Summary
Minimally invasive surgery techniques have evolved remarkably over the past few decades in the field of surgical oncology, including nascent techniques for pancreatic malignancies. The emergence of the robotic surgery platform has accelerated widespread implementation of minimally invasive pancreatectomy. However, whether minimally invasive approaches can maintain the quality of oncologic surgical procedures, particularly in superior mesenteric artery (SMA) dissection during pancreatoduodenectomy, remains unknown. We developed external retraction techniques to mitigate the limitations of the robotic surgery platform and help maintain the quality of oncologic resection. Specifically, vessel loops encircling the superior mesenteric vein are ligated with Endoloops, and the ends of the Endoloops are carefully retracted externally on the patient’s left side. This maneuver provides critical exposure of the SMA that allows safe, high-quality oncologic dissection. We describe our external retraction techniques in the video presentation, which can improve the safety and quality of robotic pancreatoduodenectomy.
Keywords: robotic surgery, pancreatoduodenectomy, surgical technique, superior mesenteric artery, pancreatic cancer
Introduction
Since the first laparoscopic pancreatoduodenectomy (PD) was reported in 1994,1 techniques for minimally invasive PD have continued to evolve,2,3 most significantly with the emergence of the robotic surgery platform.4–7 Meta-analyses have reported that minimally invasive PD is associated with less intraoperative blood loss and shorter hospital stays than open PD, with similar rates of postoperative complications such as delayed gastric emptying and postoperative pancreatic fistula.8–10 However, whether minimally invasive approaches can maintain the quality of oncologic surgical procedures, particularly in superior mesenteric artery (SMA) dissection during PD, remains unknown.
Retraction of the superior mesenteric vein (SMV) to expose the SMA is a critical step during open PD.11 Because the tumor edge often extends close to the SMA, SMV retraction and skeletonization of the right lateral aspect of the SMA are important to improve the chances of R0 resection,11 and we believe this step should not be compromised in robotic PD for patients with pancreatic ductal adenocarcinoma. Because of the current design of the robotic surgery platform, it is physically difficult for the surgical assistant to assist in exposing the cephalad aspect of the surgical field from the assistant port placed at lower abdomen. To overcome this limitation of robotic surgery platform, we developed novel external retraction techniques to optimize exposure of the surgical field, including SMA exposure by externally retracting SMV, during robotic PD. At our cancer center, we strategically developed a robotic pancreatectomy program. We designed a combined program in which gastrectomies and pancreatectomies were both performed, effectively increasing the composite case volume of robotic foregut surgery and thus shortening the learning curve. Before initiating the foregut robotic surgery program, national and international observation was done to collect the necessary knowledge for safe implementation. In addition to the effort to concentrate our robotic foregut surgery experience, we encouraged a strategic approach with a stepwise increase of case complexity. After we performed 45 robotic foregut surgery cases over 1-year period, we started to perform robotic PD. We have been performing robotic pancreatectomy under an Institutional Review Board protocol with prospective data collection for safety monitoring.
Surgical Technique [video presentation]
In this video, we introduce novel external retraction techniques that improve exposure for critical surgical views during robotic PD. External retractions are performed by using a suture passer to externalize surgical strings, and the retracted strings are clamped at the skin level with appropriate tension. Typical locations of external retraction are described below and in Figure 1. The case presented in the video is a patient with pancreatic ductal adenocarcinoma at the uncinate who underwent robotic PD after providing informed consent
Figure 1:
External retraction sites used for 1. liver retraction, 2. gastric retraction, and 3. superior mesenteric vein retraction.
Liver retraction
First, a 10-cm-long, half-inch-wide Penrose drain, with a 3–0 Vicryl suture (with needle left on) tied in the middle and 0 silk sutures tied at the ends, is used for liver retraction. The midpoint of a Penrose drain is sutured to the diaphragmatic crus, and the silk sutures at the ends of the drain are externally retracted by using a suture passer at each side of the xiphoid process. This maneuver exposes the anterior stomach and the porta hepatis for the entire procedure.
Gastric retraction
Second, a 3–0 Vicryl suture placed at the posterior stomach is externally retracted to help expose the anterior and inferior pancreas. This exposure is helpful during dissection of the inferior pancreas and the SMV, until the antrum is divided.
SMV retraction
Finally, vessel loops encircling the SMV are ligated with Endoloops, and the ends of the Endoloops are carefully retracted externally on the patient’s left side. This maneuver provides consistent, critical exposure of the SMA that allows safe, high-quality oncologic dissection (Figure 2)
Figure 2:
Critical view of the superior mesenteric artery (SMA) provided by retraction of the superior mesenteric vein.
At the time of this manuscript’s submission, we have performed 12 robotic PDs at our institution, and external retraction techniques including SMV retraction were used for all cases. We experienced consistent and safe exposure of SMA without incidence of SMV- or SMA-related complications.
Conclusion
Ensuring safety and maintaining quality of oncological resection are of paramount importance when performing robotic PD for malignancy. The external retraction techniques described in this video presentation are helpful to mitigate limitations of the current robotic surgery platform and can improve the safety and quality of robotic PD.
Supplementary Material
Video: External retraction techniques for robotic pancreatoduodenectomy. External retraction techniques mitigate the limitations of the robotic surgery platform and help maintain the quality of oncologic resection. Specifically, retraction of the superior mesenteric vein (SMV) provides critical exposure of the superior mesenteric artery (SMA) that allows safe, high-quality oncologic dissection.
Acknowledgement
Some of surgical techniques shown in the video were learned from international case observation opportunities and teaching courses supported by the following surgeons, to whom the authors would like to express appreciation: Dr. John Martini, Dr. Ichiro Uyama, Dr. Yuichi Nagakawa, and Dr. Takahiro Kinoshita.
Editorial support was provided by Bryan Tutt in Editorial Services, Research Medical Library at MD Anderson Cancer Center.
Disclosure Information: Nothing to disclose.
Support:
This work was supported in part by the US National Institutes of Health under Cancer Center Support Grant P30CA016672; the Clinical Trials Support Resource was used. Selected for presentation at the International Hepato-Pancreato-Biliary Association 14th World Congress, Melbourne, Australia, February 2021.
Footnotes
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Associated Data
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Supplementary Materials
Video: External retraction techniques for robotic pancreatoduodenectomy. External retraction techniques mitigate the limitations of the robotic surgery platform and help maintain the quality of oncologic resection. Specifically, retraction of the superior mesenteric vein (SMV) provides critical exposure of the superior mesenteric artery (SMA) that allows safe, high-quality oncologic dissection.