRIST Permanent Cautery Hook</td><td>IS</td><td>470183</td><td>Used for coagulation.</td></tr><tr><td>ENDOWRIST PROGrasp Forceps</td><td>IS</td><td>470093</td><td>Used for dissection.</td></tr><tr><td>LigaSure Dolphin Tip 37cm</td><td>Medtronic</td><td>LS1500</td><td>Used for vessel sealing and dividing.</td></tr></tbody></table>

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.

Representative results are shown in Table 2. The operative time was 388 min with 200 mL estimated intraoperative blood loss. The postoperative course was uncomplicated, thus no postoperative pancreatic fistula (POPF) was detected; on postoperative 3, the drain fluid amylase level measured was low and the drain was removed that day. The patient was discharged the next day. Pathology assessment confirmed the preoperative diagnosis of CP without malignancy.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/60301/60301fig1a.jpg" /> 
Figure 1: The appearance of the main pancreatic duct on CT scan. Diameter of the main pancreatic duct: 8.4 mm. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60301/60301fig1large.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/60301/60301fig2a.jpg" /> 
Figure 2: Trocar placement. R1: placed at the right anterior axillary line; R2: placed at the right mid-clavicular line; R3: placed on, or just right of, the midline; R4: placed at the left mid-clavicular line. L1: placed at a distance of 8 cm caudally from R2 and R3; L2: placed at a distance of 8 cm caudally from R3 and R4; Arrow: Stomach retractor, placed at the left anterior axillary line. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60301/60301fig2large.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="2"></td>
			<td colspan="5">Instruments Used</td>
		</tr>
		<tr>
			<td colspan="2" rowspan="2"></td>
			<td colspan="3">Robotic</td>
			<td colspan="2">Laparoscopic</td>
		</tr>
		<tr>
			<td colspan="3">(Console surgeon)</td>
			<td colspan="2">(Table-side surgeon)</td>
		</tr>
		<tr>
			<td colspan="2">Operative steps</td>
			<td>Dominant</td>
			<td>Non-dominant</td>
			<td>3rd arm</td>
			<td>L</td>
			<td>R</td>
		</tr>
		<tr>
			<td colspan="2">2.1. Mobilize stomach</td>
			<td>Permanent cautery hook</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Prograsp forceps or cadiere forceps</td>
			<td colspan="2">Sealing device, suction, curved scissors, clip-applier</td>
		</tr>
		<tr>
			<td colspan="2">2.2. US pancreas</td>
			<td>Permanent cautery hook</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Prograsp forceps or cadiere forceps</td>
			<td colspan="2">Suction, endo-echo device</td>
		</tr>
		<tr>
			<td colspan="2">2.3. Open pancreas</td>
			<td>Permanent cautery hook</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Prograsp forceps or cadiere forceps</td>
			<td colspan="2">Sealing device, suction, curved scissors, clip-applier</td>
		</tr>
		<tr>
			<td colspan="2">2.4. Roux limb</td>
			<td>Prograsp forceps or cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td>-</td>
			<td>Sealing device, stapler</td>
			<td>Suction</td>
		</tr>
		<tr>
			<td colspan="2">2.5. LPJ</td>
			<td>Large needle driver</td>
			<td>Cadiere forceps</td>
			<td>Prograsp forceps</td>
			<td colspan="2">Fenestrated grasper, suction, clip-applier, curved scissors</td>
		</tr>
		<tr>
			<td>2.6. JJ</td>
			<td>Positioning anastomosis site</td>
			<td>Prograsp forceps</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td colspan="2">Fenestrated graspers</td>
		</tr>
		<tr>
			<td></td>
			<td>Enterotomies for stapler</td>
			<td>Permanent cautery hook</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td colspan="2">Fenestrated grasper</td>
		</tr>
		<tr>
			<td></td>
			<td>Stapling</td>
			<td>Prograsp forceps</td>
			<td>Cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Stapler</td>
			<td>Fenestrated grasper</td>
		</tr>
		<tr>
			<td></td>
			<td>Closing enterotomies</td>
			<td>Large needle driver</td>
			<td>Cadiere forceps</td>
			<td>Prograsp forceps</td>
			<td colspan="2">Fenestrated grasper, suction, clip-applier, curved scissors</td>
		</tr>
		<tr>
			<td></td>
			<td>Positioning anastomosis site</td>
			<td>Prograsp forceps</td>
			<td>cadiere forceps</td>
			<td>Fenestrated bipolar forceps</td>
			<td>Fenestrated grasper</td>
			<td>Prograsp forceps</td>
		</tr>
		<tr>
			<td rowspan="2"></td>
			<td rowspan="2">Fixating roux-loop to the mesentery</td>
			<td rowspan="2">Large needle driver</td>
			<td rowspan="2">Cadiere forceps</td>
			<td rowspan="2">Prograsp forceps</td>
			<td>Fenestrated, grasper, Suction</td>
			<td rowspan="2">Large needle driver</td>
		</tr>
		<tr>
			<td>clip-applier, curved scissors</td>
		</tr>
		<tr>
			<td colspan="8">The configuration for instrument arms is so that the 3rd arm is on the most lateral port controlled by the robotic (console) surgeon.</td>
		</tr>
	</tbody>
</table>
Table 1: Sequence of instruments during each operative step.
<table border="1" fo:keep-together.within-page="1">
	<tbody>
		<tr>
			<td>Variable</td>
			<td>Outcome</td>
		</tr>
		<tr>
			<td colspan="2">Intraoperative</td>
		</tr>
		<tr>
			<td>Operative time (min)</td>
			<td>388</td>
		</tr>
		<tr>
			<td>Dissection (min)</td>
			<td>161</td>
		</tr>
		<tr>
			<td>Reconstruction (min)</td>
			<td>113</td>
		</tr>
		<tr>
			<td>Estimated intraoperative blood loss (mL)</td>
			<td>200</td>
		</tr>
		<tr>
			<td colspan="2">Postoperative</td>
		</tr>
		<tr>
			<td>Clavien/Dindo complication grade</td>
			<td>0</td>
		</tr>
		<tr>
			<td>Drain removal, postoperative day</td>
			<td>3</td>
		</tr>
		<tr>
			<td>Postoperative hospital stay, days</td>
			<td>4</td>
		</tr>
		<tr>
			<td>Pathological diagnosis</td>
			<td>Chronic pancreatitis without malignancy</td>
		</tr>
		<tr>
			<td colspan="2">Operative time comprises of steps 1.3&#8722;2.7.1, dissection comprises of steps 2.1&#8722;2.4.2, reconstruction comprises of steps 2.5&#8722;2.6.3.</td>
		</tr>
	</tbody>
</table>
Table 2: Representative results of the surgery.

Watch this Scientific Journal Video about Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis at JoVE.com

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

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 ...

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11.0K Views.  University of Amsterdam. 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.

Video: Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal pancreatectomy, laparoscopic pancreatoduodenectomy (LPD) has not yet obtained wide acceptance, probably due to technical challenges, especially regarding the pancreatic anastomosis.
The study describes and demonstrates all steps of LPD, including the modified Blumgart pancreaticojejunostomy. Indications for LPD are all pancreatic and peri-ampullary tumors without vascular involvement. Relative contra-indications are body mass index &#62;35 kg/m2, chronic pancreatitis, mid-cholangiocarcinomas and large duodenal cancers.
The patient is in French position, 6 trocars are placed, and dissection is performed using an (articulating) sealing device. A modified Blumgart end-to-side pancreaticojejunostomy is performed with 4 large needles (3/0) barbed trans-pancreatic sutures and 4 to 6 duct-to-mucosa sutures using 5/0 absorbable multifilament combined with a 12 cm, 6 or 8 Fr internal stent using 3D laparoscopy. Two surgical drains are placed alongside the pancreaticojejunostomy.
The described technique for LPD including a modified Blumgart pancreatico-jejunostomy is well standardized, and its merits are currently studied in the randomized controlled multicenter trial. This complex operation should be performed at high-volume centers where surgeons have extensive experience in both open pancreatic surgery and advanced laparoscopic gastro-intestinal surgery.

Laparoscopic pancreatoduodenctomy (LPD) may offer advantages over open pancreatoduodenectomy, including early postoperative mobilization, less delayed gastric emptying and a shorter hospital stay. However, LPD is technically challenging and not well-standardized, especially regarding the pancreatic anastomosis. We describe a standardized technique for the pancreatic anastomosis during LPD: modified Blumgart pancreaticojejunostomy.

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal ...

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 ...

Colonial Wig Pancreaticojejunostomy

Postoperative pancreatic fistula (POPF) is one of the most problematic complications after pancreaticoduodenectomy (PD). We describe a series of 48 pancreatic-head resections from our institution, in which we compare a new technique to create the pancreaticojejunostomy (PJ) reconstruction with standard techniques. The goal is to achieve a lower rate of POPF. This new PJ is termed the &#34;Colonial Wig&#34; (CW) PJ due to the novel appearance of the jejunum wrapping around the pancreas, resembling a Colonial wig wrapping around the head of a Colonial Whig (e.g.,&#160;George Washington). In our consecutive series, 22 cases were performed using the new CW technique to perform the PJ and were compared to 26 traditional PDs with traditional reconstruction. There was an incidence of clinically relevant POPF of 0% in the CW group, compared to 15% in 26 conventional PJs. Our proposed CW PJ reconstruction is&#160;associated with a lower the incidence of POPF following PD, and hence may be a way to improve outcomes after PD.

We describe a new technique for pancreaticojejunostomy reconstruction after pancreaticoduodenectomy that is associated with a very low rate of postoperative pancreatic fistula.

Postoperative pancreatic fistula (POPF) is one of the most problematic complications after pancreaticoduodenectomy (PD). We describe a series of 48 ...

Modified Single-Loop Reconstruction for Pancreaticoduodenectomy

Modified single-loop reconstruction in pancreaticoduodenectomy separates pancreatic secretion from bile. It is performed in cases of high-risk pancreatic remnants to reduce the severity of postoperative pancreatic fistulas and moreover the overall postoperative morbidity. This reconstruction technique is characterized by an extra-long jejunal loop for the construction of the pancreaticojejunostomy and hepaticojejunostomy. The longer distance between these anastomoses and an additional jejuno-jejunostomy between the afferent and efferent limb of the hepaticojejunostomy separate the fluids and prevent backflow of bile towards the pancreaticojejunostomy. Thus, the secretions cannot activate each other and aggravate an existing anastomotic leakage. We observed a reduced rate of severe postoperative pancreatic fistulas after modified single-loop reconstruction compared to conventional single loop reconstruction. The technique is easy to perform, safe, and less time-consuming than a traditional double-loop reconstruction.

The technique of modified single-loop reconstruction following pancreaticoduodenectomy separates pancreatic secretion from bile, thus reducing the severity of POPF without prolonging the duration of surgery.

Modified single-loop reconstruction in pancreaticoduodenectomy separates pancreatic secretion from bile. It is performed in cases of high-risk pancreatic ...

Technical Detail for Robot Assisted Pancreaticoduodenectomy

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

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

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

Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological resection of left-sided pancreatic cancer. Several surgical techniques have been described in recent years, but few were specifically designed for minimally invasive approaches. This study describes and demonstrates a standardized and reproducible technique for an adequate oncological resection of pancreatic cancer: laparoscopic radical left pancreatectomy (LRLP).
A 61-year-old woman presented with an incidental finding of a 3 cm mass in the left pancreas suspect for malignancy. Imaging did not reveal distant metastases, central vascular involvement, or morbid obesity, hence the patient was suitable for LRLP. This study describes the main steps of LRLP for pancreatic cancer. First, the lesser sac is opened by transecting the gastrocolic ligament. The splenic flexure of the colon is mobilized and the inferior border of the pancreas including Gerota&#39;s fascia is dissected down to the inferior border of the spleen. The pancreas is tunneled and hung, including Gerota&#8217;s fascia with a vessel loop. At the pancreatic neck, a tunnel is created between the pancreas and the portal vein, likewise a vessel loop is passed. The pancreas is then transected using the graded compression technique with an endostapler. Both the splenic vein and artery are transected before completing the resection. The entire specimen is extracted in a retrieval bag via a small Pfannenstiel incision.
Duration of the surgery was 210 min with 250 mL blood loss. Pathology revealed a R0-resection (&#62;1 mm) of a well-to-moderately differentiated adenocarcinoma originating from an intraductal papillary mucinous neoplasm. A total of 15 tumor-negative lymph nodes were resected. This is a detailed description of LRLP for left-sided pancreatic cancer as is currently being used within the international, multicenter randomized DIPLOMA (Distal Pancreatectomy Minimally Invasive or Open for PDAC) trial.

Oncologically safe left pancreatectomy requires radical resection (R0), Gerota&#8217;s (perirenal) fascia resection, and adequate lymph node dissection. This study describes the technical details of laparoscopic radical left pancreatectomy (LRLP), used in the first international multicenter randomized trial comparing minimally invasive with open left pancreatectomy for pancreatic cancer, the DIPLOMA trial.

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological ...

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.