The authors have no acknowledgments.

NOTE: Both patients provided written and oral informed consent for the use of medical data and operative videos for educational and scientific purposes. The protocol was approved by our institution (Amsterdam University Medical Centers).
1. Case 1 (Warshaw technique)
<ol>
	<li>Positioning
	<ol>
		<li>Place the patient in a supine position with legs split in a French position.</li>
		<li>Abduct the left arm to 90&#176; and lower the right arm alongside the body.</li>
		<li>Tilt the operating table 10&#176; in reverse Trendelenburg position and 10&#176; to the right.</li>
	</ol>
	</li>
	<li>Trocars position and robot docking
	<ol>
		<li>Introduce a Veress needle on Palmers&#39; point to insufflate the abdomen.</li>
		<li>Introduce four 8 mm robot trocars (R1-4). Start with the introduction of the camera port (R3) in a line from the crossing of the left midclavicular line and the inferior costal cartilage to the umbilicus, approximately 11 cm from the costal margin at the expected level of the pancreatic tail. 
		NOTE: The trocars are placed in a semi-curved line above the umbilicus with a distance of 7 cm between them. R1 is placed in the right anterior axillary line, trocar R2 in the right midclavicular line and trocar R4 in the left midclavicular line (Figure 4).</li>
		<li>Introduce one assistant 12 mm trocar, 3 cm below the middle of R3 and R4.</li>
		<li>Place one 5 mm trocar in the right subcostal area for stomach and liver retraction.</li>
		<li>Dock the robot from the right shoulder of the patient.</li>
	</ol>
	</li>
	<li>Mobilization
	<ol>
		<li>Identify the gastrocolic ligament and divide it with the vessel sealing device, so that the lesser sac is opened.</li>
		<li>Introduce the liver retractor from the patient&#39;s right side and retract both the liver and the stomach. 
		NOTE: This enables optimal exposure of the surgical site. Alternatively, use a transabdominal stay suture through the posterior corpus of the stomach to retract it.</li>
	</ol>
	</li>
	<li>Resection
	<ol>
		<li>Create a retropancreatic tunnel by mobilizing the pancreas. Start the mobilization cranially using robotic forceps and cautery hook and dissect all tissue around the pancreas. Then mobilize caudally. Ensure that the tunnel is complete by placing the forceps caudally and advancing it until it is visible cranially.</li>
		<li>Identify the splenic vein and the splenic artery.</li>
		<li>Place a vessel-loop around the pancreas using robotic forceps as a means of retraction. Pass the loop to surround the pancreas around the transection line through the tunnel and hold the ends of the loop together using metallic or Hem-o-lock clips.</li>
		<li>Dissect the pancreas using a linear stapler, performing gradual compression for 4 min. If the transection is not complete after that step, detach the specimen using a vessel sealing device, scissors, or the cautery hook.</li>
		<li>Place a vessel loop around the vessels to facilitate retraction prior to the stapler&#39;s entering. Transect first the splenic artery and next the splenic vein.</li>
		<li>Mobilize the pancreas until the splenic hilum. In the Warshaw procedure, the splenic vessels are transected again using a stapler or hem-o-lock clips as close as possible behind the pancreatic tail to preserve all collateral vessels between the gastroepiploic vessels and the spleen.</li>
		<li>Detach the pancreatic tail from the splenic hilum using the vessel sealing device or a stapler.</li>
		<li>Place the specimen in an Endobag and remove it through a Pfannenstiel incision.</li>
	</ol>
	</li>
	<li>Spleen assessment
	<ol>
		<li>Assess the spleen&#39;s condition prior to pneumoperitoneum exsufflation. Assess the color of the spleen and look for areas of demarcation suggesting splenic infarcts.</li>
	</ol>
	</li>
</ol>
2. Case 2 (Kimura technique)
<ol>
	<li>Positioning
	<ol>
		<li>Place the patient in a supine position with legs split in a French position.</li>
		<li>Abduct the left arm to 90&#176; and lower the right arm alongside the body.</li>
		<li>Tilt the operating table 10&#176; in reverse Trendelenburg position and 10&#176; to the right.</li>
	</ol>
	</li>
	<li>Trocars position and robot docking
	<ol>
		<li>Introduce a Veress needle on Palmers&#39; point to insufflate the abdomen.</li>
		<li>Introduce four 8 mm robot trocars (R1-4). Start with the introduction of the camera port (R3) in a line from the crossing of the left midclavicular line and the inferior costal cartilage to the umbilicus, approximately 11 cm from the costal margin at the expected level of the pancreatic tail. 
		NOTE: The trocars are placed in a semi-curved line above the umbilicus with a distance of 7 cm between them. R1 is placed in the right anterior axillary line, trocar R2 in the right midclavicular line and trocar R4 in the left midclavicular line (Figure 4).</li>
		<li>Introduce one assistant 12 mm trocar 3 cm below the middle of R3 and R4.</li>
		<li>Place one 5mm trocar in the right subcostal area for stomach and liver retraction.</li>
		<li>Dock the robot from the right shoulder of the patient.</li>
	</ol>
	</li>
	<li>Mobilization
	<ol>
		<li>Identify the gastrocolic ligament and divide it with the vessel sealing device, so that the lesser sac is opened.</li>
		<li>Introduce the liver retractor from the patient&#39;s right side and retract both the liver and the stomach. This enables optimal exposure of the surgical site. Alternatively, use a transabdominal stay suture through the posterior corpus of the stomach to retract it.</li>
	</ol>
	</li>
	<li>Intraoperative ultrasonography
	<ol>
		<li>Optionally, before the pancreas transection, introduce an ultrasonography probe to identify the dilated pancreatic duct and assess the parenchymal transection.</li>
		<li>Use the cautery hook to demarcate the transection line.</li>
	</ol>
	</li>
	<li>Resection
	<ol>
		<li>Create a retropancreatic tunnel by mobilizing the pancreas. Start the mobilization cranially using robotic forceps and cautery hook and dissect all tissue around the pancreas. Then mobilize caudally.</li>
		<li>Identify the splenic vessels. Mobilize the splenic vein and the splenic artery and preserve them.</li>
		<li>Ensure that the tunnel is complete by placing the forceps caudally and advancing it until it is visible cranially.</li>
		<li>Place a vessel-loop around the pancreas using robotic forceps as a means of retraction. Pass the loop to surround the pancreas around the transection line through the tunnel and hold the ends of the loop together using metallic or Hem-o-lock clips.</li>
		<li>Dissect the pancreas using a linear stapler, performing gradual compression for 4 min. If the transection is not complete after that step, detach the specimen using a vessel sealing device, scissors, or the cautery hook.</li>
		<li>After the transection of the pancreas, the small splenic branches posterior to the pancreas are carefully ligated using metallic or Hem-o-lock clips.</li>
		<li>Mobilize the pancreas until the splenic hilum. Carefully dissect all tissue around the pancreas using the vessel sealing device until you reach the hilum of the spleen.</li>
		<li>Detach the pancreatic tail from the splenic hilum using the vessel sealing device or a stapler.</li>
		<li>Place the specimen in an Endobag and remove it through a Pfannenstiel incision.</li>
	</ol>
	</li>
	<li>Drain placement
	<ol>
		<li>Introduce an 18-20 French drain from the left side of the patient and advance it next to the pancreatic stump. Ensure the drain makes no direct contact with either the pancreas or vessels (stumps).</li>
	</ol>
	</li>
</ol>
3. Post-operative care:
<ol>
	<li>Day 0
	<ol>
		<li>Ensure the patient returns to the department after spending 6 h in the recovery room.</li>
		<li>Measure glucose levels four times daily12.</li>
	</ol>
	</li>
	<li>Day 1
	<ol>
		<li>Measure gastric retention via the nasogastric tube. Remove the nasogastric tube if the retention is below 300 mL.</li>
		<li>Start feeding after the removal of the nasogastric tube.</li>
		<li>Measure glucose levels four times daily12.</li>
	</ol>
	</li>
	<li>Day 3
	<ol>
		<li>Measure amylase levels to test for post-operative pancreatic fistula if a drain is present. If drain amylase is &#60;400 U/L and production is &#60; 300ml/24hr, remove the drain.</li>
		<li>Measure C-reactive protein (CRP) levels13.</li>
	</ol>
	</li>
	<li>Day 4
	<ol>
		<li>Repeat CRP levels if CRP&#62; 150 on day 3. CRP levels must be &#62;10% lower than on day 3. If not, perform a CT scan.</li>
	</ol>
	</li>
</ol>

<ol>
	<li>Navez, 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=Distal+pancreatectomy+for+pancreatic+neoplasia:+is+splenectomy+really+necessary?+A+bicentric+retrospective+analysis+of+surgical+specimens.">Distal pancreatectomy for pancreatic neoplasia: is splenectomy really necessary? A bicentric retrospective analysis of surgical specimens.</a> HPB (Oxford). 22 (11), 1583-1589 (2020).</li><li>Lee, S. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Spleen-preserving+distal+pancreatectomy.">Spleen-preserving distal pancreatectomy.</a> Singapore Med J. 49 (11), 883-885 (2008).</li><li>Weledji, E. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Benefits+and+risks+of+splenectomy.">Benefits and risks of splenectomy.</a> Int J Surg. 12 (2), 113-119 (2014).</li><li>Jain, G., Chakravartty, S., Patel, A. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Spleen-preserving+distal+pancreatectomy+with+and+without+splenic+vessel+ligation:+a+systematic+review.">Spleen-preserving distal pancreatectomy with and without splenic vessel ligation: a systematic review.</a> HPB (Oxford). 15 (6), 403-410 (2013).</li><li>Moekotte, A. 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=Splenic+preservation+versus+splenectomy+in+laparoscopic+distal+pancreatectomy:+a+propensity+score-matched+study.">Splenic preservation versus splenectomy in laparoscopic distal pancreatectomy: a propensity score-matched study.</a> Surg Endosc. 34 (3), 1301-1309 (2020).</li><li>Nakata, 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=Minimally+invasive+preservation+versus+splenectomy+during+distal+pancreatectomy:+a+systematic+review+and+meta-analysis.">Minimally invasive preservation versus splenectomy during distal pancreatectomy: a systematic review and meta-analysis.</a> J Hepatobiliary Pancreat Sci. 25 (11), 476-488 (2018).</li><li>Shi, N., 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=Splenic+preservation+versus+splenectomy+during+distal+pancreatectomy:+A+systematic+review+and+meta-analysis.">Splenic preservation versus splenectomy during distal pancreatectomy: A systematic review and meta-analysis.</a> Ann Surg Oncol. 23 (2), 365-374 (2016).</li><li>Juo, Y. Y., King, J. C. <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+spleen+preserving+distal+pancreatectomy:+A+technical+review.">Robotic-assisted spleen preserving distal pancreatectomy: A technical review.</a> J Vis Surg. 3, 139 (2017).</li><li>Warshaw, A. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Conservation+of+the+spleen+with+distal+pancreatectomy.">Conservation of the spleen with distal pancreatectomy.</a> Arch Surg. 123 (5), 550-553 (1988).</li><li>Kimura, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Spleen-preserving+distal+pancreatectomy+with+conservation+of+the+splenic+artery+and+vein.">Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein.</a> Surgery. 120 (5), 885-890 (1996).</li><li>Kim, E. Y., Choi, H. J., You, Y. K., Kim, D. G., Hong, T. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Spleen-preserving+distal+pancreatectomy+with+vein+scarifying+and+artery+saving+as+an+alternative+for+Warshaw+Method.">Spleen-preserving distal pancreatectomy with vein scarifying and artery saving as an alternative for Warshaw Method.</a> J Gastrointest Surg. 25 (6), 1556-1558 (2021).</li><li>Eshuis, W. 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=Early+postoperative+hyperglycemia+is+associated+with+postoperative+complications+after+pancreatoduodenectomy.">Early postoperative hyperglycemia is associated with postoperative complications after pancreatoduodenectomy.</a> Ann Surg. 253 (4), 739-744 (2011).</li><li>Giardino, 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=C-reactive+protein+and+procalcitonin+as+predictors+of+postoperative+inflammatory+complications+after+pancreatic+surgery.">C-reactive protein and procalcitonin as predictors of postoperative inflammatory complications after pancreatic surgery.</a> J Gastrointest Surg. 20 (8), 1482-1492 (2016).</li><li>Kacmaz, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+enucleation+of+an+intra-pancreatic+insulinoma+in+the+pancreatic+head.">Robotic enucleation of an intra-pancreatic insulinoma in the pancreatic head.</a> J Vis Exp. (155), e60290 (2020).</li><li>de Rooij, 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=Minimally+invasive+versus+open+distal+pancreatectomy+(LEOPARD):+A+multicenter+patient-blinded+randomized+controlled+trial.">Minimally invasive versus open distal pancreatectomy (LEOPARD): A multicenter patient-blinded randomized controlled trial.</a> Ann Surg. 269 (1), 2-9 (2019).</li><li>Bjornsson, B., Larsson, A. L., Hjalmarsson, C., Gasslander, T., Sandstrom, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+the+duration+of+hospital+stay+after+laparoscopic+or+open+distal+pancreatectomy:+randomized+controlled+trial.">Comparison of the duration of hospital stay after laparoscopic or open distal pancreatectomy: randomized controlled trial.</a> Br J Surg. 107 (10), 1281-1288 (2020).</li><li>Korrel, 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=Minimally+invasive+versus+open+distal+pancreatectomy:+an+individual+patient+data+meta-analysis+of+two+randomized+controlled+trials.">Minimally invasive versus open distal pancreatectomy: an individual patient data meta-analysis of two randomized controlled trials.</a> HPB (Oxford). 23 (3), 323-330 (2021).</li><li>Vining, C. C., Skowron, K. B., Hogg, M. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+gastrointestinal+surgery:+learning+curve,+educational+programs+and+outcomes.">Robotic gastrointestinal surgery: learning curve, educational programs and outcomes.</a> Updates Surg. 73 (3), 799-814 (2021).</li><li>Korrel, 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=Short-term+outcomes+after+spleen-preserving+minimally+invasive+distal+pancreatectomy+with+or+without+preservation+of+splenic+vessels:+A+pan-european+retrospective+study+in+high-volume+centers.">Short-term outcomes after spleen-preserving minimally invasive distal pancreatectomy with or without preservation of splenic vessels: A pan-european retrospective study in high-volume centers.</a> Ann Surg. 277 (1), 119-125 (2021).</li><li>Paiella, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long+term+outcome+after+minimally+invasive+and+open+Warshaw+and+Kimura+techniques+for+spleen-preserving+distal+pancreatectomy:+International+multicenter+retrospective+study.">Long term outcome after minimally invasive and open Warshaw and Kimura techniques for spleen-preserving distal pancreatectomy: International multicenter retrospective study.</a> Eur J Surg Oncol. 45 (9), 1668-1673 (2019).</li><li>Zhu, A., Greene, B., Tsang, M., Jayaraman, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparing+the+Warshaw+technique+with+vessel-preservation+in+laparoscopic+spleen+preserving+distal+pancreatectomy:+is+there+a+better+approach.">Comparing the Warshaw technique with vessel-preservation in laparoscopic spleen preserving distal pancreatectomy: is there a better approach.</a> HPB. 25 (1), 109-115 (2022).</li><li>Hang, 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=Splenic+vessels+preserving+versus+Warshaw+technique+in+spleen+preserving+distal+pancreatectomy:+A+systematic+review+and+meta-analysis.">Splenic vessels preserving versus Warshaw technique in spleen preserving distal pancreatectomy: A systematic review and meta-analysis.</a> Int J Surg. 103, 106686 (2022).</li><li>Granieri, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Kimura's+vs+Warshaw's+technique+for+spleen+preserving+distal+pancreatectomy:+a+systematic+review+and+meta-analysis+of+high-quality+studies.">Kimura's vs Warshaw's technique for spleen preserving distal pancreatectomy: a systematic review and meta-analysis of high-quality studies.</a> HPB (Oxford). 25 (6), 614-624 (2023).</li></ol>

The authors have no disclosures.

The critical steps concerning spleen-preserving robotic DP include positioning and robot docking, mobilization, intraoperative ultrasonography (if necessary), dissection and management of the splenic vessels, spleen assessment and drain placement. In the case of uncontrollable bleeding, conversion to laparotomy is recommended. The assessment of the spleen&#39;s viability should be performed before exsuflating the abdomen.
Modifications of the technique include the use of a second assistant trocar, the introduction of the liver retractor on either the left or the right side of the patient and the use of the energy device by either the table side surgeon or the robotic console surgeon. During training, some steps of the mobilization can be initially performed laparoscopically until complete familiarization with the robotic console is achieved. If the linear stapler is not available, multiple Hem-o-lock or metallic clips can be used to ligate the vessels.
The introduction of minimally invasive surgery in recent years has established laparoscopic and robotic approaches to spleen preserving DP as safe and feasible surgical options. A recent meta-analysis of two randomized controlled trials15,16 was published, comparing minimally invasive DP to open DP. The meta-analysis revealed no significant differences between the two approaches in major complications, but a significantly reduced the length of hospital stay and delayed gastric emptying favoring the minimally invasive technique17. The rate of spleen preservation in minimal invasive DP ranges between 29% and 86%5. However, limitations of robotic surgery include the loss of haptic feedback, the surgeons&#39; learning curve and the higher cost associated with the robotic platform and consumables18.
Comparative studies between the two techniques have addressed clinical outcomes such as safety, short- and long-term complications, operative time and intraoperative blood loss. The results of these retrospectivity studies are mixed, with some reporting comparable short- and long-term outcomes19,20,21 for the two techniques, while others suggest the KT is superior due to fewer complications associated with the WT (splenic infarction, secondary splenectomy and incidence of gastric varices)4,22. The most recent systematic review and meta-analysis of the existing studies concluded that while the two techniques are generally comparable in most postoperative outcomes, KT is superior to WT, showing significantly lower incidence of splenic infarction (OR= 0.14, p&#60;0.0001) and reduced risk of gastric varices (OR=0.1, p&#60;0.0001).23
In conclusion, robotic spleen-preserving distal pancreatectomy is a feasible and safe procedure in experienced hands. Patient&#39;s anatomy may play a crucial role in deciding the optimal surgical technique. Further research is necessary to comprehensively understand the comparative clinical outcomes of the two techniques.

Distal pancreatectomy (DP) is performed to remove benign and malignant lesions located in the pancreatic body and tail. Traditionally, DP is combined with splenectomy1. However, a spleen-preserving approach is recommended when resecting benign and low-grade/pre-malignant lesions of the distal pancreas to avoid short and long-term complications associated with splenectomy2. Such complications include hemorrhage, thrombocytosis, thromboembolic incidents, pulmonary hypertension, and overwhelming post-splenectomy infection (OPSI)3. Nevertheless, spleen preservation can lead to complications such as splenic infarction, splenic vein thrombosis, and abscess formation. Secondary splenectomy, described in 0-2% of the cases of initially intended spleen preservation, is a potential complication4,5,6,7.
Spleen-preserving distal pancreatectomy can be achieved using two different approaches8. The first approach, the Warshaw technique (WT), initially described by Warshaw in 1988, is a vessel-resecting technique9. In WT, the splenic artery and vein are resected and ligated, and perfusion of the spleen is provided by the left gastroepiploic artery and the short gastric vessels.The second technique, a vessel-preserving approach described by Kimura (KT) in 199610, involves ligating the small splenic branches posterior to the pancreas while preserving the splenic artery and vein. Recently, a third alternative that preserves the spleen with splenic vein scarifying and splenic artery preservation has been proposed by Kim et al.11. Patient anatomy plays a crucial role in deciding which approach to follow. The Kimura technique is more feasible when the splenic vessels are found in an extra-pancreatic position. However, if the splenic vessels cannot be separated from the posterior surface of the pancreas, the Warshaw technique is performed. Intraoperative findings and incidents can also alter the initial operative plan.
Here, we present two cases of robotic spleen-preserving distal pancreatectomy. Details about the patients are described below.
The first patient is a 36-year-old female presenting with atypical abdominal symptoms. She underwent a computed tomography (CT) that revealed a 26 mm round lesion in the pancreatic body without pancreatic duct dilation and without vascular involvement (Figure 1). The original differential diagnosis included a neuroendocrine tumor (NET) and an accessory spleen due to the lesion&#39;s enhancement. Consequently, the patient also underwent scintigraphy with Technetium-99m (99mTc) labeled heat-denatured erythrocyte scan, which was negative for splenosis. A positron emission tomography (PET) scan revealed strongly elevated somatostatin receptor expression in the lesion (Figure 2). Based on these results, an indication for a robotic spleen preserving distal pancreatectomy was determined. Due to the patient&#39;s anatomy and proximity of the splenic vessels to the posterior surface of the pancreas, the Warshaw approach was considered more suitable.
The second patient is a 76-year-old male with chronic pancreatitis, complaining of the pain in the lower left abdomen for the past 18 months. No history of acute pancreatitis or excessive alcohol use was reported. Initially, he underwent a CT colonography due to reported lower gastrointestinal symptoms. The scan did not show any pathological findings in the colon but described a suspected obstructive stone in the distal pancreas with a focally dilated main pancreatic duct. Endoscopic ultrasonography (EUS) confirmed the diagnosis of chronic pancreatitis but also found a lesion suspicious for a papillary tumor. Nevertheless, the fine needle aspiration (FNA) pathology revealed a low-grade adenoma. His most recent CT scan revealed an image of chronic pancreatitis with a dilated pancreatic duct in the tail up to 7 mm and an abrupt transition between the tail and the body of the pancreas. Multiple coarse calcifications were also present (Figure 3). The patient was scheduled for a robotic spleen preserving distal pancreatectomy. The patient&#39;s anatomy favored the selection of the Kimura technique, as the splenic vessels were in an extra-pancreatic position.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Arietta V70 Ultrasound</td>
			<td>Hitachi</td>
			<td>-</td>
			<td>The ultrasound system.</td>
		</tr>
		<tr>
			<td>Robotic ultrasonography transducer</td>
			<td>Hitachi</td>
			<td>L43K</td>
			<td>Used for intraoperative laparoscopic ultrasonography.</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 Surgeon Console</td>
			<td>Intuitive Surgical</td>
			<td>SS999</td>
			<td>Used to control the surgical robot.</td>
		</tr>
		<tr>
			<td>da Vinci Vision Cart</td>
			<td>Intuitive Surgical</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>Intuitive Surgical</td>
			<td>K131861</td>
			<td>The surgical robot: &#39;patient side-cart&#39;.</td>
		</tr>
		<tr>
			<td>da Vinci Xi Endoscope with Camera, 8 mm, 30&#176;</td>
			<td>Intuitive Surgical</td>
			<td>470027</td>
			<td>The camera of the da Vinci robot.</td>
		</tr>
		<tr>
			<td>ENDOEYE Rigid Video Laparoscope, 10 mm, 30&#176;</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>Intuitive Surgical</td>
			<td>470205</td>
			<td>Used for dissection and coagulation.</td>
		</tr>
		<tr>
			<td>ENDOWRIST HOT SHEARS</td>
			<td>Intuitive Surgical</td>
			<td>470179</td>
			<td>Used for cutting and coagulation.</td>
		</tr>
		<tr>
			<td>ENDOWRIST Permanent Cautery Hook</td>
			<td>Intuitive Surgical</td>
			<td>470183</td>
			<td>Used for coagulation.</td>
		</tr>
		<tr>
			<td>ENDOWRIST PROGrasp Forceps</td>
			<td>Intuitive Surgical</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>
		<tr>
			<td>Autosuture Endo Clip applier 5 mm</td>
			<td>Covidien</td>
			<td>176620</td>
			<td>Clip applier</td>
		</tr>
		<tr>
			<td>ECHELON FLEX ENDOPATH 60mm Stapler</td>
			<td>Ethicon</td>
			<td></td>
			<td>Powered surgical stapler with gripping surface technology</td>
		</tr>
	</tbody>
</table>

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).

For the patient undergoing the Warshaw technique (Patient 1), the total operation time was 190 minutes with 200 mL of blood loss. No drain was placed. On the third and fourth POD, C-reactive protein was measured, showing a non-decreasing trend. Hence, a CT scan was performed revealing a hypodense fluid collection of approximately 5 cm which was drained percutaneously using a 10 French pigtail catheter. The fluid contained high amylase (24.109 U/L, International Study Group of Pancreatic Fistula grade B). The patient was discharged on POD 5. Once drain amylase had normalized on POD 22, it was removed. The pathology revealed a grade 1 (number of mitosis 0 per 2 mm2, Ki67 proliferation: 2%) invasive NET, with 100% positive tumor cells for chromogranin and synaptophysin and 1 positive regional lymph node (station 11p) classifying it as T2N1R1 (the posterior margin was &#60;1mm) (Figure 5). Imaging 6 months after the resection revealed no recurrence or metastasis (Figure 6).
For the patient who underwent the Kimura technique (Patient 2), the total operation time was 180 min with 50 mL of blood loss. One drain was placed. The drain was removed on POD 6 and the patient was discharged the following day. On POD 18, the patient presented to the outpatient clinic complaining about pain in the lower left abdomen. A CT scan was performed revealing a fluid collection of 7 cm at the site of the resection. An endoscopic transgastric drainage was performed with a stent placement (ISGPS grade B). The follow-up CT revealed no collection (Figure 7). The histopathological examination revealed chronic atrophic pancreatitis with no sign of malignancy (Figure 8). Table 1 summaries the representative results of the two techniques.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/65216/65216fig01.jpg" /> 
Figure 1: Pre-operative CT scan of the Warshaw patient. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65216/65216fig01large.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/65216/65216fig02.jpg" /> 
Figure 2: Pre-operative PET scan of the Warshaw patient. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65216/65216fig02large.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/65216/65216fig03.jpg" /> 
Figure 3: Pre-operative CT scan of the Kimura patient. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65216/65216fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/65216/65216fig04.jpg" /> 
Figure 4: Trocars&#39; positions. This is adapted with permission from ref14. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65216/65216fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/65216/65216fig05.jpg" /> 
Figure 5: Specimen-Warshaw patient. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65216/65216fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/65216/65216fig06.jpg" /> 
Figure 6: Postoperative CT scan of the Warshaw patient. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65216/65216fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 7" class="xfigimg" src="/files/ftp_upload/65216/65216fig07.jpg" /> 
Figure 7: Postoperative CT scan of the Kimura patient. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65216/65216fig07large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 8" class="xfigimg" src="/files/ftp_upload/65216/65216fig08.jpg" /> 
Figure 8: Specimen-Kimura patient. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65216/65216fig08large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>Operation time (min)</td>
			<td>Blood loss (ml)</td>
			<td>Drain placement</td>
			<td>Complications</td>
			<td>Pathology</td>
		</tr>
		<tr>
			<td>WT patient</td>
			<td>190</td>
			<td>200</td>
			<td>No</td>
			<td>ISGPS grade B</td>
			<td>T2N1R1</td>
		</tr>
		<tr>
			<td>KT patient</td>
			<td>180</td>
			<td>50</td>
			<td>Yes</td>
			<td>ISGPS grade B</td>
			<td>Chronic atrophic pancreatitis</td>
		</tr>
		<tr>
			<td colspan="6">WT: Warshaw technique, KT: Kimura technique, ISGPS: International Study Group of Pancreatic Fistula</td>
		</tr>
	</tbody>
</table>
Table 1: Postoperative outcomes.

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).

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 ...

robotic-spleen-preserving-distal-pancreatectomy-warshaw-kimura

Nanyang Technological University

Without Section

Research

JoVE Journal

Medicine

1.3K Views.  Amsterdam UMC, location University of Amsterdam. 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).

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

Remote Magnetic Navigation for Accurate, Real-time Catheter Positioning and Ablation in Cardiac Electrophysiology Procedures

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac substrates such as left atrial flutter. This protocol describes all the clinical and invasive interventional steps performed during a human electrophysiological study and ablation to assess the accuracy, safety and real-time navigation of the Catheter Guidance, Control and Imaging (CGCI) system. Patients who underwent ablation of a right or left atrium flutter substrate were included. Specifically, data from three left atrial flutter and two counterclockwise right atrial flutter procedures are shown in this report. One representative left atrial flutter procedure is shown in the movie. This system is based on eight coil-core electromagnets, which generate a dynamic magnetic field focused on the heart. Remote navigation by rapid changes (msec) in the magnetic field magnitude and a very flexible magnetized catheter allow real-time closed-loop integration and accurate, stable positioning and ablation of the arrhythmogenic substrate.

This report provides a detailed description of a new remote navigation system based on magnetic driven forces, which has been recently introduced as a new robotic tool for human cardiac electrophysiology procedures.

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac ...

Noninvasive Intratracheal Intubation to Study the Pathology and Physiology of Mouse Lung

The use of a model that mimics the condition of lung diseases in humans is critical for studying the pathophysiology and/or etiology of a particular disease and for developing therapeutic intervention. With the increasing availability of knockout and transgenic derivatives, together with a vast amount of genetic information, mice provide one of the best models to study the molecular mechanisms underlying the pathology and physiology of lung diseases. Inhalation, intranasal instillation, intratracheal instillation, and intratracheal intubation are the most widely used techniques by a number of investigators to administer materials of interest to mouse lungs. There are pros and cons for each technique depending on the goals of a study. Here a noninvasive intratracheal intubation method that can directly deliver exogenous materials to mouse lungs is presented. This technique was applied to administer bleomycin to mouse lungs as a model to study pulmonary fibrosis.

The use of a model that mimics the condition of lung diseases in humans is critical for studying the pathophysiology and/or etiology of a particular disease and for developing therapeutic intervention. Here a noninvasive intratracheal intubation method that can directly deliver exogenous materials to mouse lungs is presented.

The use of a model that mimics the condition of lung diseases in humans is critical for studying the pathophysiology and/or etiology of a particular ...

Modeling Stroke in Mice: Permanent Coagulation of the Distal Middle Cerebral Artery

Stroke is the third most common cause of death and a main cause of acquired adult disability in developed countries. Only very limited therapeutical options are available for a small proportion of stroke patients in the acute phase. Current research is intensively searching for novel therapeutic strategies and is increasingly focusing on the sub-acute and chronic phase after stroke because more patients might be eligible for therapeutic interventions in a prolonged time window. These delayed mechanisms include important pathophysiological pathways such as post-stroke inflammation, angiogenesis, neuronal plasticity and regeneration. In order to analyze these mechanisms and to subsequently evaluate novel drug targets, experimental stroke models with clinical relevance, low mortality and high reproducibility are sought after. Moreover, mice are the smallest mammals in which a focal stroke lesion can be induced and for which a broad spectrum of transgenic models are available. Therefore, we describe here the mouse model of transcranial, permanent coagulation of the middle cerebral artery via electrocoagulation distal of the lenticulostriatal arteries, the so-called &#8220;coagulation model&#8221;. The resulting infarct in this model is located mainly in the cortex; the relative infarct volume in relation to brain size corresponds to the majority of human strokes. Moreover, the model fulfills the above-mentioned criteria of reproducibility and low mortality. In this video we demonstrate the surgical methods of stroke induction in the &#8220;coagulation model&#8221; and report histological and functional analysis tools.

Various murine models of middle cerebral artery occlusion (MCAO) are widely used in experimental brain research. Here, we demonstrate the model of transcranial permanent distal MCAO which produces consistent cortical infarction of a size corresponding to damage imposed by the majority of human ischemic strokes.

Stroke is the third most common cause of death and a main cause of acquired adult disability in developed countries. Only very limited therapeutical ...

Robotic Ablation of Atrial Fibrillation

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

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

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

A Simple Device to Rapidly Prepare Whole Mounts of the Mouse Intestine

Preparing whole mounts of the mouse small intestine and colon for subsequent analysis or quantification can be time consuming and difficult. We describe the use of a simple device to cut and &#8216;roll&#8217; mouse intestines to rapidly prepare whole mount preparations of superior and uniform quality to that which can be achieved by hand. The device comprises a base that holds 4 stainless steel rods and a top, which acts a cutting guide. The rods are inserted into the lumen of the small intestine [divided into thirds] and the colon. The rods and samples are then placed over a piece of filter paper or card into the holding slots in the base of the device. The top of the device is then positioned and serves as a cutting guide. The two angled sections in the center of the top piece are used to guide a knife or scalpel and cut the intestines longitudinally on the top of the rods. Once the intestinal sections have been cut, the top is removed and the card,&#160;tissue and rods gently removed from the device and placed on the bench. The rods are then gently rolled sideways to flatten and stick the intestinal segments onto the underlying piece of filter paper or card. The final preparation can then be examined or fixed and stored for later analysis. The preparations are invaluable for the study of intestinal changes in normal or genetically modified mouse models. The preparations have been used for the study and quantification of the effects of inflammation (colitis), damage, pre-cancerous lesions (aberrant crypt foci (ACFs) and mucin depleted foci (MDFs)) and polyps or tumors.

The use of a simple device to cut and &#8216;roll&#8217; mouse intestines to rapidly prepare whole mount preparations is described.

Preparing whole mounts of the mouse small intestine and colon for subsequent analysis or quantification can be time consuming and difficult. We describe ...

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 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 ...

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 ...

DIPLOMA Approach for Standardized Pathology Assessment of Distal Pancreatectomy Specimens

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

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

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

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 ...