Management of Intra-Operative Hemorrhage and Safe Venous Resection in Robotic-Assisted Pancreaticoduodenectomy: Techniques to Avoid Open Conversion

Abstract

Robotic-assistedpancreaticoduodenectomy (RPD) is increasingly utilized for operableperiampullary malignancies with oncologic outcomes compared to the openapproach. Indications can be carefully expanded to select borderline resectabletumors, but bleeding remains a significant threat. Moreover, the need for venousresection and reconstructions increases as more complex cases are selected to undergo RPD. Herein, we present a video compilation of our approach to safevenous resections during RPD, followed by several video examples ofintraoperative hemorrhage highlighting various techniques and tips that theconsole and bedside surgeon can utilize to control bleeding. Conversion to anopen procedure should not be seen as a failure but rather as a safe and soundintraoperative decision made in the patient’s best interest. Nonetheless, withexperience and proper technique, many intraoperative hemorrhages and venous resectionscan be managed in a minimally invasive fashion.

Introduction

Robotic-assisted pancreaticoduodenectomy (RPD) using the DaVinci platform is increasingly being utilized for operable periampullary malignancies with oncologic outcomes comparable to the open approach.¹ As surgeon experience matures, broader application of this platform to more complex resections is facilitated by the enhanced visualization, improved surgeon ergonomics, and dexterity.² Conversely, as indications expand to involve borderline tumors, so does the potential for intraoperative complications including bleeding.

Hemorrhage during a RPD can pose significant challenges to the surgeon and requires poise and technical expertise. Although conversion to laparotomy might be necessary as patient safety is paramount, several maneuvers can help avoid or control bleeding, allowing the surgeon to avert a conversion. Herein, we present a video compilation of our approach to safe venous resections during RPD, followed by several video examples of intraoperative hemorrhage highlighting various techniques and tips that can be utilized by the console and bedside surgeon to control bleeding.

Methods

Techniques for Safe Venous Resection

The University of Pittsburgh port configuration for RPD using the daVinci XI platform is shown in Fig. 1, and our technique has been previously described.³ In this segment, we demonstrate the important steps in performing a safe venous resection during RPD. Following transection of the pancreatic neck, the splenic vein, distal portal vein, and superior mesenteric vein are dissected and isolated using vessel loops. The vessel loop is moved in the horizontal plane back and forth to ensure that an adequate segment of the vein is free from surrounding tissue, so it can be easily clamped while leaving sufficient distance between the clamp and the planned transection site. Then, the uncinate/retroperitoneal dissection is carried out using a combination of hook monopolar cautery and a bipolar energy device. The assistant dynamically retracts the superior mesenteric vein (SMV) to the patients left side using a suction device, and the left hand (arm 2) of the console surgeon sequentially moves under the uncinate to lift the specimen anteriorly and laterally, exposing the mesopancreas. The surgeon and the bedside assistant need to be aware of the location and course of the superior mesenteric artery (SMA) when dissecting along the SMV, and this can be accomplished by dissecting the anterior and rights side of the SMA nearly 180 degrees so that the SMA pulsation is clearly visualized. Once the tethered portion of the vein is reached, the hook cautery is replaced with a fenestrated bipolar, and clamps are applied. It is important for the console surgeon’s right hand (arm 4) to laterally retract the vessel loops as the proximal bulldog clamp is applied on the SMV to ensure that venous tributaries (first jejunal, middle colic) are not avulsed. The second bulldog is placed onto the distal portal vein as the left hand elevates the vein to expose the space inferiorly.

Fig. 1.

Port placement for robotic pancreatoduodenectomy

Lateral Hand-Sewn Venorrhaphy

The fenestrated bipolar in arm 4 is then replaced with curved scissors, and resection of the lateral venous side wall is performed. During this step, it is important to minimize the tension applied onto the specimen with arm 1 to prevent venous tearing or avulsions. The vein is cut with small segmental bites alternating from the posterior to the anterior wall to maintain exposure on both edges at all times. The bedside assistant has a suction through the left assistant 5-mm port to evacuate the blood. Once this step is complete, both the right and left arm (arms 1 and 2) instruments are replaced with needle drivers. The console surgeon proceeds with a venorrhaphy using 5–0 or 6–0 Prolene suture in a simple continuous pattern, while the assistant dynamically exposes the vein—using the suction—to aid with visualization. To prevent tearing and narrowing of the vein, small 1-mm bites should be taken, and before tying the suture, it is important to release the lower bulldog to evacuate a clot that may have accumulated due to stasis (not shown in the video).

Stapled Side-Bite Resection

In stapled side wall resections, it is pivotal to ensure complete mobilization of the SMV to at least 270 degrees, leaving only the specimen on the left side of the vein (right side of the patient) for safe resections. Once the vein is dissected proximally and distally to its involved portion, a Maryland forceps is introduced through arm 4 (right hand), and a plane is developed underneath the tethered portion of the vein, which is then isolated with a vessel loop. Once the vessel loop is applied, it should be moved gently left and right to ensure an adequate space for the stapler. An endoGIA 45-mm vascular load with a curved tip is introduced into the abdomen through the assistant 12-mm port and is directed carefully, by the bedside assistant, with its tip first engaging the previously created space underneath the tethered segment of the vein. At the same time, the console surgeon utilized the fenestrated bipolar in the left hand (arm 2) to create a safe landing zone by pushing laterally on the distal portion of the vein to prevent an accidental puncture of the vein by the staple’s tip. In this case, the patient had a replaced right hepatic artery, originating from the SMA, which was protected as the stapler was advanced across the involved portion of the vein. For adequate exposure and to minimize excess capture of the portal vein by the stapler jaws, arm 1 (most lateral left arm) grasps and retracts the transected bile duct laterally and inferiorly, while the right arm (arm 4) pulls on the vessel loop up towards the patient’s left. Lastly, the vessel loop is removed, and the stapler is fired.

End-to-End Anastomosis

In addition to the steps outlined above, it is important to ensure that both segments of the vein can be approximated without unduly tension. To ensure this, a Catell-Braasch maneuver is usually performed during the mobilization phase of the operation, and the patient can be placed in a slight Trendelenburg position. The splenic vein may need to be divided by a stapler to achieve extra length. After the vein is cut with 2–3-mm stumps, it is important to retract the mesocolon superiorly to minimize tension on the repair. A primary end-to-end anastomosis is then performed using 5–0 or 6–0 Prolene suture. This video segment demonstrates an end-to-end primary venous anastomosis using two running continuous sutures. The console surgeon must be attentive to the force applied on the Prolene suture as the robot lacks tactile feedback and excessive manipulation of the suture thread can weaken or damage the suture. Again, before tying the suture, it is important to release the lower bulldog to evacuate any clot that might have formed.

Bleeding from the Suprapancreatic Portal Vein

During the suprapancreatic dissection phase of the operation and following ligation of the right gastric and gastroduodenal arteries, the specimen is grasped with a Cadière forceps in arm 1 and retracted caudally and to the patient’s right side. Dissection is carried out using the hook monopolar cautery in arm 4 and the fenestrated bipolar forceps in arm 2. In this video, an injury to the lateral wall of the portal vein was inadvertently created with the hook. When this happens, it is important to stay calm, inform the anesthesia team that there is a potential for significant blood loss, and then assess the location and the extent of the injury. The assistant should promptly place the suction device through the assistant port to ensure clear visualization. The console surgeon should expeditiously grasp a big bite of the vein at the level of the injury gently with the fenestrated bipolar in arm 2 to tamponade the bleeding. The hook is then removed and replaced with a needle driver. It is important to maintain exposure, and therefore, the Cadière forceps in arm 1 should not be moved. Next, the assistant will introduce a 5–0 Prolene suture through the 12-mm port, and the console surgeon, using a one hand maneuver, grasps the suture and expertly positions the needle for the first throw. After the first suture is placed, the fenestrated bipolar in arm 2 is released to grasp the suture and retract it cephalad for exposure. A figure-of-8 stitch is then completed. During suturing, it is important to ensure that the needle courses under and not through the fenestrated bipolar to prevent trapping the suture thread within the fenestrated instrument. Furthermore, the length of the suture retrieved after the first needle throw must be long enough to prepare for the second throw without creating unwanted and excessive tension on the venous wall. Lastly, arm 2 is exchanged with a non-suture cut needle driver to tie the suture.

Bleeding from the Gastrocolic Trunk of Henle

In this segment of the video, infrapancreatic dissection is being performed, and the gastrocolic trunk is iatrogenically injured using a Maryland forceps in arm 4. The same technique for bleeding control described previously should be performed in this scenario. An adequate bite of the injured vein wall is grasped with the fenestrated bipolar in arm 2 to tamponade the bleeding. The assistant suctions the blood and maintains adequate exposure of the site of the injury. The right arm is then switched to a suture cut needle driver to grab the 5–0 Prolene suture from the assistant and complete a figure-of-8 stitch. Sustaining adequate tension using the Cadière forceps in arm 1 onto the specimen is of pivotal importance to maintain exposure, and therefore, arm 1 should not move during this process. After the first suture is placed, the second arm should be released and switched out for a needle driver to tie the knot.

Bleeding from the Inferior Pancreaticoduodenal Artery

In this segment of the video, level III of the uncinate dissection is being performed using a combination of hook monopolar cautery in arm 4 and the Ligasure device by the console surgeon and the bedside assistant, respectively. In this case, bleeding was encountered from the inferior pancreaticoduodenal artery. The bleeding vessel is quickly grasped using the fenestrated bipolar in arm 2 by the console surgeon to tamponade the bleeding. When encountering bleeding from fragile arteries like the inferior pancreaticoduodenal artery or small branches originating from the SMA, one should refrain from using clips as they can lead to tear and avulsion of the bleeding vessel. The console surgeon and the bedside assistant should work harmoniously during this to maintain exposure with the Cadière forceps in arm 1 and the suction device. The hook is exchanged for a suture cut needle driver in arm 4, and a 5–0 Prolene stitch is introduced by the bedside assistant. The console surgeon, using a one hand maneuver, grabs the suture and expertly positions the needle for the first throw. After the first suture is placed, the fenestrated bipolar in arm 2 is released to grasp the suture and retract it cephalad for exposure. A figure-of-8 stitch is then completed. During suturing, it is important to ensure the needle goes under the fenestrated bipolar to prevent trapping. Lastly, arm 2 is exchanged with a non-suture cut needle driver to tie the suture.

Bleeding from the Superior Mesenteric artery

In this video segment, dissection along the SMA is being carried out to complete the uncinate dissection portion of the operation. Bleeding is encountered from the lateral surface of the SMA. As previously discussed, it is advisable to avoid placing clips as this can worsen the bleeding as shown in this video. In this case, the bedside assistant carefully but expeditiously clamps the bleeding portion of the artery using a duckbill forceps. The Cadière forceps in arm 1 grabs the specimen and retracts it anteriorly to the patient’s right for adequate exposure. The hook is exchanged for a suture cut needle driver in arm 3, and a 5–0 Prolene stitch is introduced by the bedside assistant. The console surgeon, using a one-hand maneuver, grabs the suture and precisely positions the needle for the first throw. For the SMA, the bites should be judicious ensuring each bite goes behind the duckbill forceps. Once the first stitch is taken, the console surgeon grabs the two ends of the suture using a non-suture cut needle drive in arm 2 and gently retracts it cephalad for exposure. A figure-of-8 stitch is completed, and the knot is tied. The assistant is continuously suctioning the blood and also providing adequate exposure by retracting the portal vein to the patient’s right.

Open Conversion

In the rare situation when intraoperative bleeding cannot be controlled, the bedside assistant immediately introduces a mini-laparotomy sponge that the console surgeon uses to tamponade the bleeding. The operative team is alerted immediately to prepare the laparotomy equipment including a Thompson retractor. Once the surgical maneuvers necessary to achieve a satisfactory tamponade are completed, the bedside assistant maintains compression applying appropriate pressure—often on the laparotomy sponge—on the injured structure while the console surgeon scrubs. It is important to note that a third surgeon is always called in the operating room to help perform the laparotomy. The robot is undocked, and the abdomen is opened while the beside assistant continues—with the laparoscopic instruments—to tamponade the bleeding until the surgical field is exposed. It is important to note that the pneumoperitoneum is maintained during the entire process; this aids with tamponade and decreases the chances of accidental injury to the intrabdominal organs during the first phase of the laparotomy.

Conclusion

Robotic pancreaticoduodenectomy is increasingly performed in the USA for resectable periampullary tumors. Indications can be carefully expanded to select borderline resectable tumors, but bleeding remains a major threat, and conversion to laparotomy can—at times—become necessary to control hemorrhage. Conversion to an open procedure should not be seen as a failure but rather as a safe and sound intraoperative decision made in the patient’s best interest. Nonetheless, with experience and proper technique, many intraoperative hemorrhages can be managed in a minimally invasive fashion. In this video manuscript, we demonstrate various safe and reproducible techniques to perform venous resections and detail our approach to control hemorrhage in various scenarios to avert an open conversion.