Robotic General Surgery

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CHAPTER 21 • Pancreaticoduodenectomy

kocherization, the pancreatic head and uncinate process are dissected from retroperitoneal attachments up to the superior mesenteric artery (SMA) origin. The ligament of Treitz is released from the right side in order to release the first part of the jejunum and pull it into the right upper quadrant. The proximal jejunum is divided using a 60-mm sta pler (eg, purple load Covidien) or the EndoWrist stapler (blue reload). The mesentery of the transected jejunum is ligated close to the bowel using a LigaSure up until the level of the uncinate process, ideally but necessar ily exposing the first jejunal branch of the superior mesenteric vein (SMV). Next, the stomach is divided with a 60 black linear staple load with Endo GIA or an EndoWrist stapler (green reload) and the distal stomach is pulled toward the patient’s right by arm 1 identifying the common hepatic artery and lymph node station 8A and obtaining tension on the hepatoduodenal ligament to support easy dissection. Removal of lymph node sta tion 8A creates exposure of the common hepatic artery. Upon further dissection, the right gastric artery can be clipped and divided. The portal vein is usually found underneath the lymphatic tissue in the “triangle” bor dered by the common hepatic artery cranially, the gas troduodenal artery (GDA) laterally, and the pancreatic neck caudally ( Figure 21.6 ). Upon further dissection, the GDA is transected with an Endo GIA stapler gold load or EndoWirst stapler 30 mm white staple load with an angled tip (through robotic port 4). A 10-mm robotic Hem-o-lok is additionally placed on the GDA stump. The assistant flips the specimen medially to the patient’s left to expose the lateral side of the portal vein, and robotic arm 1 takes over this function. The lateral aspect of the CBD is mobilized, and the periportal lymph nodes are dissected from the duct. In case of a replaced right hepatic artery, it needs to be dissected here. The CBD/ common hepatic duct is divided proximal/at the level of the cystic duct junction with a 45 mm gold staple load with an angled tip or EndoWrist stapler white reload. Dissection now carries on to expose the SMV as well as the right gastroepiploic vein, middle colic vein, and their common trunk (if present). The right gastroepip loic vein is divided with LigaSure and/or clips or Hem o-loks. A tunnel is carefully created posterior to the pancreatic neck and a tape passed behind the pancreatic neck. The tape is tightly secured with a Hem-o-lok to prevent bleeding from the pancreatic head side and then lifted with arm 1. The suction irrigator is used to protect the vein during division of the pancreatic neck. The pan creatic neck is divided with a monopolar robotic scissors using cautery or a hook ( Figure 21.7 ). Care is taken to divide the pancreatic duct “cold.” Any bleeding from the superior and inferior pancreatic arteries is controlled with bipolar coagulation. Then, the portal vein/SMV is completely dissected from the uncinate process/pancreatic head to expose the

M1

R1

R4

R2 R3

A1

A2

R1 R2 R3: 8 mm robotic port R4: 8-12 mm robotic port A1: 5-12 mm laparoscopic port A2: 15 mm laparoscopic port M1 : liver retractor

Dissection starts with the monopolar hook in arm 4, the fenestrated bipolar in arm 2, and a Prograsp in arm 1. Usually, we carry out dissection with hand control motion scaling setting at “Normal” for the dissection. Consider setting it at “Fine” for reconstruction. The table-side surgeon starts with a sealing device (LigaSure Maryland) and a (long!) laparoscopic suction/irrigation device. Resection Phase A 5-mm port is placed laterally in the left upper quad rant anterior axillary line through which a Mediflex liver retractor (Laproflex Triangular Retractor 60 mm Angled or 80 mm Angled, Mediflex Surgical Products, Islandia, NY) is placed. The lesser sac is opened through the gastrocolic omentum, and the transverse mesoco lon is dissected from the gastroepiploic vein pedicle and the dissection is carried on straight over the descend ing duodenum toward the hepatic flexure. The hepatic flexure and ascending colon are fully mobilized, aiding in duodenal exposure ( Figure 21.5 ). Upon complete FIGURE 21.1 Port placement for robotic pancreaticoduodenec tomy. Three 8-mm robotic ports with the camera starting in the periumbilical port (R3), an 8- to 12-mm robotic port (R4), and two assistant ports (A1, 5-12 mm; A2, 15 mm) are shown. An additional liver retractor port can be placed just inferior to the left costal margin (M1) if desired. An assistant port is enlarged for specimen extraction.

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