Robotic General Surgery

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

Anastomosis

Bile duct

Pancreas

Jejunum

Hepatic duct

Jejunum

A

B

Anastomosis

Bile duct

Anastomosis

Jejunum

Bile duct

Jejunum

D

C

FIGURE 21.9 Construction of hepaticojejunostomy. An end-to-side choledochojejunostomy is preferred (A). The jejunum is opened (B). The anastomosis can be created over a plastic stent (C). The anterior row of the reconstruction is shown in D.

OUTCOME DESCRIPTION Over the past decade, there has been a strong increase in the use of the robotic system in complex procedures, such as PD, which also reflects in the published litera ture. To date, as mentioned before, for PD, no random ized data are available to compare RPD with its open counterpart. Patient series have been published, report ing on a few thousand robotic pancreatic resections per formed the past 10 years, recently reviewed by Sandri et al for the E-AHPBA Innovation & Development Committee. 25 In this study approximately 2,600 RPDs were included, mostly performed for pancreatic duc tal adenocarcinoma. In this study, the overall compli cation rate was 44.7% and the severe postoperative complication (ie, Clavien-Dindo grade ≥ III) rate was 13.9%. Overall 90-day mortality was reported to be around 2.46%. These outcomes display safety of the robotic approach to PD and seem at least comparable with those of several large series on OPD, as shown earlier. 11,26

jejunal loop is marked using a Vicryl 3-0 approximately 30 cm proximal of the HJ to simplify the identifica tion of the “right jejunal limb” before performing the gastrojejunostomy. Finally, a gastrojejunostomy is performed ( Figure 21.10 ). We are used to doing this stapled with a purple load Endo GIA and closure of the opening with one or two 3-0 9-in V-Loc sutures. The jejunum is pulled to the left by the table-side surgeon until the Vicryl marker suture is identified and the jejunum is brought upward to the left upper quadrant and held in place. An open ing in the stomach is made just ventral to the staple line using hot scissors. A 6 cm purple load Endo GIA is driven in the jejunum (distal-to-proximal direction) with its thick part and the metal part driven in the stomach. After stapling, the opening is closed with V-Loc sutures. We place a drain coming from the right posterior to the HJ and anterior to the pancreaticojejunostomy. If the specimen was not taken out immediately after resection, it is taken out now in a larger retrieval bag through an enlarged trocar incision.

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