Feasibility of "cold" triangle robotic pancreatoduodenectomy

Abstract

Background: Triangle pancreatoduodenectomy adds to the conventional procedure the en bloc removal of the retroperitoneal lympho-neural tissue included in the triangular area bounded by the common hepatic artery (CHA), the superior mesenteric artery (SMA), and the superior mesenteric vein/portal vein. We herein aim to show the feasibility of "cold" triangle robotic pancreaticoduodenectomy (C-Tr-RPD) for pancreatic cancer (PDAC).

Methods: Cold dissection corresponds to sharp arterial divestment performed using only the tips of robotic scissors. After division of the gastroduodenal artery, triangle dissection begins by lateral-to-medial divestment of the CHA and anterior-to-posterior clearance of the right side of the celiac trunk. Next, after a wide Kocher maneuver, the origin of the SMA, and the celiac trunk are identified. After mobilization of the first jejunal loop and attached mesentery, the SMA is identified at the level of the first jejunal vein and is divested along the right margin working in a distal-to-proximal direction. Vein resection and reconstruction can be performed as required. C-Tr-RPD was considered feasible if triangle dissection was successfully completed without conversion to open surgery or need to use energy devices. Postoperative complications and pathology results are presented in detail.

Results: One hundred twenty-seven consecutive C-Tr-RPDs were successfully performed. There were three conversions to open surgery (2.3%), because of pneumoperitoneum intolerance (n = 2) and difficult digestive reconstruction. Thirty-four patients (26.7%) required associated vascular procedures. No pseudoaneurysm of the gastroduodenal artery was observed. Twenty-eight patients (22.0%) developed severe postoperative complications (≥ grade III). Overall 90-day mortality was 7.1%, declining to 2.3% after completion of the learning curve. The median number of examined lymph nodes was 42 (33-51). The rate of R1 resection (7 margins < 1 mm) was 44.1%.

Conclusion: C-Tr-RPD is feasible, carries a risk of surgical complications commensurate to the magnitude of the procedure, and improves staging of PDAC.

Keywords: Mesopancreas; Pancreatic cancer; Pancreatoduodenectomy; Robot assisted; Robotic; Triangle.

Fig. 1

Arterial divestment by cold dissection (tip of robotic scissors)

Fig. 2

Circumferential clearance of common hepatic artery

Fig. 3

Descending dissection along the right side of the celiac trunk reaching the right diaphragmatic crus

Fig. 4

Working from a posterior approach and following centripetal clearance of retroperitoneal lympho-neural tissues, the origin of the superior mesenteric artery and celiac trunk are clearly identified

Fig. 5

The superior mesenteric artery runs just posterior to the first jejunal vein

Fig. 6

Working from an anterior approach the right side of the superior mesenteric artery is divested. Note two pancreatoduodenal arteries that are clearly identified in preparation for selective ligature and division

Fig. 7

Retroperitoneal lympho-neural tissues are peeled off the superior mesenteric artery

Fig. 8

Completed triangle clearance of retroperitoneal lympho-neural tissues