Robotic pancreatic surgery has advanced considerably in recent years; however, morbidity and mortality remain significant. Improving outcomes requires standardised procedures with optimised perioperative settings. Proper positioning of robotic trocars plays a key role in enabling safe and effective surgical performance. This study evaluates the impact of anthropometric differences on trocar placement in robotic pancreatic surgery and assesses the feasibility of a universal trocar placement strategy. A retrospective analysis of 103 consecutive contrast-enhanced arterial-phase computed tomography scans was performed. Key distances between the target anatomy and surface landmarks, including the umbilicus and xiphoid process, were measured. The origin of the gastroduodenal artery was selected as the target anatomy for pancreaticoduodenectomy, while the origin of the celiac trunk served as the target anatomy for distal pancreatectomy. The analysis demonstrated that the widely adopted universal periumbilical trocar placement was unsuitable for a substantial proportion of patients. The target anatomy lay outside the recommended range (10–20 cm) in 24% of robotic pancreaticoduodenectomy cases and in 9% of robotic distal pancreatectomy cases. Accordingly, we propose a simple method to optimise patient-tailored yet standardised trocar placement in robotic pancreatic procedures.
Keywords: Pancreatic surgery, Robotic surgery, Pancreaticoduodenectomy, Distal pancreatectomy, Trocar placement
Highlight
Conventional vs. Novel Techniques: Robotic pancreatic surgery has emerged as an alternative to open and laparoscopic approaches. A universal approach to trocar placement is widely adopted; however, considerable inter-individual anatomical variability challenges its effectiveness.
Modifications and Innovations: This study evaluates an individualised trocar placement strategy tailored to patient-specific anatomical variation. Target anatomy corresponds to the origin of the gastroduodenal artery for pancreaticoduodenectomy and the origin of the celiac trunk for distal pancreatectomy. Preoperative contrast-enhanced computed tomography scans were used for assessment. The tailored approach incorporates measurements between the umbilicus, xiphoid process, and the target anatomy, thereby optimising robotic trocar positioning for each patient.
Implications and Recommendations: A standardised trocar placement approach may not be optimal for all robotic pancreatic procedures because of anthropometric differences. An individualised strategy may improve surgical efficiency, minimise instrument collisions, and potentially enhance perioperative outcomes.
Introduction
Background
In recent years, robotic pancreatic surgery has achieved unprecedented growth. Since Giulianotti et al. performed the first robotic pancreaticoduodenectomy (PD) in 2001 [1], robotic pancreatic surgery has become an accepted alternative to open or laparoscopic approaches in the treatment of selected pancreatic lesions [2–6]. Evidence confirms the technical feasibility, safety, oncological radicality, and overall cost rationality of robotic pancreatic surgery [3, 6, 7]. Many pancreatic centres have recently published their experience, helping to pave the way for broader adoption of robotic surgery in pancreatic procedures.
However, despite these advancements, robotic pancreatic surgery is still burdened with non-negligible morbidity and mortality [2, 3, 5]. A key step in reducing postoperative complications is completion of the learning curve, together with efforts to achieve standardisation of surgical procedures. This study focuses on the variability of anatomical arrangements relevant to optimal trocar placement during robotic pancreatic procedures. Given the substantial variability in patients’ body habitus, it is reasonable to anticipate corresponding differences in intra-abdominal anatomical configurations.
In robotic surgery, the principle of trocar placement is fundamentally determined by the concept of target anatomy. This is defined as the anatomical structure or region designated for surgical intervention. The size of the target anatomy is not defined by a strict measurement because it depends on both the type of procedure and the patient’s body proportions. Nonetheless, several factors related to anatomical size must be considered, including adequate visualisation, accessibility of relevant structures, and the capabilities of the robotic instruments employed [8, 9].
In this study, the origin of the gastroduodenal artery (GDA) from the common hepatic artery (CHA) was selected as the target anatomy for PD. The origin of the celiac trunk was selected as the target anatomy for distal pancreatectomy (DP). Both anatomical points can be readily identified on preoperative computed tomography (CT) imaging. In addition, basic anthropometric characteristics of the patients were recorded.
Rationale
One of the key factors in achieving optimal outcomes in robotic pancreatic surgery is appropriate trocar placement of the robotic system. The ideal distance between the target anatomy and the robotic trocars is reported to be between 10 and 20 cm [10], while distances greater than 20 cm or shorter than 10 cm are considered suboptimal for performing the procedure [11–13]. In the Da Vinci Xi™ system, the trocars should be aligned in a horizontal line to minimise the risk of robotic arm collision [14].
One widely adopted approach is the so-called ‘one-fits-all’ principle, in which trocars are positioned in a standardised manner, regardless of the nuances of the planned procedure [11]. This technique begins with insertion of an umbilical trocar and performance of a diagnostic laparoscopy, followed by placement of two trocars on the right side and one on the left side of the umbilical trocar along a horizontal line. The distance between the trocars is 7 cm on the right side and 14 cm on the left side (Fig. 1). Additional assistant trocars are then placed 3–5 cm below the horizontal line [11]. Surgeons may adjust trocar positions according to the patient’s body habitus and institutional practice; nevertheless, this approach lacks true standardisation.
Fig. 1.
The ‘one-fits-all’ principle universally applied in robotic pancreaticoduodenectomy and robotic distal pancreatectomy [11]
Objective
In this study, we aimed to determine whether the universal trocar placement principle is fully applicable in robotic pancreatic procedures, particularly in relation to anthropometric differences and anatomical variability within the population.
The primary aim of the study was to assess whether the distances from the target anatomy for PD and DP align with the recommended 10- to 20-cm interval for periumbilical video trocar placement. As part of this work, we developed a simple method for trocar placement that combines individualisation with standardisation, taking into account the patient’s body habitus.
Methods
CT was selected as the imaging modality for anatomical evaluation and measurement. A preoperative CT scan following the pancreatic protocol is mandatory according to the National Comprehensive Cancer Network Clinical Practice Guidelines for staging, resectability assessment, and surgical planning [15].
The origin of the GDA was selected as the target anatomy for PD. During the procedure, cholecystectomy is performed cranial to this point, jejunal transection caudally, duodenal mobilisation laterally, and construction of the pancreaticojejunal anastomosis medially (Fig. 2). The point of origin of the GDA from the CHA is relatively constant at this location, with minimal anatomical variation. Similarly, the origin of the celiac trunk from the abdominal aorta was chosen as the centre of the target anatomy for DP (Fig. 2).
Fig. 2.
Computed tomography scan in the coronal plane showing the point of origin of the gastroduodenal artery (red) and the point of origin of the celiac trunk (yellow), defined as the target anatomy for robotic pancreaticoduodenectomy and distal pancreatectomy
In total, 103 contrast-enhanced abdominal CT scans acquired in the arterial phase were retrospectively analysed. The cohort included 56 male and 47 female patients. Two patients with a history of previous pancreatic or duodenal surgery were excluded from the study. All measurements were performed in the coronal plane. The measured distances included:
The distance between the umbilicus and the origin of the GDA from the CHA.
The distance between the umbilicus and the origin of the celiac trunk from the abdominal aorta.
The distance between the margin of the xiphoid process of the sternum and the two previously described points.
Statistical evaluation
Estimates of the percentage of individuals for whom the currently recommended trocar placement is unsuitable were calculated using the exact binomial test. These estimates are presented in Tables 1 and 2, together with the corresponding graphs shown below (Fig. 3). Correlation of the anthropometric data with measured distances were obtained through linear regression and p values adjusted using the Benjamini-Hochberg method.
Table 1.
Measured distances between target anatomy and visible anatomical landmarks
| Measurement | Origin | Range (mm) | Median (mm) |
|---|---|---|---|
| Distance to umbilicus | GDA | 56.5–277.0 | 131.0 |
| Celiac trunk | 75.6–273.0 | 140.0 | |
| Distance to xiphoid process | GDA | 14.2–131.0 | 103.0 |
| Celiac trunk | 16.1–168.0 | 79.5 |
GDA, gastroduodenal artery
Table 2.
Cases in which distance between target anatomy and umbilicus fell outside recommended range
| Point not achieved | Count | Percentage estimate | 95% CI | Mean of all points | SD of all points |
|---|---|---|---|---|---|
| Real distance below 100 mm | |||||
| Celiac trunk origin | 6 | 5.8% | (2.2%–12.2%) | 138.3 | 28.0 |
| GDA origin | 23 | 22.3% | (14.7%–31.6%) | 125.8 | 32.7 |
| Real distance above 200 mm | |||||
| Celiac trunk origin | 3 | 2.9% | (0.6%–8.3%) | 138.3 | 28.0 |
| GDA origin | 2 | 1.9% | (0.2%–6.8%) | 125.8 | 32.7 |
| Real distance not within 100- to 200-mm interval | |||||
| Celiac trunk origin | 9 | 8.7% | (4.1%–15.9%) | 138.3 | 28.0 |
| GDA origin | 25 | 24.3% | (16.4%–33.7%) | 125.8 | 32.7 |
GDA, gastroduodenal artery; CI, confidence interval; SD, standard deviation
Fig. 3.
Graphic summary of the distance between the umbilicus and the target anatomy. Patients within the blue range were suitable for the universal approach, whereas those outside the range, marked in red, were not (CoT = celiac trunk, GDA = gastroduodenal artery)
Results
The study cohort consisted of 103 consecutive patients, with demographic data summarised in Table 3. We analysed CT scans of 49 female and 54 male patients, aged 20 to 93 years. Body mass index ranged from 18.8 to 50.35 kg/m2, with a median of 26.2 kg/m2. The median body trunk width was 292 mm, and the median distance between the xiphoid process and the pubic symphysis was 180 mm.
Table 3.
Demographic and anthropometric characteristics of the enrolled patients
| Total patients (n) | 103 |
|---|---|
| Female patients (n) | 49 |
| Male patients (n) | 54 |
| Age range | 20–93 years |
| Median body mass index | 26.20 (18.80–50.35) kg/m2 |
| Median body trunk width | 292 mm |
| Median distance between xiphoid process and pubic symphysis | 180 mm |
Anatomical measurements showed that the distance between the origin of the GDA and the umbilicus ranged from 56.5 mm to 277 mm, with a median of 131 mm. The distance between the origin of the celiac trunk and the umbilicus ranged from 75.6 mm to 273 mm, with a median of 140 mm.
With respect to the xiphoid process, the distance from the GDA origin varied between 14.2 mm and 131 mm, with a median of 103 mm, whereas the distance from the celiac trunk origin ranged from 16.1 mm to 168 mm, with a median of 79.5 mm (Table 1).
In our cohort, 24% of patients (95% confidence interval [CI]: 16%–34%) had the GDA origin located outside the recommended distance from the umbilicus (10–20 cm). The origin of the celiac trunk was outside this range in 9% of patients (95% CI: 4%–16%). Most patients with the celiac trunk located outside the defined range also had the GDA origin outside the recommended limits. Consequently, the overall proportion of patients with at least one target point outside the recommended range was 26% (95% CI: 18%–36%), rendering them suboptimal candidates for standard trocar placement (Table 2).
Both measured distances increase slightly with BMI by 2.75–3.75 mm per unit of BMI, supported by a p value < 0.001. The distance between the GDA origin and umbilicus grows modestly with the distance between the xiphoid and the symphysis; the increase is less than 1 mm for each 1 mm increase in the xiphoid–symphysis distance. The change of distance between the celiac trunk origin and umbilicus based on the changes of the xiphoid–symphysis distance is not statistically significant. Any changes are less than 1 mm for each 1 mm increase in the xiphoid–symphysis distance. Both measured distances are greater in men than in women. For GDA origin, the difference is approximately 21.45 mm, while for the celiac trunk, the distance is approximately 11.93 mm greater in men.
Preoperative preparations and requirements
Individualised trocar placement is guided by a preoperative contrast-enhanced CT scan performed according to a pancreatic protocol, including both arterial and venous phases.
CT imaging allows preoperative measurement of the distance between target anatomy points and the anticipated site of video trocar placement, ensuring that the recommended distance of 10–20 cm can be maintained. These measurements can be referenced against consistent external landmarks on the patient’s body, including the xiphoid process and the umbilicus.
Step-by-step description
The first step is evaluation of the preoperative CT scan in the coronal plane prior to the planned robotic pancreatic surgery. In the case of PD, the distance between the point of origin of the GDA and the umbilicus is measured, followed by a second measurement between the GDA origin and the xiphoid process. In the case of robotic DP, the distance between the point of origin of the celiac trunk and the umbilicus is measured, followed by a second measurement between the celiac trunk origin and the xiphoid process.
Measurements are recorded by the surgeon in a standardised preoperative planning sheet. If the preoperative CT indicates an inadequate distance between the periumbilical video trocar placement and the target anatomy, robotic trocar placement is individually adjusted in the operating room prior to surgery.
With the patient in the supine position, the surgeon marks on the patient’s body the anticipated location of the GDA origin or the celiac trunk origin, based on the measured distances from the xiphoid process and the umbilicus (Fig. 4).
Fig. 4.
Gastroduodenal artery (marked ‘AGD’ on the patient’s torso) as the target anatomy for pancreaticoduodenectomy
-
4.
The recommended distance from the target anatomy to the robotic trocars of the da Vinci Xi™ system is generally 10–20 cm, with a preferred average of 15 cm at our centre. A Veress needle is inserted 2 cm below the left costal margin, and the abdominal cavity is insufflated to a pressure of 12 mmHg. From the projected location of the target anatomy on the patient’s body, a distance of 15 cm is measured towards the umbilicus. This point, marked on the skin, indicates the planned site for video trocar placement.
-
5.
Once the camera trocar is inserted and diagnostic laparoscopy is performed, the remaining robotic trocars are placed, maintaining a recommended distance of 7–8 cm between each. A 12-mm trocar is placed in the patient’s left mesogastrium. Two assistant trocars are placed in a standard fashion, forming the apex of an imaginary triangle, with the two robotic trocars serving as the base points (Fig. 5).
Fig. 5.
Patient-tailored perioperative trocar placement in a patient undergoing robotic pancreaticoduodenectomy. The camera trocar is positioned below the umbilicus according to the measured distance between the target anatomy (red arrow) and the umbilicus
Tips and pearls
The proposed approach to individualised trocar placement supports standardisation of robotic surgery.
Target anatomy points are readily identifiable on preoperative planning CT imaging.
Target anatomy can be projected onto the skin using measured distances from visible anatomical landmarks (umbilicus, xiphoid process).
Measuring distances from these landmarks facilitates optimal placement of the video trocar at an appropriate distance from the target anatomy.
Discussion
Robotic pancreatic surgery is considered a safe and feasible approach for the surgical treatment of both malignant and benign pancreatic lesions. When performed by an experienced surgeon in a specialised centre, it is associated with reduced intraoperative blood loss, and a shorter hospital stay compared with open surgery [16–18]. However, appropriate trocar placement plays an important role in ensuring the smooth conduct of the procedure. Suboptimal trocar placement can lead to prolonged operative time, restricted instrument movement, and an increased risk of perioperative injury [19].
To date, no standardised strategy for robotic trocar placement has been established. In most centres, a universal approach is applied, with the initial trocar positioned at or near the umbilicus, followed by subsequent modifications according to institutional or surgeon preference [20–22].In patients with a slender body habitus, the horizontal line of trocars can be shifted above the umbilicus, whereas in obese individuals it is typically placed below the umbilicus. Assistant trocars are usually positioned in the infraumbilical area (21). Other approaches involve placing the camera trocar 11–12 cm from the costal margin and 2–3 cm from the umbilicus. Two additional trocars are then inserted along the same line in the right and left midclavicular lines, and the final trocar for robotic arm 1 is positioned 2 cm craniolateral to the trocar for robotic arm 2. In addition, slight modifications of the horizontal line of trocar placement in DP compared with PD have been proposed to improve technical convenience with respect to the anatomical area of dissection [22].
However, based on the collected data and subsequent analyses, our study indicates that a universal trocar placement strategy may be suboptimal in a substantial proportion of patients. The results demonstrate significant variability in the distance between the target anatomy and the periumbilical trocar site, which likely reflects the considerable variability in patient habitus. In our cohort of 103 patients, 27 had at least one predefined anatomical target point located outside the recommended umbilical distance. On this basis, we propose the personalised trocar placement strategy outlined above. This straightforward method may reduce the incidence of suboptimal trocar positioning and support further standardisation of robotic minimally invasive surgery.
We acknowledge several limitations of this study. The cohort size is limited, on the other hand, the patients of both female and male gender were included equally and the age variability is considerable, therefore we deem the cohort adequately representative. Distance measurements were based on preoperative CT scans, and insufflation of the abdomen may slightly alter distances, particularly between the skin and the target anatomy. Moreover, no intraoperative measurements comparing the data collected preoperatively are performed. However, because the actual intraoperative distance in an insufflated abdomen corresponds to the hypotenuse of a right-angled triangle, it is expected to differ by only a few millimetres from the preoperatively measured distance. Another limitation is the location variability of the surface landmarks due to potentially different positioning of the patient on the operation table and in the gantry during the CT examination. The study was conducted in accordance with recommended guidelines for trocar placement using the da Vinci Xi™ system. The applicability of these findings may therefore vary across institutions due to differences in the robotic platforms used. Finally, there is currently no evidence that this approach reduces postoperative complications, perioperative blood loss, conversion rates, or long-term outcomes. This data is already being collected for further analysis in a prospective study to fully support the implementation of our hypothesis into clinical practice worldwide.
Despite these limitations, we consider personalised trocar placement to be a reasonable option, and our experience suggests that it offers practical advantages and is technically straightforward. This technique has already been implemented into our clinical practice and applied routinely for preoperative preparation for both PDE and DP, conducted by the surgeon operating. In our experience, this individualized approach does not lead to significant delay of the preoperative phase of the surgery and therefore does not put the patients under the influence of unnecessarily prolonged general anaesthesia. We did not observe any interference with the docking of the robotic system. From our experience so far, issues with robotic arms collision have improved and none of them contributed to major operating difficulties nor even conversion of the surgery. Compared to robotic pancreatic surgeries performed prior to the implementation of the technique, the surgeons report largely improved overview of the operation field, accessibility to anatomical structures and instrument manoeuvring. These factors are substantial for a such complex surgeries and may eventually lead to better operative outcomes and lower complication rate. The benefit of the technique however, according to our hypothesis, should be further validated in a prospective study with measurable data.
Conclusions
Based on our findings, the use of a universal trocar placement strategy in robotic pancreatic resections would be unsuitable for more than one quarter of patients because of anatomical variability. We introduce the concept of anatomy-based individualised trocar placement, a straightforward method for preoperative planning of robotic trocar positioning using CT imaging. This approach may contribute to improved standardisation of minimally invasive pancreatic procedures, reduce the number of suboptimally positioned trocars, and potentially improve perioperative and postoperative outcomes.
Abbreviations
- GDA
Gastroduodenal artery
- CHA
Common hepatic artery
- PD
Pancreaticoduodenectomy
- DP
Distal pancreatectomy
- CT
Computed tomography
- CI
Confidence interval
Author contributions
Pavel Záruba - First co-author; conceived, developed, and implemented the technique in robotic surgery, Kristýna Pončáková - First co-author; responsible for data collection and interpretation and contributed to manuscript writing, Michael Rousek - Contributed to study design, data interpretation, and manuscript writing, Štěpán-Ota Schütz - Contributed to data interpretation, statistical evaluation, and manuscript writing, Eliška Kšírová - Performed statistical analyses and validated all quantitative results, David Kachlík - Provided expert consultation for the study and offered critical feedback on the manuscript, Radek Pohnán - Assisted with study design and data interpretation and provided administrative support.
Funding
This study was supported by the Czech Ministry of Defence Institutional Support (Grant MO 1012).
Data availability
All data supporting the findings of this study are available within the paper and its Supplementary Information.
Declarations
Conflict of interest
The authors declare no competing interests.
Ethical Statement
The patient provided written informed consent. The authors are accountable for all aspects of the, ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Pavel Záruba and Kristýna Pončáková are co-first author's.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data supporting the findings of this study are available within the paper and its Supplementary Information.