Objectives: This video depicts a robotic pancreaticoduodenectomy undertaken in a 57-year-old woman who presented with worsening anemia and has a personal medical history of GERD.
Methods: The patient was referred for an EGD which revealed abnormal findings of a 10-centimeter bleeding duodenal ulcer in the second portion of the duodenum. Further duodenal ulcer biopsy revealed a moderately differentiated adenocarcinoma.
Results: The operation began with a diagnostic laparoscopy which showed no evidence of carcinomatosis or liver lesions. Lysis of adhesions occurred in the right upper quadrant as the patient had a history of cholecystectomy. The tumor mass was bulky in nature and encompassed the duodenum and head of the pancreas. The duodenum was carefully mobilized despite a large quantity of inflammatory process and a strong adherence to the mesentery. The jejunum was brought up into the right upper quadrant and the gastrohepatic ligament was opened in a stellate fashion. The duodenum was divided allowing the stomach to be retracted to the left upper quadrant. Dissection along the duodenum, uncinate process and neck of the pancreas occurred allowing for the transection of the pancreas. Peripancreatic lymph nodes were excised and collected. Reconstruction began with the hepaticojejunostomy anastomosis with two absorbable V-Loc sutures. Next, the two-layer pancreaticojejunostomy anastomosis was undertaken with non-absorbable V-Loc sutures for the outer layer and absorbable V-Loc sutures for the inner layer. Lastly, the transverse colon was elevated to allow for the duodenojejunostomy anastomosis. A fibrin-sealant was injected over all three anastomoses and a 10-French flat JP drain was brought to the axillary line and sutured to the skin.
Conclusion: Operative duration was 9 hours with an estimated blood loss of 100 milliliters. Final pathology confirmed duodenal adenocarcinoma with presence of lymphovascular invasion with 10 of the 28 excised lymph nodes showing involvement. The patient tolerated the operation well and had an uneventful postoperative course. This video demonstrates how a pancreaticoduodenectomy, a difficult HPB procedure, may be successfully completed utilizing a robot platform while still maximizing the advantages of a minimally invasive procedure.
