Robotic General Surgery

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SECTION 2 • Discipline-Based Practice - Hepatobiliary and Pancreatic Surgery

Bile duct

GDA

A

B

GDA

Bile duct

GDA stump

Portal vein

Portal vein

GDA stump

Bile duct

D

C

FIGURE 21.6 Dissection of the gastrohepatic ligament. The lesser sac is entered (A). The hepatic and the gastroduodenal (GDA) arteries are identified (B). Division of the GDA reveals the portal vein (C). The bile duct is then divided (D).

SMA. The posterior uncinate and superior mesenteric artery are dissected ( Figure 21.7 ). Exposure is gained by placing arm 1 under the specimen and lifting the pancreas laterally and ventrally (analogous to what the surgeon’s left hand would do in an open pancreaticodu odenectomy). After further dissection around the first jejunal vein, the superior mesenteric artery is exposed. Finally, the uncinate process is dissected off of the vas cular groove in layers from caudal to cranial and from anterior to posterior, employing hook and bipolar, as well as LigaSure by the table-side surgeon. A robotic cholecystectomy is performed by an antegrade or retro grade technique. Reconstruction Phase We prefer an end-to-side pancreaticojejunostomy with splitting of the serosa and duct-to-mucosa technique (www.pancreatic-anastomosis.com). The jejunum serosa is split along the anticipated length of the anastomosis using the cautery scissors. The anastomosis is started with 4-0 PDS going into pancreas superiorly and placed

as a horizontal mattress between the pancreas and sero muscular layer of the jejunum ( Figure 21.8 ). Then a number of interrupted 4-0 PDS sutures are used for the posterior wall of the anastomosis, which are tied down one by one with the knot “inside” the anastomosis. Next, the duct is aligned against the jejunum and a small full mucosal opening in the jejunum opposite the duct is created with the cauterizing scissors. Four to eight duct-to-mucosa 5-0 PDS interrupted sutures are placed depending on duct size, over a 5Fr single pigtail pan creatic stent with the curved end placed inside the jeju num. Finally, a number of 4-0 PDS interrupted mattress sutures are placed for the anterior wall, completing the pancreaticojejunostomy. An optional wrap of the round ligament of the liver can be placed around the anastomo sis ( Figure 21.5 ). The choledochojejunostomy is begun approximately 10 cm distal to the pancreaticojejunostomy. In most cases, we use interrupted 5-0 or 4-0 PDS RB1 sutures cut to 12 cm, for both posterior and anterior ( Figure 21.9 ). After completion of the hepaticojejunostomy (HJ), the

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